reglab/statecodes huggingface dataset:
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 1 - Mississippi Trauma Care System › Subchapter 4 - Mississippi State Trauma Registry › Rule 15-3-1-1.4.1 - Applicability

Current through June 25, 2024
1. All Mississippi-licensed hospitals which
					 have an emergency service or department shall participate in the Trauma
					 Registry data collection process, whether or not they participate in the Trauma
					 Care System. All out-of-state hospitals designated as Mississippi Trauma
					 Centers shall participate in the Trauma Registry. Specialized treatment
					 centers, either in-state or out-of-state, that have contracts with the
					 Department to provide care to Mississippi trauma/burn patients, shall
					 participate in the Trauma Registry.
2. All trauma data collection instruments
					 shall include the collection of both pre-hospital and hospital patient care
					 data, and shall be integrated into the Department's data management systems.
					 Trauma registry inclusion criteria and the data dictionary can be found on the
					 Department's website.
Miss. Code Ann.
						§
												41-59-75
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 1 - Mississippi Trauma Care System › Subchapter 4 - Mississippi State Trauma Registry › Rule 15-3-1-1.4.2 - Timeliness of Submissions

Current through June 25, 2024
hospitals to the Department no later than two (2) months
						plus six (6) days after the end of the current month. For example, Trauma
						Registry data for the month of January is due no later than April
						6th.
Miss. Code Ann.
						§
												41-59-75
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 1 - Mississippi Trauma Care System › Subchapter 4 - Mississippi State Trauma Registry › Rule 15-3-1-1.4.3 - Trauma Registrar staffing

Current through June 25, 2024
Each trauma center shall have a sufficient number of
						trauma registrars to ensure all registry entries are submitted on time and are
						accurate. Registrars must complete initial training of sixteen (16) hours
						within six (6) months of hire/assignment. All registrars must complete eight
						(8) hours of registry specific continuing education annually.
Miss. Code Ann
						§
												41-59-5
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 1 - Mississippi Trauma Care System › Subchapter 5 - Administrative and Educational Support Activities › Rule 15-3-1-1.5.1 - Administrative and Educational Support Activities

Current through June 25, 2024
1. The
					 Mississippi Trauma System of Care Plan provides for a mandatory trauma system
					 that is inclusive, matching appropriate resources and responses to the needs of
					 trauma patients. The Plan provides a mechanism for improving community health
					 through an organized system of injury prevention, acute care and
					 rehabilitation, which shall be fully integrated into the statewide public
					 health system. The Plan calls for making use of a vendor or vendors for
					 administrative and/or educational services as necessary for the efficacy of the
					 program. Any vendor used for said purpose shall function under contract with
					 the Department.
Miss. Code Ann.
						§
												41-59-75
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 1 - Mississippi Trauma Care System › Subchapter 5 - Administrative and Educational Support Activities › Rule 15-3-1-1.5.2 - Establishment of a Region Board of Directors

Current through June 25, 2024
1. All Trauma
					 Care Regions designated by the Department shall establish a Board of Directors,
					 which shall be recognized as the lead administrative body of that Region. Board
					 members shall be representative(s) of participating and designated trauma care
					 centers, physicians, or any other person deemed appropriate by the Board. The
					 Board shall have administrative authority over the operation of the Trauma Care
					 Region and subsequent trauma system programs.
2. Trauma Care Region boards are authorized
					 to receive funds and to expend funds as may be available for any necessary and
					 proper trauma care program purposes in the manner provided for in these
					 Regulations or in law. Noncompliance will result in loss of funding to the
					 region for each corresponding activity.
Miss. Code Ann.
						§
												41-59-75
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 1 - Mississippi Trauma Care System › Subchapter 5 - Administrative and Educational Support Activities › Rule 15-3-1-1.5.3 - Administration of the Trauma Care Region

