Transforming a trauma performance improvement program at a Level II pediatric trauma center 

Following a regularly scheduled trauma site survey in early 2019, the survey team identified critical deficiencies in Mary Bridge Children’s Hospital’s Level II trauma program performance improvement (PI) processes. Failure to perform adequate primary and secondary case review as well as missed opportunities for loop closure and feedback to providers, led to a failure to improve care for the benefit of future patients. 

Philips led an interim leadership and performance improvement consulting engagement to develop a comprehensive corrective action plan that improved performance to meet state trauma designation standards.

As a result of the interim leadership and performance improvement engagement, Mary Bridge Children’s Hospital:

Our approach

The Plan-Do-Study-Act (PDSA) methodology was utilized to implement and test change:

Plan

The goal was to resolve the identified deficiencies in the trauma PI process by fall 2019 and satisfy Washington State trauma requirements to retain Level II Pediatric Trauma Center status. The transformation team consisted of the trauma medical director, trauma registrars, senior hospital leadership, key department stakeholders, and interim trauma program manager.

Do 

The team developed the corrective action plan to resolve the identified deficiencies, created a dashboard to monitor Key Performance Indicators (KPIs), implemented a PI database to document activities, and joined the TQIP benchmarking database.  

Study

The corrective action plan was implemented, which included multiple improvement activities to reach target goals. Lessons learned include:  early identification and involvement of key stakeholders, assessing readiness for change, education on new Washington trauma center standards, and continuous feedback and communication of progress was imperative. 

Act

A plan for continuous PI monitoring and documentation of activities was implemented to sustain performance. Identified weaknesses, or opportunities for improvement, were addressed through an ongoing proactive action plan. Following a gap analysis, maintenance of trauma center standards compliance is evident. Active recruitment for a permanent trauma program manager continues.