Closing the loop: The final step in the PI review process

As previously noted, this newsletter has featured performance improvement (PI) process steps, including event identification, levels of review, action planning and now event resolution in 2018. This is the series' final article.

Closing the loop

As trauma centers undergo PI review processes, the most frequently overlooked step is No. 4, the final one: event resolution. Centers may identify and review problems, but don't always bring them to closure.

"Just coming up with a plan doesn't resolve an event," says Terri A. Elsbernd, R.N., pediatric trauma coordinator at Mayo Clinic Hospital, Saint Marys Campus. "You need to see a change via clinical practice or data."

Carol R. Immermann, R.N., Mayo Clinic Trauma Center program manager, emphasizes trauma centers truly need the loop-closing step. If this aspect is missed or put off, the same problem initially identified is bound to recur.

Immermann tells a story of committee meetings at a hospital years ago, where the issue of the anesthesia team not appearing when paged for trauma cases arose repeatedly. No one knew the reason or even asked why — everyone was just frustrated anesthesia wasn't doing its part. Eventually, a staff member discovered why anesthesia didn't come: The team couldn't hear the overhead pages in the operating rooms. The hospital then got pagers for the anesthesia team, and arrival compliance reached 100 percent for code team needs.

In this example, what's crucial is not stopping the PI process after implementing the action plan — in this case providing pagers. Rather, it's important to evaluate the success of the plan. Monitoring anesthesia response compliance over a matter of three to six months with a continued success rate would demonstrate a successful action plan and an event ready for loop closure.

Action plan completion is not event resolution, though this notion is common in hospitals' PI processes. This is a misnomer, akin to noting a vehicle making a funny noise, taking it to a repair shop where the mechanic says, "I fixed it," then driving away and continuing to hear the noise that prompted the repair visit.

"It is easy to be a bit numb to the PI process after a while," Immermann says. "Monitoring success takes time, and often during that time new events occur. However, bringing issues to closure is crucial so as to prevent or mitigate the same problems in the future. Why bother to go through a quality review process if you're not going to see if it's successful or not?

"The bottom line is that we are doing what is needed for safe patient care."

What event resolution is

The basis of PI involves identifying a problem, looking at means to address it and moving to a solution. Beyond simply enacting an action plan, event resolution involves two components: Problem solved.

The first part of event resolution is actually fixing the problem identified. Solving the problem is like the pat on the back for your success, Immermann says. However, when trauma centers keep running into the same problem repeatedly, doing the same thing over and over while expecting different results, the problem likely is that the action plan was not the correct one.

While it's human nature to think, "I'll just keep trying harder," unless the issue is resolved, it's time to backtrack and re-engineer the plan. Even if you thought your plan definitely would fix the issue, if it's not meeting the measurement you outlined for success, it's time to propose a new one.

"It is important not to think you have failed just because the problem was not fixed," Immermann says. "Stop, reassess and consider alternate plans."

Data to prove success

Event resolution also involves providing evidence of change. The action plan needs clearly defined success criteria followed by a measurement period demonstrating problem rectification or appropriate issue mitigation. An example of showing data over time proving a change would be numbers tracked indicating that undertriage rates decreased from 20 percent to 5 percent over a six-month period after the initiation of an action plan.

Immermann says at times trauma centers run into measurement trouble by either measuring for too short a time period or measuring "forever." She recommends tracking a plan's outcomes for three months to a year to demonstrate success with sufficient data. Each trauma center's patient volume and relevant event frequency impact appropriate measurement time. For instance, if you are trying to improve timeliness of your hospital's burn patient transfer, the low frequency of this injury would require longer measurement.

Collected data should be tracked in a trauma registry or spreadsheet program and reported regularly at trauma committee meetings during the measurement process.

Benefits of event resolution

Beyond gratification experienced when data demonstrates successful event resolution, trauma centers also will reap the following benefits from seeing issues through to measurable results:

Garnering leadership support

If your trauma program's goal is increased or continued hospital support, demonstrating quality projects with data  indicating successful issue resolution can help communicate the program's high performance to administration.

Demonstrating quality PI at site visits

Trauma site reviewers are looking for PI programs that provide evidence of plans undertaken and reports indicating success. Event resolution is all the more important as many hospitals fall down in this PI phase, according to Immermann. Lack of event resolution evidence is cited as the No. 1 reason hospitals in Minnesota don't pass site visits, with many requiring extensions to demonstrate success in this area.

"This is why I've been in trauma for so long," says Immermann. "It's satisfying that we not only identify our problems and resolve them, but also that we have data proving our success. This model works for all levels of trauma care."