REGIONAL PERFORMANCE IMPROVEMENT PROCESS GUIDELINES
For
Wisconsin’s Regional Trauma Advisory Councils (RTACs)
January 2007
DEFINITION
According to the American College of Surgeons (*ACS) Performance Improvement (PI) Reference Manual, PI describes “the continuous evaluation of a trauma system and trauma providers through structured review of the process of care as well as the outcome.”
PURPOSE
The purpose of Wisconsin’s regional trauma performance improvement is to measure, evaluate and improve both the process of trauma care and the outcomes through a focus on opportunities rather than on problems.
GUIDELINES FOR THE PI PROCESS
A. Establish a Regional Trauma Advisory Council (RTAC) multidisciplinary PI committee in each RTAC.
1. According to the Trauma Care System Administrative Rules, Chapter 118 recommendations, “members should include a surgeon involved in trauma care, an emergency department physician, an EMS representative, an EMS Medical Director, a person who coordinates the trauma program or PI process in a trauma facility, and other trauma care and prevention professionals the RTAC determines appropriate.
Insure members are from a variety of backgrounds and
agencies within the RTAC including rural and urban facilities as well as rural/volunteer/paid-on-call and full-
time EMS providers.
2. All hospitals in Wisconsin may participate in the regional PI process, regardless of designation (Unclassified, Level I-IV).
B. Process – According to the Trauma Care Administrative Rules, Chapter 118, the process shall include all of the following for both pediatrics and adults:
1. Data Collection and analysis:
a. Review data generated from the State Trauma Registry.
b. Other potential data sources include, but is not limited to:
i. Pre-hospital patient care record,
ii. Trauma Care Facility (TCF) medical record,
iii. 911 Dispatch record,
iv. Inter-facility transfer record, and,
v. Report/complaint from trauma care provider.
2. Adult and pediatric-specific quality indicators for evaluating the trauma system and its components:
a. Maintain a list of quality indicators for periodic standards of trauma care as defined by the ACS. Indicators are statements of an ideal expectation.
b. The following indicators have been selected by the State Trauma Advisory Council (STAC) to initiate the PI process in each RTAC.
i. EMS scene time > 20 minutes,
ii. Completed pre-hospital patient record provided or available to the trauma care facility within 48 hours,
iii. A Glasgow Coma Scale (GCS) < or equal to 8 and no definitive (protected) airway for EMS and hospitals,
iv. The time at the referring trauma care facility exceeds 3 hours exclusive of the transport time, and,
v. Use of the regional triage and transport guidelines.
3. A system for regional case referral: (Case referral should be delayed while the RTACs are learning regional trauma systems and the PI process. The indicators in 2b.should be used to begin the regional PI process).
a. Establish criteria to trigger evaluations and/or patient cases for audit. Criteria for determining which patients should undergo monitoring and evaluation may vary among regions, however, PI should be conducted for those patients who do not meet the recommended indicators for the initial PI process.
b. Determine issues, circumstances and reasons for not meeting the indicator(s).
4. A process for indicator review and audit:
a. Take action to improve care and service.
b. Recommendations for action:
i. No further comment or action indicated,
ii. Additional information is required for a subsequent meeting to allow for further discussion,
iii. Request a follow-up report from presenting facility/agency,
iv. Make a recommendation to the presenting facility/agency,
v. Recommend a specific educational program,
vi. Suggest further action be referred to STAC, and/or
vii. Trend future cases.
5. A mechanism for loop-closure, the cycle of monitoring, finding, fixing and monitoring again (see above):
a. Establish an action plan and implement through:
i. Guidelines or protocols, and/or,
ii. Educational component, and/or,
iii. Case review presentations.
b. Measure the desired outcome of the corrective action plan:
i. Must be measurable, benchmarked, tracked and analyzed.
c. Track the action plan for completeness.
6. A mechanism for feedback to the RTAC Executive Council:
a. Communicate results,
b. Issues that do not meet deadlines or remain open should be referred to STAC except cases left open to trend.
7. An evaluation for system performance:
a. System-based PI is essential to the ongoing development and improvement of the overall effectiveness of the system. Facility-based PI is essential to the ongoing development and improvement within the Trauma Care Facility (TCF).
b. Regional PI focuses on system components and overall system effectiveness. Look at the structure (resources), process (care) provided, and results (outcomes).
8. A procedure for ensuring confidentiality throughout the performance improvement process:
a. The PI process is protected under 2005 ACT 315,
b. All information and materials provided and/or presented at the PI meetings of the RTACs are held to be strictly confidential,
c. Persons who are members of the PI committee, as well as any invited participants involved with the case, are required to sign a “Statement of Confidentiality,”
d. Establish sanctions for breaches of confidentiality:
i. Any breach of confidentiality will preclude further participation in any performance improvement opportunity.
e. Establish security efforts such as shredding copies of PI documentation, numbering and collecting all relevant papers,
f. Use a locked file for all relevant information, and,
g. See State Statute 146.84 et.al. for further information on breach of confidentiality.
PI MEETINGS
A. Meetings must be conducted in a manner that ensures the honest appraisal of medical care.
B. PI initiatives require close cooperation.
C. PI meetings must be held quarterly at a minimum.
D. Meetings should follow a structured format, with a formal agenda.
E. The Chair must be familiar with the PI process.
F. Discussions and conclusions should be documented in meeting minutes that remain confidential.
G. Issues that are not able to be resolved in the RTAC through the Executive Council must come back to STAC through the State Trauma Care System Coordinator.