Ambulance services Information on your Multidisciplinary Committee and Peer Review (who is on each, how often each committee meets, attendance requirements, etc.) PI process – how events are identified, how they are reviewed, how loop closure is achieved Re-designation visit – How opportunities identified at last visit have been addressed. TMD must be familiar with all charts and associated PI, block calendar as needed One week prior to the visit Assure all charts have been pulled and in Review each case. You will want to be familiar with them. Assure one person who is experienced in navigating the EMR is available for each site reviewer the day of the review. Assure no last minute meetings have been put on the TMD’s or administrator’s calendars. Schedule something special just for you. Schedule an after site visit “debriefing” for your trauma team. (Restaurant, party, etc.) TMD must be flexible and available to address any last minute concerns Day of visit Greet site reviewers and state hospital designation coordinator at a mutually agreed upon location. SHOW OFF YOUR PROGRAM! You have just spent a year preparing for this day. Show off what you have done! The site reviewers will offer advice based on their experience as trauma providers. Listen to them. They are really there to help. The tour of the hospital will follow the path of the patient. The reviewers will look at the ambulance bay, ED trauma bay, lab, radiology, OR, ICU, helipad. On the Minnesota Trauma System website look under site reviewers resources, then Tour checklist. Here you will see everything the reviewers need to find during the hospital tour. Much of this is equipment in the ED. (Refer to Chapter 11, Equipment) Expect at least two hours for chart review. You will be asked questions about the patients and/or PI. Having the PI sheets with the records will make everyone’s job easier. The hospital designation coordinator will go over your PI process. Be prepared to speak to how you review cases and bring things to loop closure. The site reviewers will take about 30 minutes after chart reviews to summarize their findings. You will be given a time for the exit interview. During the exit interview expect to hear strengths of your program and opportunities for improvement. Having administration present to hear about these opportunities directly from the site reviewers is powerful. Get them there! Visit is over
Oversee the trauma PI program and participate in other quality initiatives that deal with the care of injured patients. Review and investigate all trauma PI inquiries in collaboration with the TC and refer to the appropriate committees. Monitor compliance with trauma treatment guidelines, policies and protocols. Assure that the quality and appropriateness of patient care are monitored and evaluated and that appropriate actions based on findings are taken on a consistent basis. Report quality of care events promptly to appropriate individuals, including TC and hospital administration. Identify and correct deficiencies in trauma care policies, guidelines and protocols. Consult with appropriate medical staff and administration regarding quality care events and adverse outcomes; identify areas to improve patient care. Assure that continuum of care is maintained. Identify representatives from various disciplines appropriate to participate in PI activities. Coordinate, schedule and facilitate the PI peer review process. Chair the Morbidity and Mortality Committee meeting and the Multidisciplinary Trauma Conference. Review all trauma-related peer review and initiate action as necessary. Assist the TC in evaluating the effectiveness of corrective actions resulting from PI processes. Assume responsibility for the accuracy and validity of trauma statistics. Clinical Education Support the requirements for trauma CME by participating and assisting in the education and training of hospital personnel physicians and specialists. Provide education for hospital staff regarding trauma program policies and appropriate medical practices. Community Outreach Maintain relations with community organization and legislative bodies whose activities relate to trauma care and injury prevention Participate in hospital outreach activities as may be requested by administration. Develop and participate in trauma community education and injury prevention activities. Function as a liaison to other hospitals within the region. Knowledge and Lead the hospital in program development. Oversee the clinical practice of medical staff. Analyze and interpret complicated information. Determines a course of action based on research, data, standards of care and general guidelines/protocols. Communicate effectively with a wide variety of intra- and inter-facility staff and administration using both oral and written communication. Possess critical thinking, analytical, teaching/coaching and research skills Oversee, participate in and develop projects that ensure the cost-effectiveness of care provided by physicians and hospital.” Networking resources for TMDs The American College of Surgeons Local Level One and Two TMDs SMRTAC Coordinator