PERFORMANCE IMPROVEMENT AND QUALITY ASSURANCE A Trauma Receiving Facility’s Perspective Lisa Fawcett RN, CEN Sheridan Memorial Hospital Plentywood, MT

SMALLER NUMBERS… SAME OBJECTIVES Step by step Identify trauma indicators pertinent to your program for evaluation Chart review for data collection Data analysis Formal trauma review Departmental QA and case review reports Quality assurance audit frequency and loop closure

 EMS Scene times, complete VS  Spine immobilization, technique, backraft  Appropriate Trauma Team Activation/Times  Trauma flowsheet utilized  Timely airway management in ED  Complete VS in ED  Hypothermia identified/measures taken  2 large bore IV’s, Labs  Timely CXR, pelvic XR, CT scan  Pain management  Wound care  Input/output documentation  Transfer/discharge times, ED dwell time  Receiving facility feedback Examples of Trauma indicators to assess…

DATA COLLECTION AND ANALYSIS Develop a standardized format for data collection Perform individual trauma chart review assessing indicators Analyze collected data for areas needing improvement Discussion through formal trauma review of cases Develop a format for documentation of trauma case reviews

SMH Individual Trauma Case Review Form for Data Collection “performance checklist”

FORMAL CASE REVIEW DOCUMENTATION Should include: Topic discussed Opportunities for improvement Action plan for correction or solution, & follow-up Implementation time frame Evaluation method for monitoring outcomes and loop closure Who is responsible?

Format for documentation of case reviews and committee minutes…

Quality assurance audits are performed every 6 months at SMH (time frame depending on volume of trauma patients) Trauma department quality assurance reports are then generated and shared with the facility’s QA department Trauma QA chart audits and Departmental QA reports

Chart audits focus on patient care delivered Concerns and positives included Summarizes trauma care Frequency of audits related to volume of patients seen Information then summarized into a departmental report

Departmental QA Report

For example… Trauma variables chosen to address from this review are O2, complete VS documentation and timely pain management. All concerns from each individual review are then taken to case reviews for discussion. oxygen vitals pain

Example trauma case review attendance

Example of Loop Closure…

Success… Standardized format for data collection Detailed notes and minutes from case reviews Consistent follow-up on any corrective actions taken for loop closure Thank you and good luck!