Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and...

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MN Trauma System MN Trauma System Performance Improvement Performance Improvement Lisa Irwin, RN, MPA:HA Lisa Irwin, RN, MPA:HA

Transcript of Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and...

Page 1: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

MN Trauma System MN Trauma System Performance ImprovementPerformance Improvement

Lisa Irwin, RN, MPA:HALisa Irwin, RN, MPA:HA

Page 2: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

MN PI Plan MN PI Plan

Best Practices of other systemsBest Practices of other systems

National recommendationsNational recommendations

Data Driven Data Driven

MTR with linkagesMTR with linkages

Scalable to system implementationScalable to system implementation

““LivingLiving”” document document

Page 3: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

PI Plan SectionsPI Plan Sections

Overview Overview

Sections represent phase of system careSections represent phase of system care

EMSEMS

HospitalHospital

RehabilitationRehabilitation

Regional Regional

StatewideStatewide

Page 4: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

PI Plan ComponentsPI Plan Components

Purpose and goalsPurpose and goals

Structure and responsibilitiesStructure and responsibilities

Patient populationPatient population

Data collection and validationData collection and validation

Scope of review and key activitiesScope of review and key activities

Evaluation Evaluation

Improvement actionsImprovement actions

Documentation and reporting Documentation and reporting

Page 5: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

Purpose and Goals of PIPurpose and Goals of PI

Alleviate unnecessary death/disability Alleviate unnecessary death/disability

Reduce inappropriate variation in careReduce inappropriate variation in care

Target injury prevention Target injury prevention

Optimize trauma care and outcomesOptimize trauma care and outcomes

Promote efficient, cost effective carePromote efficient, cost effective care

Page 6: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

Structure for PIStructure for PI

MDH

STAC

RTRACs

Trauma Centers

EMS

Page 7: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

State/Regional PI Committee State/Regional PI Committee

Multidisciplinary Multidisciplinary

State/RegionState/Region--wide representationwide representation

Chaired by surgeon/physicianChaired by surgeon/physician

Leadership and expertise from regional Leadership and expertise from regional trauma centerstrauma centers

MDH provides oversight and guidanceMDH provides oversight and guidance

Page 8: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

Responsibilities Responsibilities

Establish expectations and system standards for Establish expectations and system standards for optimal trauma care optimal trauma care

Evaluate trauma care processes and outcomesEvaluate trauma care processes and outcomes

Identify injury causes and prevention needsIdentify injury causes and prevention needs

Develop and implement system improvement Develop and implement system improvement initiativesinitiatives

Monitor effectiveness of corrective activities Monitor effectiveness of corrective activities

Page 9: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

Patient PopulationPatient Population

Injured patients who meet criteria for trauma Injured patients who meet criteria for trauma system care system care –– Triage CriteriaTriage Criteria

Injured patients who are discharged from the Injured patients who are discharged from the hospital with an ICDhospital with an ICD--99--CM diagnosis 800.00CM diagnosis 800.00-- 959.9, excluding 905959.9, excluding 905--909.9, 910909.9, 910--924.9, and 924.9, and 930930--939.9939.9

All trauma related hospital admissionsAll trauma related hospital admissions

Any trauma related deathAny trauma related death

Any trauma transfer either into or out of the Any trauma transfer either into or out of the hospitalhospital

Page 10: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

Patient Population Patient Population

MTR MTR Inclusion CriteriaInclusion Criteria

Current algorithm excludes patients who Current algorithm excludes patients who meet trauma IDCmeet trauma IDC--9 criteria but 9 criteria but did not did not havehave::

Trauma team activated Trauma team activated -- Monitor compliance?Monitor compliance?

LOS >48 hours LOS >48 hours –– Evaluate triage criteria?Evaluate triage criteria?

ICU admitICU admit

TransferTransfer

DeathDeath

Page 11: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

Data Sources for PIData Sources for PI

MTR with data linkages MTR with data linkages --

EMS, TBI, HDIEMS, TBI, HDI

Hospital medical recordsHospital medical records

Prehospital care recordsPrehospital care records

Public safety reports Public safety reports --

FARSFARS

99--11--1 dispatch records1 dispatch records

Medical examiner reportsMedical examiner reports

Hospital PI findingsHospital PI findings

Page 12: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

MN Trauma RegistryMN Trauma Registry

Data elements that meet PI needs Data elements that meet PI needs –– Rehabilitation?Rehabilitation?

