TRAUMA QI & PEER REVIEW

1. TRAUMA QI & PEER REVIEW Katrina Strowbridge, BSN, RN, CWS How’s it happen?

2. Why a review process? Trauma Designation Organized trauma program required for all levels of designation to include: Multidisciplinary trauma committee Trauma Peer Review (with multidisciplinary committee) Performance Improvement activities related to the findings of chart review and Peer Review

3. Whatsa“Multidisciplinary Committee”??? = • RN’s • MD’s • Support Staff • Prehospital Providers Trauma Committee ………..right?

4. that does peer review of charts ……. …..right?

5. ……so, how do ya do peer review of trauma cases…. Multidisciplinary Trauma Committee is NOT the Medical Staff Peer Review Committee

6. TRAUMA COMMITTEEPEER REVIEW

7. New Process Case Selection for record review: Record Selection via Daily Rounds Trauma Coordinator gleans information from staff Trauma Registrar review of ED log ER charge review by RN Chart identified by staff, physicians, department, etc Meditech reports – ICD-9 diagnosis codes & discharge disposition

8. Focusing on: Discharge Disposition Treated and discharged home or transferred Identified via daily review as described If immediate concerns, reviewed by TC and Trauma Medical Director/Chief of Staff If no immediate concerns, coded by HIM Record reviewed by TC and TR using a review worksheet.

9. Discharge Disposition cont. Treated and Admitted to IP or OPO Identified via daily reviews as described Allows for concurrent review with more immediate documentation available in the form of progress notes, physician orders, H&P, etc. Immediate concerns reviewed with Trauma Medical Director/Chief of Staff

10. Case identified, review begins Trauma Committee Case Review Worksheet PI form used to abstract record Indicators approved by Medical Staff & Trauma Committee Tracks key indicators used for QI processes Developed from samples received from other CAH’s & WRTAC sample forms. Driving force for data collection of trauma related QI activities and documentation source for the review process.

11. Case Review “types” drive process • Primary Review • Secondary Review • Tertiary Review

12. Primary Review • Trauma Registrar • Initiates Trauma Committee Review form for each case reviewed • Forwards patient record and TCR form to Trauma Coordinator • Trauma Coordinator • Review record, validates findings, finds new issues • Immediate resolution, feedback with identified issues & documentation of PI loop closure

13. Secondary Review • Trauma Coordinator reviews/validates findings, finds new issues • Medical Staff review of identified issues, supports investigation and assists in plan development • 1:1 education (any discipline {RN: RN, MS: MS}, group education @ TC • May be closed at this level or forwarded for further action based on findings • Refer to Multidisciplinary Trauma Committee or Medical Staff Peer Review Process

14. Tertiary Review • Trauma Coordinator & Medical Staff/Peer Review • WRTAC &/or STAC • Findings documented in PI loop closure • Education may still be 1:1, generally group @ large via Trauma Committee or regional efforts if required

15. Clinical Indicator Report • Trauma Registrar is responsible for completion of and reporting of data • Data pulled from Trauma Committee Case Review form • Entered into Clinical Indicator Report • Clinical Indicator Report shared with Trauma Committee • Used for ongoing monitoring • Identification of trends and issues

16. Peer Review Confidential – confidential – confidential – confidential – confidential – confidential

17. Peer Review Process It is important that providers feel “safe” giving honest feedback to colleagues and this trust environment takes time to establish. The providers also need to feel empowered by Administration to tackle hard issues, require changed behaviors and performance of some peers and be able to hold colleagues accountable.

18. Trauma Committee Peer Review Process Trauma Coordinator is responsible for setting up the Trauma Peer Review Committee meetings, obtaining the charts, Keeping the Trauma Committee Case review form with the chart and initiating peer review form, engaging in discussion regarding any issues, transcribing the confidential feedback, participating in any performance improvement activity that may be initiated as a result of the

19. Peer Review Worksheet Form developed to assist the physicians when performing chart review. Issue - Physicians are made aware of the reason the chart has been brought to the Peer Review Committee. In reviewing the chart, other issues may be identified as well. Findings - The reviewing physician documents findings Confidentiality – issues are later transcribed into a confidential report that is forwarded to the provider involved in the care of the patient.

20. Recordkeeping Once review is completed, forms routed to Trauma Registrar A unique identification number is assigned Entered into the Trauma Committee log book A individual file is created Feedback reports filed from Medical Staff & Trauma Peer Review

21. Recordkeeping cont. State Trauma Registry abstraction Assigned a different number (with the TC#) Entered into the State Trauma Registry log book. Feedback reports from the State & abstract are all filed in the Trauma Committee file for future reference.

23. QUESTIONS????? Contact information Leah Emerson, RN, DON, TC 406-528-5224 lemerson@stlukehealthnet.org Katrina Strowbridge, RN, QI Coordinator, TR 406-528-5201 kstrowbridge@stlukehealthnet.org