Performance Improvement

Introduction:
This policy describes the Trauma Service Performance Improvement and Patient Safety (PIPS) plan at Medical Center of the Rockies (MCR).

Scope:
View the UCHealth Policy Scope Statement to see where this policy applies. This policy applies to Medical Center of the Rockies.

Philosophy of the Trauma Program
The trauma program provides a coordinated multidisciplinary approach to patient management throughout the continuum of care from pre-hospital to rehabilitation. The management of multiple, complex injuries require a team of individuals with expertise in a number of areas. A coordinated team approach prevents unnecessary delay in care, missed injuries, conflicting treatment plans, inappropriate management, disability, and death. The multidisciplinary team leader is the trauma surgeon. The trauma surgeon not only contributes specific care in the area of his or her specialty, but also oversees and coordinates the care provided by the other consulted disciplines. The Trauma Medical Director (TMD) will interpret and reconcile any conflicts in the recommendations of team members and consultants.

Mission and Vision of the Trauma PIPS Program
The goal of the Trauma Performance Improvement and Patient Safety (PIPS) program is to provide a systematic framework to support the improvement of trauma patient care and outcomes through continuous monitoring, and assessment of structures and processes, followed by the implementation of an action plan when an opportunity for improvement is identified. The results of changes are then followed by reassessment to ensure loop closure.

The Trauma Service is committed to providing measurable, high quality, cost-effective health care through active involvement of all medical and hospital staff.

Purpose and Objectives:

• To integrate and coordinate all trauma performance improvement activities throughout the hospital.
• To identify and resolve interdisciplinary process problems, prevent duplication of efforts and facilitate communication.
• To utilize continuous quality improvement concepts/techniques to improve selected processes and systems.
• To utilize external reference databases to monitor performance and to assist in setting priorities for improving performance.
• To shift the primary focus from the performance of individuals to the performance of the trauma system’s processes and systems, while continuing to recognize the importance of the individual competence of all team members.
• To maintain current written standards of professional practice and related policies and procedures that demonstrate compliance with both internally and externally established standards and regulations.
• To integrate the standards from the Colorado Statewide Trauma Care Systems Act, the American College of Surgeons’ Committee on Trauma, and the Joint Commission.

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.

Why PIPS?

• Evaluates
  • patient care outcome
  • provider response
  • system performance
• Improves patient care at bedside level
• Fosters competent and current providers
• Evaluates the cost of care
• Enhance the fiscal aspect of a surgical program

ACS-COT requirements

• “Demonstrate a continuous process of monitoring, assessment, and management directed at improving care”
• “This effort should routinely reduce unnecessary variation in care and prevent adverse effects”
• “the PIPS program must be supported by a reliable method of data collection that consistently obtains the information necessary to identify opportunities for improvement” CD 15 3 (I IV)

The response to the growing problem of injury needs to include the improvement of care of the injured (i.e. trauma care). Quality improvement (QI) programmes offer an affordable and sustainable means to implement such improvements. These programmes enable health care institutions to better monitor trauma care services, better detect problems in care, and more effectively enact and evaluate corrective measures targeted at these problems. In so doing, many deaths of injury victims can be avoided.

The goal of this publication is to give guidance on ways in which health care institutions globally can implement QI programmes oriented to strengthening care of the injured. This guidance is intended to be universally applicable to all countries, no matter what their economic level.

These guidelines provide basic definitions and an overview of the field of QI, so that those not familiar with this field will have a working knowledge of it. Evidence of the benefit of QI in general and trauma QI in particular is then laid out. The main part of the publication reviews the most common methods of trauma QI, written in a how-to-do fashion. This covers a wide range of techniques. The first two of these are especially emphasized as ways in which to strengthen trauma QI in the setting of low-income and middle-income countries. First are morbidity and mortality (M & M) conferences. These are already being regularly conducted in many hospitals worldwide, but often they are not well utilized to achieve the goal of improving trauma care. Several improvements could change this. These include more attention to detail in the procedures for conducting the conference, such as scheduling, optimizing the length of the M & M meeting, defining who should attend and who should run the meeting, as well as assuring the types of cases that should be reviewed. Needed improvements also include more attention to detail in identifying problems (especially those relating to systems issues), developing reasonable corrective action plans, following through on implementing these plans, and evaluating whether the corrective action has had its intended consequences. Several structural issues could also increase the effectiveness of M & M conferences. These include availability of adequate support staff for logistics and data management, as well assuring active participation and buy-in by a wide range of clinicians involved with trauma care.

Second are preventable death panel reviews. These provide for more formal input as to determination of preventability of trauma deaths and identification of factors of care that need to be strengthened. Such input is obtained from a range of clinicians whose involvement not only provides multidisciplinary technical expertise but also investment in the successful conduct of corrective actions that are identified. These guidelines provide how-to-do guidance on constituting the panel, preparing data for the review, conducting the case review process, and documenting and analysing the case discussions. Both M & M conferences and preventable death panel reviews are eminently feasible and widely applicable, and are especially of relevance to strengthening of care of the injured in low-income and middle-income countries.

>More advanced QI techniques are also covered. One of these is the use of the medical records system to monitor specific variables, known as audit filters. These provide objective data on the occurrence and rates of potential problems, which can then be monitored as corrective measures are put in place. These audit filters can include process-of-care measures, as well as complications, errors, adverse events, and sentinel events.

Other more advanced QI methods include statistical techniques for severity adjustment. These include use of a number of different anatomical and physiological injury scoring systems that help to compare injuries between patients objectively. These scoring methods assist QI programmes by allowing them to focus on patients who die with low injury severity (e.g. medically preventable deaths) and by allowing programmes to compare the outcome of large groups of patients against established norms.

Common to all the above techniques is that they should lead to implementation of corrective strategies to fix problems that are identified, they should monitor the effectiveness of such corrective strategies, and they should assure that these corrective strategies have had their intended effect (i.e. closing the loop). Several types of corrective strategies can be utilized, including: guidelines, pathways, and protocols; targeted education; actions targeted at specific providers; and enhanced resources, facilities, or communication. The techniques discussed are applicable to a wide range of circumstances. However, special issues arise in using QI to address system-wide and prehospital trauma care. These include specific measures of quality that need to be monitored, specific types of monitoring methods, and specific corrective actions.

All of the techniques of QI rely on adequate data. In many circumstances there is a need to address improvements in data collection and usage to better assure timely, reliable, and adequate data on which to base QI activities. This may imply better recording of data at the time of patient presentation. It may imply better handling and availability of that data from standard medical record systems. In some circumstances, it may imply the establishment of a formal trauma registry, which can be done in an affordable, sustainable and simple fashion.

These guidelines end with discussion of the appropriateness of different techniques at different levels of the health care system, and of the overlap with other related activities such as clinical algorithms for trauma care, efforts to promote patient safety, and efforts to strengthen health care management. Finally, in the annexes, several case examples are provided for practice in scrutinizing clinical data, identifying problems in care, and deriving practical and effective corrective strategies.

In summary, this document provides how-to-do guidance on a range of different trauma QI methods. These are broadly applicable to all health care institutions that care for the injured in countries at all economic levels. One or more of the methods described in this document will be directly applicable to any given institution and will enable that institution to upgrade the level of function of its existing trauma QI activities. In so doing, the quality of trauma care can be strengthened and the lives of many injured persons saved.