HISTORICAL PERSPECTIVE OF PERFORMANCE IMPROVEMENT IN TRAUMA CARE

A universal condition of trauma center designation is that specified injury data must be collected, analyzed, and maintained. In addition, the data must be monitored routinely by the trauma program in an effort to improve performance. The standards published by the American College of Surgeons (ACS) Committee on Trauma in Resources for Optimal Care of the Injured Patient are the foundation for performance review in trauma centers.¹ These standards have continued to evolve and were most recently updated in 2006.

The terms and principles related to quality have gone through many changes in recent times. “Quality assurance,” “quality improvement,” “continuous quality improvement,” “total quality management,” and “performance improvement” are all approaches to quality review that have been used in the past.² A major conceptual shift in these approaches has been the movement from a punitive quality assurance model to the more accepted system/process review. In addition, performance improvement in health care settings is being more closely integrated with patient safety. The health care industry continues to evolve its methodology for quality review, and the days of the “ABCs” of morbidity and mortality (accuse, blame, and criticize) are fading. This system/process performance improvement model is focused on outcomes, benchmarking, and performance of the system as a whole and moves away from emphasis on reviewing an individual’s practice as a root cause. There must, however, also be a structured physician peer review process to evaluate clinical competency. Traditionally, hospital performance improvement and quality improvement have been service-line or unit specific. Depending on the institution, specific performance or quality committees would develop and implement projects, quite often following The Joint Commission (formerly known as the Joint Commission on Accreditation of Healthcare Organizations [JCAHO]) format, the performance improvement cycle (Figure 3-1). In the trauma care arena, there are standards that outline the basic type of performance review that trauma centers need to complete. Included in these standards are recommendations for performance indicators (including definitions) that should be monitored over time. Because of the strict standards set forth by trauma center accrediting agencies, often it is the trauma program that leads performance improvement efforts in hospitals.

FIGURE 3-1 Performance improvement cycle.

(From The Joint Commission: Joint Commission accreditation manual, Oakbrook Terrace, Ill, 1998, The Joint Commission.)

Health care practitioners struggle to understand and operationalize the concepts of what we now call performance improvement. The popular literature on quality, which includes the works of pioneers such as Juran and Deming, is focused on industrial settings. W. E. Deming, considered one of the leading figures in the movement to measure quality in industry, developed theories that are widely published. His work has been applied to multiple venues outside the traditional business world, including health care. Out of the Crisis (1986),³ considered one of Deming’s major works, provides anecdotes and examples of how to put his theories into practice.

A particular challenge to health care practitioners is determining how to apply techniques and principles designed for more “constant” industrial environments to the unpredictable and dynamic practice of medicine. One example of a methodology that was initially developed for manufacturing and that has been applied to health care is Six Sigma. This is a structured format that uses reliable and valid data and statistics to improve performance by identifying and eliminating variations or “defects” in processes.⁴ The current environment in health care has presented additional challenges in the quest to operationalize performance improvement. Human and financial resources are lean and patient demographics are changing. To our advantage, however, are modern technologic advancements and the power of computerization in the maintenance and analysis of patient data.

PATIENT SAFETY

The Joint Commission oversees the development and annual updating of the National Patient Safety Goals and Requirements. This process is overseen by an expert panel that includes a multidisciplinary team including patient safety experts, nurses, physicians, pharmacists, risk managers, and other professionals who have hands-on experience in addressing patient safety issues in a wide variety of health care settings. Trauma programs, with mature performance improvement programs, have traditionally provided a model approach to monitoring potentially high-risk events and ensuring a review of cases where defined risk criteria are present. The ACS in the 2006 edition of Resources for Optimal Care of the Injured Patient, has recognized that performance improvement and patient safety are intricately linked and should be approached in unison. The patient safety process is focused on the environment in which care is given and the performance improvement process is directed at the care provided. The boundaries between these two often cross over and in many cases are indistinguishable.

