Trauma Center Performance Improvement - Principles and Practice, With Illustrative Case Studies

Description

First-of-its-kind book devoted to comprehensive coverage of trauma performance improvement with case studies Written by a senior, experienced trauma center site visitor Case studies will be uniquely useful to readers in that it will illustrate the relevant concepts Preface Acknowledgments Abbreviations Contents About the Author Chapter 1: What Is PI? (and What It Is Not) Why PI? Definitions of Process Improvement and Patient Safety What Is “Ego-Based” Medicine? Science of Safety Differentiating PI from the Discussion and Peer Review References Chapter 2: Philosophy of PI Avoiding Bias and Ageism Triage of Issues Frequent Versus Rare, Significant Harm Versus Trivial Harm Chapter 3: PI Techniques and Tools PDSA Brent James and Intermountain Health [2] Six Sigma [3] Lean [4] TOPIC [5] References Chapter 4: Program Personnel and Regulatory Requirements Leadership Data Collection Meetings Chapter 5: Program Setup What Is Reviewed? Deaths Audit Filters Performance Measures and Benchmarking Tools Reference Chapter 6: Trauma Registries and Other Data Sources Purpose of the Registry Registry Leadership Routine Activities Special Activities Research Versus PI Chapter 7: Event Identification Safety Reporting (Hospital and Trauma Program) Sentinel Events Collection of Events Initial Discussion Chapter 8: Levels of Review Examples Deaths Adverse Events System Issues Personal Issues Chapter 9: Documentation of PI Process and Meeting Minutes What Is the Minimum Documentation? Templates Coordination Systems Situational Awareness of Open Issues Review of Opportunities for Improvement Chapter 10: Loop Closure What Does Loop Closure Mean? Can You Close All Loops? Loop Closure Methods Discussion Education Personal Intervention Equipment Alterations Guidelines Hardwiring Change Use of EMR Gatekeepers and Safety Officers Chapter 11: Types of Issues Clinician Performance and Decision-Making Vignette 1 Performance Improvement Investigation Discussion Corrective Action Plan Blood Transfusion Error Vignette #2 Performance Improvement Investigation Discussion Corrective Actions Staffing and Education Problems Vignette #3 Performance Improvement Analysis and Opportunities for Improvement External Issues (EMS, Transfer Hospitals) Vignette #4 Transfer Hospitals Vignette #5 Chapter 12: Complex Opportunities for Improvement and Difficult Loop Closure Physician Practice and Disagreement Among Specialists Nursing and Hospital Practice Conflict with Hospital Quality Programs Financial Limitations FTEs Equipment The Interdepartmental Conflict Lack of Hospital or Clinician Commitment Chapter 13: Inspection of PI Process by Reviewers Chart and Document Setup Content of Documents Supplemental Material Open Loops Reference Chapter 14: Performance Improvement Case Studies Documents and Slides Cases Missed Injuries Failure to Rescue and Escalation The Impact of Learners on Outcomes, Airway Management Unstable Patients at Referring Hospitals New Technologies Airway Management Patients with Life-Threatening Injuries Who Die in the Operating Room Life-Threatening Thoracic Trauma Adverse Events Dislodged Gastrostomy Tubes Optimal Case Pediatric Geriatric Death with Low Injury Severity and Multiple Comorbidities A Patient with Multiple Life-Threatening Conditions Index