Transcript TRAUMA QI & PEER REVIEW

TRAUMA QI & PEER REVIEW
How’s it happen?
Katrina Strowbridge, BSN, RN, CWS
Why a review process?
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Trauma Designation
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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
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Whatsa
“Multidisciplinary Committee”???
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RN’s
MD’s
Support Staff
Prehospital Providers
=
Trauma
Committee
………..right?
that does peer review of
charts …….
…..right?
Multidisciplinary Trauma
Committee
is NOT
the Medical Staff
Peer Review Committee
……so, how do ya do peer
review of trauma cases
….
TRAUMA
COMMITTEE
PEER REVIEW
New Process
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Case Selection for record review:
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Record Selection via Daily Rounds
Trauma Coordinator gleans information from staff
 Trauma Registrar review of ED log
 ER charge review by RN
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Chart identified by staff, physicians,
department, etc
Meditech reports – ICD-9 diagnosis codes &
discharge disposition
Focusing on:
Discharge Disposition
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Treated and discharged home or
transferred
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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.
Discharge Disposition cont.
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Treated and Admitted to IP or OPO
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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
Case identified, review begins
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Trauma Committee Case Review
Worksheet
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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.
Case Review “types” drive
process
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Primary Review
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Secondary Review
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Tertiary Review
Primary Review
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Trauma Registrar
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Initiates Trauma Committee Review form for each
case reviewed
Forwards patient record and TCR form to Trauma
Coordinator
Trauma Coordinator
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Review record, validates findings, finds new issues
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Immediate resolution, feedback with identified issues &
documentation of PI loop closure
Secondary Review
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Trauma Coordinator reviews/validates findings,
finds new issues
Medical Staff review of identified issues,
supports investigation and assists in plan
development
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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
Tertiary Review
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Trauma Coordinator & Medical Staff/Peer Review
WRTAC &/or STAC
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Findings documented in PI loop closure
Education may still be 1:1, generally group @ large
via Trauma Committee or regional efforts if required
Clinical Indicator Report
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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
Peer Review
Confidential – confidential – confidential
– confidential – confidential –
confidential
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.
Trauma Committee
Peer Review Process
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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
Peer Review Worksheet
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Form developed to assist the physicians when
performing chart review.
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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.
Recordkeeping
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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
Recordkeeping cont.
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State Trauma Registry abstraction
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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.
QUESTIONS?????
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Contact information
Leah Emerson, RN, DON, TC
406-528-5224
[email protected]
Katrina Strowbridge, RN, QI Coordinator, TR
406-528-5201
[email protected]