A number of topics central to the delivery of trauma care provide excellent examples of practical links between patient safety and performance improvement. Some of the past patient safety goals set forth by The Joint Commission, such as patient identification, right site surgery, medication safety, and communications/handoffs are particularly relevant to trauma care delivery. Each of these presents unique challenges to the trauma program. Given the rapidity of the initial evaluation, the routine need for urgent surgery, and the issues related to workforce shortages, all these Joint Commission safety goals are reasonable focus points in the trauma performance improvement program.⁵

Another approach that has become very important in hospital care delivery is the concept of rapid response teams. These teams are designed to be deployed early to assist patients in distress (precardiac/respiratory arrest) and to avoid a full-arrest response. The concept is to activate an in-house emergency response team early when a patient is in trouble to potentially avoid a code situation. Some institutions have implemented rapid response/readiness teams modeled after trauma resuscitation teams. Utilizing strategies used by trauma performance improvement programs to monitor team effectiveness is a likely model to evaluate the effectiveness of rapid response teams. From a number of perspectives, closer integration of clinical effectiveness, trauma performance improvement, and patient safety initiatives throughout an institution has the potential to evaluate/affect care on a larger scale.

TRAUMA PERFORMANCE IMPROVEMENT PLAN

Trauma programs should establish a written trauma performance improvement plan that addresses basic operational details and contains an overview of the process. This plan should be the result of a multidisciplinary effort and should be a dynamic document that is reevaluated periodically and updated to encompass key changes within the hospital trauma system and trauma care standards. The trauma performance improvement plan should clearly integrate with the hospital performance improvement plan. There should be descriptions on how outcomes are shared with the hospital structure, for example, through linkages to the department of surgery, the medical executive committee, or the even the board of directors. Recommended distribution of the plan might include hospital quality improvement staff, nursing leadership, physician leadership from medical divisions involved in trauma care, and trauma program staff. This plan could be used as part of the orientation process for new hospital leadership who will be responsible for trauma patient care. The performance improvement plan should include the following:

The performance improvement plan should consider state, regional, and national standards related to trauma care. The ACS document titled Trauma Performance Improvement, A How to Handbook provides practitioners with an operational manual for establishing and maintaining a trauma performance improvement program.⁶ In addition, programs such as the Society of Trauma Nurses Trauma Outcomes Performance Improvement Course “T.O.P.I.C.” assist practitioners with developing a comprehensive trauma performance improvement plan and provides practical approaches to operationalizing performance improvement in all levels of trauma centers.⁷

INTEGRATION OF TRAUMA PERFORMANCE IMPROVEMENT WITH INSTITUTION AND SYSTEM PERFORMANCE IMPROVEMENT

Trauma programs lead the way in many institutions in terms of the depth, scope, and sophistication of performance improvement reviews. It is important that trauma programs be integrated into the overall hospital or system quality structure. Many health care organizations have adopted service-line teams to oversee performance improvement–related projects. Trauma crosses over and affects many service lines of the hospital structure, including nursing, emergency medicine, neurosurgery, anesthesia, orthopedics, rehabilitation services, radiology, laboratory services, perioperative care, critical care, nutrition, and the blood bank. It is challenging to devise a single initiative that coordinates the activities of the multiple service lines through which care is provided to trauma patients. There must be some means of overseeing continuing projects and determining areas of overlap, mutual benefit, and level of impact. For example, many hospitals collect intensive care unit (ICU) data; these data could be stratified to look at trends specifically within the trauma patient group. Conversely, data maintained by the trauma program may be stratified by phases of care and reported through the hospital performance improvement structure. Analysis of various levels of data from hospital departments can generate specific institutional projects. Projects that have the highest return on investment should be selected. Projects that target key areas or have strong potential to affect outcomes, patient satisfaction, or cost should be prioritized.

Health care organizations are required by The Joint Commission to respond to sentinel events, defined as unexpected occurrences involving death or serious physical or psychologic injury, or any event that carries a significant chance of a serious adverse outcome. Appropriate responses include the following:

The trauma performance improvement program must have a mechanism in place to report any identified sentinel events to the hospital department or committee responsible for Joint Commission compliance.

Two useful techniques for analyzing unexpected outcomes are (1) FMECA (failure mode, effect, and criticality analysis), which is a systematic way to examine a process for possible ways that failure can occur, usually initiated by a “near miss” incident, and (2) root cause analysis, which looks for the cause of variation after a sentinel event or unexpected outcome has taken place.^8,9 Regardless of the analysis technique used, benchmarking with other similar centers provides meaningful perspective for trauma programs.

PATIENT/ISSUE IDENTIFICATION

Identifying patients for trauma performance improvement review can be challenging. In hospitals without a designated trauma service, patients can be admitted to any one of a number of surgical or medical services. To help identify patients admitted with injury-related diagnoses, hospital information systems can produce reports with diagnoses, injury codes, and reasons for admission. The emergency department log or the admission log can be used to identify trauma patients. Often this is done by using an indicator assigned by emergency department admissions staff or through customized admission reports using primary or secondary diagnosis or physician name. The trauma program needs to have validation steps in place to ensure that all appropriate injured patients are captured by the registry on the basis of established inclusion criteria.