Current through June 25, 2024
1. After formation
					 of a Trauma Care Region board, the board shall appoint an administrator who
					 shall have authority over the operation of the Trauma Care Region and
					 subsequent trauma care programs, all under the direction of the Trauma Care
					 Region board. Such management may be carried out by an appointed executive
					 manager, by contracting for management services, or by some other means, to be
					 approved by the Department.
a. The functions
					 of a Trauma Care Region include, but are not limited to, the
					 following:
b. Track and assist in
					 the distribution of the Trauma Care Trust Fund to hospitals, physicians, and
					 EMS agencies;
c. Maintain a
					 regional database including, but not limited to, hospitals in the region,
					 designation status, and expiration date;
d. Monitor pre-hospital triage and transport
					 of the trauma patient;
e. Maintain
					 and ensure compliance of the Regional Trauma Plan;
f. Provide training opportunities for
					 physicians, nurses, and EMS and support personnel, maintain a schedule, and
					 ensure notification to qualifying personnel;
g. Monitor the ongoing PI program of each
					 trauma program in the respective region; and
h. Other such activities as may be required
					 by the Department in the annual contractual agreement.
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 1 - Mississippi Trauma Care System › Subchapter 5 - Administrative and Educational Support Activities › Rule 15-3-1-1.5.4

Current through June 25, 2024
Performance of each trauma region shall be evaluated
						annually with continued financial support contingent on adequate performance
						based on outcome measures.
Miss. Code Ann.
						§
												41-59-75
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 1 - Mississippi Trauma Care System › Subchapter 5 - Administrative and Educational Support Activities › Rule 15-3-1-1.5.5 - Region Trauma Plans

Current through June 25, 2024
1. A Trauma Care
					 Region intending to implement a trauma care system shall submit its Regional
					 Trauma Plan to the Department and have it approved prior to implementation.
					 Within 30 days of receiving the plan, the Department shall provide written
					 notification to the Trauma Care Region of the following:
a. That the plan has been received by the
					 Department;
b. Whether the
					 Department approves or disapproves of its Regional Trauma Plan; and
c. If disapproved, the reason for disapproval
					 of the Regional Trauma Plan
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 1 - Mississippi Trauma Care System › Subchapter 5 - Administrative and Educational Support Activities › Rule 15-3-1-1.5.6 - Required Elements of a Region Trauma Plan

Current through June 25, 2024
The Region Trauma Plan shall be comprehensive and the
						objectives shall be clearly outlined. The Plan shall contain, at the minimum,
						the following elements:
1. Table of
					 contents;
2. Plan summary;
3. Administrative structure;
4. Medical organization and
					 management;
5. Inclusive regional
					 design which includes all facilities involved in the care of acutely injured
					 patients, including coordination with neighboring Trauma Care Regions;
6. Documentation of all
					 inter-facility transfer protocols;
7. Written documentation of participation
					 (hospital/medical staff);
8. System
					 design which addresses the implementation of the policies developed;
9. Description of the critical care
					 capability within the Region including but not limited to burns, spinal cord
					 injury, rehabilitation, and pediatrics;
10. Performance improvement process; and
11. General policies of the Trauma
					 Care Region Board of Directors.
Miss. Code Ann.
						§
												41-59-75
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 1 - Mississippi Trauma Care System › Subchapter 5 - Administrative and Educational Support Activities › Rule 15-3-1-1.5.7 - General Policies of the Trauma Care Region

Current through June 25, 2024
A designated Trauma Care Region shall develop policies
						which provide a clear understanding of the structure of the trauma system and
						the manner in which it utilizes the resources available to it. Those policies
						shall address the following:
1. System
					 organization and management;
2.
					 Trauma care coordination within the Region;
3. Trauma care coordination with neighboring
					 Regions and/or jurisdictions, including designated Trauma Care Region
					 agreements;
4. Data collection and
					 management;
5. Coordination of
					 designated Trauma Care Regions and trauma systems for transportation including
					 inter-Trauma Center transfers, and transfers from a receiving hospital to a
					 Trauma Center;
6. The integration
					 of pediatric hospitals, including pediatric triage criteria;
7. Performance improvement and system
					 evaluation to include responsibilities of the Multidisciplinary Trauma/Peer
					 Review Committee;
8. Training of
					 pre-hospital personnel to include trauma triage;
9. Public information and education about the
					 trauma system;
10. Lay and
					 professional education about the trauma system;
11. Coordination with public and private
					 agencies and Trauma Centers in injury prevention programs; and
12. Expected participation in regional
					 operations by pre-hospital providers and hospitals.
Miss. Code Ann.
						§
												41-59-75
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 1 - Mississippi Trauma Care System › Subchapter 5 - Administrative and Educational Support Activities › Rule 15-3-1-1.5.8 - Additional Standards and Prohibitions

