APPLICATION FOR SURVEY - 2000 - STRAC



center305435Insert logo of your hospitalName of your hospital00Insert logo of your hospitalName of your hospitalPERFORMANCE IMPROVEMENTPLANTRAUMA CENTER PERFORMANCE IMPROVEMENT PLAN COMPONENTS OF PLANPAGETable of Contents2Mission, Vision, Scope, Authority3Goals3Patient Population4Data Collection4Sources4Data Analysis5Audit Filters, Indicators, PMG Variance Tracking5-6Issue Identification7Concurrent and Retrospective Review7-8Levels of Review 8Determination of Preventability9Factors Related to Issues10Credentialing10-11Data Management11Data Validation and Inter-rater Reliability11Name of your official Trauma Meeting12Trauma Multi-disciplinary Peer Review Committee13Trauma M&M Committee14Corrective Action Plan and Implementation15Loop Closure and Re-evaluation15Information Flow and Integration into Hospital PI16Trauma Performance Improvement Level of Review Process17MissionYour trauma mission statement – Example: To provide comprehensive and compassionate care to trauma victims in _____ Texas.VisionYour vision – Example: Maintain a trained and ready healthcare force that seeks, thrives on, and embraces change while accomplishing the health care mission, utilizing outcomes to drive medical decisions. We will excel at providing the best trauma care anywhere to the best our city has to offer; we will improve patient outcome by continuously refining and improving the process of care.Scope and AuthorityThe trauma performance improvement process falls under the direction of XXX. The Trauma Medical Director and the Trauma Program Manager are responsible for reporting pertinent information to hospital risk management. The Trauma Medical Director has overall institutional responsibility for trauma quality.GoalsThe primary purpose of the trauma performance improvement program is to deliver optimal care to victims of trauma-related incidents. The care of injured patients depends on complex network of people working together as a team. The emergent nature of trauma care relies on each member of the team to perform well on a regular basis. The performance improvement program is designed to monitor the system and determine ways in which it can improve. When a component of the system is not functioning, the performance improvement program should be able to identify that deficiency and formulate a plan to resolve the issue. An effective performance improvement process not only identifies that there is an issue, but determines why the issue exists and mediates the issue in a dignified manner, leading to an improvement in outcome.In order to sustain effectiveness, the performance improvement process must be an inclusive process that draws from the expertise of each individual member of the trauma care team. In addition, the performance improvement program must always maintain certain principles so that it can function in a fair and autonomous way. These principles include; objectivity, a data driven process, an issue oriented process, efficiency, effectiveness, care directed, Education-oriented and non-punitive. It is essential that each member of the trauma care team engage the performance improvement program as a member of the process. In this way, each member of the trauma care team will be able to directly enhance the system of care by offering expertise as to how it can function better. The net result of the process should be a system of trauma care that allows team members to provide care in an effective and efficient manner. Patient Population The injured patient is a victim of an external cause of injury that results in major or minor tissue damage or destruction. Those with a major injury have a significant risk of adverse outcome that is influenced by the patient's age, the magnitude or severity of the anatomic injury, the physiologic status of the patient at the time of admission to the hospital, the pre-existing medical conditions, and the external cause of injury.The trauma patient population includes any patient with at least one injury ICD9-CM discharge diagnosis of 800.00 – 959.9 or ICD-10 S00-S99, T07, T14, T20-T28, T30-T32 and T79.A1-T79.A9.Data CollectionPrimary data collection is achieved through the (Insert name of your particular) trauma registry. Quality indicators for continuous or periodic evaluation of aspects of care are determined from the American College of Surgeons, the Texas Department of State Health Services, and (insert name of your institution) institution specific audit filters designed to evaluate provided trauma plications are defined utilizing clear, concise, and explicit definitions. In order to utilize the data from (insert your registry name) it is necessary to relate it to provider-specific information, which can then facilitate the credentialing process and corrective action process.SourcesData abstraction is a daily process whereby all activities in the trauma center are