Information for performance improvement review comes from many sources. Prehospital records, including fire, rescue, or ambulance records, and flight records from air ambulances, can provide information about the scene conditions, treatment rendered, and length of time at the scene. The patient’s medical record is the main source for identifying performance improvement issues. The emergency department and trauma resuscitation documents should be designed to capture the timing and sequence of the resuscitation easily because this is key to evaluating care. Parts of the medical record that provide important performance improvement information may include the following:

Because many hospitals have converted to electronic records, it will become essential for the person responsible for performance improvement to have access to the entire medical record, including electronically stored documents/information.

In addition to review of the medical record, it is helpful to have a mechanism for health care providers in all areas of the hospital, on all shifts, to provide referrals to the performance improvement process. They can report issues by a confidential, dedicated phone “hotline” or through issue identification forms, which can be submitted confidentially. Significant issues that affect patient care should also be reported to risk management through appropriate institutional channels. Ideally, communication with risk management is two way. Issues reported to the hospital-wide incident/quality reporting system can be channeled to the trauma program for further action and follow-up. Audiovisual recording of trauma resuscitations can identify opportunities for improvement that may not be evident through medical record review. Examples are provider compliance with standard precautions, evaluation of overall team interactions, and the monitoring of proper technique during procedures such as urinary catheter placement.

Other departments in the hospital may be a source of information regarding performance improvement issues. Infectious disease reports can identify patients with complications such as urinary tract infections or pneumonia, supporting or validating trauma performance improvement data. Postdischarge records are a source of information regarding outcomes because they may identify missed injuries, delayed diagnoses, readmissions, or patient satisfaction issues. It is important that there are processes to identify and report performance improvement issues in the trauma outpatient arena. Postdischarge information can be obtained from outpatient records, feedback from rehabilitation facilities, follow-up from home care agencies, or autopsy reports. The medical examiner or coroner can often provide additional valuable data at mortality review forums. This can be achieved through direct participation of medical examiner staff or through the retrospective review of written or verbal autopsy reports.

TRAUMA PERFORMANCE IMPROVEMENT PROCESS: LEVELS OF REVIEW

There are many ways to structure a review of clinical care. Having both concurrent and retrospective features is ideal. Key steps should be established and should be modified on the basis of the specific features of the trauma program (size, volume, resources, etc.). Key elements in the performance improvement process are diagrammed in Figure 3-2.

FIGURE 3-2 Trauma performance improvement process: levels of review. PIC, Performance improvement coordinator; PI, performance improvement; ID, identification; TPD, trauma program director; TCA, trauma clinical administrator; CMG, case mix group.

Data collection for performance improvement can occur concurrently with abstraction of data while care is being provided (primary review). The person in charge of concurrent review, usually a nurse (typically the trauma coordinator/program manager, trauma performance improvement coordinator, trauma case manager, or trauma advanced practitioners), or trained trauma registrar, uses various mechanisms to identify and follow up on issues as they occur. Patient care rounds, chart reviews, and direct staff and patient interaction are among the sources of data for concurrent review. The major advantages of concurrent review are that it allows (1) changes to occur in the patient’s plan of care, which can influence outcome immediately, and (2) prompt feedback to providers regarding quality-of-care issues. One disadvantage is that it precludes an overview of the entirety of the case with all patient data from dictated radiology reports, discharge information, and postdischarge follow-up. Retrospective review occurs after the patient has been discharged, with data abstracted from medical records, registry reports, and so on (secondary review). During secondary review, decisions are made to determine where in the performance process the case/issues should go next. This could include closing the case (no action needed), referral to other service for review and comment, referral to an established performance improvement committee for in-depth review, and analysis by the peer review judgment determination process (tertiary review).

Retrospective review provides a comprehensive assessment of overall care and affords the opportunity to see trends in data and to compile statistics on groups of patients for analysis. The limitations of performing only retrospective reviews are (1) feedback to individual providers is delayed, (2) incidents must be reconstructed from memory, and most important, (3) patient care cannot be affected in “real time.” A mature, comprehensive performance improvement program will have components of both concurrent and retrospective reviews.

