Trauma Center Performance Improvement And Patient Safety Plan printable pdf download

Trauma Center Performance Improvement and Patient Safety Plan

Mission and Goals of the Trauma PI Program

The Trauma Program Performance Improvement and Patient Safety Plan is designed to

ensure efficient, cost effective, quality patient care that is facilitated by continuous,

systematic and objective data analysis and multidisciplinary peer review to identify

opportunities to improve patient safety through all phases of trauma care. The ultimate goal

is to reduce mortality and morbidity in the Trauma patient population.

Credentialing For Call Panel Participation

All physicians who participate in the care of injured patients will be credentialed according to

the Medical Staff Bylaws. The Trauma Medical Director has the authority to set additional

criteria, and to recommend changes to the trauma call panel based on performance review.

Patient Population

Trauma patients are defined by the inclusion criteria contained in Appendix A.

Administrative Structure

Performance improvement consists of ongoing evaluation of all facets of trauma care

provided to the trauma patient. The Trauma Medical Director and Trauma Program

Manager provide ongoing and systematic monitoring of care provided by medical, nursing,

and ancillary personnel. Performance Improvement review consists of the utilization of state

pre-selected performance improvement “audit filters” and additional hospital and regional

indicators. In addition, a process of tracking complications, systems issues, provider issues,

and adverse events is determined. The Trauma Program Manager will report all issues and

opportunities for improvement to the Trauma Medical Director for determination of the need

for further review via the Trauma Peer Review Committee, Trauma Operational Committee,

or Hospital Quality Committee. Documentation of resolution of identified issues (loop

closure) is the responsibility of the Trauma Medical Director and the Trauma Program

Manager.

The use of indicators to measure, evaluate, and improve performance is an important

component of the Trauma Performance Improvement Plan. Examples of suggested

indicators are contained in Appendix B.

Data Collection and Analysis

Concurrent and retrospective data is collected and entered in the Arkansas Trauma

Registry. Data definitions are consistent with those of the Arkansas Trauma Registry Data

Dictionary.

ataGuide.pdf

Created 01-12-2012

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Trauma Center Performance Improvement And Patient Safety Plan