evaluated, abstracted and entered directly into (insert the name of your registry) the trauma registry. Any part of the trauma care system that does not perform well should be identified in a timely and accurate manner. In order to achieve this goal, several mechanisms are needed. These include but are not limited to;EMS runsheetsTrauma Morning Report/RoundsWord of mouthEmailConcurrent medical record review Diagnostic interpretations (lab, x-ray, etc)Trended reports from trauma registry Trauma logsDaily Performance improvement review should include:Review all trauma admissions/deaths/trauma team activations from the last 24 hoursReview all trauma transfers out for issues to include timelessness of transferReview system issues identified from last 24 hoursIdentify any lab or radiology issues from last 24 hoursClarify any complications or audit filter fallouts from last 24 hoursData AnalysisThe trauma program analyzes information identified through the peer review process. This information will be tabulated on a monthly/quarterly basis. Trend analysis will be computed and compared with the trends identified in the concurrent process and reported at the Multidisciplinary Peer Review Committee. Once information has been abstracted, it is analyzed and the identified issues are reviewed in the context of what type of deficiency it is as well as whether it has occurred before. The PI team looks at several factors in order to make this determination. These factors include but are not limited to the following issues; -occurrence based -audit filter based -system issue based -provider specific -trended data relevant to the issue-resource deficiency Trauma PI Team Members Responsible: Trauma Medical DirectorTrauma Program ManagerEmergency Physician Representative Trauma Nurse CliniciansTrauma RegistrarAudit Filters, Practice Guidelines Variance Tracking(Insert your hospital’s name) Trauma Center utilizes a selection of pertinent ACS and DSHS audit filters which are assessed on an ongoing manner and do not have a projected completion date. The following indicators are reported to the (Insert name of your Trauma Committee) on a monthly basis.Audit Filters, Practice Guidelines Variance TrackingAbsence of EMS RunsheetInadequate pre-hospital airwayNo trauma team activation/consultation for patient meeting TTA criteriaLack of EC Nursing documentation (V/S, temp, GCS) Pediatric weight/Broselow color not documentedOver/under fluid resuscitation for pediatric patientTrauma resuscitation record not used No documentation of Burn resuscitation to include weight, %, TBSA and fluidNo staff note EC LOS >2 hours Initiation of Massive Transfusion ProtocolDeathTransfers OutDiversionTertiary Survey not documentedAdmit to non-Surgical ServiceUnplanned return to the ORReadmission to the ICUMissed InjuryDelay in DiagnosisReintubation within 48 hours of extubationReadmission within 72 hoursComplicationsIssue identificationOnce the data has been properly analyzed and interpreted, specific issue identification takes place. Each issue is looked at carefully, taking every detail into consideration. An accurately identified issue will include several elements, which include but are not limited to;Types of issuesOccurrencesComplicationsOutcomes basedAudit filtersInstitution Specific Audit FiltersProvider specific issuesPhysicianNursingHospital staffPre-HospitalSystem specific issuesSTICUORPACUMED/Surg UnitsRespiratory careRadiology /PACsBlood bankLaboratory Physical/Occupational therapySocial Services/Case Management Concurrent and Retrospective ReviewConcurrentReview of PI events takes place at (insert if there is a forum or your process) Report at ____ on a daily basis and all trauma patients are reviewed from previous 24 hours. The team consists of the Trauma Medical Director, off going trauma team as well as the oncoming team.Events are presented to the team for discussion and validation.Registry identified patients will be reviewed for appropriateness of inclusion into the registry. Any deviations from practice guidelines, or care issues identified are referred to the appropriate individuals. All responses received from the concurrent process are reviewed for appropriateness. Judgments are rendered based upon the American College of Surgeons definitions and the input of identified clinical experts. Clinical Practice Guideline development and/or revision, standard operating procedures (SOP) development, counseling or education is then put into action as indicated.Levels of ReviewPrimaryPrimary review of performance issues will occur by the trauma program staff concurrently with data abstraction and collection while care is being delivered. Events are identified and validated, as they occur. This may occur during morning report, patient care rounds, chart review, and direct staff and patient interaction. Changes in patient’s plan of care or implementation of clinical guidelines may