Continuous performance improvement (PI) is a vital component of trauma care. All trauma centers that are verified by the American College of Surgeons (ACS) are mandated to have a multidisciplinary trauma PI program that continuously evaluates its processes and outcomes to ensure optimal and timely care.1 The ACS Committee on Trauma in 1976 developed key elements of quality care, which included measures of structure, process, and outcome.2 The last few revisions to the "Resources for Optimal Care of the Seriously Injured Patient" focused more on the multidisciplinary process developed at each institution that reviews care delivery and outcomes. Measuring and reporting quality of care is now recognized as a critical step to improving patient care. Limited research exists on exactly how trauma centers measure outcomes.3 A 2012 study by Santana and Stelfox4 surveyed trauma centers in 4 different countries and described the various quality indicators that trauma centers use for quality measurement and PI. Quality indicators are intended to compare actual trauma care against ideal criteria and to identify patients in who care was not optimal necessitating further review. They found that most trauma centers use indicators designed to examine safety, effectiveness, efficiency, and timeliness of prehospital and hospital processes and outcomes of care. There were a few indicators that were broadly utilized by the majority of centers. They concluded that opportunities exist to standardize existing quality indicators to allow for broader implementation.4
As traumatic injury is still a major pediatric health concern, it is imperative that pediatric trauma centers develop and implement best treatments and strategies. Variations in the treatment and outcomes of common injuries suggest that there is no broadly accepted body of evidence for best practices for the care of pediatric patients with traumatic injuries.5 It is hoped that with ongoing research in this area, patient-centered pediatric-specific quality indicators are developed and adopted. Tracking PI progress is also varied, dependent on individual trauma centers.
PURPOSE
The PI process has been an essential component of the ACS verification process for trauma centers since its inception. Although the ACS requires each verified trauma center to have a multidisciplinary committee that examines trauma-related care operations, each trauma center can develop their own template to track performance through changeable quality indicators. The ability to identify, resolve, and trend specific indicators related to patient care and to show effective loop closure can be especially challenging. There is no universal template to follow, especially for pediatric trauma centers. An electronic dashboard can enhance tracking and compliance with specific process and outcome measures.6 This article describes one pediatric trauma center's development of their PI program, utilizing a uniquely created electronic trauma dashboard.
PROCESS IMPLEMENTATION
As this unique pediatric trauma center journeyed from level IV to level I status over the past 10 years, our PI processes matured. The ability to identify and then categorize problems so that they could be easily trended and acted on was a challenge. As a very young trauma center, our PI program focused on trauma registry statistics and minimal process indicators, as shown in Table 1. Such data points as types of activations, delays, response teams, documentation, and specific trauma indicators were trended and compared to the previous year. (Table 1) Most of these indicators were defined by the ACS or other trauma center national forums. These indicators were tracked manually, primarily by the trauma program staff. Specific departments were asked to work to improve results relating to them. Results were reported quarterly to the trauma operations committee.
As our program matured, the trauma program staff worked with all hospital departments that care for trauma patients. Together, we developed both process and outcome indicators that were identified as areas of concern, such as documentation related to time on a backboard or completion of history and physical by the trauma attending within 24 hours. We devised ways to measure and track improvement. Using the hospital's overall quality process tool as a template, the trauma program built its own electronic dashboard, which is an Excel spreadsheet that allows tracking of specific trauma indicators related to both departmental and interdepartmental care factors. Each department tracks their individual data and provides that data to the trauma program staff on a monthly basis. Information is then manually entered into the dashboard by the trauma analyst and trauma program manager. Thresholds are defined and progress is tracked monthly to be shared quarterly with the trauma operations committee. As thresholds are met and sustained, those indicators are dropped for the next year. Red, yellow, and green colors highlighted areas of either concern or accomplishment (Table 2).
Loop Closure and Action Plans
Performance improvement not only includes monitoring of department-specific indicators but also involves improving the overall performance of a trauma program. Indicators, which do not meet benchmarks, are identified as needing corrective action. If a specific department indicator is deemed "in the red," that department is asked to devise an action plan, in conjunction with the trauma program, to positively impact that performance indicator (Table 3). As shown in Table 2, the blood bank did not meet their goal for receiving type and screen samples for 3 quarters; their action plan is shown in Table 3. Action plans are documented in the dashboard and discussed quarterly at the multidisciplinary trauma committee. These action plans are designed on the basis of the plan, do, check, and act methodology.7 Constant reevaluation of the action plan is completed to ensure that progress is being made. Figure 1 shows the updated process map for the newly revised blood bank policy.
Effective PI programs demonstrate that identified opportunities for improvement lead to specific interventions.3 Dashboard results continue to be trended and reported to the trauma multidisciplinary committee. Annually, the trauma multidisciplinary committee evaluates the indicators, which are being monitored to determine the need to continue to evaluate. If an indicator continues to meet benchmarks, it may need periodic spot checks and not constant evaluation. The visual display of the trauma dashboard serves as a reminder, while also tracking progress, of all the hard work that a department is doing to achieve its threshold and improve patient care. In addition to tracking opportunities for improvement, positive gains are celebrated among the entire committee and relayed to administration.
CONCLUSION
Our maturing trauma PI program now guides the overall trauma care provided to our pediatric patients. Development and utilization of the electronic dashboard was an essential part of this growth. It provides a highly visible scoreboard, highlighting successes and areas for improvement. All trauma-related departments own at least one performance indicator and must report out on results, while also providing action plans for improvement. Some action plans require multidisciplinary process improvements as a solution. Quarterly progress is color coded, and departments share their successes at our trauma operations committee meetings. Departments now strive to show their indicators "in the green." Even if a department has not met its predetermined threshold for the year, if improvement is noted, then this progress is also celebrated, but that indicator remains for the following year. We are hopeful that we can link meeting thresholds and sustaining that success to overall improved patient care outcomes. In the future, we hope to develop interfaces between our institution's electronic medical record and our electronic dashboard to reduce the amount of manual input. Increased participation from all trauma-related departments demonstrates everyone's commitment to improving trauma patient outcomes.
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