Standardized data definitions and Standardized data definitions and reportingreporting

Uniform coding (ICDUniform coding (ICD--9, ISS, E9, ISS, E--code)code)

Data validation of at least 5% of casesData validation of at least 5% of cases

Standardized reports and data requestsStandardized reports and data requests

Page 13: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

Scope of Review and Key ActivitiesScope of Review and Key Activities Local EMS AgencyLocal EMS Agency

Communications Communications

Medical controlMedical control

Triage and transportTriage and transport

EMT training and certificationEMT training and certification

Equipment & safetyEquipment & safety

DocumentationDocumentation

Case reviewCase review

Page 14: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

Case ReviewCase Review

Led by physician director or advisorLed by physician director or advisor

Review injured patients who:Review injured patients who:

Die or require CPR Die or require CPR

Had prolonged extricationHad prolonged extrication

Require online medical authorizationRequire online medical authorization

Meet physiologic or anatomic triage criteriaMeet physiologic or anatomic triage criteria

MassMass--casualty or multiple patient scenescasualty or multiple patient scenes

Helicopter transport or requestsHelicopter transport or requests

Met trauma triage criteria but transported to a nonMet trauma triage criteria but transported to a non-- trauma facilitytrauma facility

Complaints and referrals from any sourceComplaints and referrals from any source

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EMS EvaluationEMS Evaluation

Goal of EMS Goal of EMS

Prevent Prevent further injuryfurther injury

Focus on care processes Focus on care processes and outcomeand outcome

Timely assessment and Timely assessment and extricationextrication

Appropriate and timely Appropriate and timely resuscitation/stabilizationresuscitation/stabilization

Safe and rapid transport to Safe and rapid transport to appropriate facilityappropriate facility

Page 16: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

Local Trauma Center PILocal Trauma Center PI

Level I/II Level I/II

ACSACS

Level III/IV Level III/IV

MN requirementsMN requirements

MN Trauma PI Plan serves as guideMN Trauma PI Plan serves as guide

Purpose/goals are the same at every levelPurpose/goals are the same at every level

Principles are the same at every level Principles are the same at every level

Page 17: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

Local Trauma Center PI Local Trauma Center PI

Defined PI program and structureDefined PI program and structure

Multidisciplinary trauma PI committee Multidisciplinary trauma PI committee chaired by TMD chaired by TMD –– includes EMSincludes EMS

Peer reviewPeer review

Driven by trauma registry data Driven by trauma registry data

Case reviewCase review

Page 18: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

Trauma CommitteeTrauma Committee

Evaluates care processes and outcomes Evaluates care processes and outcomes including EMSincluding EMS

Reviews cases that Reviews cases that ““fall outfall out”” & deaths& deaths

Evaluates trends Evaluates trends

focused auditsfocused audits

Implements corrective action with Implements corrective action with f/uf/u

Refers cases for further reviewRefers cases for further review

Identifies cases for educationIdentifies cases for education

Page 19: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

Trauma Peer ReviewTrauma Peer Review

Process/structure variesProcess/structure varies

Chaired by TMDChaired by TMD

Attended by TNCAttended by TNC

Deaths, complications, Deaths, complications, and sentinel eventsand sentinel events

Case determinationsCase determinations

Outside peer review?Outside peer review?

Page 20: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

Injury Rehabilitation PI Injury Rehabilitation PI -- GoalsGoals

Mitigate injury related disability and Mitigate injury related disability and secondary conditions by promoting secondary conditions by promoting optimal care practices optimal care practices

Establish systemEstablish system--wide expectations of care wide expectations of care

Monitor and evaluate care processesMonitor and evaluate care processes

Implement PI initiatives for variationsImplement PI initiatives for variations

Page 21: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

StructureStructure

Hospitals, Rehabilitation facilities, and Hospitals, Rehabilitation facilities, and State PI CommitteeState PI Committee

Evaluate process of rehabilitative care Evaluate process of rehabilitative care (therapies, timeliness, access, etc)(therapies, timeliness, access, etc)

Evaluate outcomes Evaluate outcomes

function, cognition, function, cognition, mobility, secondary conditions, etc.mobility, secondary conditions, etc.

