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15 Miss. Code R. Part 3, Subpart 1, Chapter 2 – Performance Improvement and Patient Safety | Midpage
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Mississippi Administrative Code
Title 15
15
Part 3
Subpart 1
Chapter 2
15 Miss. Code R. Part 3, Subpart 1, Chapter 2
Performance Improvement and Patient Safety
MISSISSIPPI DEPARTMENT OF HEALTH
2.1.1
Each designated trauma center shall have a Performance Improvement and Patient Safety
2.1.2
A reporting structure for the trauma program and service must be defined
2.1.3
The TMD and trauma program manager (TPM) shall maintain the trauma PIPS program
2.1.4
The TMD is responsible for the review of all physician related issues, including all
2.1.5
There must be a process to address trauma program operational issues
2.1.6
Mortalities, significant complications, and process variances associated with unanticipated
2.1.7
Each trauma center shall define criteria for case selection for formal trauma mortality and
2.2.1
Each trauma center shall prepare a written Performance Improvement and Patient Safety
2.2.2
Each trauma center shall define a trauma population to perform data collection and
2.3.1
Identified cases shall be reviewed by the TPM and TMD, as appropriate, for determination
2.3.2
Levels of review can be accomplished in a variety of formats, depending on the volume of
2.3.3
Reviewed issues shall have a determination classified in a manner consistent with the
2.3.4
The TMD must oversee corrective action planning at their institution
2.4.1
Process and outcomes measures, referred to as audit filters or indicators, require defined