Current through June 25, 2024
1. No health care
					 facility within a Region shall advertise in any manner or otherwise hold itself
					 out to be a Trauma Center unless so designated by the Department.
2. No pre-hospital provider shall advertise
					 in any manner or otherwise hold itself out to be affiliated with the trauma
					 system or a Trauma Center unless the provider of has been so designated or
					 licensed by the Department.
3. All
					 participating hospitals and licensed EMS providers in each Region shall abide
					 by the Region Trauma Plan and policies.
4. Documentation of a pre-hospital provider's
					 Medical Control Plan review and compliance must be submitted to BEMS and the
					 Trauma Care Region annually.
5. A
					 Trauma Care Region shall withhold Trauma Care Trust Fund distributions from
					 participating hospitals and licensed EMS providers for non-compliance with
					 regional plans and policies.
Miss. Code Ann.
						§
												41-59-75
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 1 - Mississippi Trauma Care System › Subchapter 5 - Administrative and Educational Support Activities › Rule 15-3-1-1.5.9 - Level IV Trauma Center Site Visits

Current through June 25, 2024
At least once during each three (3) year designation
						period, the Trauma Care Region shall conduct a Site Visit at each Level IV
						Trauma Center. The primary purpose of this visit will be to ensure compliance
						with the regulations, with particular emphasis on practitioner training;
						protocols and procedures; and Performance Improvement. A written report of any
						deficiencies shall be forwarded to the Department within 90 days of the
						visit.
Miss. Code Ann.
						§
												41-59-75
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 1 - Mississippi Trauma Care System › Subchapter 6 - Inter-facility Transfers Of Trauma Patients › Rule 15-3-1-1.6.1 - Inter-facility Transfers

Current through June 25, 2024
1. Patients may be
					 transferred from trauma center to other trauma center and/or specialty referral
					 centers provided that any such transfer is medically prudent, as determined by
					 the transferring trauma center physician of record, and is conducted by the
					 appropriate level of emergency medical service provider.
2. Trauma centers shall develop written
					 criteria for consultation and transfer of patients needing a higher/specialty
					 level of care. Trauma Center/specialty referral centers that repatriate trauma
					 patients shall provide data required by the Trauma Registry to the receiving
					 trauma center.
3. Trauma
					 Centers/specialty hospitals receiving transferred trauma patients shall provide
					 written feedback to the transferring facility and shall participate in the
					 state performance improvement process.
Miss. Code Ann.
						§
												41-59-75
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 2 - Performance Improvement and Patient Safety › Subchapter 1 - Authority and Scope › Rule 15-3-1-2.1.1

Current through June 25, 2024
Each designated Trauma Center shall have a Performance
						Improvement and Patient Safety (PIPS) program. The PIPS program shall be
						multidisciplinary in nature with every member of the trauma team playing a
						vital role in PIPS. The Trauma Medical Director (TMD) shall maintain overall
						accountability for the execution of the PIPS program. The trauma program shall
						have the authority to monitor all events that occur during a trauma-related
						episode of care within the organization.
Miss. Code Ann.
						§
												41-59-5
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 2 - Performance Improvement and Patient Safety › Subchapter 1 - Authority and Scope › Rule 15-3-1-2.1.2

Current through June 25, 2024
A reporting structure for the trauma program and service
						must be defined. The trauma service routinely functions under the
						organization's department of surgery and reports to the medical executive
						committee or equivalent. In addition, the trauma program shall report to the
						administrative structure of the organization.
Miss. Code Ann.
						§
												41-59-5
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 2 - Performance Improvement and Patient Safety › Subchapter 1 - Authority and Scope › Rule 15-3-1-2.1.3

