Trauma Center Performance Improvement And Patient Safety Plan (Page 3 of 9) in pdf

Trauma Center Performance Improvement And Patient Safety Plan Page 3

D. Purpose of the Meetings

Process Improvement-issues identified in the review that deal with the

system of care in the facility are appropriate to discuss in this

venue. These include issues such as:

Creation of Trauma Activation Criteria

ii.

Creation of pathways and protocols

iii.

Process for utilizing a call team for OR cases

iv.

Determination of additional requirements for service on the

trauma call panel

These issues deal more with the system of care and not an individual

provider. It is important to have representation from all hospital and pre-

hospital stakeholders (representatives) at this meeting

b) Provider Peer Review-issues identified in the review that deal with specific

cases and provider issues that arise. These include issues such as :

Timeliness of response to a high level activation

ii.

Appropriateness of evaluation and treatment

iii.

Appropriateness of admission or transfer

iv.

Trauma Death

A judgment will be rendered by the committee with regards to the appropriateness of

the issue referred for further review and on all mortality being reviewed according to

the following metrics:

• Survival with Opportunity for Improvement(OFI) in the care

• Unanticipated Mortality with Opportunity for Improvement (OFI)

• Anticipated Mortality with Opportunity for Improvement (OFI)

• Mortality without Opportunity for Improvement (OFI)

Further recommendations for performance improvement based on tertiary review will

be made to the relevant hospital committees who with the trauma program are

responsible for loop closure.

E. Performance Improvement Action Plan

All corrective action planning and implementation will be overseen by the

Trauma Medical Director and Trauma Program Manager. Possible corrective

actions may include:

• Education

• Trending of Issue

• Policy or Guideline Development/Revision

• Counseling

• Referral (TRAC, Quality etc.)

• Peer Review

• Focused Audit

• Resource Enhancement

• Privilege Action

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

TRAC within defined time limits

Created 01-12-2012

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Trauma Center Performance Improvement And Patient Safety Plan Page 3

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