Rule 15-12-32-2.4.9 - Performance Improvement/Evaluation1. A key element in trauma system planning is evaluation. All licensed hospitals which have organized emergency services or departments will be required to participate in the statewide trauma registry for the purpose of supporting peer review and performance improvement activities at the local, regional and state levels. Since these data relate to specific trauma patients and are used to evaluate and improve the quality of health care services, this data is confidential as provided in Miss. Code Ann.§ 41-59-77. Level I trauma facilities may be responsible for direct assistance to all other levels of referring facilities in providing data for inclusion in the registry.2. Each trauma center must develop an internal trauma specific Performance Improvement (PI) plan that minimally addresses the following key components and is fully integrated into the hospital wide program: a. An organizational structure that facilitates performance improvement (Multidisciplinary Trauma Committee).b. Clearly defined authority and accountability for the program.c. Clearly stated goals and objectives one of which should be reduction of inappropriate variations in care.d. Development of expectations (criteria) from evidenced based guidelines, pathways and protocols. These should be appropriate, objectively defined standards to determine quality of care.e. Explicit definitions of outcomes derived from institutional standards.f. Documentation system to monitor performance, corrective action and the result of the actions taken.g. A process to delineate credentialing of all trauma service physicians.h. An informed peer review process utilizing a multidisciplinary method.i. A method for comparing patient outcomes with computed survival probability.j. Autopsy information on all deaths when available.k. Review of pre-hospital care.l. Review of times and reasons for trauma bypass.m. Review of times and reasons for trauma transfers.n. Audit of trauma deaths.o. Morbidity and Mortality review.3. Representatives from the Level I Trauma Center shall participate in the Trauma Care Region and statewide performance improvement process.15 Miss. Code. R. 12-32-2.4.9
Miss. Code Ann. § 41-59-5