The performance improvement review process and how to make it work in any size hospital

April 27, 2018

As announced in January 2018, throughout the year this newsletter will feature performance improvement (PI) process aspects, including event identification, levels of review, action planning and event resolution.

If, during a patient's episode of care, an event is identified — whether from nurses reporting esophageal damage from a tracheostomy, a patient complaining about delays in his or her hospital transfer, or a death triggering an internal audit filter — the case needs to be examined through a formal review process. This process is required nationally by the American College of Surgeons Committee on Trauma and is also an expected part of PI by the Minnesota Department of Health.

The 4 PI review levels, explained

A PI review process is critical at every size trauma center. A PI review process is critical at every size trauma center.

A PI review may include multiple levels, as follows:

Primary review

At this level, the PI coordinator or other professional overseeing the trauma PI program will initiate a primary review. This individual gathers information and timelines for the identified event to confirm the concern is valid and occurred as reported. The decision to be made at this level is: Can the case close with this one review, or does it need further review?

Some events have mandated progression to further review, such as mortalities or cases where action is needed to prevent event recurrence. Other events, though triggering an audit filter, may be deemed trivial and not require additional review. An example of this may include an extended time a patient remains in the trauma bay. No matter what action is taken after the primary review, accurate and complete documentation is critical to the ongoing PI process.

Secondary review

At this review level, the primary reviewer sends the case for physician review; typically this involves the trauma medical director, a staff physician or both. The physician reviewer digs deeper into the event's clinical situation, determining if policies and procedures were followed with no omitted steps, standards of care were met and clinical judgement was sound, or if opportunities for improvement existed. The decisions to be made at this level are: Was care appropriate? Is there opportunity for improvement? Is further action needed, such as education? Is this a recurring issue? Is further review warranted?

If the secondary reviewer determines none of these are needed, the case is closed; if further review is indicated, the case is referred for committee-level tertiary review. If the event needs further review, the individual overseeing the PI process sends out a tertiary review committee agenda and distributes event details to all trauma stakeholders involved. Again, whether the case is closed or sent for further review, accurate and complete documentation after the secondary review is critical.

Tertiary review

At this level, event review is conducted by a multidisciplinary committee. Tertiary review is always conducted with mortalities or high-stakes events, such as sentinel events, registration errors or incorrect patient identification. Committee membership will be determined by the level of the trauma center and the administrative policies of the medical staff. Tertiary review is more in-depth, considering all detailed event aspects, allowing for attendees' questions and perspectives. This level's decision to be made is: Was there opportunity for improvement in this patient's care? If so, what actions or system fixes might prevent recurrence? What follow-up is needed?

This committee determines an action plan for the identified event and determines responsible individuals. Tertiary review documentation involves event decisions made and follow-up plans. Documentation, as with previous levels of review, is critical, as is loop closure.

Quaternary review

If tertiary review dictates, a quaternary review may take place in each department, division or unit involved in the event, following a similar pattern of detailed review, questions and answers, next-step determination, and documentation of all activities at this level. An outside agency also may be asked to provide a quaternary review. For example, if a pediatric patient dies of an injury in a low-volume adult center, the pediatric trauma center in that region could provide such a review. A low percentage of events undergo quaternary review.

How to make the review process work in any size hospital

Review processes are essential in hospitals of all sizes, as PI and care analysis after an event are necessary to optimize care for future patients in the trauma center. "It doesn't matter what level trauma center you are," says Terri A. Elsbernd, R.N., trauma coordinator at Mayo Clinic's Level I Pediatric Trauma Center in Rochester, Minnesota. "All centers should have the same PI process."

The sticking point, then, may be how to operationalize the review process — the secondary review in particular — at a lower volume trauma center.

Suggestions follow for implementing PI review processes at smaller hospitals, from Todd M. Emanuel, R.N., Trauma Center PI coordinator at Mayo Clinic Hospital — Rochester, and Eduardo Antpack, M.D., of Trauma/Critical/General Surgery at Mayo Clinic's Rochester, Minnesota, campus and Mayo Clinic Health System locations in Albert Lea and Austin, and Austin trauma medical director:

Inspire involvement and engagement

Dr. Antpack recommends making a concerted effort to engage more people in the review process, thus providing more heads to think through the event and more buy-in. Without this effort, the same assigned committee members may come all the time. One option he suggests for broadening involvement is asking a whole group, such as Emergency Medicine, to look at the event and offer input, rather than just a department representative. In committee review meetings, Dr. Antpack makes clear he wants everyone's input, and he tries to stay mostly quiet to let others talk.

Emanuel also suggests that the trauma program coordinator model involvement and engagement to inspire other hospital employees' trust in the PI process. He encourages courtesy and respectful dialogue during the review process communications.

Create a nonpunitive, positive culture

In order to successfully conduct event reviews, a nonpunitive, positive process is critical. The approach, says Emanuel, should be to reframe the case by asking, "If this was your family member, how could we better care for a patient like this next time?"

Emanuel also advocates attention to review process nomenclature: avoiding words such as "error" or "wrong," and using words such as "concern," "event" or "issue," stating, "This is not internal affairs — it's blameless."

Dr. Antpack says he tries to establish immediately that the review process is not to blame or find someone to punish. Alternatively, he's found focus on the system and devising a solution is preferable, making clear the process is in the patient's best interest. He also concentrates on positive aspects of event conversation. Another tactic Dr. Antpack utilizes is spending time reviewing cases that went well, in addition to cases that went poorly, to keep attitudes more positive.

Flatten hierarchy

To have an effective review process where all can speak freely and address issues, every person participating needs to be empowered. At tertiary review committee meetings, Dr. Antpack proactively solicits input from all attendees, asking specific members: What do you think? How can we improve?

Dr. Antpack admits sometimes he's seen employees feel intimidated by surgeons involved in the review process. "Based on historical personalities, surgeons tend to be more intense," he says. "I try to break that paradigm and be very personable and approachable. Surgeons don't know it all and need help from those with other expertise."

To flatten hierarchy and make himself more relatable, Dr. Antpack works hard at building relationships broadly, even creating opportunities for employees to get to know him outside the patient care atmosphere.

Don't procrastinate on paperwork

Make time to review one or two cases a day, and don't let the work pile up. Incremental progress can be satisfying, says Dr. Antpack.

"You must not amass a huge stack of charts — you'll just look at it and sigh," Dr. Antpack says. "The more charts you see, the less likely you are to work on that review. If you divide it into smaller daily parts, you can get it off your desk and give it to those who can close the loop. Letting a lot of things accumulate will drag the process down."

Make use of available resources

Many resources are available for trauma center personnel navigating the PI review process. Trauma center or hospital intranet policies, PI and clinical practice guidelines, and also Southern Minnesota Regional Trauma Advisory Committee website's practice management guidelines may be invaluable for reference when reviewing a case.

For more information

Trauma Quality Improvement Program. American College of Surgeons.

Hospital performance improvement. Minnesota Department of Health.

Trauma Coordinator Orientation Manual for Level IV Trauma Centers. Southern Minnesota Regional Trauma Advisory Committee.