Md. Code Regs. 30.08.14.06

Current through Register Vol. 51, No. 12, June 14, 2024

Section 30.08.14.06 - Quality Management

A. The hand and upper extremity trauma center shall have an ongoing quality management program integrated with the hospital's overall quality management system.

B. Quality management for the hand and upper extremity trauma center shall include:

(1) Maintaining the hand physician representative on the following hospital committees to discuss quality management issues during monthly meetings:

(a) The hospital operating room committee; and

(b) The hospital emergency room committee;

(2) Attendance by the hand and upper extremity trauma center representative responsible for quality management and quality improvement activities at:

(a) The hand policy committee meetings; and

(b) The monthly hospital quality management meetings;

(3) Participation in State emergency medical services quality management activities;

(4) Maintenance of a hand and upper extremity trauma registry on patients admitted to the hand and upper extremity trauma center;

(5) Monthly review of hand and upper extremity trauma registry data and reports;

(6) Maintenance of a patient care database on patients treated through the hand and upper extremity trauma rehabilitation unit and evaluation of the various outcomes, measures, and protocols;

(7) Monthly review of morbidity and mortality data from the hand and upper extremity trauma center weekly patient sessions for trainees in which cases and complications can be discussed;

(8) Making available to MIEMSS documentation of quality management including:

(a) Problem identification;

(b) Analysis;

(c) Action plan;

(d) Implementation; and

(e) Reevaluation; and

(9) A monthly ethics in medicine forum to discuss ethical considerations that confront today's physician.

Md. Code Regs. 30.08.14.06