SCAL RTCC QI Program

Gill Cryer MD

Measurement of Quality

• Virtually absent in medicine compared to industry and service organizations

• Needs redesign• Donabedian Model

– Structure– Process– Outcomes

DonabedianDonabedian

IOMIOM

04/22/23 3

Crossing the Quality ChasmCrossing the Quality Chasm

• Redesign care processes on best practicesRedesign care processes on best practices

• Use information technology to support clinical Use information technology to support clinical decision makingdecision making

• Improve knowledge and skills managementImprove knowledge and skills management

• Develop effective teamsDevelop effective teams

• Coordinate careCoordinate care

• Incorporate performance and outcome Incorporate performance and outcome measures for quality improvement and measures for quality improvement and accountabilityaccountability

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NQF Accountability ModelNQF Accountability Model

Develop “Systems of Care” and Hold Develop “Systems of Care” and Hold Accountable for Longitudinal PerformanceAccountable for Longitudinal Performance

• Quality health care is a team sportQuality health care is a team sport• Patients’ needs cross settings and Patients’ needs cross settings and

professionals professionals • Organizational supports are criticalOrganizational supports are critical• Greater system integration needed Greater system integration needed

Standardization of care processes Standardization of care processes Shared accountability & shared rewardsShared accountability & shared rewards

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Components of ideal PIPS planComponents of ideal PIPS plan

• Accurate regional/ national clinical database Accurate regional/ national clinical database

• Identification of risk factors Identification of risk factors

• Accurate measurement of complications Accurate measurement of complications

• Risk adjusted outcomes measurement Risk adjusted outcomes measurement

• Identification of best practices/ evidence Identification of best practices/ evidence based guidelines based guidelines

• Benchmarking Benchmarking • National and regional monitoring and National and regional monitoring and

feedbackfeedback

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ACS COT PIPS Program: ACS COT PIPS Program: HistoryHistory

• Optimal resources Optimal resources document 1979-2006document 1979-2006

• ATLS 1980-2008ATLS 1980-2008• Benchmarking (TRISS) 1982 Benchmarking (TRISS) 1982 • Verification Committee 1987 Verification Committee 1987 • NTDB 1989NTDB 1989• PIPS Web manual 2002-2008PIPS Web manual 2002-2008• Good PIPS= good outcomesGood PIPS= good outcomes• TQIP 2010TQIP 2010

The National Study on Costs and Outcomes

of Trauma Center Care

NSCOTNSCOT

25% - Mortality Reduction <55

The Evidencefor trauma systems

• All measurement techniques:

8-10% mortality reduction

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• Professional society led national trauma quality improvement program (TQIP) to decrease variability in care and outcomes nation wide

• National risk adjusted clinical data-base with verified data accuracy and 100% participation

• Take benchmarking, feed-back, and identification, dissemination and monitoring of best practices to the next level

• Raise outcomes of all trauma centers to an ever increasing higher level

COT PIPS Program: FutureCOT PIPS Program: Future

Why do we need benchmarking?

• If we do take responsibility for being accountable ourselves somebody else will do it to us!

• LA Times 1-22-09: California measures quality of hospitals

• We all think we are above average• What do you do if somebody tells you are

below average?• What do you do if you find that you are below

average by risk adjusted criteria that you believe to be true?

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Using Surgical Outcomes Using Surgical Outcomes to Improve Care & Lower to Improve Care & Lower

CostsCosts

ACS - NSQIPACS - NSQIP

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*: Statistically significant high outlier (inferior performance)

#: Statistically significant low outlier (superior performance)

1

0

2

3

NSQIP Annual Report: Risk AdjustedMortality O/E Ratios for All Operations

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VAH Improved Mortality

2.572.75

2.552.33

2.14 2.08 1.99

1.70

3.163.16

2.38 2.28

0

1

2

3

4

Phase I 10/91-12/93

Phase II1/94-8/95

FY 96 FY 97 FY 98 FY 99 FY 00 FY01 FY02 FY03 FY04 FY05

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VAH Reduction in Complications