Current through June 25, 2024
The TMD and trauma program manager (TPM) shall maintain
						the trauma PIPS program with data support from the trauma registry.
						Representatives from other clinical and hospital departments involved in the
						care of trauma patients, as well as the hospital's performance
						improvement/quality department, shall participate when appropriate to ensure
						multidisciplinary collaboration and compliance with the hospital's PIPS
						plan.
Miss. Code Ann.
						§
												41-59-5
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 2 - Performance Improvement and Patient Safety › Subchapter 1 - Authority and Scope › Rule 15-3-1-2.1.4

Current through June 25, 2024
The TMD is responsible for the review of all physician
						related issues, including all mortalities and screened complications. Although
						the TMD remains responsible for the overall function of the trauma program, the
						TPM shall be responsible for the operational and logistical aspects of the
						trauma PIPS program. The TPM is responsible for identification of issues and
						their initial validation, the maintenance of the trauma PIPS database/files and
						protection of their confidentiality, facilitating data trends and analysis, and
						coordinating surveillance of protocols/guidelines/clinical paths. The trauma
						registry shall assist the TPM in these activities.
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 2 - Performance Improvement and Patient Safety › Subchapter 1 - Authority and Scope › Rule 15-3-1-2.1.5

Current through June 25, 2024
There must be a process to address trauma program
						operational issues. Typically, this function is accomplished by a
						multidisciplinary trauma committee that examines trauma-related hospital
						operations and includes representative from all phases of trauma care. PIPS
						activities may also be accomplished within this committee. The committee must
						be chaired by the TMD and shall be comprised of department directors and
						physicians representing all phases and disciplines of care provided to the
						injured patient. The committee shall meet routinely with a defined attendance
						requirement.
Miss. Code Ann.
						§
												41-59-5
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 2 - Performance Improvement and Patient Safety › Subchapter 1 - Authority and Scope › Rule 15-3-1-2.1.6

Current through June 25, 2024
Mortalities, significant complications, and process
						variances associated with unanticipated outcomes shall undergo a systematic
						multidisciplinary trauma peer review to determine opportunities for
						improvement. This effort may be accomplished in a variety of formats but shall
						involve the participation and leadership of the TMD, the group of general
						surgeons on the trauma call panel, and the liaisons from emergency medicine,
						orthopedics, neurosurgery, anesthesia, critical care, and radiology. Ideally,
						other surgeons and other non-liaison members of other specialties involved in
						trauma call shall attend when a case in which they participated is being
						discussed. This meeting shall be held routinely with the frequency determined
						by the TMD based on case volume and the needs of the PIPS program. Meeting
						minutes and other documentation of this peer review activity shall be
						confidential.
Miss. Code Ann.
						§
												41-59-5
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 2 - Performance Improvement and Patient Safety › Subchapter 1 - Authority and Scope › Rule 15-3-1-2.1.7

Current through June 25, 2024
Each Trauma Center shall define criteria for case
						selection for formal trauma mortality and morbidity review. Documentation of
						case review shall be completed by the TMD and the TPM. Corrective action plans
						shall be developed and issues trended as appropriate.
Miss. Code Ann.
						§
												41-59-5
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 2 - Performance Improvement and Patient Safety › Subchapter 2 - Performance Improvement and Patient Safety Plan › Rule 15-3-1-2.2.1

Current through June 25, 2024
Each Trauma Center shall prepare a written Performance
						Improvement and Patient Safety (PIPS) Plan. There is no precise prescription
						for the PIPS plan, however, the trauma program must demonstrate a continuous
						process of monitoring, assessment, and management directed at improving care. A
						trauma PIPS plan shall practice a multidisciplinary and multi-departmental
						approach to reviewing the quality of patient care across departments and
						divisions. The trauma PIPS program shall integrate with the hospital quality
						and patient safety effort and have a clearly defined reporting structure and
						method for provision of feedback.
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 2 - Performance Improvement and Patient Safety › Subchapter 2 - Performance Improvement and Patient Safety Plan › Rule 15-3-1-2.2.2

Current through June 25, 2024
Each Trauma Center shall define a trauma population to
						perform data collection and analysis. Some programs may choose to define their
						trauma population as per Mississippi State Department of Health Trauma Registry
						Inclusion Criteria, while other programs monitor all injured patients treated
						at the facility regardless of registry inclusion.
Miss. Code Ann.
						§
												41-59-5
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 2 - Performance Improvement and Patient Safety › Subchapter 2 - Performance Improvement and Patient Safety Plan › Rule 15-3-1-2.2.3

