System Quality Management Program

Trauma Plan- System Quality Management Program

Reviewed June 2013; Oct 2014; Oct 2015; Oct 2016; Oct 2017; Oct 2018; Oct 2019; Oct 2021

Continuous Quality Improvement (CQI)

Introduction: What is CQI?
Continuous Quality Improvement (CQI) is, in its most basic sense, a way of approaching and examining any process within a system and seeking to create beneficial changes in that process in order to provide improved service (or product) within that system. The term “system” is extremely important in approaching any problem by CQI standards, as this approach seeks to view the issues under consideration more from a generalized standpoint, and is less interested (at the onset) in the individual inputs into the system (or in the case of Trauma care, less in the individual providers of the care, and more into the overall functioning of the system as a whole.) In even more basic terms, CQI seeks to examine the “forest” first, instead of starting with the individual “trees”. An old axiom in CQI circles is that “any problem is (usually) 80% due to the system, and only 20% due to the individual inputs.”

A well-developed CQI process, however, does not ignore individual inputs into the system, but should be organized to look at those individual inputs as a part of the greater whole. For example, as in the case of a trauma care system, an individual ambulance crew serves as an input to the system, bringing an injured patient from the field, and administering important initial care. While a CQI process would be most interested in the overall care of the trauma patient (outcome of care and efficiency of passage of the patient from the field, to a Level IV facility, and then on to definitive care, for example), the CQI process must also address the performance issues and the needs of this individual ambulance crew.

CQI begins with (1) Identification of the problem to be considered, then moves through the following steps: (2) elaborating the causes of the problem, (3) developing aids or remedies to the problem, (4) laying out a plan to correct the problem, (5) enforcing the plan of correction, and then (6) re-examining the problem. This final step is known also as “closing the loop,” and is a key element in the process. This system-based approach to problem solving is ideally suited to TSA-C in its efforts to implement and improve care in the area that it serves.

Current Limitations of CQI in TSA-C
The primary and most daunting limitation to the CQI process for TSA-C is the process’ dependence on the collection of the meaningful data for analysis of systems-based issues. Steps have been taken to institute a system for regional trauma data collection for both EMS and hospital providers (see below). Until this is accomplished in a manner that would allow for the tracking of cases through the entire system, the CQI committee’s functions will be limited.

The CQI Committee:
This committee of NTRAC, composed of volunteers from the general membership of the association, and with a chair appointed by the Executive Committee, is charged with overseeing the CQI process within TSA-C. Its membership should be diverse, representing all aspects of the trauma care process, including first responders, EMS providers, nurses, physicians, educators, and hospital administration, as well as interested lay people.
Regular meetings shall be held by the committee as determined by the chair and as per the Bylaws of NTRAC, and an annual budget shall be submitted to the Finance Committee as per the Bylaws of TSA-C.

Functions of the Committee:

1.  Supervision of the collection of data from the regional trauma database
2.  Determining parameters for analysis of data from the database
3.  Providing trauma-related data to the other committees of NTRAC
4.  Providing data to the media and other interested entities regarding trauma and trauma care in the region
5.  Providing objective statistical interpretation of trauma data as it relates to patient care and outcomes in the region
6.  Ensuring the confidentiality of trauma data
7.  Performing and modifying needs assessments within TSA-C for trauma system    resources, including educational funding, system development funding, basic trauma equipment funding, and TSA-C administrative needs
8.  Prioritizing the utilization of limited resources within the system

1. Data Collection:

Data collection will be taken from completed audit forms from member EMS agencies and hospitals.  NTRAC will also utilize data collected from the trauma registry maintained by each member entity.

2. Data Analysis:
Using statistical models, the data from NTRAC members will be utilized to determine several parameters of use in improving the quality and availability of care in the region. These parameters may include:

* Injury patterns and distribution – types and locations of trauma injury
* Morbidity and mortality – severity of injuries from trauma
* Availability of services – trauma care speed and access to care
* Quality of services – review of patient outcomes as related to care received

3. Data Sharing within TSA-C:
It shall be a primary concern of the CQI committee to serve as a conduit for data, and as a source for data analysis for particular needs. Grant applications relating to preventive medicine and educational funding, for example, would require objective data to support the need for these projects being funded.

4. Data Sharing with the Regional Community:
The media and other interested community groups, including law enforcement and public health entities, may need access to trauma-related data for their own public awareness programs and other needs that would complement the mission of NTRAC. The CQI Committee can provide these entities with accurate information, based on the actual care records.

5. Data Interpretation:
One of the most valuable functions that the CQI Committee can provide to NTRAC member entities, is the objective assessment and interpretation of trauma data as it relates to patient care.  It is important to note that this statistical data should not be utilized as a punitive tool to punish sub-par performers within the trauma system, but as a tool to identify areas in need of improvement, and further, the committee should present remedies for improving performance, with the object of improving the system in its entirety. These conclusions may also be passed on to other committees, for the purposes of initiating appropriate remedies within that particular committee’s scope of authority.

6. Data Security:
The committee shall also be charged with devising mechanisms to ensure the maintenance of absolute confidentiality in patient information and in the information regarding individual providers within the system.

7. Needs Assessment:
With access to significant information from the trauma data, the CQI Committee is ideally suited to develop short and long-term needs assessments for the regional trauma system.

8. Resource Utilization Prioritization:
The CQI Committee shall, by virtue of its information access ability, be ideally suited to provide input for the regional needs assessments in the areas of injury prevention, education, equipment, and personnel.