Trauma Center Performance Improvement - Principles and Practice, With Illustrative Case Studies

Preface
Acknowledgments
Abbreviations
Contents
About the Author
Chapter 1: What Is PI? (and What It Is Not)
	Why PI?
	Definitions of Process Improvement and Patient Safety
	What Is “Ego-Based” Medicine?
	Science of Safety
	Differentiating PI from the Discussion and Peer Review
	References
Chapter 2: Philosophy of PI
	Avoiding Bias and Ageism
	Triage of Issues
		Frequent Versus Rare, Significant Harm Versus Trivial Harm
Chapter 3: PI Techniques and Tools
	PDSA
		Brent James and Intermountain Health [2]
	Six Sigma [3]
	Lean [4]
	TOPIC [5]
	References
Chapter 4: Program Personnel and Regulatory Requirements
	Leadership
	Data Collection
	Meetings
Chapter 5: Program Setup
	What Is Reviewed?
		Deaths
		Audit Filters
		Performance Measures and Benchmarking Tools
	Reference
Chapter 6: Trauma Registries and Other Data Sources
	Purpose of the Registry
	Registry Leadership
	Routine Activities
	Special Activities
	Research Versus PI
Chapter 7: Event Identification
	Safety Reporting (Hospital and Trauma Program)
	Sentinel Events
	Collection of Events
	Initial Discussion
Chapter 8: Levels of Review
	Examples
	Deaths
	Adverse Events
	System Issues
	Personal Issues
Chapter 9: Documentation of PI Process and Meeting Minutes
	What Is the Minimum Documentation?
	Templates
		Coordination Systems
	Situational Awareness of Open Issues
	Review of Opportunities for Improvement
Chapter 10: Loop Closure
	What Does Loop Closure Mean?
	Can You Close All Loops?
	Loop Closure Methods
		Discussion
		Education
		Personal Intervention
		Equipment Alterations
		Guidelines
		Hardwiring Change
			Use of EMR
			Gatekeepers and Safety Officers
Chapter 11: Types of Issues
	Clinician Performance and Decision-Making
		Vignette 1
		Performance Improvement Investigation
		Discussion
		Corrective Action Plan
	Blood Transfusion Error
		Vignette #2
		Performance Improvement Investigation
		Discussion
		Corrective Actions
	Staffing and Education Problems
		Vignette #3
		Performance Improvement
		Analysis and Opportunities for Improvement
	External Issues (EMS, Transfer Hospitals)
		Vignette #4
		Transfer Hospitals
		Vignette #5
Chapter 12: Complex Opportunities for Improvement and Difficult Loop Closure
	Physician Practice and Disagreement Among Specialists
	Nursing and Hospital Practice
	Conflict with Hospital Quality Programs
	Financial Limitations
		FTEs
		Equipment
	The Interdepartmental Conflict
	Lack of Hospital or Clinician Commitment
Chapter 13: Inspection of PI Process by Reviewers
	Chart and Document Setup
	Content of Documents
	Supplemental Material
	Open Loops
	Reference
Chapter 14: Performance Improvement Case Studies
	Documents and Slides
	Cases
	Missed Injuries
	Failure to Rescue and Escalation
		The Impact of Learners on Outcomes, Airway Management
	Unstable Patients at Referring Hospitals
	New Technologies
	Airway Management
	Patients with Life-Threatening Injuries Who Die in the Operating Room
	Life-Threatening Thoracic Trauma
	Adverse Events
	Dislodged Gastrostomy Tubes
	Optimal Case
	Pediatric
	Geriatric Death with Low Injury Severity and Multiple Comorbidities
	A Patient with Multiple Life-Threatening Conditions
Index