Current through June 25, 2024
Representatives from the Level II trauma center shall
						participate in the Trauma Care Region and statewide performance improvement
						process.
Miss. Code Ann.
						§
												41-59-5
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 2 - Performance Improvement and Patient Safety › Subchapter 3 - Case Review Process › Rule 15-3-1-2.3.1

Current through June 25, 2024
Identified cases shall be reviewed by the TPM and TMD, as
						appropriate, for determination of need for further action. The TMD provides
						oversight for the review process for all aspects of the multidisciplinary
						trauma care from the time of the injury through discharge. PIPS data shall be
						routinely presented to a committee within the hospital charged with trauma
						PIPS; the trauma program shall also interact with the organization's
						performance improvement/quality program referring appropriate issues for
						review.
Miss. Code Ann.
						§
												41-59-5
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 2 - Performance Improvement and Patient Safety › Subchapter 3 - Case Review Process › Rule 15-3-1-2.3.2

Current through June 25, 2024
Levels of review can be accomplished in a variety of
						formats, depending on the volume of trauma patients at a given center and the
						structure of the trauma PIPS program in the context of the hospital's quality
						program. The levels of review are:
a.
					 First Level Review: TPM or designee performs the initial case review to verify
					 and validate the issue. If the first level of review is completed, affirming
					 that clinical care is appropriate and no issues are identified, the case does
					 not require second level or formal committee review. However if after review of
					 all the pertinent information, it may be determined that the issue shall be
					 addressed by the TMD and/or the committee charged with trauma PIPS review. In
					 some instances, immediate feedback and resolution may be possible at this
					 level. Even if issue resolution occurs during this level, the issue and
					 activities shall be documented for ongoing monitoring and trend analysis.
b. Second Level Review: This level
					 encompasses cases consisting of clinical care, provider care, or systems issues
					 which require medical director expertise and judgment. The TPM and TMD may
					 initiate further investigation, implement action without formal referral to a
					 peer review or system committee, or decide to send it to the appropriate
					 performance improvement/quality committee or to a hospital department for
					 further investigation/peer review and request follow-up. If immediate feedback
					 and resolution are obtained, the issue may be resolved. If not, the issue shall
					 be referred for multidisciplinary committee review, including peer review or
					 some other appropriate PIPS committee capable of further analysis and event
					 resolution.
c. Third Level Review:
					 The TPM and TMD will perform an initial case review, consisting of
					 identification all background information, pertinent protocols (or deficiency
					 of), and specify all individual issues to be discussed, in preparation for
					 multidisciplinary review. Cases may be referred to the appropriate hospital
					 department via appointed liaisons, committee, or department chair. The TMD
					 and/or trauma committee will then review the response of the referral for
					 follow-up planning.
d. Fourth
					 Level Review: The TPM, TMD, and multidisciplinary review committee perform the
					 initial review. Cases are then referred to the appropriate body for external
					 review with review response to the TMD and/or trauma committee for follow-up
					 planning.
Miss. Code Ann.
						§
												41-59-5
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 2 - Performance Improvement and Patient Safety › Subchapter 3 - Case Review Process › Rule 15-3-1-2.3.3

Current through June 25, 2024
Reviewed issues shall have a determination classified in
						a manner consistent with the trauma center's institution-wide performance
						improvement program. Mutually agreed upon nomenclature shall be utilized. Based
						on this review process, both the appropriateness and timeliness of care shall
						be reviewed, and opportunities for improvement (i.e. errors in judgment,
						technique, treatment, or communication, along with delays in assessment,
						diagnosis, technique, or treatment) shall be determined and documented. When an
						error can be attributed to a single credentialed provider, use of the
						departmental or institutional formal medical peer review process shall be
						considered.
Miss. Code Ann.
						§
												41-59-5
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 2 - Performance Improvement and Patient Safety › Subchapter 3 - Case Review Process › Rule 15-3-1-2.3.4

