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9/22/2015 Performance Improvement and Taxonomy: Trauma Taxonomy as a PI Tool Annual Trauma Center Association of America Conference Donald H Jenkins, MD FACS Professor of Surgery and Director of Trauma Division of Trauma, Critical Care and Emergency General Surgery Saint Marys Hospital, Rochester MN September 2015 Disclosures • None Acknowledgements • • • • • • • Carol Immermann Jorie Klein Chris Cribari Blaine Enderson Glen Tinkhoff Ronald Stewart Eric Epley • • • • • • • Kathie Martin ACS COT PIPS STN/TOPIC Terri Elsbernd Brenda Schiltz Deb Horsman Chris Ballard 1 9/22/2015 What is most important with respect to assessing trauma center care? A range of view points. VRC Processes TQIP Outcomes Current Verification Good (risk adjusted) Outcomes Good VRC Processes and Structure ✔ Poor VRC Processes and Structure ✖ Poor (risk adjusted) Outcomes ✔ ✖ How to Incorporate Outcomes into Verification? Good (risk adjusted) Outcomes Poor (risk adjusted) Outcomes Good VRC Processes and Structure ✔ ✔? Poor VRC Processes and Structure ✖? ✖ 2 9/22/2015 Model Best Practice Site Study and disseminate approach to care + Implement Future VRC Approach?Verifiy approved COT PIPS Good VRC Processes and Structure Poor VRC Processes and Structure Good (risk adjusted) Outcomes ✔ Plan Poor TQIP Best Practices RA Outcomes ✔ ✖ ✖ ?✔ ? Verify + Implement approved COT PIPS Plan TQIP Best Practices Not verified Implement approved COT PIPS Plan TQIP Best Practices Culture of Safety Taxonomy Objectives • Origin of the culture of safety taxonomy • Goals of Implementation • 5 Nodes of the Taxonomy • • • • • Impact Type Domain Cause Mitigation/prevention (event resolution) • Benefits of adopting this new taxonomy The National Quality Forum Taxonomy has been recommended by the ACS COT PIPS Committee and the ACS VRC as best practice and should be implemented in trauma performance improvement programs. This taxonomy should be implemented now and will be a criterion (required) in the next version of the Resources for Optimal Care of the Injured December 2013 3 9/22/2015 National Quality Forum (NQF) Taxonomy Step-By-Step Implementation • Do PI the way you have always done PI • Events act as triggers for case review: • Deaths • Other non-discretionary events (i.e., specific complications [i.e., NTDS complications]) • Discretionary events • Essential criteria that are integral to PI are used • Classify the relevant factors for the event using the NQF taxonomy - Define cut offs for primary review, secondary review, tertiary review Define cutoffs for track/trend versus action plan development - • Develop computerized application to enhance ease of use • Import NTDS complications as baseline sentinel events • Allow users to add additional sentinel event types Taxonomy • Building blocks • Common definitions and classifications • Unambiguous and translatable terminology • Scope • • • • Comprehensive classification tool Applicable to all health care delivery settings Includes multiple levels of patient harm Addresses sentinel or serious events, adverse events, no-harm events, near misses or close calls, and potential events 11 12 4 9/22/2015 Taxonomy (Ivatury et al. JT, Feb 2008) • Impact: Outcome or effect of event • Type: Processes that were faulty • Domain: Setting where incident occurred or phase of care • Cause/Factors: System and human factors and agents that led to incident • Prevention and mitigation: Universal, selected or indicated, an action plan 13 Framework of the Taxonomy Severity of harm (e.g. TJC sentinel events reports, NCC MERP) Type of health care service provided I. Impact Type of individual involved (physician, nurse, etc.) and type of setting (hospital, clinic, etc.) II. Type ‐Overuse, underuse, misuse ‐Active & latent failures ‐Negligence III. Domain IV. Cause Primary Classifications Further Defined 1. Impact: the outcomes or effects of medical error and systems failure, commonly referred to as harm to the patient. 2. Type: the implied or visible processes that were faulty or failed. 3. Domain: the characteristics of the setting in which an incident occurred and the type of individuals involved. 4. Cause: the factors and agents that led to an incident. 5. Prevention and Mitigation: the measures taken or proposed to reduce the incidence and effects of adverse occurrences. 