PI in low-volume centers takes commitment, creativity

Few jobs are more challenging than medical director of a low-volume trauma center. Most directors have other, equally demanding positions — their trauma FTE may be as little as 0.2 or 0.3 — and many have little actual training in trauma management. Both problems compound the inherent difficulty of performance improvement (PI) in Level III and Level IV centers.

John Cumming, M.D., a trauma surgeon at Hennepin County Medical Center in Minneapolis who is actively involved in helping small hospitals develop successful PI programs, is keenly aware of the challenges their directors face.

"It's very, very difficult when your primary focus isn't the program you help run, so you have to be absolutely committed to the process. That is vital," he says. "When I talk to folks, I tell them that what matters at the end of the day isn't about passing the review or getting redesignation, it's about providing the best care the facility can provide with the resources it has available. The whole goal is doing the best for our sons and daughters — everyone in the community — and it's easy to tell who is really committed and who isn't."

Wide latitude in PI process

Yet even the most dedicated directors are likely to find meeting PI process requirements daunting. What makes it possible, Dr. Cumming says, is that although certain elements of PI are proscriptive, the process itself isn't.

He explains, "You have to meet the elements, but how that gets done is up to each institution. For instance, it's almost impossible to have a separate meeting for PI when you have limited personnel with limited availability. So instead, when you have a quarterly staff meeting, take 15 or 20 extra minutes to talk about PI issues, and that's your meeting. You have to meet the parameters, but no one is telling you how to do it."

In addition to identifying issues, an effective PI process requires developing an action plan — another challenge for trauma directors with limited resources and trauma experience. But here, too, there is room for adaptation and innovation.

"The Eastern Association for the Surgery of Trauma (EAST) practice management guidelines don't always apply to tiny rural hospitals," Dr. Cumming points out. "Sometimes EAST guidelines can be modified to suit a particular facility, but hospitals often need to develop their own after they've identified issues and come up with an action plan."

The regional trauma advisory committee helps walk small hospitals through the process, but sometimes there just aren't enough providers to make it work.

"At the extreme end, some Level IV centers aren't continually staffed by doctors. Sometimes it's just a physician assistant or two. How do you review cases effectively when it's just two people?"

One idea, he says, is to remove identifiers from a few of the more challenging cases and have them reviewed at the annual meeting of the Southern Minnesota Regional Trauma Advisory Committee (SMRTAC). Members would then discuss how to develop an action plan. But he acknowledges that so far no good solutions have been found for situations where there are just too few people to undertake peer review.

On the other hand, most issues at that level are related to systems, not providers.

"People tend to ask questions such as, 'Why is the CT scanner down most of the time?' or 'Why is it taking 45 minutes to get patients through the scanner?' " Dr. Cumming says. "And if that's what they can do as far as PI, based on limited time and personnel, we should be happy because they're raising the bar for all trauma systems across the state. They need to look critically at systems and processes to see how they can improve things at the hospital to do the best they can with their resources."

Ultimately, though, trauma PI, however modest, isn't going to work without a committed director.

"What makes the program is if someone is really committed to performance improvement for the sake of the community and not just to pass a test," Dr. Cumming says. "These are the people who understand that care at their hospital is important because the next patient might be their son or daughter."

That ideal can be difficult to put into practice, though. Dr. Cumming notes, "One of the biggest challenges facing the trauma medical director is that not everyone has the same level of commitment."