Reduction of morbidity (45%) in VA hospitals since the introduction of the NSQIP

0

2

4

6

8

10

12

14

16

18

20

Phase 1 Phase 2 1996 1997 1998 1999 2000

Mo

rbid

ity

Ra

te (

%)

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Lessons from NSQIP: Assurance of Data Quality/Reliability

• Dedicated surgical clinical nurse reviewer (SCNR)

• Centralized nurse training• Standardized protocol• Definitions Committee• Mandatory web-based competency tests• Hotline to address nurse questions • IRR assessed periodically by traveling SCNRs• Site visits on request

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NSQIP: Centers of concern: problems NSQIP: Centers of concern: problems accounting for higher mortalityaccounting for higher mortality

• Poor coordination of care • Gradual cutbacks in fiscal support• Service lines that fragment care• Poor monitoring of quality• Lack of surgeon led team with

administrative support• An issue of systems not providers

NSQIP ReportsNSQIP Reports

• Ability to view your data onlineAbility to view your data online• Comparisons with national dataComparisons with national data• Selection of time frameSelection of time frame• Can drill down on individual patientsCan drill down on individual patients• O/E’s are equivalent to “dashboard warning light”O/E’s are equivalent to “dashboard warning light”• Online report allows you to “look under the hood”Online report allows you to “look under the hood”• NTDB exploring online report capability for TQIPNTDB exploring online report capability for TQIP

ACS Committee on Trauma

COT NSQIP Retreat• Risk factor and outcomes data in trauma

registries much different than NSQIP

• Adding a NSQIP trauma module to trauma centers would duplicate infrastructure

• COT already has fixed much of what NSQIP found to be concerning problems

• COT and NSQIP to collaborate to add NSQIP principles to trauma PIPS program

• TQIP task force

Sept. 2005Sept. 2005

TQIP task force questions

• Have we already picked the low hanging fruit?– Variation in outcome in verified centers?

• Is NSQIP methodology workable in trauma?• Is NTDB data accurate enough ?• What complications are important?• What outcomes other than mortality should

we keep track of?• What modifications to our current process

will be required?

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Decreased mortality

Increased mortality

-50

510

W u

sing

AC

SIS

6

Hospitals with >250 cases, 80% complete data, n=487,776

Index ACS 1 ACS 2 Other

Do you want to know who you are?

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• Build upon existing trauma center infrastructure

• Standardized data collection and validation• Risk adjusted benchmarking• Performance feedback• Identification and sharing of best practices• Ongoing performance monitoring• Raise the performance of all trauma centers

and trauma systems to a higher level

Trauma Quality Improvement Project

What should a state trauma system PI plan look like?

• Trauma center ACS COT verified PIPS program

• LEMSA trauma system program

• Regional state LEMSA program

• State program

• Just how we have to decide

• Why do we need to do this?

Multicasualties In Southern Calif.Year Injured Deaths

ZOOT SUIT RIOTS 1943 > 150

BEL AIR FIRE 1961 > 50 0

WATTS RIOTS 1965 > 1000 34

SYLMAR QUAKE 1971 14

WESTWOOD DISASTER 1984 51 1

RODNEY KING RIOT 1992 > 1200 38

NORTHRIDGE QUAKE 1994 138 33

SANTA MONICA CRASH 2003 73 10

GLENDALE TRAIN 2005 106 11

CHATSWORTH TRAIN 2008 133 26

Systems PI and disaster managementSystems PI and disaster managementSystems PI and disaster managementSystems PI and disaster management

Glendale train crash 2005

Glendale metrolink train crash 2005

• 106 injured patients, 25 critical• Only 2 patients transported by air to

a trauma center• Only 11/25 (44%) of critical patients

were transported to trauma centers• 13 critical and 75 total patients were

taken to 4 local community hospitals and overwhelmed them

QI Debriefing • 5 level I trauma centers agreed to take 12

“immediate”patients between them• 8 level II trauma centers agreed to take 17

immediates• Local area hospitals agreed to take 75!• Patients were sent to local community

hospitals >15 miles away when 8 closer hospitals received none!

