1. Colorado Trauma Network
Spring Conference
May 11, 2017

2. Trauma Programs Outcome effectiveness
Clinical and Operational Platform
Data Data Data
Quality/Process Improvement
Injury Prevention

3. Data, Data, Data Trauma Registry Injury Coding
Front line review of quality
Inter-rater reliability
Informs QI/PI
Informs house-wide education
Program for external validation of data

5. Quality/Process Improvement
Understanding your quality filters
Updating your quality filters annually and with each review
Developing immediate feedback loops when possible
Enlist stakeholder support for complex hospital-wide processes and education

6. SAH PI Plan…..

7. Incorporating TOPIC Classification: IMPACT > Medical > Physical
Level of Harm: Definitions
Level I: No harm/no detectable harm
Level II: No detectable harm
Level III: Mild temporary harm
Level IV: Mild permanent harm
Level V: Moderate temporary harm
Level VI: Moderate permanent harm
Level VII: Severe temporary harm
Level VIII: Severe permanent harm
Level IX: Death

11. Protocol Compliance

12. St Anthony Hospital
Trauma Services
FY2013 Quarterly Reports

13. KNOW YOUR NUMBERS Under Triage Evaluation 1/1/2013-3/31/2013
Patients identified in QI as under activation 4
Patients with No level of activation
Patients activated at lower Level than indicated
Total Activations
240
Patients who should have been activated or activated at a higher level
244
Total Expected Trauma Activations
484
Patients with no activation
Under triage activation *
1.98%
* Under triage defined as patients who met TTA criteria and were not activated at any level of activation

14. Trauma Multidisciplinary Peer Review Committee Cases
All or Select deaths
Select occurrences
Sentinel events
Problem trends
Unusual or uncommon cases
Unexpected outcomes
Great Saves

15. Trauma Multidisciplinary Peer Review Committee Members (LI/II)
Trauma Medical Director*
Trauma/General Surgeons*
Orthopedics*
Neurosurgery*
Emergency Medicine*
Anesthesia*
Critical Care*
Radiology*/Interventional Radiology
Pediatrics
Thoracic
Plastics
Medical Examiner
Rehab Medicine
Trauma Program Manager
Trauma Registrar
Invited Sub-Specialist Involved with Case
*Minimum 50% attendance

16. Trauma Surgeons & Liaisons Roles and Responsibilities
Structured orientation to PIPS plan and process
Awareness of defined event review, complications definitions, and defined judgment or review determination language
Report identified events and occurrence to trauma team
Shared responsibility: extensive review for cases going to PIPS meeting
Participate in peer review discussion and determinations
Participate in developing corrective action plans
Routine feedback (weekly, monthly, annually)