FOUNDATION NEWS: Volume 13 Issue 2 PAGE 1 In pursuit of optimal support for injured persons in Pennsylvania Opening Lines of Communication Submitted by: Juliet Altenburg, Executive Director Welcome to our Spring edition of the PTSF newsletter! With Spring comes new growth not only in nature but in trauma system development activities. The PTSF staff and board are preparing for a busy calendar ahead as hospitals continue to reach out inquiring about trauma center development and planning for site survey visits. With an anticipated increased volume of trauma centers coming into the trauma system, PTSF staff and board members are updating policies and streamlining activities, many of which are featured in this newsletter. Communication with all hospitals continues to be paramount. Beginning in April, we will begin a series of web chats at 1 p.m. on the third Thursday of every month. This will be an opportunity for any hospital staff member to ask questions and get fast answers from me and my fellow PTSF colleagues. In the coming weeks, email communications will come to you with further details. PTSF continues to use the website to post revised policies and current educational opportunities. For hospitals pursuing accreditation, don’t forget to sign-up for the “Hospitals Pursuing Foundation News Board of Directors Spotlight 1 Foundation Board Action Items 2 Technology/Trauma Registry Update 3 Foundation Staff Update 4 Our Trauma Partners & Stakeholders 5 Committee Updates 6-7 Committee Roster 7-8 Educational Opportunities 9 Do you have information you would like to share in this newsletter? If so, please contact Kevin Burd at [email protected] for information related to submission deadlines. Volume 14 Issue 2 | Spring 2016 FOUNDATION NEWS Accreditation” Community. This is a one-stop-shop for all resources. Lastly, mark your calendars for The Hospital & Healthsystem Association of Pennsylvania’s (HAP) Council of Accredited Trauma Center meetings. Trauma program management staff members from both accredited and pursuing trauma centers are invited. Meetings are scheduled on May 10, 2016 and September 30, 2016 from 10 a.m. until 12:30 p.m. The location for the May meeting is at the Pennsylvania Medical Society located at 777 East Park Drive, Harrisburg, Pa. Kathryn Slatt from HAP Headquarters ([email protected]) is the HAP support to the council and will disseminate communications. The President of the Council this year is Michael Lloyd, MS, RN, Adult Trauma Program Manager at Penn State Milton S. Hershey Medical Center. Whether your hospital is accredited or pursuing accreditation, thank you for all that you do for injured patients. It is our privilege to support you in whatever way possible to accomplish our mission of optimizing care for the injured patients you serve.
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FOUNDATION NEWS: Volume 13 Issue 2 PAGE 1
In pursuit of optimal support for injured persons in Pennsylvania
Opening Lines of CommunicationSubmitted by: Juliet Altenburg, Executive Director
Welcome to our Spring edition of the PTSF newsletter! With Spring comes new growth not only in nature but in trauma system development activities. The PTSF staff and board are preparing for a busy calendar ahead as hospitals continue to reach out inquiring about trauma center development and planning for site survey visits. With an anticipated increased volume of trauma centers coming into the trauma system, PTSF staff and board members are updating policies and streamlining activities, many of which are featured in this newsletter.
Communication with all hospitals continues to be paramount. Beginning in April, we will begin a series of web chats at 1 p.m. on the third Thursday of every month. This will be an opportunity for any hospital staff member to ask questions and get fast answers from me and my fellow PTSF colleagues. In the coming weeks, email communications will come to you with further details.
PTSF continues to use the website to post revised policies and current educational opportunities. For hospitals pursuing accreditation, don’t forget to sign-up for the “Hospitals Pursuing
Foundation News Board of Directors Spotlight 1Foundation Board Action Items 2
Do you have information you would like to share in this newsletter? If so, please contact Kevin Burd at [email protected] for information related to submission deadlines.
Volume 14 Issue 2 | Spring 2016
FOUNDATION NEWS
Accreditation” Community. This is a one-stop-shop for all resources.
