Tag Archives: PI

Performance Improvement

Timed PI Audit Filters: When Does The Clock Start?

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This is a question that comes up frequently in trauma performance improvement programs. Several of the performance improvement (PI) audit filters typically used at trauma centers include a time parameter. Some of these include:

  • Craniotomy > 4 hrs
  • Laparotomy > 4 hrs
  • OR for open fracture > 8 hrs (although this is now outdated)
  • OR for compartment syndrome > 2 hrs

The question that needs to be asked is: 2 or 4 or 8 hours after what?

There are several possible points at which to start the clock:

  • Time of the scene of the traumatic event
  • Recognition at an outside hospital (for referred patients)
  • Arrival in your  ED
  • When the diagnosis is made in your ED
  • When the decision to operate occurs

The answer is certainly open to interpretation. 

Here is my opinion on it:

The purpose of a PI filter is to measure system performance. There are a myriad of system problems that can delay taking a patient to the OR. These include care delays in the ED, delays in getting or interpreting diagnostic tests, delays in contact or response for consultants, delays in diagnosis, delays in OR scheduling or availability, and more. Does it make sense to limit the evaluation of your system by setting one of the later decision points as your start time?

Bottom line: I recommend starting the audit filter clock at the time of patient arrival in your ED. This enables the PI program to evaluate every system in your hospital that can possibly enable or impede your patient’s progress to the OR. However, if the issue was recognized at an outside hospital, scrutiny of their processes also needs to occur. Their trauma PI coordinator needs to know so they can make sure the transfer to definitive care occurred as quickly as possible. 

General

Trauma Care And HIPAA Demystified

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There is a lot of confusion and misinformation out there regarding HIPAA (Health Insurance Portability and Accountability Act). This law was enacted in 1996 with the intent of protecting the health insurance benefits of workers who lose or change their jobs, providing standards for electronic health care transactions, and protecting a patient’s sensitive health information. This last part has caused much grief among trauma professionals.

It is commonplace for a trauma patient to require the services of many providers, from the initial prehospital crew, doctors and nurses at the initial hospital, yet another ambulance or aeromedical crew, professionals at a receiving trauma center, rehab or transitional care providers, and the patient’s primary physician to name a few. Unfortunately, because there can be significant financial penalties for violating the HIPAA privacy guidelines, providers are more likely to err (incorrectly) on the side of denying information to others outside their own institution.

All of the people mentioned above are considered “covered entities” and must abide by the HIPAA Privacy Rule. This rule allows us to release protected information for treatment, payment and “health care operations” within certain limits. The first and last items are the key provisions for most trauma professionals.

Treatment includes provision, coordination and management of care, as well as consultations and referrals (such as transferring to a trauma center). Think of this as the forward flow of information about your patient that accompanies them during their travels.

Health care operations include administrative, financial, legal and quality improvement activities. These quality improvement activities depend on the reverse flow of information to professionals who have already taken care of the patient. They need this feedback to ensure they continue to provide the best care possible to everyone they touch.

Bottom line: Trauma professionals do not have to deny patient information to others if they follow the rules. Obviously, full information must be provided to EMS personnel and receiving physicians when a patient is transferred to a trauma center. But sending information the other way is also okay when used for performance improvement purposes. This includes providing feedback to prehospital providers, physicians, and nurses who were involved in the patient’s care at every point before the transfer. The key is that the information must be limited and relevant to that specific encounter.

Feedback letters and forms, phone conversations and other types of communications for PI are fine! But stay away from email, which is not secure and is usually a violation of your institutional privacy policies.

Always consult your hospital compliance personnel if you have specific questions about HIPAA compliance.

Reference: HIPAA Privacy Rule

General

Help Your PI Meetings Run Smoothly

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Multidisciplinary Trauma PI Committee is an essential part of all trauma centers verified by the American College of Surgeons. A lot happens in that one hour (or so) meeting. But efficiency hinges on being prepared, and we’ve all experienced meetings where the case presentations just weren’t crisp. 

