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TRAUMA QI & PEER TRAUMA QI & PEER REVIEWREVIEW
Katrina Strowbridge, BSN, RN, CWSKatrina Strowbridge, BSN, RN, CWS
How’s it How’s it happen?happen?
Why a review process?Why a review process?
Trauma DesignationTrauma Designation Organized trauma program required for Organized trauma program required for
all levels of designation to include:all levels of designation to include: Multidisciplinary trauma committeeMultidisciplinary trauma committee Trauma Peer Review (with multidisciplinary Trauma Peer Review (with multidisciplinary
committee)committee) Performance Improvement activities related Performance Improvement activities related
to the findings of chart review and Peer to the findings of chart review and Peer ReviewReview
Whatsa Whatsa “Multidisciplinary “Multidisciplinary Committee”???Committee”???
RN’sRN’s MD’sMD’s Support StaffSupport Staff Prehospital Prehospital
ProvidersProviders
== Trauma Trauma CommitteeCommittee
………………..right?..right?
that does peer review of that does peer review of charts …….charts …….
……..right?..right?
…………so, how do ya do peer so, how do ya do peer
review of trauma casesreview of trauma cases….….
Multidisciplinary Trauma Multidisciplinary Trauma
Committee Committee
is NOT is NOT
the Medical Staff the Medical Staff
Peer Review CommitteePeer Review Committee
TRAUMA TRAUMA COMMITTEECOMMITTEE
PEER REVIEWPEER REVIEW
New ProcessNew Process Case Selection for record review:Case Selection for record review:
Record Selection via Daily RoundsRecord Selection via Daily Rounds Trauma Coordinator gleans information from Trauma Coordinator gleans information from
staffstaff Trauma Registrar review of ED logTrauma Registrar review of ED log ER charge review by RNER charge review by RN
Chart identified by staff, physicians, Chart identified by staff, physicians, department, etcdepartment, etc
Meditech reports – ICD-9 diagnosis Meditech reports – ICD-9 diagnosis codes & discharge dispositioncodes & discharge disposition
Focusing on:Focusing on: Discharge Disposition Discharge Disposition Treated and discharged home or Treated and discharged home or
transferredtransferred Identified via daily review as describedIdentified via daily review as described If immediate concerns, reviewed by TC If immediate concerns, reviewed by TC
and Trauma Medical Director/Chief of and Trauma Medical Director/Chief of StaffStaff
If no immediate concerns, coded by HIMIf no immediate concerns, coded by HIM Record reviewed by TC and TR using a Record reviewed by TC and TR using a
review worksheet.review worksheet.
Discharge Disposition cont.Discharge Disposition cont.
Treated and Admitted to IP or OPOTreated and Admitted to IP or OPO Identified via daily reviews as describedIdentified via daily reviews as described Allows for concurrent review with more Allows for concurrent review with more
immediate documentation available in immediate documentation available in the form of progress notes, physician the form of progress notes, physician orders, H&P, etc.orders, H&P, etc.
Immediate concerns reviewed with Immediate concerns reviewed with Trauma Medical Director/Chief of StaffTrauma Medical Director/Chief of Staff
Case identified, review beginsCase identified, review begins
Trauma Committee Case Review Trauma Committee Case Review
WorksheetWorksheet PI form used to abstract recordPI form used to abstract record Indicators approved by Medical Staff & Trauma Indicators approved by Medical Staff & Trauma
CommitteeCommittee Tracks key indicators used for QI processesTracks key indicators used for QI processes Developed from samples received from other CAH’s Developed from samples received from other CAH’s
& WRTAC sample forms.& WRTAC sample forms. Driving force for data collection of trauma related QI Driving force for data collection of trauma related QI
activities and documentation source for the review activities and documentation source for the review process.process.
Case Review “types” drive Case Review “types” drive processprocess
Primary ReviewPrimary Review
Secondary ReviewSecondary Review
Tertiary ReviewTertiary Review
Primary ReviewPrimary Review
Trauma Registrar Trauma Registrar Initiates Trauma Committee Review form for Initiates Trauma Committee Review form for
each case reviewedeach case reviewed Forwards patient record and TCR form to Forwards patient record and TCR form to
Trauma CoordinatorTrauma Coordinator Trauma CoordinatorTrauma Coordinator
Review record, validates findings, finds new Review record, validates findings, finds new issues issues Immediate resolution, feedback with identified issues Immediate resolution, feedback with identified issues
& documentation of PI loop closure& documentation of PI loop closure
Secondary ReviewSecondary Review Trauma Coordinator reviews/validates Trauma Coordinator reviews/validates
findings, finds new issuesfindings, finds new issues Medical Staff review of identified issues, Medical Staff review of identified issues,
supports investigation and assists in plan supports investigation and assists in plan developmentdevelopment 1:1 education (any discipline {RN: RN, MS: 1:1 education (any discipline {RN: RN, MS:
MS}, group education @ TCMS}, group education @ TC May be closed at this level or forwarded for May be closed at this level or forwarded for
further action based on findings further action based on findings Refer to Multidisciplinary Trauma Committee or Refer to Multidisciplinary Trauma Committee or
Medical Staff Peer Review ProcessMedical Staff Peer Review Process
Tertiary ReviewTertiary Review
Trauma Coordinator & Medical Staff/Peer Trauma Coordinator & Medical Staff/Peer ReviewReview
WRTAC &/or STACWRTAC &/or STAC Findings documented in PI loop closureFindings documented in PI loop closure Education may still be 1:1, generally group @ Education may still be 1:1, generally group @
large via Trauma Committee or regional efforts large via Trauma Committee or regional efforts if requiredif required
Clinical Indicator ReportClinical Indicator Report
Trauma Registrar is responsible for Trauma Registrar is responsible for completion of and reporting of datacompletion of and reporting of data
Data pulled from Trauma Committee Case Data pulled from Trauma Committee Case Review form Review form
Entered into Clinical Indicator ReportEntered into Clinical Indicator Report Clinical Indicator Report shared with Trauma Clinical Indicator Report shared with Trauma
Committee Committee Used for ongoing monitoringUsed for ongoing monitoring Identification of trends and issuesIdentification of trends and issues
Peer ReviewPeer Review
Confidential – confidential – Confidential – confidential – confidential – confidential – confidential – confidential –
confidential –confidential –
confidentialconfidential
Peer Review ProcessPeer Review Process
It is important that providers feel “safe” It is important that providers feel “safe” giving honest feedback to colleagues giving honest feedback to colleagues and this trust environment takes time to and this trust environment takes time to establish. The providers also need to establish. The providers also need to feel empowered by Administration to feel empowered by Administration to tackle hard issues, require changed tackle hard issues, require changed behaviors and performance of some behaviors and performance of some peers and be able to hold colleagues peers and be able to hold colleagues accountable.accountable.