be influenced immediately. Prompt feedback to providers will occur in parallel. Some retrospective review may be necessary, but the case may also be able to be closed.SecondaryEvents which have been identified concurrently may require additional review, input from various providers, and/or review by the Trauma Medical Director or the Trauma Program Manager. Events are validated, additional information collected, analyzed, and in some cases the event may be closed. If peer review is indicated, the case is forwarded to the monthly (insert cycle of your MPRM) Multidisciplinary Peer Review Meeting. TertiaryCriteria for determining which cases go to Multidisciplinary Peer Review conference are:Selected deathsSelected complicationsSome specialty referral casesSelected Transfer OutsCases are reviewed, factor determinations made, preventability established, surgical grading defined, corrective actions developed, and resolution of event is completed, if indicated at the time. Determination of PreventabilityOne of the essential tasks of a trauma PI forum is to identify opportunities for improvement in care. This step is necessary if an effective action plan is to be developed. When confronted with an issue, each forum will use an objective process to determine preventability. Each forum will use the criteria defined below;Unanticipated mortality with opportunity for improvementanatomic injury or combination of injuries considered survivable.standard protocols not followed with unfavorable consequences.inappropriate provider care with unfavorable consequences.P(s) > 0.5 by TRISS methodology. Anticipated mortality with opportunity for improvementanatomic injury or combination of injuries severe but survivable under optimal conditions.standard protocols not followed, possibly resulting in unfavorable consequence.provider care considered sub-optimal, possibly resulting in unfavorable consequence.P(s) 0.25 - 0.5 by TRISS methodology. Mortality without opportunity for improvementanatomic injury or combination of injuries considered non- survivable with optimal care.standard protocols followed or if not followed, did not result in unfavorable consequence.Provider related care appropriate or if sub-optimal, did not result in unfavorable consequence.P(s) <0.25 by TRISS methodology.Preventability Status for Occurrences and Other PI IssuesUnanticipated mortality with opportunity for improvementanatomic injury or combination of injuries considered reasonable for issue to have been preventable.standard protocols not followed with unfavorable consequences.inappropriate provider care with unfavorable consequences. Anticipated mortality with opportunity for improvementanatomic injury or combination of injuries severe but issue is considered preventable under optimal conditions.standard protocols not followed, possibly resulting in unfavorable consequence.provider care considered sub-optimal, possibly resulting in unfavorable consequence.Mortality without opportunity for improvementanatomic injury or combination of injuries makes the issue non-preventable with optimal care.standard protocols followed or if not followed, did not result in unfavorable consequence.Provider related care appropriate or if sub-optimal, did not result in unfavorable consequence.Factors Related to IssuesWhen an event is determined to have opportunities for improvement, the forum must also decide which contributory factors were involved in allowing the event to occur. This is a necessary part of the PI process because effective action plans need to address the factors that led to the variation of practice. The factors that relate to an event include but are not limited to;Factors related to issueNo factors identifiedError in managementError in techniqueDelayed diagnosisMissed diagnosisDeviation from protocolDeviation from standard of careEquipment failureEquipment/Supply DeficiencyProtocol DeficiencyProtocol FailureDepartmental DeficiencyCommunication DeficiencyCommunication FailureMortality - Anatomic diagnosisMortality survival probabilityDNR OrderWithdrawal of CareDOA/DOSPre-Existing ConditionsDisease Related/Co-MorbidityCredentialingPhysiciansCredentialing is essential in order to permit practitioners, who have competency, commitment and experience to participate in the care of this unique population. Physician and Nursing requirements include those outlined by the ACS Standards for Accreditation and (insert your hospital name)In addition, satisfactory physician performance in the management of a trauma patient is determined by outcome analysis in the peer review process through annual performance evaluations.The Trauma Medical Director are responsible for recommending physician appointment to and removal from the trauma on call service, along with the medical staff credentials committee. NursingThe Chief Nursing Officer is responsible for overseeing the credentialing and continuing education