Develop, implement, and monitor PI initiativesDevelop, implement, and monitor PI initiatives

Page 22: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

Disability and Rehabilitation Data Disability and Rehabilitation Data

Develop data Develop data ““corecore”” within MTR within MTR

Functional (physical, cognitive, etc.) status Functional (physical, cognitive, etc.) status measures through care continuummeasures through care continuum

Rehabilitation therapies Rehabilitation therapies –– timeliness, access, timeliness, access, appropriateness, support services, etcappropriateness, support services, etc

Development of secondary conditions Development of secondary conditions

Hospital discharge dispositionHospital discharge disposition

LongLong--term followterm follow--up up –– Quality of lifeQuality of life

Page 23: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

Regional PIRegional PI

Multidisciplinary PI Committee (RTAC)Multidisciplinary PI Committee (RTAC)

Lead regional hospital Lead regional hospital

leadershipleadership

Meet in executive session Meet in executive session

Evaluate system care processes and outcomes Evaluate system care processes and outcomes

Review deaths within region Review deaths within region

Develop, implement, and monitor PI initiativesDevelop, implement, and monitor PI initiatives

Data from MTR, medical recordsData from MTR, medical records

Page 24: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

Evaluation Evaluation –– Process of Care Process of Care Appendix AAppendix A

Aspect of CareAspect of Care IndicatorIndicatorTriage Triage Under and overUnder and overResponseResponse Timeliness of respondersTimeliness of respondersAccessAccess Hospital, specialists, OR, Hospital, specialists, OR,

radiology, lab, blood, etc.radiology, lab, blood, etc.CareCare ATLS and practice guidelinesATLS and practice guidelinesTransferTransfer Timeliness, transport mode, Timeliness, transport mode,

personnel, communication, etc. personnel, communication, etc.

Page 25: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

Evaluation Evaluation –– OutcomeOutcome Appendix BAppendix B

Outcome MeasureOutcome Measure IndicatorIndicatorComplication Complication Any event that deviates from an Any event that deviates from an

anticipated uneventful recoveryanticipated uneventful recoveryMortalityMortality Any trauma deathAny trauma deathLength of stayLength of stay ICU and total hospital daysICU and total hospital daysCostCost Cost of care and servicesCost of care and servicesDisability Disability FIM, DRS, Rancho, GOS, FIM, DRS, Rancho, GOS,

Quality of Life Quality of Life SatisfactionSatisfaction Patient perspectivePatient perspective

Page 26: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

Regional Mortality ReviewRegional Mortality Review

Mortality prediction Mortality prediction ––

TRISS or alternate logistic TRISS or alternate logistic model (ISS, age, BP, and Glasgow motor score) model (ISS, age, BP, and Glasgow motor score)

Review unexpected outcomes Review unexpected outcomes ––

preventability, preventability, trends, improvement opportunities, etc trends, improvement opportunities, etc

Preventability determination based on prePreventability determination based on pre-- defined definitions (Appendix D)defined definitions (Appendix D)

Monitor rates and trends; implement Monitor rates and trends; implement improvement initiativesimprovement initiatives

Page 27: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

Statewide PI Statewide PI

Multidisciplinary committee (STAC)Multidisciplinary committee (STAC)

MDH MDH

oversight and staff supportoversight and staff support

MTR MTR

reports and datareports and data

Evaluates system processes and outcomesEvaluates system processes and outcomes

Develop, implement, and monitor PI Develop, implement, and monitor PI initiativesinitiatives

Page 28: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

Scope of Review Scope of Review –– Global Issues Global Issues Appendix JAppendix J

Examples Examples

EMS time EMS time –– 911 to hospital arrival (dispatch, 911 to hospital arrival (dispatch, response, scene, transport) response, scene, transport)

AirAir--medical usage medical usage

Triage criteria Triage criteria

Morbidity and mortality ratesMorbidity and mortality rates

DisabilityDisability

Demographic and injury characteristics Demographic and injury characteristics

Data is stratifiedData is stratified by county, region, hospital, by county, region, hospital, injury severity, diagnoses, Ps, age, etc.injury severity, diagnoses, Ps, age, etc.

