Section 22-B2717. PROGRAMS FOR PERFORMANCE IMPROVEMENT

 

2717.1In adult trauma facilities, programs for performance improvement shall have the following elements:

 

(a)Trauma registry;

 

(b)Special audit for all trauma deaths;

 

(c)Morbidity and mortality review;

 

(d)Multidisciplinary trauma conference;

 

(e)Medical nursing audit, utilization review, tissue review;

 

(f)Review of prehospital trauma care;

 

(g)Review of times and reasons for transfer of injured patients;

 

(h)Times of and reasons for trauma-related bypass documentation; and

 

(i)Quality improvement personnel specifically dedicated to the trauma service program.

 

2717.2Performance improvement programs in each adult trauma care facility shall be met by establishing the following:

 

(a)A hospital organizational structure that facilitates the process of quality improvement by providing the responsible surgeon with authority to change policies, procedures, and protocols that address the care of the injured trauma patient;

 

(b)The development of standards of quality care;

 

(c)A process for monitoring compliance with or adherence to trauma care standards that includes at a minimum:

 

(1)Defining the population of trauma patients to whom the standards are applied;

 

(2)Defining adverse outcomes or deviations from quality (for example, death or complications from injury or treatment);

 

(3)Defining quality indicators or audit filters that examine the process of care; and

 

(4)Developing a systematic process for collection, evaluation, and analysis of data that describe or define the process of care and outcome;

 

(d)A process of peer review to evaluate specific cases or problems identified by the monitoring process. This requires:

 

(1)Documentation of the process and outcome of peer review; and

 

(2)Tabulation of the judgments from peer reviews to provide a basis for trend analysis and to assess the effect of any corrective action;

 

(e)A process for implementing corrective action to address problems or deficiencies identified by either the monitoring process or the peer review process; and

 

(f)A process for reevaluating and documenting the effect of the corrective action taken.

 

2717.3A performance improvement program shall consist of the following components:

 

(a)Standards and organization:

 

(1)Define the population to be monitored;

 

(2)Develop standards of care;

 

(3)Establish credentialing standards for practitioners;

 

(4)Provide administrative support for the process; and

 

(5)Designate a responsible surgeon and provide him or her with the appropriate authority to enact the process;

 

(b)Data collection:

 

(1)Establish a process for data collection;

 

(2)Establish quality indicators (audit filters) for the continuous or periodic evaluation of specific aspects of care;

 

(3)Define adverse outcomes according to an explicit list of well-defined complications; and

 

(4)Monitor the incidence of adverse outcomes on a regular basis and to compare to regional and national norms;

 

(c)Evaluation and analysis:

 

(1)Establish a systematic peer-review process using multiple disciplines for the continuous or periodic evaluation of tended data, sentinel events, or specific cases; and

 

(2)Provide written documentation of identified problems and opportunities to correct the problem and improve care;

 

(d)Corrective action:

 

(1)Define corrective actions needed to address problems identified in the analysis;

 

(2)Implement corrective action;

 

(3)Assess the effect of the corrective action; and

 

(4)Periodically reassess or monitor the effectiveness of the action to document improvements and define future objectives.

 

2717.4In each adult trauma care facility, the governing body of a hospital has the ultimate authority and responsibility to provide for the delivery of quality patient care.

 

2717.5Each adult trauma care facility shall have a designated clinician with authority, responsibility, and accountability for the assessment and improvement of quality of care.

 

2717.6In each adult trauma care facility, the Trauma Service Director shall be responsible for performance improvement.

 

2717.7Repealed.

 

2717.8In each adult trauma care facility, standards of quality care shall emphasize the outcome of care and the process by which it is rendered. To ensure quality care, trauma facilities and trauma systems shall have the following attributes of care:

 

(a)Systematic actions designed to improve the health of the patient;

 

(b)Be rendered in a timely fashion, relative to the severity of the illness;

 

(c)Be rendered by teaching the patient about the principles of health maintenance and disease prevention;

 

(d)Be rendered to a completely informed patient so that the patient can be knowledgeable, cooperative, and participate in health care decisions;

 

(e)Be based on sound scientific principles and standards;

 

(f)Be rendered with sensitivity and concern for the patient and his or her family;

 

(g)Be rendered with a cost-efficient use of available technology; and

 

(h)Be accurately documented in the patient's medical record.

 

2717.9Elements critical to the consistent delivery of quality care in adult trauma facilities include:

 

(a)Delineation of privileges to limit trauma care duties to those with demonstrated skills, commitment, and experience;

 

(b)Reevaluation of privileges and reappointment to the trauma team shall be based on the following criteria:

 

(1)Maintenance of good standing in the primary specialty;

 

(2)Evidence of continuing education in trauma care;

 

(3)Documented attendance at a multidisciplinary conference where either morbidity or mortality comprises more than fifty percent (50%) of the subject matter, and hospital peer review conferences that deal with care of injured patients; and

 

(4)Satisfactory performance in managing trauma patients based on performance assessment and outcome analysis;

 

(c)Identification of trauma patients;

 

(d)A surveillance program, including at a minimum all trauma patients who:

 

(1)Are admitted to the hospital for more than two (2) days;

 

(2)Are admitted to an intensive care unit or operating room;

 

(3)Are transferred into or out of the hospital; and

 

(4)Die as a result of trauma injuries;

 

(e)Autopsy information, including complete anatomical diagnosis of injury to assess quality of care. A postmortem examination shall be sought in all trauma-related deaths.

