Sec. 30.08.06.10. Quality Management (QM) Program

A. Policies and Procedures.

(1) A burn service shall have a QM program that is multidisciplinary.

(2) A burn center director is responsible for the QM program.

(3) A burn unit multidisciplinary committee shall:

(a) Oversee the QM program;

(b) Meet at least monthly; and

(c) Maintain sufficient documentation to:

(i) Verify problems;

(ii) Identify opportunities for improvement;

(iii) Take corrective actions; and

(iv) Demonstrate evidence of loop closure.

B. Weekly Patient Care Conferences.

(1) A burn center shall hold patient care conferences at least weekly to review and evaluate the status of each patient admitted to the burn center.

(2) Each clinical discipline shall be represented to appropriately contribute to the treatment plan for each patient.

(3) Patient care conferences shall be documented in the progress notes of each patient or in minutes of the conferences.

C. A burn center shall:

(1) Hold morbidity and mortality conferences at least monthly; and

(2) Maintain appropriate documentation of morbidity and mortality conferences.

D. A burn center shall conduct focused quality reviews at least annually that shall include:

(1) Severity of burns;

(2) Mortality;

(3) Incidence of complications;

(4) Length of hospitalizations; and

(5) Hospital charges for care.