Signed Electronically Performance Improvement Plan Made Easy

Signed electronically performance improvement plan

welcome everyone to today's webinar transforming the trauma performance improvement program at Mary bridge Children's Hospital I'm Mackenzie beam with Becker's hospital review we will begin today's webinar with a presentation and we'll have time at the end of the hour for a question and answer session you can submit any questions you have throughout the webinar by typing them into the Q&A box you see on your screen we are looking forward to hearing your questions today's session is being recorded and will be available after the event you can use the same link you used to login to today's webinar to access the recording at this time it is now my pleasure to start today's webinar by introducing our presenters dr. Tony Escobar is a PD act pediatric surgeon and medical director of pediatric surgery and trauma at Mary bridge Children's Hospital in Tacoma Washington dr. Escobar recently completed two terms as the hospital's chief of staff he graduated from Baylor School of Medicine in Houston and completed his surgical residency at Indiana University where he served as chief resident in his final year he then completed his pediatric surgical residency at women and children's hospitals buffalo once again serving as chief resident in his final year Jennifer Brown is a consultant for the healthcare transformation services business within Phillips she graduated from the University of Alabama Birmingham with the Masters in nursing and has certifications in nursing informatics clinical nurse leadership and nurse executive administration earlier in her career Jennifer spent more than 10 years leading technology-driven emergency and trauma process improvement initiatives at a pediatric level one trauma center since then she has served in numerous emergency and trauma leadership roles in academic and community hospitals angie Chisholm is a consulting manager for the healthcare transformation services business within Phillips Angie has served on many state and national trauma committee she is a trauma certified registered nurse and a certified flight registered nurse she's a passionate lulz driven leader was nationally recognized expertise and travel program operation at this time I am pleased to turn the floor over to Jennifer to begin today's presentation thank you this is just a slide again of everyone on our team that's on the call today picture of dr. Escobar myself and Angie so a little bit about Mary bridge to start us off is Mary bridge Hospital Children's Hospital is part of multi care Health System they join the multi care Health System back in 1980 they are also only one of two pediatric trauma centers for the state of Washington and in the western region they are the only Children's Hospital and state designated level two trauma center their licenses eighty two beds they have 24-hour pediatric emergency department only for Pediatrics they dedicated outpatient surgery Suites an advanced pediatrics and patient Surgery Center with rapid response environment controls in more than 30 outpatient pediatric specialty clinics I'm going to turn the next slide over to AG engi I'm unable to hear you are you on the call are you on yes I'm sorry so thank you sorry thank you allow me tell you a little bit about Philips health care transformation services Philips is well known in healthcare for their equipment like monitors and CT scanners and more widely recognized by consumers for the toothbrush but did you know we offer healthcare consulting services we are delivering solutions oriented and people focused recommendations to help improve clinical care patient experience operational effectiveness and financial performance to ensure sustainable results for long-term success we have over 50 us-based consultants with clinical IT and healthcare leadership experience and a global network of consulting expertise in seven countries today's presentation is just one example of what we can do so for today we aim to provide you with an understanding of the importance of performance improvement on the trauma center designation process while helping you identify the critical deficiencies that lead to a site survey failure we will also discuss the impact that vacancies and key positions may have on the trauma program and the designation process now I believe dr. Escobar may be on and hi emergency surgery hi so I am going to no worries patients come first so I am going to let dr. Escobar give you the information next so thank you everybody and I really appreciate your patience um so in a february of last year we had the experience that every trauma team dreams of with an extraordinarily difficult site review and as many of you have experienced at the heart of the findings was our p i-- program and so our trauma program went through many changes following that site review but one of the critical key elements are trying to recover from the site review and address the findings that the Department of Health had for us was to surround myself with an experienced team to be able to address those pis and so we vetted many many applicants but ultimately chose to go with Philips Blue Jay because I had worked with Angie in the past through the trauma center Association of America and knew the credentials that she brought and then I was extraordinarily fortunate to meet and work with Jennifer Brown on the ground to essentially rebuild our trauma program from the bottom up and although P I was a key finding there were many elements as most of you could imagine that had to be addressed as well and we really took the program and looked at it as an opportunity to rebuild it from the ground up and what we've come out with on the other end is so much more robust and I think it tells our story so much better to the site reviewers to the state and I won't