Colorado Trauma Network Spring Conference May 11, 2017

Trauma Programs Outcome effectiveness Clinical and Operational Platform Data Data Data Quality/Process Improvement Injury Prevention

Data, Data, Data Trauma Registry Injury Coding Front line review of quality Inter-rater reliability Informs QI/PI Informs house-wide education Program for external validation of data

Quality/Process Improvement Understanding your quality filters Updating your quality filters annually and with each review Developing immediate feedback loops when possible Enlist stakeholder support for complex hospital-wide processes and education

SAH PI Plan…..

Incorporating TOPIC Classification: IMPACT > Medical > Physical Level of Harm: Definitions Level I: No harm/no detectable harm Level II: No detectable harm Level III: Mild temporary harm Level IV: Mild permanent harm Level V: Moderate temporary harm Level VI: Moderate permanent harm Level VII: Severe temporary harm Level VIII: Severe permanent harm Level IX: Death

Protocol Compliance

St Anthony Hospital Trauma Services FY2013 Quarterly Reports

KNOW YOUR NUMBERS Under Triage Evaluation 1/1/2013-3/31/2013   Patients identified in QI as under activation 4 Patients with No level of activation Patients activated at lower Level than indicated Total Activations 240 Patients who should have been activated or activated at a higher level 244 Total Expected Trauma Activations 484 Patients with no activation Under triage activation * 1.98% * Under triage defined as patients who met TTA criteria and were not activated at any level of activation

Trauma Multidisciplinary Peer Review Committee Cases All or Select deaths Select occurrences Sentinel events Problem trends Unusual or uncommon cases Unexpected outcomes Great Saves

Trauma Multidisciplinary Peer Review Committee Members (LI/II) Trauma Medical Director* Trauma/General Surgeons* Orthopedics* Neurosurgery* Emergency Medicine* Anesthesia* Critical Care* Radiology*/Interventional Radiology Pediatrics Thoracic Plastics Medical Examiner Rehab Medicine Trauma Program Manager Trauma Registrar Invited Sub-Specialist Involved with Case *Minimum 50% attendance

Trauma Surgeons & Liaisons Roles and Responsibilities Structured orientation to PIPS plan and process Awareness of defined event review, complications definitions, and defined judgment or review determination language Report identified events and occurrence to trauma team Shared responsibility: extensive review for cases going to PIPS meeting Participate in peer review discussion and determinations Participate in developing corrective action plans Routine feedback (weekly, monthly, annually)