Lastly, mark your calendars for The Hospital & Healthsystem Association of Pennsylvania’s (HAP) Council of Accredited Trauma Center meetings. Trauma program management staff members from both accredited and pursuing trauma centers are invited. Meetings are scheduled on May 10, 2016 and September 30, 2016 from 10 a.m. until 12:30 p.m. The location for the May meeting is at the Pennsylvania Medical Society located at 777 East Park Drive, Harrisburg, Pa. Kathryn Slatt from HAP Headquarters ([email protected]) is the HAP support to the council and will disseminate communications. The President of the Council this year is Michael Lloyd, MS, RN, Adult Trauma Program Manager at Penn State Milton S. Hershey Medical Center.
Whether your hospital is accredited or pursuing accreditation, thank you for all that you do for injured patients. It is our privilege to support you in whatever way possible to accomplish our mission of optimizing care for the injured patients you serve.
FOUNDATION NEWS: Volume 14 Issue 2 PAGE 1
PTSF Welcomes Dr. McCarthyPTSF is pleased to welcome John McCarthy, DO, FACEP as its newest board member.
Dr. McCarthy represents the Pennsylvania Emergency Health Services Council (PEHSC). Dr. McCarthy is the Chief of the Division of the Emergency Medical Service (EMS) in the Department of Emergency Medicine at Lehigh Valley Health Network (LVHN) in Allentown, Pennsylvania.
Dr. McCarthy initiated his career as an EMT/Firefighter in Berwyn, Pennsylvania at the age of 16. He received his medical degree at the Philadelphia College of Osteopathic Medicine; he completed his Emergency Medicine Residency and EMS Fellowship at the Albert Einstein Medical
Center in Philadelphia. Dr. McCarthy is the Medical Director of LVHN MedEvac air and ground critical care transport program.
Board Approves “Standards” RevisionsOn behalf of the Standards Committee, Committee Chairman Michelle Fontana, MSN, CCRN presented revisions to three Standards of Accreditation that were approved by the board of directors, including:
• New Appendix D: This includes a log of all of the changes to the accreditation standards.
• Standard 6: Performance Improvement - The addition that TQIP participation is required.
• Standard 10: Physicians - Clarification to the trauma attending response time for highest level activations.
• Standard 10: Physicians - Clarification to the back-up trauma attending response expectations for highest level activations.
• Standard 10: Physicians - Clarifications to the orthopedic and neurosurgical designee parameters.
• Standard 13: Nursing - Adding CNRN (Certified Neuroscience Registered Nurse) to the list of acceptable advanced certification list.
These changes will be incorporated into the online Standards documents. The document revision date will be added to the front covers to indicate the most up-to-date versions. A communication will be sent via email when the revised document is posted to the PTSF website.
2016 Board Meetings
March 22, 2016
SAVE THE DATE
The 20th Annual PaCOT/PTSF
Fall Conference & Meeting
October 25-28, 2016Sheraton Harrisburg-Hershey Hotel
Harrisburg, PA
John McCarthy, DO, FACEP
PTSF BOARD OF DIRECTORS SPOTLIGHTWelcome; Standards Revisions
2016 Board Meetings
March 22, 2016
July 28 & 29, 2016(Deliberations of Level I/II Hospitals)
September 29 & 30, 2016(Deliberations of Level III/IV Hospitals)
Board Requires ACS TQIP Involvement for all Trauma CentersOn January 1, 2017 all accredited level 1, 2 and 3 trauma centers will be required to enroll in the Trauma Quality Improvement Program (TQIP) hosted by the American College of Surgeons (ACS). The PTSF Board of Directors approved this decision in keeping with the PA EMS Act which dictates that PTSF must align its Standards with those of the ACS. This mandate was initially communicated by the ACS in November, 2015.
Enrollment in TQIP will allow Pennsylvania to benchmark its trauma outcomes as a state with other states in the country. PTSF submitted a fee to the ACS allowing Pennsylvania trauma centers to be part of a “TQIP Collaborative” which reduces the TQIP fee by five percent for each enrolled trauma center. Additional benefits will include national ACS TQIP education brought locally to Pennsylvania, featured at our annual statewide PaCOT/PTSF Fall Conference.
