Mich. Admin. Code r. 325.135 - Performance improvement

Performance improvement

The trauma registry will be phased in and ultimately administered by regional trauma advisory committees.  The regional committees must use the data collected through the trauma registry to improve trauma care.  Each regional trauma advisory committee must abide by the confidentiality provisions of HIPAA. 

The performance improvement process should include the following standards:

1.      Data collection and analysis;

2.      Adult and pediatric specific quality indicators;

3.      A system for referral;

4.      A process for review and audit;

5.      A mechanism for action and improvement;

6.      A process for feedback to various committees; and

7.      An evaluation of system performance that includes designation, triage, mortality and morbidity, and various other technical performance measures. 

Trauma centers’ performance improvement process must focus on structure, process, and outcome evaluations that discover the causes of problems. The system must allow for input and feedback from patients and hospital staff. In addition to individual performance improvement processes, every trauma care region must develop a region-wide trauma performance improvement program.