What to do? Here’s a set of guidelines to help your presenters do the best job possible. They rely on advance preparation and good communication with your trauma program. 

image

Download a pdf copy of the guidelines here

And please comment with your own twists and turns on making trauma PI an efficient and meaningful process!

Thanks and a hat tip to Mary Carr MD for suggesting these guidelines!

General

Help Your PI Meetings Run Smoothly

Leave a comment

Multidisciplinary Trauma PI Committee is an essential part of all trauma centers verified by the American College of Surgeons. A lot happens in that one hour (or so) meeting. But efficiency hinges on being prepared, and we’ve all experienced meetings where the case presentations just weren’t crisp. 

What to do? Here’s a set of guidelines to help your presenters do the best job possible. They rely on advance preparation and good communication with your trauma program. 

image

Download a pdf copy of the guidelines here

And please comment with your own twists and turns on making trauma PI an efficient and meaningful process!

Thanks and a hat tip to Mary Carr MD for suggesting these guidelines!

General

Trauma PI: The 7 Deadly Sins

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Trauma performance improvement is the backbone of any trauma center. And it’s the most common reason that a center runs into problems or deficiencies during a site review. Today, I’ll review the seven most common problems encountered during site surveys and provide some possible solutions for them.

  1. No loop closure. Closing the loop is talked about all the time. One would think that this should never be a problem, but it is. It becomes evident to the reviewers in two ways: reviewing PI meeting minutes, and sin #2 below. This topic is complicated, so see my four part series on loop closure here.
  2. Repeat offenses. The same problem keeps coming up again and again. This usually happens because the problem was never really solved in the first place. See the link above on loop closure for the solution to this one.
  3. Superficial peer review discussions. This means that the minutes don’t reflect any in-depth discussion of PI issues. There are two possible reasons: there wasn’t any meaningful discussion, or the documentation just wasn’t that good (see point 4 below). The discussion must include a summary of the case, identification of the significant quality issues, and a description of what will be done to avoid the problem in the future and who is responsible for carrying it out. If issues are referred to other committees (trauma operations or hospital PI), then this should be stated and it should be possible to follow the PI trail in those minutes as well.
  4. Poor peer review meeting minutes. This is a carry-on from the last point. Sometimes there is robust discussion on an issue, but the minutes don’t reflect it. This occurs due to concern for discoverability by the public or outside legal counsel in some states, but most frequently happens because the person charged with documenting the minutes is not very good at it. Minutes need not mention specific names, but do need to detail the gist of any discussion, including specific points of concern and remedies. Most discussions will run several paragraphs long; a single brief one just won’t do.
  5. Poor record organization. All PI activity and documentation regarding a specific patient needs to be organized in a single location. A paper or electronic folder is recommended. A similar folder is recommended for each system issue that involves multiple patients. During a site review, be sure to include the appropriate folder of information with each of the patient charts that are inspected by reviewers. Don’t scatter your records across several file cabinets or notebooks. And make sure several people in the trauma program understand the organization system in case a key person gets sick or quits.
  6. No cooperation from other hospital services. Your trauma program sends a case to be reviewed out to another department. Two months pass and you finally notice you never received a reply. Repeat a couple of times with the same chart and at that point, no one remembers anything about the case. This is a sure-fire way to keep making the same patient care mistakes. Create the expectation of quick turnaround (2 weeks is reasonable) and start nagging when time is up. Escalate to your trauma medical director if it continues to be a problem. In more extreme cases, you may need to select another liaison to deal with, or enlist hospital administration or hospital PI to help put pressure on them from above.
  7. No cooperation between trauma program manager and trauma medical director. These two people must work very closely for the trauma PI program to function efficiently. Regular meetings (weekly) are essential so they can review and process the various items that must be addressed. The TMD must deal with any physician related items, such as counseling, verbal discussions, memos and letters. The TPM deals with items involving nursing and other personnel. Dysfunction at this level is somewhat common at Level II trauma centers and quickly drags the program down.
Please feel free to comment or ask questions below!

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