Tag Archives: performance improvement

Performance Improvement

How To “Track And Trend”

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One of the most overused terms in trauma performance improvement is “track and trend.” It implies that the event in question will be closely monitored, with the promise of potential future action.

But the reality is that, much of the time, these events are largely ignored, and a running tally is either kept somewhere or will be calculated at some undefined time in the future. The ultimate result is that these events tend to get “swept under the rug” and ignored.

All is not lost! If done correctly, “track and trend” can be very valuable.  Here are the key components of an effective “track and trend” process:

  • A definition of the problem event. Be very specific. For example, the occurrence of VTE interruption in patients with orthopedic injuries requiring surgery.
  • Occasionally optional: An intervention that has been implemented to address the event and make it “better.” If you have experienced what you believe is a truly one-off event and want to confirm its rarity, an intervention is not necessary. However, this is not a common occurrence. Most events will require some type of intervention, especially if they are serious or seem to be recurring.
  • A length of time for monitoring. Again, be specific. The length of time must be based on the specific event being tracked. Sometimes the time frame may be brief, e.g., three months. But in this VTE example, a longer time may be required, such as a year.
  • A threshold goal. This is the new minimum acceptable performance standard. It will be dependent on the event being tracked.  Sometimes, guidance can be found in the literature. But most of the time, the current incidence will need to be calculated, and then reduced by an arbitrary amount to arrive at the new threshold. In this example, if the current incidence is 20%, the program may want to drop it to 10%.

In this example, the full “track and trend” text reads like this:

We will track the occurrence of interruption of VTE chemoprophylaxis in patients undergoing operative repair of orthopedic injuries after implementing a new VTE practice guideline. This will be monitored for 12 months, with a goal of an incidence of less than or equal to 10%.

Here is another example. A trauma surgeon took a hypotensive patient to CT scan during a trauma activation, where the patient suffered a cardiac arrest due to inadequate resuscitation. The PI process captured this, and the TMD counseled the surgeon.

Here’s the track and trend text in this case:

After counseling by the TMD, we will track the occurrence of hypotensive patients being taken to CT during trauma activations by Surgeon X for six months, with a goal of no occurrences during that period.

The final part of the track and trend process is to see if the goal was met. If so, create solid documentation for loop closure, and your job is done! If not, it’s time to put on your thinking cap, change the intervention, and start again. Repeat until the final goal is reached.

By implementing this process, the track and trend process can actually be a meaningful part of the PI program.

Performance Improvement, Philosophy

Don’t Write This In Your PI Committee Minutes!

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One of the more poorly understood concepts in trauma performance improvement is the focus of the process. Are we really discussing the patient who had a quality issue?

I occasionally see something like the following in the published multidisciplinary trauma PI committee minutes:

“Although an opportunity for improvement was found, it was non-contributory and had no impact on patient outcome.”

Unfortunately, the true purpose of the committee discussion has been lost. The simple truth is that we are trying to learn from a patient we have cared for. None of the events or opportunities for improvement identified can impact them. Time has passed, and if there were any irregularities in their care, it is too late to fix them. For this patient.

However, the proper focus of the performance improvement program is to make things better for the next, similar patient. Here’s an example:

Scenario 1: An elderly patient presents after a fall with a mild head strike. They are awake and alert and present to a trauma center where this is recognized as a high-risk mechanism. A limited activation occurs, the patient is rapidly assessed, and she is whisked off to CT scan 20 minutes after arrival. The report is back in 10 minutes and shows a 1.5cm subdural hematoma with mild ventricular effacement.

Neurosurgery is rapidly consulted and sees the patient within 15 minutes. He plans an emergent operation. The patient is taken to the OR two hours later for a successful craniectomy and drainage. She does well and is discharged home neurologically intact four days later.

Everything looks great, right? Unfortunately, no.

