Mississippi Administrative Code
Title 15 - Mississippi Department of Health
Part 3 - Bureau of Acute Care Systems
Subpart 3 - Stroke System of Care
Chapter 1 - Mississippi Stroke System of Care
Subchapter 8 - Performance Improvement and System Evaluation
Rule 15-3-3-1.8.2 - Specific audit filters will be established by the Stroke PI committee
Universal Citation: MS Code of Rules 15-3-3-1.8.2
Current through March 31, 2025
a. In general, the following performance improvement processes should be performed by each Stroke Center. The results of these reviews shall be reported to the Stroke PI committee.
i. Each Stroke Center assigns a PI person to
oversee the process
ii. Standards
established
iii. Determine audit
filters
iv. Collect data
v. Evaluate data
vi. Determine PI issues present
vii. Develop corrective action plan
viii. Re-evaluate to document
results/effectiveness of CAP
b. The following performance elements should be considered by each pre-hospital entity:
i.
Quality measure regarding response times (time to dispatch, EMS response,
on-scene time, and transport time) will be collected and analyzed
ii. Accuracy of patient assessment
iii. Transport protocol adherence
iv. Procedures initiated/completed
v. Medical control interaction
vi. Transport mode (air/ground)
vii. Record/documentation
viii. Inter-facility care/transport
c. The following performance elements should be considered by each Stroke Center:
i. Outcome review
ii. Complications
iii. Deaths
iv. Achievement of time sensitive goals (CT
completed/reporting times and Door to Alteplase administration times)
v. Core stroke quality measures
established for hospital stroke care will be entered into the approved national
registry platform for blinded comparison between hospitals
Miss. Code Ann. § 41-3-15
Disclaimer: These regulations may not be the most recent version. Mississippi may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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