The burn center must develop an internal, specific Performance Improvement (PI) plan that minimally addresses the following key components and is fully integrated into the hospital wide program:
a. An organizational structure that facilitates performance improvement (Multidisciplinary Committee).b. Clearly defined authority and accountability for the program.c. Clearly stated goals and objectives one of which should be reduction of inappropriate variations in care.d. Development of expectations (criteria) from evidenced based guidelines, pathways and protocols. These should be appropriate, objectively defined standards to determine quality of care. e. Explicit definitions of outcomes derived from institutional standards.f. Documentation system to monitor performance, corrective action and the result of the actions taken.g. A process to delineate credentialing of all burn service physicians.h. An informed peer review process utilizing a multidisciplinary method.i. A method for comparing patient outcomes with computed survival probability.j. Autopsy information on all deaths when available.k. Review of pre-hospital care.l. Review of times and reasons for burn bypass.m. Review of times and reasons for burn transfers.o. Morbidity and Mortality review.p. Feedback process with the referring hospital/physician.15 Miss. Code. R. 3-1-2.8.2