Section 3-2 - Trauma System Evaluation All designated facilities will be required to participate in quality initiatives within these rules.
(a) The following key components shall be addressed by the quality improvement plan designed by each facility: - (i) Clearly stated goals and objectives;
- (ii) An organizational structure which facilitates the process of quality improvement;
- (iii) The development of standards of care;
- (iv) Established quality indicators (audit filter);
- (v) A plan to define adverse outcomes by using a code that describes the complications;
- (vi) A systematic peer review process utilizing a multi disciplinary method and involving prehospital care providers;
- (vii) A plan to incorporate autopsy information, where available, regarding all trauma patients; and
- (viii) A facility plan that includes a method for computing survival probability and comparing patient outcome.
(b) All designated trauma care services shall: - (i) Document the trauma care quality assurance program's proceedings, findings, conclusions, recommendations, the actions taken, and the result of these actions, demonstrating that relevant findings are used to study and improve processes that affect trauma patient care;
- (ii) Evaluate the results of the trauma quality assurance program and include them with the hospital's general quality assurance program; and
- (iii) Participate in the state trauma registry as required by Section 1 of Chapter 2.
(c) A standard or protocol adopted or studied by the individual facilities may not be used by the OEMS to demonstrate negligence by a health care provider or health care facility to whom the standard or protocol applies.