PERFORMANCE IMPROVEMENT FORUMS

CASE SELECTION GUIDELINES FOR TERTIARY REVIEW

Criteria for determining which cases need to be discussed at a trauma performance improvement committee (tertiary review) must be established. These will vary on the basis of volume and on local and state standards related to trauma performance improvement. Many institutions may review only cases that meet criteria for submission to the state and regional trauma registry (e.g., International Classification of Diseases, Clinical Modification [ICD-CM] 800 to 959.9, deaths, ICU admissions, hospital length of stay [LOS] more than 48 to 72 hours, pediatrics). Depending on resources available, an institution may opt to review only clinical sentinel events, cases with unexpected outcomes, and those that involve preventable or potentially preventable occurrences as calculated through the trauma registry system and Trauma Injury Severity Score (TRISS) analysis. Other issues can be reviewed as aggregate data, and focused audits should be performed when data trends reflect significant fluctuations. Review of systems issues should be included in performance improvement committees. Appropriate hospital or system staff should be included in the forums when system issues will be discussed.

Ensuring attendance at performance improvement forums can be difficult. To facilitate attendance, a set calendar of meetings should be established on a routine day and time that are convenient for team members with consideration of their clinical responsibilities. It may be helpful to incorporate trauma performance improvement committees into existing hospital and departmental forums, such as departmental morbidity and mortality conferences. There should be records of attendance (ACS standard for participation in multidisciplinary peer review forums), and confidential files should be kept on the topics, patients, and participants at performance improvement forums. Preparation before meetings should include compiling a roster of cases to be presented, obtaining/accessing the on-line medical records (when possible), and gathering the performance improvement case files. The guidelines for reaching peer review decisions and summary trauma registry data on individual cases should be available at performance improvement committee meetings. Using technology to enhance interactivity can be beneficial. Projecting patient case summaries to a screen viewable to participants during performance improvement meetings is one method that has been used to improve team participation in performance improvement discussions.

A key component of the performance improvement process is the provision of a peer review forum to discuss individual cases, trends in data, and comparative data related to system performance. Peer review forums should involve key trauma program/hospital staff (Table 3-1). Hospital/medical staff bylaws may dictate attendance at physician peer review sessions. These should be considered when determining the structure for peer review forums. Performance improvement committees can be structured in a variety of ways depending on the resources available, the volume of cases, and the local, state, and regional rules related to performance improvement reviews.

TABLE 3-1 Performance Improvement Roles of Trauma Program Staff in a Level I Trauma Program

Personnel	Role in Performance Improvement
Trauma Performance Improvement Coordinator RN or Trauma Coordinator/Program Manager	• Identifies issues concurrently • Creates case file • Selects cases for performance improvement committees • Validates registry data • Reports on clinical management guideline compliance • Monitors trends in performance improvement reports/provider profile development • Tracks loop closure/resolution • Maintains performance improvement data
Trauma Performance Improvement Medical Director	• Selects cases for performance improvement committees • Moderates performance improvement committee meetings • Performs chart review • Analyzes performance improvement trended data/provider profiles • Coordinates generation of correspondence for performance improvement follow-up • Leads peer review judgment discussions with trauma director
Trauma Program Manager/Coordinator	• Analyzes trended performance improvement reports • Participates in peer review judgment discussions • Manages follow-up on performance improvement system issues • Oversees development and implementation of performance improvement/registry plans • Provides backup coverage for performance improvement coordinator • Validates trauma registry data • Facilitates interdisciplinary performance improvement team • Oversees clinical management guideline process: development implementation and surveillance • Directs loop closure—practice/policy changes/educational changes • Links to hospital/system performance improvement structures < div class='tao-gold-member'> Only gold members can continue reading. Log In or Register to continue Share this: Click to share on Twitter (Opens in new window) Click to share on Facebook (Opens in new window) Related Related posts: EVOLUTION OF THE TRAUMA CYCLE TRAUMA IN THE ELDERLY MASS CASUALTY INCIDENTS BURN INJURIES WOUND HEALING AND SOFT TISSUE INJURIES SPINAL CORD INJURIES Stay updated, free articles. Join our Telegram channel Join Tags: Trauma Nursing From Resuscitation Through Rehabilitation Jul 22, 2016 | Posted by admin in PHYSICAL MEDICINE & REHABILITATION | Comments Off on PERFORMANCE IMPROVEMENT AND PATIENT SAFETY IN TRAUMA CARE Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access