PTSF “Standard V: Registry” requires trauma centers to submit data to the National Trauma Data Bank (NTDB). Typically for non-TQIP centers, the ACS charges a fee for this submission. Recognizing the additional financial impact of the new TQIP requirement, the PTSF Board INITIALLY waived the Standard requiring NTDB submission for non-TQIP centers for the 2016 data submission period. After a memo was released to the trauma centers and shared with the ACS, the ACS decided to waive NTDB data submission fees for Pennsylvania due to our full statewide TQIP participation starting in 2017. In
light of the ACS’s new determination, the Board Executive Committee revisited the decision and decided to continue the NTDB data submission standard requirement. This will give trauma centers joining TQIP in 2017 the full benefit of TQIP reporting.
For more details on the TQIP enrollment process go to the ACS website at: https://www.facs.org/quality-programs/trauma/tqip/getting-started. Please also contact Digital Innovations (www.dicorp.org) for installation of TQIP software and associated fees.
A PTOS Risk Adjusted Mortality report will be generated for all adult trauma centers in 2016. We hope to disseminate the reports in August 2016. The cost of these reports is covered by the PTSF annual trauma center participation fee.
Accreditation Dates for New Trauma Centers Coming Earlier Beginning in 2016, accreditation dates for new trauma centers will be effective much sooner than in the past following PTSF board deliberations.
The new policy outlines that Certificates of Accreditation are effective on the first day of the 2nd month following the board approval. This means that any new trauma centers (levels 1, 2 or 3) approved by the board in July will receive a Certificate of Accreditation effective September 1, 2016 instead of October 1, 2016.
For hospitals being accredited as level 4 trauma centers for the first time, their effective date of accreditation will
remain November 1, 2016. In 2017, board accreditation deliberations will occur at each quarterly board meeting due to the high volume of trauma centers under review.
The new policy reflects a change from what was done in the past. Historically when a hospital was surveyed for the first time, the PTSF Board of Directors approved accreditation effective October 1 for level 1 and 2 trauma centers or November 1 for level 3 and 4 trauma centers. Go to the PTSF resources area of the website to view the details of the revised “Policy AC-114: Certificates of Accreditation.”
Surveyor Selection Reflects Program Development Needs for Consultative Visits Surveyor team composition for consultative visits is now flexible for hospitals pursuing level 1, 2 and 3 accreditation.
Consultative visits will now have a minimum of two team members (one physician and one nurse). It is up to the discretion of the hospital to add additional team members, as well as choosing their specialty. For hospitals pursuing level 4 accreditation, consultative visits will still require the minimum of one physician team member with the option of adding additional team members.
Fees are based on the number of surveyors on the team. The PTSF Fee Schedule has been updated to reflect this change. Go to the PTSF resources area of the website to view the details of the revised “Policy AC-119: Surveyor Selection Criteria” and Fee Schedule.
No Fee for DI Support of NTDB SubmissionA few trauma centers have had questions regarding a possible fee for Digital Innovations, Inc. (DI) support during the NTDB submission process.
To clarify, there is no additional fee for accessing DI support to help with NTDB submission. The confusion may have resulted because of a new service DI is offering called the NTDB Personal Assistant Program. This service is above and beyond normal NTDB submission support from DI.
DI’s NTDB Personal Assistant Program allows your center to work one-on-one with a specifically assigned DI Customer Support Representative. This representative assists you and your facility with: verifying the most current version of the NTDB module, menu mapping, data validation, assistance with reviewing errors, uploading data to the NTDB data center, reviewing the Validator Report and Submission Frequency Report, as well as accepting the 2015 Data Submission. You are not required to subscribe to this service from DI. Please note, if you are a TQIP center you are already a participant in the Personal Assistant program.
DI does offer some free training courses to review the NTDB submission process. Their next session is offered on April 13, 2016. Go to the DI website or contact [email protected] for more information on the NTDB Personal Assistant Program, or for information on the free NTDB submission course.
Electronic Application for SurveyReflecting the changes from the new Standards of Accreditation, the Application for Survey (AFS) will change significantly for the 2016-2017 site survey cycle. Amy Krichten, Director of Accreditation, will host a webinar demonstrating major content changes.
In addition to the change in standard numerical order, content within each standard is being updated to adequately capture the new requirements. A workgroup is diligently working through content changes. Digital Innovations, Inc. will update the software this spring, in the hope to have a demo version available by summer.