skip to the punchline because I'd like Jennifer and Andy to be able to present that part but the experience has been extraordinary and it's a trauma Medical Director the growth for mice for me personally has been absolutely extraordinary thank you dr. Esther ward so maybe not as Marcus best/worst said is that we got brought in the survey actually was in February and one thing that's so amazing about the Mary bridge team and also make I think one of the things that makes them a leader is they did not wait for the state's final recommendations to come out in April actually in February they already started making a plan and dr. square worked with the leadership team and coming up with let's push me forward and let's make this an even better program than it was before so one of the great things is before we even arrived at Mary bridge dr. Escobar sent us a copy of all his notes from the final report out of the survey and that really helped Iggy and I determine how we were going to come in and start making the improvements and working with a Mary bridge team so made a decision to use the PDSA methodology and so we came up with the plan and on what we were going to need to change and what we needed to focus on and then we carried that out and of course we observed and studied the data behind it and then made any kind of modifications or changes that we need to make to go on and carry that out to act just to stay in that performance so again part of your plan that is so important is that we slow down and we take the time to truly know and identify what the problem is so again following the regular scheduled trauma site survey the team identified that there were critical deficiencies in the performance improvement processes and these included failure to perform adequate primary secondary case review as well as missed opportunities for adequately closure and feedback to providers leading to failures to improve care for the benefit of future patients so the goal of our project was very important that when actually when the state did release the findings in April what we found out was I think what the team expected all along is that they would be the corrective action plan and with the corrective action plan the state of Washington gate it gave a date that they wanted to see the changes in place and also show that these changes had taken place about October 31st and so that was to meet the state of Washington requirements to retain the level 2 pediatric trauma center status so also part of the plan included one of the most amazing teams so having a good transformation team which of course included dr. Escobar is a trauma medical director and I've been able to serve as the interim trauma program manager and honey Mallory who is our lead trauma register as well as Hilary Lindley as our own register and inches Consulting the user to help directing us along the way and then I can't say enough about the leadership Singh at meri bridge about how proactive and how involved they are and how much they want to say the trauma program succeed very supportive group of people and then of course the key department stakeholders everyone was very involved they wanted to make sure that we we had this taken care of so in a very very high level what did we do again very very hard level there's a lot behind us of course as we developed a corrective action plan for the deficiency now in that also included with a dashboard of key performance indicators and then of course what we did was in focusing on performance improvement before what was being used actually to track performance improvement was an Excel spreadsheet well with an Excel spreadsheet it doesn't necessarily allow you to be able to really monitor and track and trend so a decision was made in the hospital we've supported purchasing API database to be able to make sure that these activities that were being done and going to be done we're documented well and they could be tracked and trended and then it is so important for benchmarking and so he quit participation we joined sequence and so we could begin national benchmarking against other level two pediatric trauma centers the first thing we did of course is we had a timeline we had to meet an October 31st deadline that we created again order those key things tasks that have to be done in order for us to make the October deadline and those are identified here now we talked about having a PDSA that each of these items also have PD essays and even PD essays in there to make sure these things happen so the problem identification was one of the first steps that we knew needed to be done and that took care that happened in March and in April to really in April when we got that final report we were able to say that the notes that dr. Esper and actually Hadi had taken well we're right on target so there were not a lot of surprises maybe one or two that we were able to very quickly work through so we're able to in turn determine and find what we needed to work on and again as I just got through talking about is we implemented a PI data base we had that up and going and being able to input data as of May and then in June we were able to accomplish revising the job description of the trauma program manager so in hiring the permanent trauma program manager we would be able to set them up for success the creation of audit filters to make sure that we have structured methodology for collecting data and then again we talked about developing a key performance dashboard those things are all completed in the June timeframe and in the tale remission or the performance improvement policy we needed to make sure that the policy match the practices that were taking place and also included the other thing very interesting is in January the state of Washington had updated their trauma standards so there are new standards and those rules needed to be referenced as