Section R. 330.260 - Regional performance improvementRule 10.
(1) Each regional stroke system shall develop and implement a regional stroke care performance improvement program. This program must include the standards under R 330.254(1)(d) and R 330.257(5) and the development of an annual process for reporting to the department a review of all region-wide policies, procedures, and protocols.(2) Each regional stroke system is responsible for monitoring, assessing, and evaluating the system to improve stroke care, reduce death and disability, surveillance of stroke incidence and implementation of stroke risk reduction initiatives.(3) Each regional stroke system shall appoint an RPSRO.(4) Deviations from protocols established and adopted by local MCAs and approved by the department for stroke patients must be addressed through a documented stroke care performance improvement process established by a PSRO.(5) Each regional stroke 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, the data confidentiality provisions under the code, and any confidentiality provisions established by the RPSRO.(6) The performance improvement process must include the standards under R 330.254(1)(d), and include all of the following system components to be evaluated: (a) Components of the regional stroke care plan.(b) Triage criteria and effectiveness.(c) Stroke center diversion.(d) Data driven provision of care defined by available data metrics supported by the region, the statewide stroke care advisory subcommittee, and the department.(7) Each regional stroke system is responsible for the ongoing evaluation of the stroke system of care. Accordingly, each region shall develop a procedure for receiving information from the regional stroke care system constituents on the implementation of various components of that region's stroke care system, and include the standards under R 330.254(1)(e), and include all the following: (a) Components of the regional stroke care plan.(b) Triage criteria, and effectiveness.(c) Stroke center diversion.(d) Data analytics as defined by the department with the advice of the statewide stroke care advisory subcommittee.(8) Based on 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, if needed. The report must be made available to all regional stroke system constituents.(9) The region shall ensure that all stroke centers participate in this annual evaluation process and encourage all other hospitals that treat stroke patients to participate. 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. 330.260
2023 MR 21, Eff. 11/6/2023