Please anticipate that due to the volume of question changes, the current eAFS will not auto-map old answers or documents into the new platform. Previous versions are, as always, available for reference. A “cut-and-paste” technique will work if desired. (Continued on page 7)
TECHNOLOGY & TRAUMA REGISTRY UPDATEDI Support of NTDB Submission; Accreditation Update
FOUNDATION NEWS: Volume 14 Issue 2 PAGE 4
Snavely approved as STN-TOPIC InstructorCongratulations to Terry Snavely, Performance Improvement Specialist, on meeting the criteria and being selected as faculty for the Society of Trauma Nurses (STN) Trauma Outcomes & Performance Improvement Course (TOPIC). STN looks forward to adding her “experience and proven leadership to [the] TOPIC team.”
Krichten Completes Master’s DegreeCongratulations to Amy Krichten, Director of Accreditation, for completing her Master of Sciencedegree in Nursing Leadership and Management from Western Governors University. Amy received her diploma in April 2016.
Amy Krichten, MSN, RN, CEN
FOUNDATION STAFF SPOTLIGHT
SAVE THE DATE
Trauma Registrars Day -
May 15, 2016
Thank you to all of our Pennsylvania
Trauma Registrars for being a vital and
intregrel part of the Trauma Team!
SAVE THE DATE
National Nurses Week -May 6-12, 2016
Join the American Nurses Association in celebrating the important role nursesplay in healthcare! Many
thanks to our Pennsylvania nurses.
FOUNDATION NEWS: Volume 14 Issue 2 PAGE 5
Congratulations to Sarah Mattocks, MSN, FNP-C Sarah was recently elected to the Society of Trauma Nurses (STN) Board of Directors as a “Director at Large.” Sarah was also selected as course faculty for the STN-TOPIC Course.
TOPIC is the “Trauma Outcomes and Performance Improvement Course” that is sponsored by the Society of Trauma Nurses. Completion of this course is a PTSF Standards requirement for Trauma Program Medical Directors, Trauma Program Managers/Coordinators and Trauma Performance Improvement Coordinators.
Sarah is the Trauma Program Manager at UPMC Hamot, an accredited level 2 adult trauma center in Erie, Pennsylvania.
Congratulations to Jill Volgraf, BA, RN Jill was recently selected as STN’s Leadership Extern for 2016!
Jill is the Trauma Program Manager at Temple University Hospital, an accredited level 1 adult trauma center in Philadelphia, Pennsylvania.
Collaboration with ATS and the PTSF Trauma Injury Prevention Committee For the first time, PTSF will host the American Trauma Society (ATS) Injury Prevention Course. This two-day course is scheduled as a pre-conference session October 25-26, 2016. Stay tuned for registration announcements; contact Kevin Burd at [email protected] if you have any questions.
Congratulations to the trauma program staff at Penn Presbyterian and Reading Hospital Congratulations to the trauma program staff at Penn Presbyterian and Reading Hospital for their Advanced Practice publication in the “Journal of Trauma Nursing,” Volume 23, Number 2, March-April 2016, titled “Advanced Practitioners Are Peers in Trauma Performance Improvement Review.”
Authors included Tara Ann Collins, CRNP; Corinna P. Sicoutris, CRNP, FCCM; Amanda McNicholas, CRNP; Nicole Krumrie, MD; Abby Eddinger, PA-C; Forrest B. Fernandez, MD; C. William Schwab, MD; Patrick Reilly, MD and Patrick K. Kim.
Collaboration with PATNAC for Trauma Program Manager Course The Trauma Program Manager (TPM) course is scheduled as a pre-conference session on Wednesday, October 2016 of the Fall Conference. In collaboration with the Pennsylvania Trauma Nurse Advisory Council (PATNAC), Amy Krichten is preparing the day-long session. This course is designed for both new and seasoned TPM’s and will offer insights and recommendations for TPM success. Stay tuned for additional details; however, if you have any specific content requests—please email Amy at [email protected].