wellness policies so we were able to get that done and approved through community process by July and then reduce registry backlog before when they were working with just the state of Washington the goal was to have everything abstracted within 90 days of discharge that we did to t quit that was a more progressive plan so we needed to make sure that obstructions happen you get sixty days after discharge and then of course our goal of implementing the I'm submitting to the state by October 31st which I have great news to share with you about that just a minute so the specifics of what this state um think this isn't coming up on the so I'm going to give me one quick second so I can make sure I have those for you so I was going to share with you specifically what the state said so the recommendations that they gave the first recommendation is of course they wanted to see an improvement of the collection monitoring analysis and reporting of the data drives quality improvement what better way to do that than to have a P a database to help do that so there we go so we were able to implement the P a database to be able to do that for quality improvement the net funding was of course to improve the prefer to perform the primary and secondary levels of review a part of that even if you do are doing the primary and secondary review it is so important to document those things so we were boss the process to ensure that not only the primary secondary review or being completed but also that we were documenting those meetings that were occurring so to track the audit filters across the spanned as a continuum there we implemented on audit filters and created um also we implement those audit filters and created the dashboard for those and then regular reporting and benchmarking of the metrics so again creating the dashboard the scorecard to make sure that we can get that done and then a well of course implementing she quit so HN I thought it was really important that we showed you what a dashboard looks like so this is actually the one we created for Mary bridge this is not meant for you to actually see any of the details but to see what it looks like on the left of course are all the different audits that we're conducting and then also we had a target that we have created for each of those specific audit remember to the right is that they would have specific data it to be a percentage or a number that is in each of these fields that using green saying that we are sustaining and meeting the target read be in areas that we look out further and make plans around so we went through a lot there's a lot of work but the results were absolutely worth it so we were able to actually submit the corrective action plan by September 23rd and with a due date of being October 31st you're ready to submit a little bit earlier than been expected through the written plan that we actually gave back to the state included that revised job description and the revised TI plan as well as the scorecard I just showed you on the earlier slide as well as showing them case summaries that demonstrated the different level of review also including of course any kind of systems or case review meetings and then the loop closure around home for the event revolution for those cases for the state to see so lessons learned is that it is so important to identify the right stakeholders and have them in the right meetings at the right time also to make sure that our team is ready and they understand what we're going to be doing and making sure those things are carried out and then education around any kind of new standards that a state has so having early education to understand what those are and making sure that the team knows what will be the new changes coming forward and then of course it's so important for us all of us to constantly to make sure that we're continuously giving feedback clarification and communication so next step to sustain this great funds that we have is we are continuing continuing our PR process and documentation of activities and then also with the next steps included are the way the state of Washington says that instead of weaknesses they say here are the recommendations that we want you to take a look at and fix so our next steps that we have been working on is of course resolution of any identified weaknesses and then ongoing compliance of the new trauma center standards and we are working with the team to recruit a permanent trauma program manager so those areas are those weak weaknesses as they could be called or recommendations of the state mirror here and whoever helped me again last time if you could do that for me again to advance this was to demonstrate the compliance of the new state of Washington standards at the time of redoes Ignatian in 2022 so what we did was we created a gap analysis to look at each of the changes that the state wanted to see if they were already in place at Mary bridge or if it was something that we were going to need to work on a little bit further and have that completed and as demonstrated it's happening by 2020 and the outdated PR Qi plan that we had regarding the rural reference that was part of what we presented I'm sorry that we completed actually in July and it contained that new rule part of when I talked about earlier that we made changes to the trauma program manager Job Description we went ahead and included topic as being one of the courses we want to have seen this that this trauma program manager has taken or that we can have them take within a period of time I currently I completed the topic course and then again of course like I just said that we made sure we added that to the job description but provide I went to EMS regarding patient care issues and one of the things that has happened or happened as part of our process is we have an amazing actually pediatric emergency medicine physician who serves