Issue identification
- Trauma patient’s length-of-stay in ED was 90 minutes. Delayed transfer due to radiological studies performed before transfer.
Specific goal & measure of achievement
- Trauma patient requires transfer out of ED within 60 minutes
- Ninety percent of the time
Analysis w/data (when available)
- Eight of 15 cases (53%) met 60-minute standard
Develop and implement action plan
- Send case to peer review; review trauma transfer protocol, discuss rationale for refraining from obtaining studies that do not impact the resuscitation, etc
Evaluation, re-evaluation, re-re-evaluation
- Trend, measure performance and strategize solutions
- Six months later 10 out of 12 new cases (83%) met 60- minute standard. >>> New action plan, continue to trend and measure performance
Loop closure
- Goal attained; action(s) resulted in goal attainment
- Eight months later 12 of 13 cases (92%) met the goal.
- Once goal is attained, can close the loop or continue to trend to verify continued success.
