Florida Administrative Code › 64 - DEPARTMENT OF HEALTH › 64J - Division of Emergency Preparedness and Community Support › Chapter 64J-2 - TRAUMA › Section 64J-2.016 - Site Visits and Approval

Current through Reg. 50, No. 138; July 16, 2024
(1) As used in
				this rule, the term "applicant" includes a hospital seeking selection as a
				trauma center, a current verified trauma center seeking a change or
				redesignation in status, or a current verified trauma center seeking renewal.
				Each applicant will receive an on-site evaluation to determine the quality of
				trauma care and whether the applicant is in substantial compliance with
				standards published in DHP 150-9, January 2010, Trauma Center Standards, which
				is incorporated by reference in Rule
				 64J-2.011, F.A.C.
(2) The on-site evaluation will be conducted
				by a review team of out-of-state reviewers with knowledge of trauma patient
				management as evidenced by experience in trauma care at a trauma center
				approved by the governing body of the state in which they are licensed.
				Prospective out-of-state reviewers must disclose to the department and to the
				applicant under review any conflict of interest that may affect or be perceived
				to affect their findings.
(3) All
				applicants will receive a site visit no later than one year following the
				submission of a renewal application or beginning operations as a trauma center.
				Applicants that submit a completed Trauma Center Application to Renew, Form DH
				2032R, more than 14 months before expiration of the current certification will
				receive an initial on-site survey not less than 100 days from the date the
				current certification expires.
(4)
				The reviewers will assess each applicant's compliance with the standards
				published in DHP 150-9, Trauma Center Standards, and the quality of trauma
				patient care and patient management by direct observation, review of call
				schedules, patient charts, hospital trauma mortality data, trauma case
				summaries, and minutes of trauma quality management committee
				meetings.
(5) Evaluation of the
				Quality of Trauma Patient Care and Trauma Patient Management:
(a) The reviewers will assess the quality of
				trauma patient care and the quality of trauma patient management by analyzing
				each applicant's trauma patient care and trauma patient outcomes, by reviewing
				trauma patient charts and by evaluating the effectiveness of the trauma quality
				management program through reviews of trauma case summaries and minutes of
				trauma quality management committee meetings.
(b) Evaluations of trauma patient care and
				trauma patient management will also be conducted using trauma patient data
				collected from the hospital trauma registry and the Florida Trauma Registry
				from a period of time between the date that the applicant began operations
				through the date of the onsite review. Trauma patient data may also be
				collected from the emergency department patient log, audit filter log, or
				quality management committee minutes.
(c) Patient charts to be reviewed will be
				selected by the department from cases meeting the criteria listed in Standard
				XVIII B.2., published in DHP 150-9, Trauma Center Standards. A minimum of 75
				cases will be selected for review. If the case total is less than 75, all cases
				are subject to review.
(d) Patient
				charts will be reviewed to identify factors related to negative patient outcome
				or compromised patient care. When such factors are identified, trauma case
				reviews by the medical director of the trauma service or the trauma nurse
				coordinator, as well as minutes of trauma quality management committee
				meetings, will be reviewed to determine if corrective action was taken by the
				trauma service and appropriate peer review committees.
(e) Reviewers will study the trauma case
				reviews and trauma quality management committee meeting minutes to evaluate the
				overall effectiveness of the quality management program.