is our EMS coordinator and she and I meet monthly and we review the CMS audit filters that we have put in place we review those and look for opportunities to give feedback to our pre-hospital team I think there's one last one and then of course to demonstrate the trauma surgeon arrival time now Mary bridge is very innovative and had the ability to do badge swiping for the team as they arrived but the problem with that is the badge swipes through not interfaced with the actual electronic medical record so what we've done is we've implemented that the nurse scribe in the trauma documents those times in the electronic medical records but eg I'm going to turn this over to you now Thank You Jennifer I think it's worth noting that the Mary bridge leadership including dr. Escobar recognized the need for support and acted very quickly which is why we were able to meet that deadline for the resolution so what we're going to talk about in these next few slides is actually how to avoid these criterion deficiencies and how to better prepare for a site survey I will note that the Mary bridge team were they weren't we're not making mistakes if you will with their PII they just needed to enhance it a bit and document it a bit better they were providing excellent patient care as they continue to do today but they needed to gather that information and make a proof point of that information so there are a lot of people on the call and a lot of different backgrounds so we're going to get a little basic here just for a minute so bear with me I just want to make sure that everybody understands the context of what we are trying to present today and what is a trauma center it is a hospital that's equipped to care for the multi injured patient throughout the continuum and has also undergone a review of compliance with trauma center standards to become designated or verified there are two different definitions here trauma center designation is state based the criteria varies from state to state it is rule-based and many times at ly outlined in law through legislative or regulatory authorities trauma centers undergo read designation surveys depending on the state agency sometimes every three years sometimes up to ten years the trauma center verification is different however the American College of Surgeons Committee on trauma does verify that the standards are being met to operate as a trauma center they started these guidelines back in 1976 with their first book the resources for optimal care of the injured patient today they are on another edition which is the we called the orange book which is our Bible if you are an ACS verified facility the trauma centers undergo acs verification every three years so if your ACS verified and state designated and your cycles don't match you may be in perpetual survey mode participation is optional or it may be required depending on your state requirements so what is site survey it's many times just like a Joint Commission survey it's a pain of trauma experts they complete an on-site review of the hospital and provide an objective external review of the trauma centers resources and performance some of the things that they are looking for these surveyors is the commitment of the hospital to the trauma program the readiness of the trauma program and caring for those patients the resources available to the patient to make sure that you have all the resources to the level of trauma center that you are being designated at that they have all the recommended policies and guidelines to care for the patient they look at the patient care they review the EMR and they also look at your performance improvement documentation trauma center surveys take a significant amount of time and money upwards around $20,000 depending on where which organization that you're working with and that's why it's so important for you to get it right the first time a typical preparation period can be 14 months I've seen it done in as little as six months but that's pretty labor-intensive the site survey reporting year is a full 12 months it's not very quick so what criteria are you being surveyed on I have a copy of this orange book here and behind that is just a screenshot of a state standard I'm going to talk about the ACS criteria because that's standard across all states if they participate with ACS as I said in the previous slide state standards may change between states and it would be pretty difficult to review all 50 of those in this presentation so we'll talk about the ACS there are two types of criteria that you must meet in order to be verified as trauma center there is type one criteria that must be in place at the time of the verification and type two which is also required but less critical the survey team determines if the trauma center has met the obligations of the rule or standard and provides a summary of strengths weaknesses or opportunities for improvement and deficiencies the classification terminology may be different depending on the state but the intent is the same is the facility compliant or deficient in meeting the standards and rules so how do you avoid those site survey deficiencies well according to the ACS the essential requirements for verification include compliance with type 1 and type 2 criteria as we just discussed they go on to say if any type 1 or more than 3 type 2 deficiencies are identified the facility fails to achieve verification and a focus review must occur 6 to 12 months from the initial site visit as an additional cost if fewer than 3 type 2 and no type 1 deficiencies are identified the facility can get a one-year certificate that they must correct the deficiencies and tell you that the site survey is not the time to identify that you have a gap in your program and if this story sounds familiar to you it is very common and that is why we are able to help the no program is perfect but they