Current through June 25, 2024
The TMD must oversee corrective action planning at their
						institution. Structured plans may be created by any of the PIPS team members or
						trauma committees in an effort to improve sub-optimal performance identified
						through the PIPS process. The goal is to create forward momentum to effect
						demonstrable outcome change leading to subsequent loop closure. An evaluation
						and re-evaluation process will be part of the plan according to the
						institution's action plan methodology. Examples of corrective action categories
						are:
a. Counseling
b. Credentialing/privilege change
c. Education
d. External review
e. Guideline, protocol, or pathway
					 development or revision
f. PEER
					 review
g. Resource addition or
					 enhancement
h. Trending
Miss. Code Ann.
						§
												41-59-5
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 2 - Performance Improvement and Patient Safety › Subchapter 4 - Trauma Core Indicators › Rule 15-3-1-2.4.1

Current through June 25, 2024
Process and outcomes measures, referred to as audit
						filters or indicators, require defined criteria and metrics. Trauma Core
						Indicators (TCI) are mandatory indicators within the Mississippi Trauma Care
						System.
Miss. Code Ann.
						§
												41-59-5
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 2 - Performance Improvement and Patient Safety › Subchapter 4 - Trauma Core Indicators › Rule 15-3-1-2.4.2

Current through June 25, 2024
Compliance with the above will be evidenced by:
1. Review of compliance with EMS Triage
					 Guidelines and Protocols;
2.
					 Compliance with written Trauma Team Activation Criteria;
3. Compliance with the principles of ATLS;
4. Peer Review of all trauma
					 deaths to determine timeliness and appropriateness of care and preventability
					 of death;
5. Review of trauma
					 related morbidities for appropriateness of care and preventability;
6. Nursing Audit (clinical review of nursing
					 documentation and quality of care rendered to trauma patients);
7. Review of timeliness and appropriateness
					 of all transfers out;
8. Review of
					 pre-hospital trauma care;
9. Review
					 of times/reasons for trauma-related bypass;
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 2 - Performance Improvement and Patient Safety › Subchapter 4 - Trauma Core Indicators › Rule 15-3-1-2.4.3

Current through June 25, 2024
This information must be documented and reported at a
						trauma specific meeting or in conjunction with other ongoing performance
						improvement committees in the facility.
Miss. Code Ann.
						§
												41-59-5
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 2 - Performance Improvement and Patient Safety › Subchapter 5 - Tertiary Pediatric Trauma Centers: Performance Improvement/ Evaluation › Rule 15-3-1-2.5.1

Current through June 25, 2024
A key element in trauma system planning is evaluation.
						All licensed hospitals which have organized emergency services or departments
						will be required to participate in the statewide trauma registry for the
						purpose of supporting peer review and performance improvement activities at the
						local, regional, and state levels. Since these data relate to the specific
						trauma patients and are used to evaluate and improve the quality of health care
						services, the data is confidential as provided in Miss. Code An.
						41-59-77.
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 2 - Performance Improvement and Patient Safety › Subchapter 5 - Tertiary Pediatric Trauma Centers: Performance Improvement/ Evaluation › Rule 15-3-1-2.5.2

Current through June 25, 2024
The tertiary pediatric trauma center must develop an
						internal trauma specific Performance Improvement (PI) plan that is pediatric
						specific and must minimally address the following key components. The pediatric
						PI plan must be fully integrated into the hospital wide PI
						program:
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 2 - Performance Improvement and Patient Safety › Subchapter 5 - Tertiary Pediatric Trauma Centers: Performance Improvement/ Evaluation › Rule 15-3-1-2.5.3

Current through June 25, 2024
An organized structure that facilitates performance
						improvement. (Multidisciplinary Trauma Committee)
1. Clearly defines authority and
					 accountability for the program.
2.
					 Clearly stated goals and objectives one of which should be reduction of
					 inappropriate variations in care.
3. Development of expectations (criteria)
					 from evidence based guidelines, pathways and protocols.
4. 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 the actions taken.
7. A process
					 to delineate credentialing of all trauma service physicians.
8. An informed peer review process utilizing
					 a multidisciplinary method.
9. A
					 method of 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. Morbidity and
					 mortality review.
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 2 - Performance Improvement and Patient Safety › Subchapter 5 - Tertiary Pediatric Trauma Centers: Performance Improvement/ Evaluation › Rule 15-3-1-2.5.4