OUR TRAUMA PARTNERS & STAKEHOLDERS
FOUNDATION NEWS: Volume 14 Issue 2 PAGE 6
POPIMS Standardization Becomes PIPS Committee The POPIMS Standardization Committee will transition into the new “PIPS Committee” in 2016. This is an effort to position our Commonwealth for success in meeting the new ACS standards and to embrace broader focused performance improvement that is inclusive, multidisciplinary and collaborative.
Matt Mowry, RN, MSN, CEN, Trauma PI Coordinator at Allegheny General Hospital, an adult level 1 trauma center has agreed to continue in a position of leadership, as Committee Co-Chair. He is teaming up with Dr. Denise Torres, MD, Trauma Program Medical Director at Geisinger Medical Center, an adult level 1 trauma center, as the physician Committee Co-Chair. Terry Snavely, PTSF Performance Improvement Specialist will be the PTSF liaison and support to the group.
The organizational meeting of the new PIPS Committee occurred via conference call on February 16, 2016 and the following focus and goals, with actions to be carried out in the upcoming transitional year, were drafted:
“The Performance Improvement and Patient Safety (PIPS) Committee shall develop a standardized approach to the development of comprehensive, multidisciplinary and inclusive aspects of trauma performance improvement and patient safety in Pennsylvania’s trauma centers and trauma system.”
Initial work groups and goals:
1. POPIMS Central Site Standardization—
• Establish standardized data and submission process;
• Analyze data points previously submitted to the Central Site Pilot identifying utility and impact of trending practice, care events, and outcomes.
2. PIPS Core Measure Report Reference
• Compile, review, standardize and create reference tools of currently used reports by various POPIMS/Collector software users that meet required PIPS Core Measures reporting;
• Create gap analysis of current report content and needed data to satisfy “Standard 6 PIPS Indicators.”
3. PIPS Management Guideline (ACS required)
• Obtain, submit and post minimum sampling of various ACS required Practice Management guidelines;
• Obtain and post variance indicators for each Practice Management guideline to illustrate methods of variance trending and utilization to improve patient care outcomes.
4. POPIMS Outcomes Software (Previous POPIMS Development Com-mittee to be utilized.)
• Review proposed POPIMS carve-out from current v5 Collector; • Hold monthly meetings to analyze design process; • Anticipate beta testing July 2016; implementation January 2017; v5
Collector 2018. • Workgroup to continue to analyze, design, and refine POPIMS
fields and data elements.Committee members were asked to sign up for a workgroup of interest
and commitment. The work groups will be developed with assigned team leaders and work to achieve approved goals and tasks as determined and followed by the team leader.
Ideally, the future goal is to have representation from each Pennsylvania trauma center on either the statewide PIPS Committee or the Outcomes Committee. (Please see the Committee Roster section of this newsletter for current membership.)
To facilitate transparency, communication and input from all PA trauma centers, the committee member’s progress and completion of goals will be posted on PTSF website. Highlights will be summarized in the PTSF quarterly newsletter. Valuable educational initiatives from these PIPS work-groups will be shared through PTSF webinars and reference documents.
New Trauma Program LeadershipThe Foundation staff and Board of Directors welcome new trauma program staff members. We encourage trauma programs to reach out, and welcome these new staff members—please share best practices and serve as mentors to further the mission and vision of PTSF. New Trauma Medical Directors:
• Lars Ola Sjoholm, MD—Temple University Hospital, Philadelphia, Pa. New Trauma Program Managers:
• Christine Campbell, RN, BSN, MS, SANE-A, Trauma Program Director - Lehigh Valley Health Network Cedar Crest, Allentown, Pa.
• Michele Dunstan, MSN, RN, CCRN - Pediatric Trauma Coordinator, Lehigh Valley Health Network Cedar Crest, Allentown, Pa.
• Amanda McNicholas, CRNP – Trauma Program Director - Reading Hospital, Reading, Pa.
• Anthony Martin, BSN, RN, CCRN, ATCN – Trauma Program Coordinator - Reading Hospital, Reading Pa.
• Diane Perks, DNP, CRNP – Trauma Program Manager – Children’s Hospital of Philadelphia, Philadelphia, PA.
PERFORMANCE IMPROVEMENT & OUTCOMES UPDATES
FOUNDATION NEWS: Volume 14 Issue 2 PAGE 7
Trauma Research Committee Update Trauma Research Initiatives Moving ForwardPart of the Foundation’s strategic plan is to enhance trauma research in Pennsylvania. PTSF is moving forward with goal this in two major ways.
