15 MAC Pt. 3, R. 2.3.2

Levels of review can be accomplished in a variety of formats, depending on the volume of trauma patients at a given center and the structure of the trauma PIPS program in the context of the hospital’s quality program. The levels of review are: a. First Level Review: TPM or designee performs the initial case review to verify and validate the issue. If the first level of review is completed, affirming that clinical care is appropriate and no issues are identified, the case does not require second level or formal committee review. However, if an issue is identified, the issue shall be addressed by the TMD and/or the committee charged with trauma PIPS review. In some instances, immediate feedback and resolution may be possible at this level. Even if issue resolution occurs during this level, the issue and activities shall be documented for ongoing monitoring and trend analysis. b. Second Level Review: This level encompasses cases consisting of clinical care, provider care, or systems issues which require medical director expertise and judgment. The TPM and TMD may initiate further investigation, implement action without formal referral to a peer review or system committee, or decide to send it to the appropriate performance improvement/quality committee or to a hospital department for further investigation/peer review and request follow-up. If immediate feedback and resolution are obtained, the issue may be resolved. If not, the issue shall be referred for multidisciplinary committee review, including peer review or some other appropriate PIPS committee capable of further analysis and event resolution. c. Third Level Review: The TPM and TMD will perform an initial case review, consisting of identification of all background information, pertinent protocols (or deficiency of), and specify all individual issues to be discussed, in preparation for multidisciplinary review. Cases may be referred to the appropriate hospital department via appointed liaisons, committee, or department chair. The TMD and/or trauma committee will then review the response of the referral for follow-up planning. d. Fourth Level Review: The TPM, TMD, and multidisciplinary review committee perform the initial review. Cases are then referred to the appropriate body for external review with review response to the TMD and/or trauma committee for follow-up planning.