Rule 15-12-32-5.4.5 - Performance Improvement/Evaluation1. The trauma center must develop and implement a trauma specific performance improvement plan. Key elements in trauma system planning are evaluation, measurement and improvement of performance. The goal is to decrease variation in care and improve patient outcomes.2. Compliance with the above will be evidenced by: a. Review of compliance with EMS Triage Guidelines and Protocols;b. Compliance with written Trauma Team Activation Criteria;c. Compliance with the principles of ATLS;d. Peer Review of all trauma deaths to determine timeliness and appropriateness of care and preventability of death;e. Review of trauma related morbidities for appropriateness of care and preventability;f. Nursing Audit (clinical review of nursing documentation and quality of care rendered to trauma patients);g. Review of timeliness and appropriateness of all transfers out;h. Review of prehospital trauma care;i. Review of times/reasons for trauma-related bypass;3. This information must be documented and reported at a trauma specific meeting or in conjunction with other ongoing performance improvement committees in the facility.15 Miss. Code. R. 12-32-5.4.5
Miss. Code Ann. § 41-59-5