First, the Research Committee will be awarding both a research grant and research award through money acquired from the State of Ohio for the PTSF’s Research committee work on reviewing Ohio grant applications. 2016 will mark the third year the committee has supported Ohio in their endeavor which will create a fund totaling $15,000. Look for more information regarding the research award and grant in the coming weeks.
Second, PTSF is developing a Research Tab for the website. This new tab will bring attention to trauma program research, as well as showcasing the use of PTOS data. Several sections will be included within this tab including a searchable database of published research utilizing PTOS data. In time, this will serve as a database to promote Pennsylvania’s trauma research, as well as serving as a tool to report compliance with the Foundation’s Research Standard (for level 1 trauma programs). Similarly, subsections will include a research request form, background about PTOS data, information about the research award/grant, as well as an area to donate to the research fund.
Committee goals in 2016 will include developing studies to look at the quality of care delivery of non-trauma centers prior to admission to trauma centers, and the post discharge outcome of trauma patients.
(Continued from page 3)Also, new for 2016, the level 4 application will be integrated into the
electronic platform. Stay tuned for further details!
Year-Round Site Survey Calendar ApprovedIn response to the growing volume of trauma center site surveys, the PTSF Board of Directors approved a year-round site survey and deliberation calendar. Level 1 and 2 trauma centers surveys will continue to be scheduled within the months of March through June. Logistically, level 3 and 4 surveys could be scheduled during this timeframe, as well as extending into the months of August through November. Communication regarding 2017 “Save-the-Dates” are occurring now. Contact Kevin Burd, PTSF Director of Operations with any questions at [email protected].
Deadline for Letters of Request for 2017 Site SurveysJuly 1 is the deadline for Letters of Request for a site survey in 2017 from any hospital pursuing trauma center accreditation. Please contact Director of Accreditation, Amy Krichten with any questions at [email protected].
2016 PTSF Committee RosterA special thank you to those who serve on PTSF committees. We understand the time and commitment that it takes. Membership renews annually after “committee interest queries” are sent to all Trauma Program Managers (TPMs). The following is the list of both approved Board and Non-Board committee members.
Trauma Injury Prevention Committee Kimberly Everett - Chairman Reda Willis, Chairman Margaret Austin Ron Baier Kathryn Bommer Thomas Causer Scott Charles Gina Duchossois Lisa Eckenrode Deb Erdman Loreen Evans Noel Faust Stephanie Felke Kimberly Fleissner Leigh Frederick Pat Gifford Karl Henry Jessica Holmes Nora Kramer Nicole Lohrman Cathy Markey Christine McKeever William McQuilken Francis Nelson Melissa Ross Emmy Sasala Amy Stayer Chris Vitale
PAGE 9
IN PURSUIT OF OPTIMAL SUPPORT FOR INJURED PERSONS IN PENNSYLVANIA
UPCOMING EDUCATIONAL OPPORTUNITIESCheck the “Events” section of the website for additional educational opportunities in your area.
Annual Conference: “The Leading Edge of Trauma Prevention & Care: Our Communities Count on Us” American Trauma Society—Pennsylvania DivisionApril 20-21, 2016Hershey Lodge & Convention CenterHershey, Pennsylvaniawww.atspa.org
Society of Trauma Nurses (STN)TOPIC CourseApril 29, 2016Erie, PennsylvaniaFor further information, contact Sarah Mattocks ([email protected])
Horizons ’16 State ConventionEmergency Nurses Association—Pennsylvania State CouncilJune 2-3, 2016Mohegan Sun Arena at Pocono DownsWilkes-Barre, Pennsylvaniawww.pa-ena.org
20th Annual PaCOT/PTSF Fall Conference and Meeting Pre-Conference Sessions: October 25-26, 2016 General Session: October 27-28, 2016 Sheraton Harrisburg-Hershey Hotel Harrisburg, Pennsylvania www.ptsf.org
Rossmoyne Corporate Center
4999 Louise Drive Suite 104 Mechanicsburg, PA 17055