Current through June 25, 2024
Representatives from the tertiary pediatric trauma center
						shall participate in the Trauma Care Region(s) and statewide performance
						improvement process.
Miss. Code Ann.
						§
												41-59-5
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 2 - Performance Improvement and Patient Safety › Subchapter 6 - Secondary Pediatric Trauma Center: Performance Improvement/ Evaluation › Rule 15-3-1-2.6.1

Current through June 25, 2024
A key element in trauma system planning is evaluation.
						All licensed hospitals which have organized emergency services or departments
						will be required to participate in the statewide trauma registry for the
						purpose of supporting peer review and performance improvement activities at the
						local, regional and state levels. Since these data relate to specific trauma
						patients and are used to evaluate and improve the quality of health care
						services, the data is confidential as provided by Miss. Code Ann. §
											41-59-77.
						Tertiary pediatric trauma facilities may be responsible for direct assistant to
						primary and secondary pediatric trauma centers, referring facilities in
						providing data for inclusion in the registry. All pediatric admissions that
						meet Trauma Registry inclusion criteria shall be reviewed by the PI
						process.
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 2 - Performance Improvement and Patient Safety › Subchapter 6 - Secondary Pediatric Trauma Center: Performance Improvement/ Evaluation › Rule 15-3-1-2.6.2

Current through June 25, 2024
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.
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 2 - Performance Improvement and Patient Safety › Subchapter 6 - Secondary Pediatric Trauma Center: Performance Improvement/ Evaluation › Rule 15-3-1-2.6.3

Current through June 25, 2024
Representatives from the secondary pediatric trauma
						center shall participate in the Trauma Care Region(s) and the statewide
						performance review process.
Miss. Code Ann.
						§
												41-59-5
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 2 - Performance Improvement and Patient Safety › Subchapter 7 - Primary Pediatric Trauma Center: Performance Improvement/ Evaluation › Rule 15-3-1-2.7.1

Current through June 25, 2024
The trauma center must develop and implement a trauma
						specific performance improvement plan. Key elements in trauma system planning
						are evaluation, measurement and improvement of performance. The goal is to
						decrease variation in care and improve patient outcomes. All pediatric
						admissions that meet Trauma Registry inclusion criteria shall be reviewed by
						the hospital and Trauma Region PI process.
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 2 - Performance Improvement and Patient Safety › Subchapter 7 - Primary Pediatric Trauma Center: Performance Improvement/ Evaluation › Rule 15-3-1-2.7.2

Current through June 25, 2024
Compliance with the above will be evidenced by:
1. Review of compliance with EMS Triage
					 Guidelines and Protocols;
2.
					 Compliance with written Trauma Team Activation Criteria;
3. Compliance with the principles of ATLS;
4. Peer Review of all trauma
					 deaths to determine timeliness and appropriateness of care and preventability
					 of death;
5. Review of trauma
					 related morbidities for appropriateness of care and preventability;
6. Nursing Audit (clinical review of nursing
					 documentation and quality of care rendered to trauma patients);
7. Review of timeliness and appropriateness
					 of all transfers out;
8. Review of
					 pre-hospital trauma care;
9. Review
					 of times/reasons for trauma-related bypass
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 2 - Performance Improvement and Patient Safety › Subchapter 7 - Primary Pediatric Trauma Center: Performance Improvement/ Evaluation › Rule 15-3-1-2.7.3

Current through June 25, 2024
This information must be documented and reported at a
						trauma specific meeting or in conjunction with other ongoing performance
						improvement committees in the facility.
Miss. Code Ann.
						§
												41-59-5
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 2 - Performance Improvement and Patient Safety › Subchapter 8 - Burn Centers: Performance Improvement/ Evaluation › Rule 15-3-1-2.8.1

