University of Arizona; Trauma Program PI Guide for Level IV Trauma Centers

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.