of nurses working on units who admit injured patients. Trauma nursing orientation may include certification in TNCC, ENPC, PALS, ABLS and unit based competencies. Data ManagementData is collected and organized for review under the direction of the Trauma Medical Director and the Trauma Program Staff. The primary source of trauma data is the Trauma Registry. The Trauma Registrars enter all data into the (Name of your registry) trauma registry. Trauma Registry: (Name/Company/Brand)RAC: STATE:Data Validation and Inter-rater ReliabilityThe Program Manager and the Trauma Medical Director routinely abstract data elements and audit filters to review accuracy. Resuscitation interventions, injury coding and complications are reviewed for consistency with data dictionary definitions. All data abstracted from the registry for reporting is validated on an on-going basis. (Insert the Title of your Multidisciplinary Committee)1. PURPOSE: To optimize trauma performance through monitoring of trauma related hospital operations by a multidisciplinary committee that includes representatives from all phases of care provided to injured patients. This committee will document the review of operational issues and appropriate analyses and proposed corrective actions. This process must identify problems and demonstrate problem resolution with adequate loop closure. 2. REFERENCES: Resources for Optimal Care of the Injured Patient: Committee on Trauma, American College of Surgeons. Trauma Outcomes and Performance Improvement Course: Society of Trauma Nurses Course.Trauma Performance Improvement: A Reference Manual; trauma/handbook.html3. MEMEBERSHIP: Trauma Medical Director (Chairperson)Trauma Program Manager Core Emergency/Trauma Staff PhysiciansChief Nursing Officer Representative, EC NursingRepresentative, Ward Nursing Representative, ICU NursingRepresentative, RadiologyRepresentative, Blood Bank/LabRepresentative, Rehabilitation Representative, Infection ControlTrauma Registrar Trauma Social Workers 4. MINUTES APPROVING AUTHORITY: (Insert the name of your multidisciplinary committee)5. ISSUES ELEVATED TO: Hospital Risk Management6. MEETS: (insert your cycle of meeting date & time)7. OFFICE OF RECORD FOR APPROVED MINUTES: Committee Files, Trauma Program8. COMMITTEE REQUIRED BY: American College of Surgeons, Committee on Trauma; Texas Department of State Health Services TRAUMA MULTIDISCIPLINARY PEER REVIEW COMMITTEE(Forum can function as an M&M Committee as well with the exclusion of Radiology and Blood Bank/lab)PURPOSE: The purpose of the Trauma Multidisciplinary Peer Review Committee is to improve trauma care by critical physician review of cases in a multidisciplinary setting. Review of trauma deaths, complications, and sentinel events with objective identification of events, and appropriate responses are achieved. Preventability and judgment is determined and recorded. Resolution of events on clinical issues is documented in this forum. REFERENCES: Resources for Optimal Care of the Injured Patient: Committee on Trauma, American College of SurgeonsTrauma Performance Improvement: A Reference Manual; trauma/handbook.html MEMBERSHIP: Trauma Medical Director (Chair)*Trauma Program ManagerRepresentative, Emergency On-call Physicians *Representative, RadiologyRepresentative, Blood Bank/LabRepresentative, Orthopedic, Internal Medicine, Family Practice etc. contingent upon case being reviewed to discuss (* must attend at least 50% of scheduled meetings)MINUTES APPROVING AUTHORITY: Trauma Medical Director ISSUES ELEVATED TO: Hospital Risk ManagementMEETS: Monthly ((insert your cycle of meeting date & time)OFFICE OF RECORD FOR APPROVED MINUTES: Committee Files, Trauma ProgramCOMMITTEE REQUIRED BY: American College of Surgeons, Committee on Trauma; Texas Department of State Health ServicesCorrective Action Plan Development and ImplementationAt this step in the trauma PI process, the forum is ready to decide on an action plan. The details of the plan need not be decided in a formal meeting, but a decision as to what type of action to take is possible. Working with members of the forum and appropriate hospital staff, the trauma service can help formulate a plan that meets the specific recommendations of the committee. Categories of specific action plans include but are not limited to;Action plan:Action pending reviewChange in policy or procedureEducational OfferingEquipment obtained/repairedFindings presented at M&MFormulation of new policy/procedureIndividual counseling and discussionInstitution of formal QA auditLetter to Chief of ServiceLetter to MDLimit/suspend/revoke privilegesMD reply Modifications of dept. training/Education programNo action requireOther: describe in commentsSystem related eventTabulation & tracking for further reportingImplementationAction plans will need to involve many areas of the hospital. Because of this, it is essential to have an inclusive process