This case could very easily be called a great save. But the patient’s identical twin sister comes in two weeks later with exactly the same presentation. What if the patient vomits, becomes unresponsive, and blows her pupils just one hour after the neurosurgeon sees her? They get a stat repeat CT, and the neurosurgeon now pronounces the larger lesion a non-survivable injury.

The second case will definitely end up being discussed by your multidisciplinary trauma PI committee as a death. Perhaps the one-hour delay is deemed acceptable because “that’s how we do it here” (shudder, a big red flag).

But what if the PI process picks up that two-hour delay in the first case and deems it suboptimal despite the rosy outcome? Processes are implemented to get an OR ready quicker and ensure the neurosurgeon’s availability. Now, a patient can theoretically be in the OR within 30 minutes of this “emergency” designation. When the second patient arrives two weeks later, this new process works flawlessly, and she, too, has a great outcome.

Bottom line: Your PI program is designed to protect the next similar trauma patient arriving at your center. Don’t forget that. Scrutinize care closely, even if the outcome was great and it’s exactly how you “normally” do it. Ask yourself if you would be satisfied if it were your spouse, parent, or child receiving that care. If not, fix everything that isn’t right. For all you know, that next patient could very well be your family member!

Performance Improvement

Blame The Trauma Surgeon?

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I found an interesting paper published a couple of years ago that purports to examine individual surgeon outcomes after trauma laparotomy. This was presented at the annual AAST meeting in 2021 and then published in the Journal the following year.

Everyone seems to be giving this paper a pass. I won’t be so easy on it. Let me provide some details.

The authors observe that the mortality in patients presenting in shock who require emergent laparotomy averages more than 40%, and hasn’t changed significantly in at least 20 years. They also note that this mortality varies widely from 11-46%, and therefore, “significant differences must exist at the level of the individual surgeon.” They go on to point out that damage control usage varies between individuals and trauma centers, which could lead to the same conclusion.

So the authors designed a retrospective cohort study of results from their hospital to try to look at the impact of individual surgeon performance on survival.

Here are the factoids:

  • Over the 15-month study period, there were over 7,000 trauma activations and 252 emergent laparotomies for hemorrhage control
  • There were 13 different trauma surgeons, and the number of laparotomies for each ranged from 7 to 31, with a median of 15
  • There were no differences in [crude, in my opinion] patient demographics, hemodynamics, or lab values preop
  • “Significant” differences in management and outcomes between surgeons were noted:
    • Median total OR time was significantly different, ranging from 120-197 minutes
    • Median operation time was also different, from 75-151 minutes across the cohort of surgeons
    • Some of the surgeons had a higher proportion of patients with ED LOS < 60 minutes and OR time < 120 minutes
    • Resuscitation with red cells and plasma varied “significantly” across the surgeons
  • Mortality rates “varied significantly” across surgeons at all time points (24-hour, and hospital stay)
  • There were no mortality differences based on surgeons’ volume of cases, age, or experience level

The authors acknowledged several limitations, included the study’s retrospective and single-center nature, the limited number of patients, and its limited scope. Yet despite this, they concluded that the study “suggests that differences between individual surgeons appear to affect patient care.” They urge surgeons to openly and honestly evaluated ourselves. And of course, they recommend a large, prospective, multicenter study to further develop this idea.

Bottom line: This study is an example of a good idea gone astray. Although the authors tried to find a way to stratify patient injury (using ISS and individual AIS scores and presence of specific injuries) and intervention times (time in ED, time to OR, time in OR, op time), these variables just don’t cut it. They are just too crude. The ability to meaningfully compare these number across surgeons is also severely limited by low patient numbers. 

The authors found some fancy statistical ways to demonstrate a significant difference. But upon closer inspection, many of these differences are not meaningful clinically. Here are some examples:

  • Intraoperative FFP ranged from 0-7 units between surgeons, with a p value of 0.03
  • Postoperative FFP ranged from 0-7 units, with a p value of 0.01
  • Intraoperative RBC usage was 0-6 units with the exception of one surgeon who used 15 in a case, resulting in a p value of 0.04

The claim that mortality rates varied significantly is difficult to understand. Overall p values were > 0.05, but they singled out one surgeon who had a significant difference from the rest in 22 of 25 mortality parameters listed. This surgeon also had the second highest patient volume, at 25.

