Assessing the situation
The trauma center staff had been struggling to maintain and adequately document performance improvement activities that properly mapped against internal metrics and industry standards. Difficulty in prioritization, follow-through, and adherence to new processes, put them at a disadvantage when it came time for their ACS verification survey.
The initial job was to assess the current situation and determine trauma center shortfalls. In a review of the trauma center’s people, places, processes, and operations, limitations to optimal quality and patient outcomes were identified. This was accomplished through interviews with staff, department leaders, and administration, in addition to onsite observations of departmental processes, meetings, communication, and trauma team activations.