Section R. 325.135 - Regional performance improvementRule 11.
(1) Each trauma care region shall be required to develop and implement a regional trauma performance improvement program. This program shall include the standards that are incorporated by reference pursuant to R 325.129(1)(e), R 325.129(1)(k), and R 325.130(6)(d), and shall 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 trauma network is responsible for monitoring, assessing, and evaluating its regional trauma system to improve trauma care, reduce death and disability, surveillance of injury, and implementation of injury prevention activities.(3) Each regional trauma network shall appoint a RPSRO.(4) Deviations from protocols, which are established and adopted by local medical control and approved by the department for trauma patients, shall be addressed through a documented trauma performance improvement process established by a professional standards review organization.(5) Each regional trauma advisory council shall observe the confidentiality provisions of the health insurance portability and accountability act under 45 CFR Part 164, data confidentiality provisions under the code, or as established by the regional professional standards review organization.(6) The performance improvement process shall include the following standards that are incorporated by reference in these rules, pursuant to R 325.129(1)(e), R 325.129(1)(k), and R 325.130(6)(d) and include all of the following system components to be evaluated for both pediatrics and adults:(a) Components of the regional trauma plan.(b) Triage criteria and effectiveness.(c) Trauma center diversion.(d) Data driven provision of care defined by available data metrics supported by the region, the statewide trauma advisory subcommittee, and the department.(7) Each trauma care region shall be responsible for the ongoing evaluation of its trauma care system. Accordingly, each region shall be responsible for the ongoing receipt of information from the regional trauma system constituents on the implementation of various components of that regions trauma system, and shall include the standards that are incorporated by reference pursuant to R 325.129(1)(e), R 325. 129(A)(12), and R 325.130(6)(d), and include all of the following system components to be evaluated: (a) Components of the regional trauma plan.(b) Triage criteria and effectiveness.(c) Trauma center diversion.(d) Data analytics as defined by the department with the advice of the statewide trauma 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 shall be made available to all regional trauma system constituents. The region shall ensure that all trauma facilities participate in this annual evaluation process, and encourage all other hospitals that treat trauma patients to participate in the annual evaluation process. The region shall not release specific information related to an individual patient or practitioner. Aggregate system performance information and evaluation will be available for review.Mich. Admin. Code R. 325.135
2007 AACS; 2017 MR 10, Eff. 5/31/2017