 

2717.10Continuous audits, periodic focused audits, specific case review, and trend analysis shall be available to evaluate the process of care in order to review outcome. Deaths and major complications shall have specific case review. Complications may be monitored by trend analysis, which requires determining the incidence of the complication over a given interval (for example, monthly or quarterly) and following the incidence over subsequent intervals. Changes in trends or unexpected variations should provoke a focused audit of the patient developing the complication.

 

2717.11The requirements of § 2717.10 shall be carried out as follows:

 

(a)Audit filters shall be used to examine the timeliness, appropriateness, and effectiveness of care rendered to an individual patient, and the value of continuous or periodic use of these filters in the quality improvement program shall be reviewed regularly by individual trauma facilities. Minimum filters to be applied include the following:

 

(1)Selected complications, monitored as either trends or sentinel events. Trauma Service Directors shall select those complications for audit and review those complications that are frequent or severe in their cohort of trauma patients; and

 

(2)All trauma deaths.

 

(b)A focused audit shall be used periodically to examine the process of care;

 

(c)The Trauma Score/Injury Severity Score (TRISS) method shall be used to estimate the likelihood of patient survival based on a regression equation and shall take into account:

 

(1)Patient age;

 

(2)The severity of anatomical injury as measured by the Injury Severity Score (ISS);

 

(3)The physiological status of the patient on admission based on the Revised Trauma Score (RTS); and

 

(4)The type of injury (blunt or penetrating);

 

(d)An internal review shall be conducted to identify patients to receive an in-depth peer review and audit. In-depth review of the charts of nonsurvivors who were expected to survive is mandatory;

 

(e)External comparison, to relate trauma center performance to an external reference, shall be performed, and shall include summing the individual calculated probabilities of survival for any cohort of patient to provide the number of expected survivors for the cohort;

 

(f)A multidisciplinary trauma peer-review committee shall meet regularly. The committee shall be chaired by the Trauma Service Director and have representation from all of the major services that treat trauma patients. The task of the committee is to conduct critical reviews, evaluate, and discuss the quality of care in cases of adverse outcome (complications and deaths), particularly focusing on those deaths of persons statistically expected to survive, which were identified using outcome norms; and

 

(g)Following identification and documentation of a specific problem in patient care or system performance by the peer-review process, corrective action shall be taken through one of the following mechanisms:

 

(1)Change of existing policies and procedures that govern or define the standard of care;

 

(2)Professional education: cases shall be selected for discussion at the trauma service morbidity/mortality review conference; deficits in knowledge shall be addressed through education of the whole group of trauma care providers or of specific trauma care providers;

 

(3)Physician counseling: review of a special case or cases shall be made by the Trauma Services Director with the individual physician; the process of evaluation and counseling shall be carefully documented; and

 

(4)Credentialing process: information from quality improvement activities shall be considered at the time of credentialing and in the delineation of privileges; serious deficits may result in the limitation of privileges or the failure to be reappointed in the discretion of the Director of Trauma Services.

 

2717.12In addition to the requirements set out in § 2717.1 (a), adult trauma care facilities shall have a Trauma Registry that provides accurate data describing patient injury severity, process of care, and outcomes.

 

2717.13An adult trauma care facility shall satisfy the requirements of § 2717.11(g) by establishing a multidisciplinary review committee that shall require a quorum of a majority of the members at each meeting. The multidisciplinary review committee shall consist of the following members:

 

(a)Chairperson - Trauma Service Director;

 

(b)Trauma nurse coordinator;

 

(c)A representative of the neurosurgery department;

 

(d)A representative of the orthopedic surgery department;

 

(e)A representative of the emergency medicine department;

 

(f)A representative of the anesthesiology department;

 

(g)A staff pathologist;

 

(h)A staff radiologist; and

 

(i)A representative from rehabilitation medicine.

 

2717.14The goals of a multi-disciplinary review committee shall be as follows:

 

(a)Review selective deaths;

 

(b)Review complications;

 

(c)Discuss sentinel events; and

 

(d)Review organizational issues on a regular basis and in a systematic fashion.

 

2717.15The objectives of this multi-disciplinary peer review committee shall be as follows:

 

(a)To identify and resolve problems or specific issues; and

 

(b)To identify new policies or protocols and have the representatives from the various departments listed in § 2717.13 transmit the information back to their respective departments.

 

source

Notice of Final Rulemaking published at 46 DCR 8741 (October 29, 1999); as amended by Notice of Emergency and Proposed Rulemaking published at 51 DCR 3915 (April 16, 2004) [EXPIRED]; as amended by Final Rulemaking published at 51 DCR 7260 (July 23, 2004).