Designated GACH Quality Improvement and Evaluation Requirements.

22 CCR 100161.03

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22 CCR 100161.03

§ 100161.03. Designated GACH Quality Improvement and Evaluation Requirements.

(a)

All PedRCs shall have a QI program, that includes, at a minimum:

(1)

System Performance Evaluation. A process that integrates:

(A)

Emergency department QI activities with the prehospital, trauma, inpatient pediatrics, pediatric critical care, and hospital-wide quality QI activities, as applicable;

(B)

Findings from quality improvement QI audits and reviews into education and clinical competency evaluations of staff.

(2)

Multidisciplinary QI Committee. Participation in a multidisciplinary pediatric quality improvement (QI) committee that reviews prehospital, emergency department, and inpatient care. The committee shall include, but is not limited to:

(A)

Cardiopulmonary or respiratory arrests;

(B)

Child maltreatment cases;

(C)

Deaths;

(D)

Intensive care unit admissions and length of stay;

(E)

Operating room admissions and type of surgery;

(F)

Transfers and emergency department boarding;

(G)

Trauma admissions.

(3)

National Pediatric Readiness Project Self-Assessment. Completion of an online or paper assessment of the National Pediatric Readiness Project self-assessment, the results of which shall be shared with the local EMS agency LEMSA at a minimum of every three (3) years.

(4)

Pediatric IFT.

(A)

Process improvement focused on pediatric IFT processes. PedRCs shall provide feedback to referring GACHs as well as to the LEMSA's QI programs.

(B)

GACHs that send or receive pediatric patients shall participate in system and PedRC QI activities for transferred pediatric patients.

(5)

Confidentiality Protections. Compliance with the California Evidence Code, Section 1157.7 to ensure confidentiality, and a disclosure protected review of selected pediatric cases.

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