Md. Code Regs. 30.08.17.17

Current through Register Vol. 51, No. 25, December 13, 2024

Section 30.08.17.17 - Quality Management

A. In addition to the requirements of COMAR 30.08.11.14, the hospital shall incorporate into the hospital's quality assurance process reports about:

(1) Specific acute stroke treatment benchmarks; and

(2) Stroke treatment quality improvement goals.

B. The hospital shall establish a multidisciplinary institutional quality assurance/performance improvement committee that meets on a regular basis to:

(1) Monitor quality benchmarks;

(2) Review complications; and

(3) Review and modify practice patterns as appropriate.

C. In cases where mechanical endovascular reperfusion therapy is appropriate, the hospital shall achieve door-to-device times (arrival to first pass of thrombectomy device) in 50 percent or more of eligible acute ischemic stroke patients within 120 minutes (for direct arriving patients) and within 60 minutes (for inter-facility transfer patients) treated with endovascular therapy.

D. The hospital shall demonstrate progress towards reducing door-to-device times in 50 percent or more of eligible acute ischemic stroke patients within 90 minutes for direct arriving patients.

Md. Code Regs. 30.08.17.17

Regulation .17 amended effective 48:22 Md. R. 938, eff. 1/1/2022