Performance improvement: Identifying problems is just the first step

Performance improvement (PI) — the confidential, systematic review of patient care — is vital to the success of trauma programs. But implementing and maintaining an effective PI process is challenging for high-volume centers and even more so for smaller hospitals with limited resources.

"All trauma programs must have a PI process to improve systems and patient safety, but it's never quick or easy," says Terri A. Elsbernd, R.N., pediatric trauma director at Mayo Clinic Hospital, Saint Marys Campus, a Level I Trauma Center in Rochester, Minn.

For one thing, continual monitoring of systems, processes and outcomes for areas needing improvement is time- and data-intensive, even when audit filters — clinical events that trigger a review — are used to help identify issues.

Proactive PI

"The audit filter brings the case forward for review," Elsbernd explains. "Every time a patient is transferred to a higher level of care, we have to review that. And we need to review every trauma patient who dies in the hospital. We look for opportunities for improvement — if a patient dies, is it because of something we did or didn't do? Or would that death have occurred no matter what we did? That's what a PI review seeks to discover."

In Minnesota, Level III and Level IV Trauma Centers are required to use certain audit filters, which can be expanded, depending on program needs. For example, centers with a low-volume pediatric population might consider adding pediatric-specific filters, such as transfers to a nonpediatric trauma center or fluid resuscitation greater than 40 cc per kilogram in a child without hemodynamic instability.

Minnesota-mandated filters for Level III and Level IV Trauma Centers

  • Trauma care provided by a doctor who does not meet educational requirements
  • Trauma transfers
  • Trauma deaths
  • ED provider noncompliance with on-call response times
  • General surgeon noncompliance with on-call response times (Level III only)
  • Admission to a nonsurgical service
  • Trauma care rendered by nurse practitioners or physician assistants

Elsbernd cautions that trauma centers shouldn't wait for a bad outcome to review a case, noting that Donald Jenkins, M.D., medical director of Mayo Clinic's Level I Trauma Center describes proactive PI this way: "Imagine a football game in which the quarterback is repeatedly sacked. Just before being sacked again, he throws a Hail Mary pass. The receiver almost misses the ball but manages to catch it just inches from the sideline. The team wins, but the execution is terrible. The point is, don't assume a case doesn't need review, just because it has a good outcome."

Addressing problems

Identifying issues is just the beginning of the process. Once a problem is found, an action plan must be developed to address it. In some cases, a hospital might create a new practice management guideline to ensure standardized care. In others, team development, classes, simulation training, counseling or changes in resource allocation may be the best way to resolve issues. Ideally, whatever changes take place lead to better outcomes and a strengthened commitment to improved care.

When a trauma team is developing an action plan, Elsbernd stresses that the takeaway message for both large and small hospitals is the same.

"The question I always have in the back of my mind is, 'If this case were to occur again, what can I do to make sure the outcome is not the same? Will what I'm going to do make a difference?' "

Help for low-volume centers

When the Minnesota trauma system was first developed a decade ago, it became clear that few resources were available to help Level III and Level IV centers initiate a PI process in their hospitals.

"All the courses are geared for Level I and Level II hospitals, but the trauma issues are very different in smaller centers," Elsbernd says. And it's not intuitive; it's not something you learn in nursing school. You have to teach smaller hospitals how to do it. How do you get the team clued in to issues? How do you create audit filters? How do you track issues and move forward?"

To meet this need, the Mayo Clinic Trauma Center, under Dr. Jenkins' guidance, developed a PI seminar series specifically for smaller hospitals. The response to the seminars has been overwhelmingly positive, PI has improved significantly in participating centers and the entire curriculum has become a staple of the Southern Minnesota Regional Trauma Committee's educational programs.

Performance Improvement seminars

Contact Debra (Deb) E. Horsman R.N., for more information on the Level III and Level IV Performance Improvement seminars.