1. CLINICAL CASE REVIEW QUALITY ASSESSMENT PREVENTABLE DEATH MODEL Stuart Reynolds, MD

2. QUALITY ASSURANCE PHILOSOPHY HOSPITAL REGIONAL

3. QUALITY ASSESSMENT QA QA QI QI PIC PIC 10 STEP 10 STEP FADE FADE IMPROVE IMPROVE PDCA PDCA TQM TQM TQI TQI PI PI

4. REALITY TRAUMA IS SURGICAL DISEASE MULTIDISCIPLINARY MEDICAL PROCESSES

5. REALITY TRAUMA CARE ASSESSMENT INCLUDES THE SYSTEM MULTIDISCIPLINARY

6. QA/QI PROCESS A TOOL OPPORTUNITY FOR IMPROVEMENT BAD APPLES TEAM GOOD OUTCOME BAD OUTCOME

7. PURPOSE BLAME---NO TARGET PHASE, PROVIDER---NO IMPROVE SYSTEM---YES IMPROVE PATIENT CARE---YES COMPARE---YES

8. FOCI SYSTEMS ISSUES PROCESSES CLINICAL CARE EQUITABLE

9. HOSPITAL TRAUMA PROGRAM AUTHORITY REGISTRY IDENTIFIERS/SYSTEM

10. PREVENTABLE MORTALITY STUDIES URBAN AUTOPSY PANEL

11. RURAL PREVENTABLE MORTALITY STUDY URBAN/RURAL PREVENTABLE MORTALITY INAPPROPRIATE CARE RESOURCE UTILIZATION

12. MONTANA RPMS 1990 PREVENTABLE 13% HOSPITAL PREVENTABLE 27% INAPPROPRIATE CARE ED 68%

13. MONTANA RPMS 1998 PREVENTABLE 8% HOSPITAL PREVENTABLE 15% INAPPROPIATE CARE ED 40%

14. INTERESTING FINDINGS DELAY IN DISCOVERY LONG TRANSPORT BLS (VOLUNTEER) PREHOSPITAL RURAL/URBAN NON-SYSTEM

15. SCOPE OF STUDY GEOGRAPHY TIME FRAME NUMBER OF DEATHS

16. PANEL TRAUMA SURGEONS EMERGENCY PHYSICIANS ED NURSING FLIGHT SERVICE PREHOSPITAL ALS/BLS CONSULTANTS PRIMARY/SECONDARY REVIEWERS

17. SOURCES OF DATA DEATH CERTIFICATE AMBULANCE TRIP REPORT HOSPITAL MEDICAL RECORD AUTOPSY REPORT INVESTIGATIVE REPORTS CORONER LAW ENFORCEMENT FARS

18. CHALLENGES DIVERGENT DATA SOURCES INCONSISTENT COMPLETENESS AND ACCURACY VOLUNTARY DATA SUBMISSION CONFIDENTIALITY CONCERNS DESIGN REQUIREMENTS

19. CHART REVIEW PROCESS NOT DOCUMENTED, NOT DONE DOCUMENTED  DX  SEQUENCE AVOID TUNNEL VISION NO PREJUDICE SYSTEMATIC

20. ABSTRACTS/CHECK LIST GLOBAL VIEW DECISIONS REGARDING CARE – AFTER COMPLETE REVIEW

21. DATA SOURCES REGISTRY TRAFFIC REPORTS CORONER REPORT AUTOPSY

22. PREHOSPITAL EMS TIMES EVALUATION INTERVENTIONS/PROTOCOLS NARRATIVES INTERHOSPITAL TRANSFER

23. ED TRAUMA FLOW SHEET THE IDEAL RESPONSE/RX TIMES DIAGNOSTIC TESTS INTERVENTIONS SEQUENCE

24. HOSPITAL RECORDS H&P CONSULTATIONS NURSING NOTES NARRATIVE MIS DISCHARE SUMMARY

25. OR RECORD/OP REPORT TIMES PROCEDURES VITAL SIGNS/INITIAL OPERATION NUMBER/TIMING OF OPERATIONS

26. INTENSIVE CARE UNIT APPROPRIATE RX/MONITORING WHO CARES FOR THE PATIENT

27. ANCILLARY APPROPRIATE STUDIES APPROPRIATE RESPONSE QUALITY/TIMELINESS OF REPORTS

28. PREVENTABILITY ACS GUIDELINES – FRANKLY PREVENTABLE – POSSIBLY PREVENTABLE – NON PREVENTABLE

29. CARE INAPPROPRIATE ATLS/PHTLS GUIDELINES ACLS PROTOCOLS FUTILE RECUSSITATION

30. RESOURCE UTILIZATION PRESERVE SYSTEM RESPONSE INAPPROPRIATE COST

31. PREVENTABLE DEATH STUDIES REGIONAL/STATE NATIONAL GUIDELINES SYSTEM FUNCTION NOT PUNATIVE