Trauma Committee Trauma Committee Peer Review ProcessPeer Review Process
Trauma Coordinator is responsible for Trauma Coordinator is responsible for setting up the Trauma Peer Review Committee setting up the Trauma Peer Review Committee
meetings, meetings, obtaining the charts, obtaining the charts, Keeping the Trauma Committee Case review form Keeping the Trauma Committee Case review form
with the chart and initiating peer review form,with the chart and initiating peer review form, engaging in discussion regarding any issues,engaging in discussion regarding any issues, transcribing the confidential feedback,transcribing the confidential feedback, participating in any performance improvement participating in any performance improvement
activity that may be initiated as a result of the activity that may be initiated as a result of the
Peer Review WorksheetPeer Review Worksheet
Form developed to assist the physicians Form developed to assist the physicians when performing chart review. when performing chart review. Issue - Physicians are made aware of the Issue - Physicians are made aware of the
reason the chart has been brought to the Peer reason the chart has been brought to the Peer Review Committee. In reviewing the chart, Review Committee. In reviewing the chart, other issues may be identified as well. other issues may be identified as well.
Findings - The reviewing physician documents Findings - The reviewing physician documents findings findings
Confidentiality – issues are later transcribed Confidentiality – issues are later transcribed into a confidential report that is forwarded to into a confidential report that is forwarded to the provider involved in the care of the patient. the provider involved in the care of the patient.
RecordkeepingRecordkeeping Once review is completed, forms Once review is completed, forms
routed to Trauma Registrarrouted to Trauma Registrar A unique identification number is A unique identification number is
assignedassigned Entered into the Trauma Committee Entered into the Trauma Committee
log booklog book A individual file is createdA individual file is created Feedback reports filed from Medical Feedback reports filed from Medical
Staff & Trauma Peer ReviewStaff & Trauma Peer Review
Recordkeeping cont.Recordkeeping cont.
State Trauma Registry abstractionState Trauma Registry abstraction Assigned a different number (with the Assigned a different number (with the
TC#) TC#) Entered into the State Trauma Registry Entered into the State Trauma Registry
log book.log book. Feedback reports from the State & Feedback reports from the State &
abstract are all filed in the Trauma abstract are all filed in the Trauma Committee file for future reference.Committee file for future reference.
Treatment provided:patient discharged, transferred oradmitted, case logged into ER Log
Case Identification:Daily rounds by Trauma Coordinator (TC)Daily review of ER Log by Trauma Registrar (TR)Chart identified by staff, TR, TCReview initiated based on DC disposition
Trauma Patient
Transferred Treated & admitted toInpatient or Observation
Treated anddischarged to home
Concurrent Review:Daily rounds by Trauma Coordinator(TC)Daily review of ER Log by TraumaRegistrar (TR)Chart identified by staff, TR, TCRecord reviewed and concernsdiscussed with TR, Medical Director orTrauma Surgeon as needed
Retrospective Review:Daily review of ER Log by TraumaRegistrar (TR)Chart identified by staff, TR, TCRecord coded by HIMRecord reviewed and concernsdiscussed with TR, Medical Directoror Trauma Surgeon as needed
State Registry SubmissionSR number assignedEntered into State TraumaRegistry Log book
Trauma Committee Log:Case entered into log, numberassigned
Trauma CommitteePeer Review ( TCPR)
Multi-disciplinaryTrauma Committee
WRTAC
STAC
Education
QI
ProcessChange
Monitoring
ClinicalIndicator Report
QI Filters Flagged for Review
CaseClosed
Primary Secondary Tertiary
FilingRecords filed bynumber.QI forms & paperworkfiled with cases
State Reports: received back fromState Registry
PDSA
Evaluate & Re-evaluate
Trend Monitor
St. Luke Community HospitalTrauma ServicesQuality Improvement Diagram
QUESTIONS?????QUESTIONS?????
Contact informationContact information Leah Emerson, RN, DON, TCLeah Emerson, RN, DON, TC
Katrina Strowbridge, RN, QI Coordinator, TRKatrina Strowbridge, RN, QI Coordinator, TR
