Rule 15-12-32-7.4.14 - Performance Improvement/Evaluation1. The burn program must have a performance improvement program that is multidisciplinary. The burn center director must be responsible for the performance improvement program. The burn center multi-disciplinary committee, which oversees the performance improvement program, must meet at least quarterly. Sufficient documentation must be maintained to verify problems, identify opportunities for improvement, take corrective actions, and resolve problems. Morbidity and mortality conferences must be held at least monthly with physicians other than the immediate burn care team to ensure objective review of the presentations. Attendees at this conference must include specialist staff members other than those practicing in the burn center. All significant complications and deaths must be discussed. Actions recommended must also be documented, and there must be documentation of loop closure. Records of this conference must be kept.2. The burn center must develop an internal, 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 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 burn 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 burn bypass.m. Review of times and reasons for burn transfers.o. Morbidity and Mortality review.p. Feedback process with the referring hospital/physician.3. Representatives from the burn center shall participate in the Trauma Region committees and the statewide performance improvement process.15 Miss. Code. R. 12-32-7.4.14
Miss. Code Ann. § 41-59-5