UC Health; PI Safety Plan

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.