Current through June 25, 2024
The burn program must have a performance improvement
						program that is multidisciplinary. The burn center director must be responsible
						for the performance improvement program. The burn center multi-disciplinary
						committee, which oversees the performance improvement program, must meet at
						least quarterly. Sufficient documentation must be maintained to verify
						problems, identify opportunities for improvement, take corrective actions, and
						resolve problems. Morbidity and mortality conferences must be held at least
						monthly with physicians other than the immediate burn care team to ensure
						objective review of the presentations. Attendees at this conference must
						include specialist staff members other than those practicing in the burn
						center. All significant complications and deaths must be discussed. Actions
						recommended must also be documented, and there must be documentation of loop
						closure. Records of this conference must be kept.
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 2 - Performance Improvement and Patient Safety › Subchapter 8 - Burn Centers: Performance Improvement/ Evaluation › Rule 15-3-1-2.8.2

Current through June 25, 2024
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.
n. Audit of burn deaths.
o. Morbidity and Mortality review.
p. Feedback process with the referring
					 hospital/physician.
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 2 - Performance Improvement and Patient Safety › Subchapter 8 - Burn Centers: Performance Improvement/ Evaluation › Rule 15-3-1-2.8.3

Current through June 25, 2024
Representatives from the burn center shall participate in
						the Trauma Region committees and the statewide performance improvement
						process.
Miss. Code Ann.
						§
												41-59-5
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 3 - Level I Trauma Centers › Subchapter 1 - Hospital Organization › Rule 15-3-1-3.1.1 - General

Current through June 25, 2024
1. Level I Trauma Centers shall act as
					 tertiary care facilities at the hub of the trauma care system. The facility
					 must have the ability to provide leadership and total care for every aspect of
					 injury from prevention to rehabilitation. As a tertiary facility, the Level I
					 Trauma Center must have adequate depth of resources and personnel.
2. The Level I Trauma shall provide
					 leadership in education, trauma prevention, research, system planning and
					 performance improvement.
Miss. Code Ann.
						§
												41-59-5
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 3 - Level I Trauma Centers › Subchapter 1 - Hospital Organization › Rule 15-3-1-3.1.2 - Hospital Departments/Divisions/Sections

Current through June 25, 2024
1. The Level I
					 Trauma Center must have the following departments, divisions, or sections:
a. Emergency Medicine
b. General Surgery
c. Orthopedic Surgery
d. Neurological Surgery
e. Anesthesia
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 1 - Trauma System of Care › Chapter 3 - Level I Trauma Centers › Subchapter 1 - Hospital Organization › Rule 15-3-1-3.1.3 - Trauma Program

Current through June 25, 2024
1. There shall be a
					 written commitment on behalf of the entire facility to the organization of
					 trauma care. The written commitment shall be in the form of a resolution at the
					 time of application passed by an appropriate quorum of the members of the
					 governing authority. Should the business organization be other than a
					 corporation, a letter explaining such, together with a written commitment of
					 the hospital's chief executive officer, to the establishment of a trauma care
					 program may be sufficient. The trauma program must be established and
					 recognized by the medical staff and hospital administration. The trauma program
					 must come under the direction of a board-certified general surgeon with special
					 interest in trauma care. An identified hospital administrative leader must work
					 closely with the trauma medical director to establish and maintain the
					 components of the trauma program including appropriate financial support. The
					 trauma program location in the organizational structure of the hospital must be
					 such that it may interact effectively with at least equal authority with other
					 departments providing patient care. The administrative structure must minimally
					 include an administrator, medical director (TMD), trauma program manager (TPM),
					 trauma registrar and appropriate support staff Administrative support includes
					 human resources, education activities, community outreach activities, and
					 research. The trauma program must be multidisciplinary in nature and the
					 performance improvement evaluation of this care must be extended to all the
					 involved departments.
2. Compliance
					 with the above will be evidenced by but not limited to:
a. Governing authority and medical staff
					 letter of commitment in the form of a resolution;
b. Written policies and procedures and
					 guidelines for care of the trauma patient;
c. Defined trauma team and written roles and
					 responsibilities;
d. Appointed
					 Trauma Medical Director with a written job description;
e. Appointed Trauma Program Manager with a
					 written job description;
f. A
					 written Trauma Performance Improvement plan; and
g. Documentation of representative attendance
					 at statewide performance improvement meetings.