Yesterday I discussed loop closure for system issues. Today I’ll look at the interesting relationship between peer and system issues.

Although most PI issues that arise seem to be related to something done (or not done) by an individual, that doesn’t mean that the issue is peer-related. Frequently a significant portion of the problem is caused by a system issue. How can this be?

Let’s take the example of DPL. A physician performs a DPL in the trauma bay and the trauma PI program notes that it was performed without the requisite placement of an NG tube and urinary catheter first. At first look, this is a peer-related problem, right? Just counsel the doctor and everything will be better.

Wrong! Your PI program needs to assume that every apparent peer-related problem is a manifestation of one or more system issues. In my example, another DPL is performed 6 months later by a different physician, and once again the catheters are not inserted first. What gives?

I recently wrote that DPL was a dying art. Most institutions perform this procedure only a few times a year. People get rusty with uncommon procedures because they can’t practice. So instead of considering this a physician problem, look at it as a system problem. How can you keep them from forgetting something they seldom do? Simple! Attach a gastric tube and a urinary catheter directly to the DPL kit. When the physician grabs the kit, they will be instantly reminded of the need to insert them first. Problem solved.

Bottom line: always assume that people are doing their best to provide excellent care to their patients. Look closely for possible system problems that are keeping them from doing just that. Then put your thinking cap on and come up with some creative solutions.

Yesterday I discussed loop closure for peer-related issues. Today I’ll delve into loop closure for system issues.

System issues are those that tend to involve multiple patients. They are not as easy to identify, because it may take a while for you to see a problem pattern emerging. And they are definitely harder to fix because they require a multi-faceted problem solving approach.

Here’s an example: You are presenting a complication (pulmonary embolism) in your trauma morbidity and mortality (M&M) conference. One of your colleagues notes that this is the third such presentation this year, which seems to be higher than previously. And come to think of it, the number of deep venous thrombosis presentations seems to be higher as well. 

You ask your trauma registrar to run some reports on these complications, and you find that the incidence of both in your trauma patients has increased 80% over the previous year! Time to put on your thinking cap, review the literature and critically look at your care and what other centers are doing. You conclude that your trauma patient population hasn’t changed, but that your DVT surveillance and prophylaxis are spotty and vary considerably by physician.

Your solution consists of a new protocol or practice guideline that 1) identifies the risk level for each trauma patient, 2) defines what prophylactic measures will be used based on the risk assessment, and 3) determines what kind of screening will be done and how often. This protocol is implemented by your trauma operations committee, with all trauma physicians instructed to use it. It is monitored by your trauma program staff, and regular scorecards are sent to each physician. Regular reports detailing physician compliance and patient complications are made at each M&M or Trauma PI Committee meeting as well.

Six months later, registry data is reviewed again and you find that the incidence of DVT has decreased (but not to baseline because you are screening better and finding more), and the number of pulmonary emboli has dropped nearly to zero. Problem solved? Maybe. Periodic monitoring and continuation of the scorecard system is probably needed to make sure that the protocols are maintained.

What do you need to close the loop? You need a “folder” to save your information as I discussed previously. Since this problem involves many patients, it doesn’t fit as well into current registry packages that are oriented to single patient records. Whether your folder is paper or electronic, here are the items that need to be saved:

• Minutes from the first M&M meeting where the discussion reflects the recognition of the problem
• The registry reports that show the increasing incidence of the problem
• The new protocol and scorecard that were developed, along with any tracking tools
• The operations committee minutes showing approval of the protocol
• Completed scorecards for the physicians
• M&M minutes for meetings at which DVT/PE reports were given
• Registry reports that show the decreased incidence of DVT/PE. You can consider the item closed at this point.
• Any followup registry reports for monitoring done on a regular basis can be added to the folder later

As you can see, this is much more complicated than a peer issue. However, system issues show the value and strength of your trauma PI program. Trauma reviewers focus on how well you identify and address system problems because it is an indication of the maturity and power of your trauma program.

Related posts:

• Loop closure (Part I)
• Peer-related loop closure (Part II)
• System issue loop closure (Part III)
• Peer issue vs system issue (Part IV)