TRAUMA QI & PEER REVIEW. Katrina Strowbridge, BSN, RN, CWS. How’s it happen?. Why a review process?. Trauma Designation Organized trauma program required for all levels of designation to include: Multidisciplinary trauma committee Trauma Peer Review (with multidisciplinary committee)
Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.
Katrina Strowbridge, BSN, RN, CWS
How’s it happen?
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
the Medical Staff
Peer Review Committee
Case Selection for record review:
Record Selection via Daily Rounds
Trauma Coordinator gleans information from staff
Trauma Registrar review of ED log
ER charge review by RN
Chart identified by staff, physicians, department, etc
Meditech reports – ICD-9 diagnosis codes & discharge disposition
Treated and discharged home or transferred
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.
Treated and Admitted to IP or OPO
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
Trauma Committee Case Review
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.
Confidential – confidential – confidential – confidential – confidential –
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 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
Form developed to assist the physicians when performing chart review.
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.
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
State Trauma Registry abstraction
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.
Leah Emerson, RN, DON, TC
Katrina Strowbridge, RN, QI Coordinator, TR