promote quality improvement. The plan should contain these essential elements for successful implementation: authority and accountability for the program, a well-defined organizational structure for the committee composition and member responsibilities, defined standards to determine quality of care, and explicit definitions for outcomes required by the facility’s prescribed standards. A. The trauma service shall have written evidence on file indicating the governing body’s commitment to the trauma quality improvement program. This evidence shall include the following: 1. The trauma program must have a trauma medical director with the authority and administrative support to implement changes related to the process of care and 3.29 outcomes across multiple specialty departments. The administrative support commitment must assure that the defined lines of authority guarantee comprehensive evaluation of all aspects of trauma care. 2. The trauma center shall demonstrate a clearly defined performance improvement program for the trauma population that is integrated into the hospital-wide program. The trauma program’s monitoring and evaluation process must show identification of process/outcome issues, corrective actions taken, and loop closure, when applicable, for evaluations of the desired effects. B. The trauma service shall have written evidence on file indicating an active and effective trauma quality improvement program. This evidence shall include procedures and mechanisms for at least the following: 1. Population of cases for review – The trauma medical director and the trauma program manager shall review all trauma patient records from the following categories: a. All trauma alert cases admitted to the hospital (patients identified by the state trauma scorecard criteria in Rule 64J-2.004, Florida Administrative Code). b. Critical or intensive care unit admissions for traumatic injury. c. All operating room admissions for traumatic injury (excluding same day discharges or isolated, non-life threatening orthopedic injuries). d. Any critical trauma transfer into or out of the hospital. e. All in-hospital traumatic deaths, including deaths in the trauma resuscitation area. 2. Process/outcome indicators – The facility shall monitor at least ten indicators relevant to process or outcome measures. The trauma medical director or trauma program manager shall apply the following indicators to screen each trauma case identified in Standard XVIII.B.1.a-e above: a. The facility must monitor four state-required indicators relevant to process and outcome. The initial four indicators shall be as follows: (1) All deaths. (2) Any trauma patient with an unplanned re-admittance to the hospital within thirty days of discharge. (3) Any trauma patient readmitted to ICU, or an unplanned admission to the ICU from a medical/surgical unit. (4) Percentage of all traumatic C1, C2 and/or C3 spinal cord injury patients, permanently dependent on mechanical ventilator support, who were admitted or transferred to the ICU during the quarter or who remained in the ICU from the previous quarter; who received the diaphragm pacer surgery and were discharged to a 3.30 less restrictive facility, home or home-health. (See Note #8 for eligibility criteria for the Diaphragm Pacer Program) As process and outcome issues are resolved through evidence of the implementation of an action plan, evaluation, and closure when applicable, new indicators shall be introduced and monitored for a minimum of at least six months. The identification of indicators shall be based on defined criteria (expectations) that can be determined from consensus institutional guidelines and nationally derived evidence-based guidelines. b. The facility must identify and monitor six indicators relevant to its respective facility for a period of six months and submit these indicators to the Department of Health. The identification of indicators shall be based on defined criteria (expectations) that can be determined from consensus institutional guidelines and nationally derived evidence-based guidelines. As process and outcome issues are resolved through evidence of the implementation of an action plan, evaluation, and closure when applicable, new indicators shall be introduced and monitored for a minimum of at least six months. New indicators must be submitted to the Department of Health. 3. Evaluation of cases – The trauma medical director or trauma program manager shall evaluate each case identified by one of the indicators in Standard XVIII.B.2.a and b to determine whether the case should be referred to the TQM committee for further review. (The trauma medical director and the trauma program manager shall also present a summary of reviewed cases not referred to the TQM committee.) 4. Committee discussion and action – The members of the TQM committee shall review and discuss each case referred by the trauma medical director or trauma program manager. The members shall recommend or take action on those cases where the committee finds opportunities for improving performance, system process, or outcomes. (The trauma medical director is responsible for monitoring the outcome of each case referred to persons or committees outside the TQM committee. The medical director is also responsible for providing a comprehensive report to the TQM committee regarding those