<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".10" citation="COMAR 30.08.06.10" title_num="30" subtitle_num="08" chapter_num="06" heading="Quality Management (QM) Program.">
  <paragraph num="A.">
    <text>Policies and Procedures.</text>
    <paragraph num="(1)">
      <text>A burn service shall have a QM program that is multidisciplinary.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>A burn center director is responsible for the QM program.</text>
    </paragraph>
    <paragraph num="(3)">
      <text>A burn unit multidisciplinary committee shall:</text>
      <paragraph num="(a)">
        <text>Oversee the QM program;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Meet at least monthly; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Maintain sufficient documentation to:</text>
        <paragraph num="(i)">
          <text>Verify problems;</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>Identify opportunities for improvement;</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>Take corrective actions; and</text>
        </paragraph>
        <paragraph num="(iv)">
          <text>Demonstrate evidence of loop closure.</text>
        </paragraph>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>Weekly Patient Care Conferences.</text>
    <paragraph num="(1)">
      <text>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.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Each clinical discipline shall be represented to appropriately contribute to the treatment plan for each patient.</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Patient care conferences shall be documented in the progress notes of each patient or in minutes of the conferences.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>A burn center shall:</text>
    <paragraph num="(1)">
      <text>Hold morbidity and mortality conferences at least monthly; and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Maintain appropriate documentation of morbidity and mortality conferences.</text>
    </paragraph>
  </paragraph>
  <paragraph num="D.">
    <text>A burn center shall conduct focused quality reviews at least annually that shall include:</text>
    <paragraph num="(1)">
      <text>Severity of burns;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Mortality;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Incidence of complications;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Length of hospitalizations; and</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Hospital charges for care.</text>
    </paragraph>
  </paragraph>
</regulation>