Section R. 330.211 - Regional performance improvementRule 11.
(1) Each regional STEMI system shall develop and implement a regional STEMI care performance improvement program. This program must include the standards that are incorporated by reference pursuant to R 330.204(1)(d), R 3330.204(1)(j), and R 330.208(5) and include the development of an annual process for reporting to the department a review of all region-wide policies, procedures, and protocols.(2) Each regional STEMI system is responsible for monitoring, assessing, and evaluating the system to improve STEMI care, reduce death and disability, surveillance of STEMI incidence, and implementation of STEMI risk reduction initiatives.(3) Each regional STEMI system shall appoint an RPSRO.(4) Deviations from protocols established and adopted by local MCAs and approved by the department for STEMI patients must be addressed through a documented STEMI care performance improvement process established by a PSRO.(5) Each regional STEMI care advisory council shall observe the confidentiality provisions of 45 CFR part 164, the health insurance portability and accountability act of 1996, Public Law 104-191, data confidentiality provisions under the code and any confidentiality provisions established by the RPSRO.(6) The performance improvement program must include the standards under R 330.204(1)(p), R 330.208(5), and include all the following: (a) Components of the regional STEMI care plan.(b) Triage criteria and effectiveness.(c) STEMI diversion and bypass.(d) Data driven provision of care defined by available data metrics supported by the region, the statewide STEMI care advisory subcommittee, and the department.(7) Each regional STEMI system is responsible for the ongoing evaluation of the system. Accordingly, each region shall develop a procedure for receiving information from the regional STEMI system constituents on the implementation of various components of that region's STEMI system, and include the standards under R 330.204(1)(d) and R 325.208(5), and include all of the following: (a) Components of the regional STEMI care plan.(b) Triage criteria and effectiveness.(c) STEMI diversion and bypass.(d) Data analytics as defined by the department with the advice of the statewide STEMI care advisory subcommittee.(8) Based upon information received by the region in the evaluation process, the region shall annually prepare a report containing results of the evaluation and a performance improvement plan. The report must be made available to all regional STEMI system constituents.(9) The region shall ensure that all STEMI centers and facilities participate in this annual evaluation process and encourage all other hospitals that treat STEMI patients to do likewise. The region shall not release specific information related to an individual patient or practitioner. Aggregate system performance information and evaluation must be available for review.Mich. Admin. Code R. 330.211
2023 MR 22, Eff. 11/9/2023