Trauma Center Performance Improvement And Patient Safety Plan (Page 2 of 9) in pdf

Trauma Center Performance Improvement And Patient Safety Plan Page 2

Data sources for the collection of this information include:

• Hospital Medical Record

• Pre-hospital Patient Care Report (run sheets)

• Referring Hospital Record

• Medical Examiner Reports

Performance Improvement Process

A. First Level of Review

The Trauma Program Manager or designee will do the initial case review of all

trauma patients. Appropriate clinical care without provider or system issues

identified will need no further review.

B. Second Level of Review

Opportunities for improvement in the system or provider and sentinel events

are referred to the Trauma Medical Director (TMD). The Trauma Medical

Director and the Trauma Program Manager will perform the second level of

review. Further analysis of the case and issue(s) identified will occur. Those

cases in which a simple action plan, such as trending of the issue, targeted

education, provider counseling or discussion is the only corrective action

identified need not proceed to the next level of review. Deaths, significant

adverse events and cases involving more than one service or provider with

opportunities for improvement should be elevated to the Third Level of Review.

Trauma PI issues will be documented on the “Trauma Review Form” in Appendix

C. This form tracks all patient care issues, serves as a reference for all PI

activity, and assures proper documentation and loop closure by tracking all

aspects of the case review to include:

• Clinical summary,

• Trauma Medical Director review,

• Judgment of committee,

• Corrective actions,

• Re-evaluation and loop closure date.

• Referral to TRAC for further review and PI with feedback to hospital by

TRAC within defined time limits

C. Third Level of Review

Tertiary Review will occur at the committee level. Cases for tertiary review

may be referred to the Trauma Peer Review Committee, Trauma Operational

Committee, or Hospital Quality Committee.

Created 01-12-2012

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Trauma Center Performance Improvement And Patient Safety Plan Page 2