that collaboratively works with all areas of the institution that involve care of the trauma patient. The PI process must be able to develop action plans in association with the appropriate people and departments that relate to the event. Once this is done, the plan is ready to be implemented. Frequently, action plans require the involvement of more than one provider or element of the system. Resolution of Event and Re-evaluationAfter the action plan is implemented, the process must shift focus back to the data. The plan must include data points that allow the changes made to the system to be monitored. If the data is followed and the event is resolved, the PI loop is closed. The effectiveness of corrective action will be monitored following corrective action. In order for an event to be resolved, it must be followed through the above-mentioned steps. Even after an event is thought to be resolved, it must be tracked from time to time to ensure that it does not recur. The trauma PI process must be able to follow an event closely over an extend period of time. Many events can recur if factors that relate to the event change, making it possible for original circumstances to return and cause the same issue to manifest. Documentation of the entire PI process from issue identification to resolution is imperative.-3238593980TRAUMA PROGRAMPERFORMANCE IMPROVEMENTHOSPITAL INTEGRATION00TRAUMA PROGRAMPERFORMANCE IMPROVEMENTHOSPITAL INTEGRATION-454660855980HOSPITAL PERFORMANCE IMPROVEMENT COMMITTEEMORBIDITY & MORTALITY(Weekly-Wednesdays)TRAUMAMULTIDISCIPLINARY PEER REVIEW(Clinical)(Monthly)Secondary Review TMD, PTMD, DTS,ADTS, ADTS-P(Daily/weekly)TRAUMAMORNING REPORT(Daily)ICU ROUNDS(Daily)WARD ROUNDS(Daily)REVIEW ED ADMIT LOG(Daily) CLINICAL MANAGEMENTTEAM(System)(Monthly)00HOSPITAL PERFORMANCE IMPROVEMENT COMMITTEEMORBIDITY & MORTALITY(Weekly-Wednesdays)TRAUMAMULTIDISCIPLINARY PEER REVIEW(Clinical)(Monthly)Secondary Review TMD, PTMD, DTS,ADTS, ADTS-P(Daily/weekly)TRAUMAMORNING REPORT(Daily)ICU ROUNDS(Daily)WARD ROUNDS(Daily)REVIEW ED ADMIT LOG(Daily) CLINICAL MANAGEMENTTEAM(System)(Monthly)4966335-568960PI Information SourcesTrauma Morning Report, Daily Rounds, Provider Review, Chart Audit, Trauma Registry Data Review, ED/Injury Report00PI Information SourcesTrauma Morning Report, Daily Rounds, Provider Review, Chart Audit, Trauma Registry Data Review, ED/Injury Report7480935-568960Phase of Care Pre-hospital Resuscitation Inpatient Care Outpatient CareParticipants:TMD, TPM, EC staff,00Phase of Care Pre-hospital Resuscitation Inpatient Care Outpatient CareParticipants:TMD, TPM, EC staff,5652135916940Paperwork Reviewed: Trauma Flow Sheet, H&P, EMS Run sheet, Inpatient Chart00Paperwork Reviewed: Trauma Flow Sheet, H&P, EMS Run sheet, Inpatient Chart72523351488440Purpose:Event ValidationParticipants:TPM, EC nursing representative00Purpose:Event ValidationParticipants:TPM, EC nursing representative48520354231640ForumsMultidisciplinary Peer Review MeetingTrauma Meeting Committee00ForumsMultidisciplinary Peer Review MeetingTrauma Meeting Committee48520351259840Types of ReviewProvider and Second Reviewer00Types of ReviewProvider and Second Reviewer-6343656060440LEGEND: Trauma Medical Director (TMD), Trauma Program Manager (TPM)00LEGEND: Trauma Medical Director (TMD), Trauma Program Manager (TPM)5086351374140ACTIONS00ACTIONS1994535171704000-1771654574540Event Resolution Continued Monitoring00Event Resolution Continued Monitoring-1771652288540PolicyDevelopmentEducational ConferencesRegionalTrauma PICommitteeTrend/MonitorHospital/SystemImprovementsProviderFeedback00PolicyDevelopmentEducational ConferencesRegionalTrauma PICommitteeTrend/MonitorHospital/SystemImprovementsProviderFeedback-405765503174000-40576511684000-4057651168400022231354117340002223135446024000210883533172400027946354688840TERTIARY REVIEW:Monthly/Quarterly00TERTIARY REVIEW:Monthly/Quarterly48520352745740Types of ReviewMonthly/Quarterly M&M, Peer Review/Death Review00Types of ReviewMonthly/Quarterly M&M, Peer Review/Death Review370903538887400027946352974340SECONDARY REVIEW:Daily/Weekly Review00SECONDARY REVIEW:Daily/Weekly Review370903521742400027946351374140PRIMARY REVIEW:Daily/Concurrent Review00PRIMARY REVIEW:Daily/Concurrent Review370903557404000622935-791210(Your facility name) TRAUMA PERFORMANCE IMPROVEMENT PROCESS00(Your facility name) TRAUMA PERFORMANCE IMPROVEMENT PROCESS2794635-226060EVENT IDENTIFICATION00EVENT IDENTIFICATION73666354051935Purpose:Peer ReviewEvent Resolution Re-evaluationParticipants:TMD, TPM, Risk Management/Patient Safety, CEO00Purpose:Peer ReviewEvent Resolution Re-evaluationParticipants:TMD, TPM, Risk Management/Patient Safety, CEO72523352680335Purpose:Event DiscussionParticipants:TMD, TPM, Specialty Services i.e., EMS00Purpose:Event DiscussionParticipants:TMD, TPM, Specialty Services i.e., EMS ................
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