Code of Maryland Regulations
Title 30 - MARYLAND INSTITUTE FOR EMERGENCY MEDICAL SERVICES SYSTEMS (MIEMSS)
Subtitle 08 - DESIGNATION OF TRAUMA AND SPECIALTY REFERRAL CENTERS
Chapter 30.08.05 - Trauma Center Designation and Verification Standards
Section 30.08.05.14 - Quality Management

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A. The ongoing Quality Management (QM) of the trauma program shall be:

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(1) Integrated into the hospital's overall quality management program; and

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(2) Reported to the hospital's governing body.

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B. Trauma Centers shall have:

(1) A QM comprehensive written plan outlining the configuration and identifying both adequate personnel to implement that plan and an operational data management system: and

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(2) A designated QM Process Improvement (PI) position in Trauma Centers with a trauma registry volume greater than 1500 patients per year which is separate from the TPM position. This position should initiate the concurrent review process and, in conjunction with the TPM, facilitate the PI process to loop closure. This position should report directly to the TPM.

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C. The TMD shall have a leadership role in trauma center QM.

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D. The following shall be included in the QM of the trauma program:

(1) Structure to ensure that defined program outcomes and performance measures are developed and monitored regularly; to include:

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(a) Trauma Patient Identification;

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(b) Peer Review; and

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(c) Audit filters;

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(2) A hospital trauma registry with participation in the State trauma registry;

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(3) Special audit of all trauma deaths;

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(4) Morbidity and Mortality reviews;

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(5) Evaluation of nursing care, medical care, utilization review, tissue review, and pre hospital care;

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(6) Trauma center by-pass status including, if applicable, both medevac fly-by and ground unit re-route statistics; and

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(7) Documentation of quality management available to demonstrate the multidisciplinary approach to the quality management program including and if appropriate:

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(a) Problem Identification;

(b) Analysis;

(c) Action plan;

(d) Implementation;

(e) Reevaluation; and

(f) Loop Closure/Resolution.

E. The liaisons on the multidisciplinary trauma peer review committee shall attend a minimum of 50 percent of those committee meetings.

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F. The TMD shall be involved in the development of the trauma center's bypass (diversion) protocol.

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G. The trauma surgeon shall be involved in the decision regarding bypass (diversion) each time the center goes on bypass.

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H. The Trauma Center shall minimize trauma bypass hours with a goal of less than 5 percent per month of the total monthly hours.

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I. Trauma center diversion-bypass hours shall be routinely monitored, documented, and reported, including the reason for initiating the diversion policy.

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J. Monthly Review.

(1) At one or more appropriate forums in the hospital, the trauma program shall be reviewed monthly, including both clinical care and administration.

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(2) When a resource is required to be within a specified period of time, the time the resource is requested and the time the resource is available shall be documented as part of the QM process and the response times shall be reviewed monthly.

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(3) The following aspects shall be addressed:

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(a) Trends;

(b) All deaths;

(c) All transfers;

(d) Morbidities;

(e) Problem identification and solution;

(f) Issues identified from the quality management process; and

(g) Other trauma system issues.

(4) Minutes shall be maintained for all meetings and shall reflect the review of operational events and, when appropriate, the analysis and proposed corrective actions.

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