Trauma Center Performance Improvement And Patient Safety Plan (Page 4 of 9) in pdf

Trauma Center Performance Improvement And Patient Safety Plan Page 4

F. Loop Closure and Re-Evaluation

An essential component in Performance Improvement is demonstrating that a

corrective action has the desired effect. The outcome of any action plan will be

monitored for expected change and re-evaluated accordingly so that the PI loop can

be closed. No issue will be considered as “closed” until the re-evaluation process

has been complete and it demonstrates a measure of performance that has been

deemed acceptable. This evaluation usually occurs within three to six months of the

corrective action. Documentation should include the following aspects of follow-up

and re-evaluation:

• Time Frame for Re-evaluation

• Documentation of Findings

• Results of Re-monitoring

G. Integration into the Hospital Performance Improvement

Trauma Performance Improvement issue reports are prepared in summary

format of problem identification and resolution. These reports are then integrated into

the Hospital Quality Department through reporting of committee meeting minutes.

Confidentiality

All performance improvement activities that are a component of the Trauma

Performance Improvement peer review committee, or that are related to the treatment of

specific patients are confidential. All documents are designated as “Quality Assurance,”

and separate records and minutes are maintained in accordance with Federal and

Arkansas statutes. Confidential issues that involve outside agencies or hospitals that

cannot be adjudicated should be referred to the Regional Trauma Advisory Committee.

Created 01-12-2012

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Trauma Center Performance Improvement And Patient Safety Plan Page 4