5 9/22/2015 Classification: Impact Medical Non-Medical Psychological Physical Legal Social I. No harm/no detectable harm II. No detectable harm I. No harm/no detectable harm II. No detectable harm III. Mild temporary harm IV. Mild permanent harm III. Mild temporary harm IV. Mild permanent harm Extremely satisfied Satisfied V. Moderate temporary harm VI. Moderate permanent harm V. Moderate temporary harm VI. Moderate permanent harm Neutral Dissatisfied VII. Severe temporary harm VIII. Severe permanent harm VII. Severe temporary harm VIII. Severe permanent harm Extremely dissatisfied IX. Profound mental harm Economic Patient/Family Satisfaction IX. Death Differentiating Levels of Harm • None – patient outcome is not symptomatic or no symptoms detected and no treatment is required (I. & II. Impact) • Minimal – patient outcome is symptomatic, symptoms are mild, loss of function or harm is minimal or intermediate but short term, and no or minimal intervention (e.g., extra observation, investigation, review or minor treatment) is required (III. & IV. Impact) • Moderate – patient outcome is symptomatic, requiring intervention (e.g., additional operative procedure; additional therapeutic treatment), an increased length of stay, or causing permanent or long term harm or loss of function (V. & VI. Impact) Differentiating Levels of Harm • Severe – patient outcome is symptomatic, requiring lifesaving intervention or major surgical/medical intervention, shortening life expectancy or causing major permanent or long term harm or loss of function (VII. & VIII. Impact) • Death – on balance of probabilities, death was caused or brought forward in the short term by the incident (IX. Impact) 6 9/22/2015 IMPACT The outcome or effects of a medical error and systems failure, commonly referred to as harm to the patient Physical 1. No Harm & No Undetectable Harm-Sufficient information or able to determine that no harm occurred 2. No Detectable Harm-Insufficient information or unable to determine any harm 3. Minimal-Temporary Harm- Requires little or no intervention 4. Minimal Permanent Harm-Requires initial but not prolonged intervention 5. Moderate-Temporary Harm- Requires initial but not prolonged hospitalization 6. Moderate-Permanent-Harm-Requires intensive but not prolonged hospitalization 7. Severe-Temporary Harm-Requires intervention necessary to sustain life but not prolonged hospitalization 8. Severe-Permanent Harm- Requires intervention necessary to sustain life and prolonged hospitalization, long-term care, or hospice 9. Death Classification: Type Patient Management Communication Clinical Management Inaccurate & incomplete information Questionable delegation Questionable advice or interpretation Questionable tracking or follow-up I. Correct diagnosis, questionable intervention I. Correct procedure with complication II. Correct procedure incorrectly performed I. Correct prognosis Questionable consent process Questionable referral or consultation II. Inaccurate diagnosis III. Correct procedure but untimely IV. Omission of essential procedure II. Incorrect prognosis Questionable disclosure process Questionable use of resources III. Incomplete diagnosis V. Procedure contraindicated VI. Procedure not indicated III. Incomplete prognosis IV. Questionable diagnosis VII. Questionable procedure VIII. Wrong patient IV. Questionable prognosis Pre-Intervention Questionable documentation Intervention Post-Intervention Classification: Domain Period Setting Hospital Non-Hospital Staff Physicians Date Nurses Patient Therapists Others Physical therapist Health professions student Target Age Diagnostic Gender Therapeutic Emergency room Ambulatory care Practitioner]s Office Subacute care Skilled nursing care facility Ambulatory Care Clinic Month Resident Licensed practical nurse Occupational therapist Pharmacist Diagnosis Rehabilitative Diagnostic procedures Clinical laboratory Nursing Home Day Attending Registered nurse Speech therapist Pharmacy technician Coexisting Conditions Preventive Home Care Holiday Dentist Nurse practitioner Radiation technician Duration of Disease Palliative Podiatrist Optometrist Socioeconomic Status Research Physician assistant Other Education Cosmetic Other Other Rehabilitation Hospice Other Mental health Pharmacy Hospice Rehabilitation Facility Mental health Facility Year Time Intern Nurse’s aide Other Facility 7 