• Data presented to LA EMS THAC

ACS Triage Inclusive Trauma System

Mackersie, Prehosp Emergency Care ’06

Disaster ManagementDisaster ManagementDisaster ManagementDisaster Management

Revised LA County disaster plan

• LA City Fire is asked to respond to a multicasualty event

• LA City fire notifies Medical Alert Center (MAC)• MAC sends multicasualty incident poll via

reddinet to area hospitals reg bed availability• MAC relays bed availability to paramedics who

organize transfer• Trauma centers automatically are responsible for

6 beds at each level 1 and 3 beds at each level 2 (48 total)

• Critical patients distributed to trauma centers

Metrolink train crash 9-12-08

Chatsworth 9-12-08

Freight engine inside metrolink

Extrication

Field triage

Transport by ground

Transport by air

Cooperation of different agencies

2008 Metrolilnk crash

Think about how it would turn out if this Think about how it would turn out if this Crash occurred near your hospitalCrash occurred near your hospital

Metrolink train crash 2008

• 133 victims• 25 dead at the scene• 98 patients transported to hospitals

– 25 by air to 4 level 1 trauma centers– 39 by air and ground to 4 level 2 trauma

centers– 34 by ground to 8 local community hospitals

• Only 1 transported patient died (Massive TBI)

Metrolink train crash 2008

• 33 patients critical– 27/33 (82%) went to level 1 and 2 trauma

centers

• 45 patients seriously injured– 22/45 (49%) went to level 1 and 2 trauma

centers

• 13 patients minor injuries– 9/13 (69%) went to level 1 and 2 trauma

centers

Train disaster comparison

• Glendale- 2005– 13/25 (56%) critical and 75/106 (71%) total

patients to 4 local community hospitals– 11/25 (44%) critical and 31/106 (29%) total

patients to 3 level I and II trauma centers

• Chatsworth-2008– 6/33 (18%) critical and 34/98 (34%) total

patients to 8 local community hospitals– 27/33 (82%) critical and 64/98 (66%) total

patients to 8 level I and II trauma centers

Patients to OR within 1 hour

• Pancreatic/duodenal, liver, vascular• Pancreatic transection• Perforated viscus, mesenteric vascular• Craniotomy• Exploratory laparotomy• Bilateral tension pneumothorax• Scalp avulsion• 11 open fracture/peripheral vascular• If you needed to do all these operations in your

hospital in 1 hour could you do it?

8 level I and II trauma centers8 level I and II trauma centers

Emerging Concepts• Bombings / shootings most common

• Triage: 20 – 25% require urgent care

• Coord. interaction of all area hospitals

• Most severely injured to trauma center

• They do it all the time!

• Utilize trauma systems

• They do it all the time!

• Regionalize planning and practice

Disaster ManagementDisaster ManagementDisaster ManagementDisaster Management

USGS Shakeout scenario

USGS Shakeout scenario

• 7.8 magnitude

• Shaking in downtown LA 55 sec

• 1800 deaths

• 50,000 seek help in Ers

• 67% of hospital bed nonfunctional

• Are we ready? We better be

• Disasters are Unpredictable but not unexpected• Analysis and planning essential

• Building around a trauma system: critical

Disaster ManagementDisaster ManagementDisaster ManagementDisaster Management

Look familiar?

State regional trauma systems

• Develop state and national trauma systems as foundation for disaster preparedness

• Combine with a regional, state and national QI plan

• Care of the injured will improve markedly as will other emergencies

disaster preparedness priority

Thank youThank you