Coordinating Trauma Performance Improvement (PI) and Hospital-wide Quality Assurance (QA) Departments

The Trauma PI program practices a multi-disciplinary departmental approach to reviewing the quality of patient care across all departments and divisions.  The trauma Performance Improvement Committee is integrated with and collaborates with the appropriate performance improvement committees as needed.

The Trauma PI program will report all activity through the department of surgery and to the risk management and patient safety hospital committee as specified in the Hospital Quality Improvement Committee Plan.

The multidisciplinary trauma performance improvement program must have the authority to evaluate the care across disciplines, identify opportunities for improvement, and implement corrective actions.

Trauma centers must have a PIPS (Performance Improvement and Patient Safety) program that includes a comprehensive written plan outlining the configuration and identifying both adequate personnel to implement that plan and an operational data management system (CD 16–1).

The PIPS program must be supported by a reliable method of data collection that consistently obtains the information necessary to identify opportunities for improvement (CD 15–1).

The processes of event identification and levels of review must result in the development of corrective action plans, and methods of monitoring, reevaluation, and benchmarking must be present (CD 2–17).

Problem resolution, outcome improvements, and assurance of safety (“loop closure”) must be readily identifiable through methods of monitoring, reevaluation, benchmarking, and documentation (CD 16–2).

Peer review must occur at regular intervals to ensure that the volume of cases is reviewed in a timely fashion (CD 2–18).

The trauma PIPS program must integrate with the hospital quality and patient safety effort and have a clearly defined reporting structure and method for provision of feedback (CD 16–3).

Furthermore, trauma centers should undergo external assessment at routine intervals to verify and validate the effectiveness of the trauma program and trauma care. The trauma PIPS program should integrate with local and regional trauma system performance improvement efforts. A verification process should be present to validate that the trauma PIPS program can effectively assess the quality and safety of care.

Because the trauma PIPS program crosses many specialty lines, it must be empowered to address events that involve multiple disciplines and be endorsed by the hospital governing body as part of its commitment to optimal care of injured patients (CD 5–1).

There must be adequate administrative support to ensure the evaluation of all aspects of trauma care (CD 5–1).

The trauma medical director and trauma program manager must have the authority and be empowered by the hospital governing body to lead the program (CD 5–1).

Although the trauma medical director remains responsible for the overall function of the trauma program, the trauma program manager is responsible for the operational and logistical aspects of the trauma PIPS program.

TPI & Patient Safety (PIPS)

The objective of a Trauma Performance Improvement and Patient Safety (PIPS) program is to improve patient outcomes, eliminate problems, and reduce patient variance in care, in both patient specific and systemic scenarios.

The prime non-clinical responsibility of the trauma service is PIPS.  The criteria requirements clearly direct that the multidisciplinary trauma performance improvement program have unrestricted authority to evaluate care across disciplines, identify opportunities for improvement, and implement corrective actions. It is further expected that the Trauma Medical Director is the chair of the Trauma multidisciplinary performance improvement program.  The findings of the trauma PIPS program should then be reported to Hospital Quality Improvement Committee through the department of surgery.  One method to report the findings is for the Trauma Service to have a “seat” on the Hospital Quality Improvement Committee.

During the audit filter reviews all patient specific concerns should be investigated for systemic involvement.  The trauma service should initiate the corrective action plans for both patient specific and systemic concerns, being sure to incorporate all areas affected during systemic corrections. The patient specific corrections should be reported, and the systemic corrections should be discussed during Hospital Quality Improvement committee meetings, further demonstrating the value of Trauma PIPS.