Each trauma center must develop an internal Pediatric Performance Improvement plan that minimally addresses the following key components.
1. An organizational structure that facilitates performance improvement (Multidisciplinary Trauma Committee).2. Clearly defined authority and accountability for the program.3. Clearly stated goals and objectives one of which should be reduction of inappropriate variations in care.4. Development of expectations (criteria) from evidence based guidelines, pathways and protocols. These should be appropriate, objectively defined standards to determine quality of care. 5. Explicit definitions of outcomes derived from institutional standards.6. Documentation system to monitor performance, corrective action and the result of actions taken.7. A process to delineate privileges credentialing all trauma service physicians.8. An informed peer review process utilizing a multidisciplinary method.9. A method for comparing patient outcomes with computed survival probability. 10. Autopsy information on all deaths when available.11. Review of pre-hospital care.12. Review of times and reasons for trauma bypass.13. Review of times and reasons for trauma transfers.14. Audit of all trauma deaths.15. Morbidity and Mortality review.15 Miss. Code. R. 3-1-2.6.2