The authors are claiming that they are able to detect significant variations in surgeon performance which impacts timing, resuscitation, and mortality. I don’t buy it! They believe that they are able to accurately standardize these patients using simple demographic and performance variables. Unfortunately, the variables selected are far too crude to accurately describe what is wrong inside the patient and what the surgeon will have to do to fix it.

Think about your last 10 trauma laparotomies where your patient was truly bleeding to death. How similar were they? Is there no difference between a patient with a mesenteric laceration with bleeding, an injury near the confluence of the superior mesenteric vessels, and a right hepatic vein injury? Of course there is. And this will definitely affect the parameters measured here and crude outcomes. Then add some unfavorable patient variables like obesity or previous laparotomy.

In my estimation, this paper completely misses the point because it’s not possible to retrospectively categorize all the possible variables impacting “surgeon performance.” This is particularly true of the patient variables that could not possibly be captured. The only way to do this right is to analyze each case as prospectively as possible, as close to the time of the procedure and as honestly as possible. And this is exactly what a good trauma M&M process does!

So forget the strained attempts at achieving statistical significance. Individual surgeon performance and variability will come to light at a proper morbidity and mortality conference, and should be evened out using the peer review and mentoring process. It’s not time to start blaming the surgeon!

Reference: It is time to look in the mirror: Individual surgeon outcomes after emergent trauma laparotomy. J Trauma 92(5):769-780, 2022.

Performance Improvement

How Often Should My Trauma Operations Committee Meet?

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In my last post, I discussed how often your multidisciplinary trauma performance improvement committee (PI) should meet. As you know, one other mandatory committee is required of all trauma centers, the Trauma Operations Committee (Ops). In this post, I will:

  • describe how often your operations committee should meet
  • help you determine whether your two committees should meet on the same day or separately

How Often?

The short answer to this question is practically the same as for your PI committee, “it depends.” Whereas the PI committee schedule is determined more by the volume of your performance improvement activity, your ops committee is driven by its agenda.

First, look at what items are on your typical agenda:

  • Reports
  • Announcements
  • Policy discussion and revision
  • Marketing and outreach planning
  • TQIP report analysis
  • System issue analysis
  • Workgroup reports
  • Other stuff

Now, think back to your previous meetings. Do you sometimes have to cancel due to a lack of agenda items? Do you struggle to keep to the time allotted and frequently go over it? These are your biggest clues that let you know that you need to adjust the meeting frequency,

In general, your ops committee frequency is reasonably predictable from your trauma center level:

  • Level I – monthly
  • Moderate to high volume Level II – monthly
  • Lower volume Level II – bimonthly
  • Level III – bimonthly to quarterly
  • Level IV – quarterly

However, the agenda is really what drives meeting frequency. If you have a very active ops committee or are a “young” trauma center, this group may be very busy and need to meet more frequently than this. Base your final decision on your level of “busyness.”

To Combine Or Not Combine?

Combining your PI and Ops committee meetings has several pros and cons.

  Pros:

  • Decreases the number of meetings for everybody by one
  • Easier scheduling for attendees and venue
  • Consolidates agenda planning for the trauma admin team

  Cons:

  • May lead to loooong meetings
  • Frequently results in a less predictable start time for the second meeting
  • Requires extra administrative effort to maintain separate minutes and content
  • Often involves required attendees changing between meetings

Consider the logistics and personalities involved in your committees carefully. Do the attendees value shorter meetings with a predictable start time? Or do they just want to power through and take care of all of the business at hand?

