referrals.) 5. Resolution and follow-up – The TQM committee shall evaluate and document the effectiveness of action taken to ensure problem resolution, improvements in patient care, or improved patient outcomes. C. The TQM committee shall meet a minimum of 10 times per year to review trauma cases referred by the trauma medical director or trauma program manager including cases identified by the indicators listed in XVIII.B.2.a and b and other cases with quality of care concerns, systems issues, morbidity, or mortality. D. The trauma quality management committee shall be composed of at least the following persons: 1. Trauma medical director (as chairperson). 3.31 2. Trauma program manager. 3. Medical director of emergency department or emergency physician designee. 4. Trauma surgeon, other than the trauma medical director. 5. Surgical specialist other than trauma surgeon, such as neurosurgeon, orthopedic surgeon, and pediatric surgeon. 6. Representative from administration. 7. Operating room nursing director or designee. 8. Emergency department nursing director or designee. 9. Intensive care unit nursing director or designee. E. There shall be at least one of the above committee members (there must always be another representative from the trauma service in addition to the trauma medical director) at the trauma quality management committee meetings. F. The trauma service shall maintain written minutes of all TQM committee meetings for at least three years. The trauma service shall have these minutes available for the Department of Health to review upon request. The minutes shall include at a minimum the following: 1. The names of attendees. 2. The subject matter discussed including an analysis of all issues related to each case referred by the trauma medical director or the trauma program manager, cases involving morbidity or mortality determining whether they were disease related or provider related and the preventability, and cases with other quality of care concerns. 3. A summary of cases with variations not referred to the committee. 4. A description of committee discussion of cases not requiring action, with an explanation for each decision. 5. Any action taken to resolve problems or improve patient care and outcomes. 6. Evidence that the committee evaluated the effectiveness of any action taken to resolve problems or improve patient care and outcomes. G. The trauma quality management committee shall prepare and submit a quarterly report to the Department of Health. The reports shall be submitted at the end of each calendar year quarter by the 15th of the month following the end of the previous quarter. The report shall: 1. List every case selected for corrective action by the trauma quality management committee (do not include information that would identify the patient) and shall provide the following regarding each case: a. Hospital case number. 3.32 b. Description of questionable care. c. Corrective action taken. If corrective action is not necessary, an explanation is required. 2. List the clinical indicators with the number of patients per quarter, number identified, and committee involvement. 3. List all the complications experienced by trauma patients in the quarter by number of patients and number of total patients in the quarter. H. The trauma service shall maintain an in-hospital trauma registry containing information on all cases identified in Standard XVIII.B.2.a and b. The minimum data set for the trauma registry shall include the following: 1. Medical record number. 2. Mechanism of injury. 3. Injury severity score. 4. Discharge diagnosis(es) (narrative description of top 10 minimum). 5. Discharge date. 6. Case criterion(a) from section B.1.a-e. 7. Applicable indicators that identified cases for review ( B.2.a and b). 8. Quality improvement review date. 9. Quality improvement review disposition (for example, pending, acceptable, or unacceptable, with preventable, unpreventable, or possibly preventable for all deaths). STANDARD XIX – DISASTER PLANNING AND MANAGEMENT The trauma center shall meet the disaster related requirements pursuant to s. 395.1055(1) c, F.S., and the Agency for Health Care Administration, Comprehensive Emergency Management Plan, Chapter 59A-3.078, Florida Administrative Code, and Joint Commission on the Accreditation of Healthcare Organizations’ Standards. Northwest Indiana (NWI) is a unique geography for many reasons: It sits between Michigan and Illinois; is less than a few hour drive from the nation’s third largest city, Chicago; does not share the same time zone as the rest of Indiana; has significant lakefront property (Michigan); has a major airport in Gary; is home to United States Steel Corporation’s largest manufacturing plants; and is also home of the Indiana Dunes – a unit of the National Park system. In addition to these distinctive characteristics, there is an equally interesting healthcare landscape in Northwest Indiana. With 11 general short-term acute care hospitals in Lake and Porter counties alone, there is a significant healthcare provider presence in the heart of NWI. Katz Sapper and Miller’s (KSM’s) primary focus for this project is to research and to validate that there is a lack of designated trauma service and support in NWI as well as an economic and social opportunity for the expansion of an academic