9/22/2015 Classification: Cause Human (actual or near misses) Structure/Process Organizational Technical External to organization Management Facilities Organizational culture Protocols/ procedures External Patient Practitioners Patient factors Other External Skill-based Negligence Recklessness Rule-based Transfer of knowledge Knowledge-based Unclassifiable Classification: Prevention (P) & Mitigation (M) aka Action Plan Universal Improve the accuracy of patient identification (P) Improve the effectiveness of communication among caregivers (P) Improve the effectiveness of clinical alarm systems (P) Reduce the risk of healthcare-acquired infections (M) Selective Eliminate wrong-side, wrong-site, wrongprocedure surgery (M) Indicated Improve the safety of using high-alert medications (P) Improve the safety of using infusion pumps (P) TJC Taxonomy Via Software • Advantages • Ease of use • Improved data collection • Improved data collation • Disadvantages • Development time • Distribution • Training 8 9/22/2015 Why Do This? • We will be able to PI our PI • Benchmark our PI • Consider risk stratifying TQIP reportable events (complications) (?using Charlson Index?) • Focus PI on TQIP AE’s? • Focus PI on TQIP AE’s that are outliers on benchmarking report? • Focus PI on Hospital QA initiatives and customize registry? • Chpt 16 says to align trauma PI with hospital quality programs ACSCOT Update • Enhance the interaction of PIPS with NTDS, NTDB, VRC and TQIP • Definitions of NQF taxonomy are not ‘traumafied’ and are incomplete from NTDB and TQIP perspective (this is being fixed) • Many NTDB and TQIP adverse events have elements that are not defined in the NQF taxonomy (this is being fixed) • Evaluate best practices and advise low performing centers on these • Commitment to ‘fix’ this as of 8 Jan 15 COT Executive Meeting Trauma PIPS Levels of Review Primary Review Opportunity for Improvement/Validation Adverse Event/ Audit Filter Review Secondary Review Issues Elevated to Hospital PIC Monthly Tertiary Review Trauma Peer Review (Monthly) Trauma Committee (Monthly) Trauma M&M (Weekly) Actions Education Counseling Track/Trend Guideline Development PIPS Team Project 9 9/22/2015 Benchmark Comparison with NTDB Compare your trauma hospital data with national data Examples: Examples: • Patient Demographics • Hospital demographics • Survivors vs. nonsurvivors: • LOS • mean ISS & ICU days • Age • Blunt vs. penetrating percentages • ISS by age group • Mortality rates • Mortality by ISS • ED disposition • Hospital disposition • ISS and hospital charge • Mechanism of injury and restraint usage • ISS with LOS 28 Benchmarks and Measurements: Outcome Data Report Examples: • Functional status on discharge (FIM Scores) • Results of patient satisfaction surveys • Complication rates • Compliance with practice management guidelines • Mortality and morbidity • Severity-adjusted mortality and morbidity • Unplanned return to OR • Unplanned upgrade to an intensive care unit • Unplanned hospital readmission • Surgical wound infections • Organ donation activity 29 Trauma Quality Improvement Project [TQIP] Risk Adjusted Benchmarking • Required at Level I, II, and III centers • Reduce variability in trauma process/outcomes/cost • A trauma PIPS program for evaluating risk adjusted performance and benchmarking • Goals: • Reduce variability in trauma care thus improving outcomes and decreasing costs • Develop data elements to measure processes of care • Standardize care management via trauma centers nationally • Implement uniform defined audit filters and universally accepted data definitions • Develop model PI plan and program 30 10 9/22/2015 TJC Taxonomy Implementation • Do PI the way you have always done PI • Events act as triggers for case review: • Deaths • Other non-discretionary events (i.e., specific complications [i.e., NTDS complications]) • Discretionary events • Essential criteria that are integral to PI are used • Classify the relevant factors for the event using the TJC taxonomy - Define cut offs for primary review, secondary review, tertiary review Define cutoffs for track/trend versus action plan development - • Develop computerized application to enhance ease of use • Import NTDS complications as baseline sentinel events • Allow users to add additional sentinel event types Questions? 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