Bottom line: First, determine the ideal frequency for your operations committee meeting. Is it the same as your PI committee? If so, consider combining them. If not, you will probably be forced to live with separate meetings. It is possible, however, to be creative. Consider a monthly PI meeting combined with the Ops meeting every other month.

What is the usual combined duration of the two meetings? If it is more than 2 hours, I recommend not combining them. That is just too long for your attendees to stay focused. If you can combine them, then look at the specific attendees for each meeting. Are they mostly the same? If they are, you are more likely to be successful when combining them. Reach out to your attendees to see if they would welcome a single meeting date and time. But warn them that it will routinely be 1.5 to 2 hours in length.

Now, plan your agendas carefully. If you have a substantial number of attendee changes between meetings, figure out how people will know when to show up for the second. It is easiest to have the smaller meeting first, and then add attendees when the second one starts. As for timing, there are two choices: always make each meeting a fixed length, or limit your first meeting to an exact length and allow the second to start at a fixed time and have a variable duration.

Finally, make sure the contents and minutes of the two meetings are separate. This keeps your documentation clean and easier to follow.

Performance Improvement

How Often Should My Trauma Multidisciplinary Performance Improvement Committee Meet?

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Every trauma center is required to have two specific committees: a multidisciplinary trauma performance improvement committee (PI) and a trauma operations committee (ops).  However, a common question is, “How often do my committees need to meet?” Let’s start with your PI committee.

The answer, of course, is “it depends.” There is no cookie-cutter, one-size-fits-all answer. In this post, I’ll review the six factors you must consider when designing your meeting schedule.

Total Patient Volume

The number of patients seen at your center directly impacts your PI committee meeting schedule. The more patient encounters, the more likely that performance issues will arise and the more likely that some will need to be aired at the full committee meeting.

PI Issue Volume

What is the total number of PI items that your program identifies over time? Busy Level I centers may find five or ten items
every day!

In contrast, an average Level IV center may only find a PI issue to pursue every few weeks. This has a noticeable impact on how often these items need to be escalated, analyzed, and discussed at your PI meeting.

PI Issue Severity

What fraction of your PI cases actually require discussion by the full committee? How many can be processed and closed by the Trauma Program Manager alone (primary review) or with the Trauma Medical Director (secondary review)? Only complex cases that require the input of multiple liaisons actually need to go to the committee.

Alternate review pathways

There are more options for review other than the primary and secondary pathways mentioned in the previous paragraph. Typical options would be direct correspondence with a liaison for simple one-service issues or discussion (and good documentation) from a morbidity and mortality conference. The use of these alternatives will reduce the number of potential cases for your PI committee and decrease the overall number of meetings needed.

Age of your Trauma Program

Are you part of a mature, long-standing trauma center? Or is your program newly minted by the American College of Surgeons or state designating agency? Newer centers benefit from sending more items to the PI committee to build engagement of the liaisons and other attendees. More frequent meetings help get them used to the review process and the frank but friendly discussions required for effective PI review.

PI Committee “Leftovers”

How often do you need to table issues or cases until the next meeting because you ran out of time? If you are chronically short of time to discuss all the agenda items, it’s time to either make the meeting longer (groan!) or schedule them more frequently.

Bottom line: These six factors listed above must be considered when choosing your meeting schedule. Here are my starting suggestions for the ideal frequencies for adult trauma centers:

  • Level I – monthly
  • Moderate to high volume Level II – monthly
  • Lower volume Level II – bimonthly
  • Level III – bimonthly to quarterly
  • Level IV – quarterly

Most pediatric centers admit lower volumes and less complex patients, which usually only warrants a bimonthly meeting.
Remember, these are starting meeting frequencies only.
If you are a new trauma center, consider more frequent meetings for your first year to get your attendees used to and invested in the process. And if you need more cases to fill the meeting or have more hold-overs until the next meeting, adjust your calendar appropriately.

In my next post, I’ll cover this same topic for your trauma operations committee.