Page 29: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

Process Process –– EMS ResponseEMS Response

Standards Standards established in planestablished in plan

Response monitored Response monitored quarterlyquarterly

Benchmarks Benchmarks evaluated annuallyevaluated annually

10.62

8.08

10.86

14.31

14.41

11.8

15.89

23.02

15.02

15.65

16.23

16.46

16.38

15.32

16.26

16.03

15.77

17.29

13.43

16.11

17.06

17.28

13.73

16.98

19.85

15.7

22.33

20.42

22.01

18.12

Statewide

ATAB 1

ATAB 2

ATAB 3

ATAB 4

ATAB 5

ATAB 6

ATAB 7

ATAB 8

ATAB 9

0 10 20 30 40 50 60

Minutes

Response SceneTransport

Excludes cases with extricationIncludes transporting agency times only

Page 30: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

PI ActionsPI Actions Appendix IAppendix I

Revisions to protocols, policies, and practice Revisions to protocols, policies, and practice guidelinesguidelines

Targeted Education Targeted Education –– ““M & MM & M”” ConferencesConferences

Provider counseling Provider counseling -- physician, TC, EMS, etc.physician, TC, EMS, etc.

Change in credentialing or designationChange in credentialing or designation

Focused Reviews Focused Reviews

Page 31: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

Focused Reviews, Audits, StudiesFocused Reviews, Audits, Studies……..

State PI State PI Examples Examples

3rd trimester pregnant trauma 3rd trimester pregnant trauma –– M & M M & M conference, practice guideline conference, practice guideline

CHI CHI –– M & M Conference, practice guideline ( M & M Conference, practice guideline ( Appendix I)Appendix I)

Geriatric trauma Geriatric trauma –– M & M, guideline, IP, M & M, guideline, IP, publishedpublished

Triage Criteria Triage Criteria –– Protocol revision, publishedProtocol revision, published

Page 32: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

Focused Reviews, Audits, StudiesFocused Reviews, Audits, Studies……..

Regional PI Regional PI Examples Examples

AirAir--medical utilization medical utilization –– protocol revision, protocol revision, educationeducation

TrachTrach/PEG placement /PEG placement –– practice guidelinepractice guideline

InterInter--hospital transfers hospital transfers –– M & M conference, M & M conference, protocol, standard formprotocol, standard form

EMS CPR EMS CPR –– protocol, educationprotocol, education

Field ETT Field ETT –– protocol revision, training standards, protocol revision, training standards, equipment, and educationequipment, and education

Page 33: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

Documentation and ReportingDocumentation and Reporting

Minutes with discussion, findings, actionsMinutes with discussion, findings, actions

Annual report (TC, regions, state) Annual report (TC, regions, state) –– mortality/morbidity rates, improvement mortality/morbidity rates, improvement initiatives, results, etc. initiatives, results, etc.

Protect against discovery and disclosureProtect against discovery and disclosure

Page 34: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

Confidentiality ProtectionConfidentiality Protection

Convene in executive sessionConvene in executive session

Confidentiality statement (Appendix F)Confidentiality statement (Appendix F)

Meeting materials Meeting materials --

# documents, marked # documents, marked ““confidentialconfidential””, statutory citation, statutory citation

Stored in locked file cabinetStored in locked file cabinet

Legal sanctions for breaches Legal sanctions for breaches

Page 35: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

RecommendationsRecommendations

Establish specific trauma system PI Establish specific trauma system PI confidentiality statute (Appendix H)confidentiality statute (Appendix H)

Revise MTR inclusion criteria to capture overRevise MTR inclusion criteria to capture over-- triage and measure compliancetriage and measure compliance

Evaluate MTR data points to assure PI questions Evaluate MTR data points to assure PI questions can be answered can be answered

Establish data linkages Establish data linkages –– EMS, TBI, ME, Vital statsEMS, TBI, ME, Vital stats

Establish rehabilitation data core Establish rehabilitation data core

Page 36: Trauma System PI - Minnesota Department Health Plan Components Purpose and goals Structure and responsibilities Patient population Data collection and validation Scope of review and

Recommendations Cont.Recommendations Cont.

Implement data validation process Implement data validation process (Appendix K) (Appendix K)

surveyssurveys

Provide trauma PI education and support Provide trauma PI education and support to Level III and IV hospitals, and EMSto Level III and IV hospitals, and EMS

Establish PI structure (Establish PI structure (RTACsRTACs, STAC), STAC)

Adopt methods for evaluating care Adopt methods for evaluating care processes and outcomes processes and outcomes

Appendix AAppendix A--EE


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