should have a continuous improvement process in place with documentation of p.i activities the minimum standards of designation verification must be in place for faith jeopardy of closing downgrading or given provisional status these are five common reasons why your program may be in jeopardy registry non-compliance that is non-compliance with your data abstraction your PII compliance failure to demonstrate that loop closure or document nor case reviews your call schedule coverage gaps physicians and nursing education inventory is incomplete and a vacancy in a key position these are just some common reasons again that your program may be in jeopardy that is certainly not an exhaustive list of potential areas of opportunity so how do you find out if you are in jeopardy do it by asking the right questions but when is the next survey is probably the most important question that you would want to ask if whether you are the senior administrator responsible for the trauma program your the trauma program manager director you're the trauma Medical Director it doesn't matter what your role is everyone should know in the next survey is so that we can have a complete state of readiness for that survey questions you can ask of your registry what is the trauma registry inclusion criteria and are you capturing all of the relevant data ask to see that information ask to run a report of that information what is the registry abstraction rate is it 80% within 60 days of discharge that is the ACS standard and you heard from Jennifer that the Washington standard was different it was 80% within 90 days of discharge but that doesn't marry up to the T quit participation so making sure that you're meeting the obligation do you have any vacancies any open positions in registry your PI program your leadership any surgical specialties with vacancies where you can't have a complete call schedule those are all questions to ask and things that will put your program in jeopardy looking at physician qualifications when was the last time that you performed a physician qualification inventory on each specialty on the trauma call panel making sure that all of your physicians and surgeons are board certified in their specialty making sure they have the CMEs making sure that they have a TLS if it's required making sure their credential appropriately to provide that level of care in your trauma center that meet that should be done every year and kept up with year-over-year performance improvement can you show me two examples of loop closure from recent cases ask to see that information how many cases remain open and are you concurrent in your chart review or do you have a stack of charts that you cannot get to because you have a vacancy are the physician liaisons actively participating in peer and system meetings what is their attendance compliance ask to see that reviewed and stash port if you don't have a performance dashboard then create one review the PRQ data tables the pre review questionnaires so prior to any survey you're required to 30 days out provide a document called the PRQ pre review questionnaire some states have an RFP request for a proposal but those have data tables in them I recommend that you run those data tables of data analysis every year make sure that you have that information in front of you at all times so that you understand what your program is being measured against and it's not thirty days ahead of time trying to figure out what that data means to you nursing qualifications to go along physician qualifications when was the last time you did a performing education inventory the ACS many states are very prescriptive about nursing education but the ACS however is not quite as prescriptive but it is valuable to run that inventory of each of your care areas and make sure that your nurses are qualified to care for your patients so when was the last time that you get a gap analysis getting a list of all of your standards and seeing how you meet those how can you prove that you meet those standards VI compliant for example is evident at the case review meeting look for cases that are more than three months old for an idea of how concurrent the case review is so talking about the fallout from vacancies this is why vacancies are so important not to have in a trauma program travel program personnel has unique skills that are not intuitive to typical clinical or leadership staffing leading to a difficulty in hiring you also it's very difficult to just take a leader that's in the hospital and move them into the trauma leadership role they obviously they can learn the role because we all do that's how we we all get started somehow but it is not that easy to just walk in and be successful in a trauma program manager role or a registrar role I have I have worked in facilities where the the senior leadership wanted to remove the trauma registry and just have a Cancer Registry doing all of the abstraction well cancer is very different from trauma and the data points that are extracted so you need to know what skill set is required if all of your key positions they can see in a key position according to the American College of Surgeons may be viewed as a lack of commitment if you are allowing vacancies to give you in your facility then it may show that you aren't committed to the success of that program as I said earlier an active survey period is twelve months before the actual site survey so this is not a last minute gross on one end of the position and hope that we can pull this off so for proof of all of this criterion deficiency two point one in the American College of Surgeons book the trauma center must have an integrated concurrent p.i and patient safety program to ensure optimal care and continuous improvement care that is a type one deficiency if you have a vacancy in a PIR or a trauma program manager or director and you are not concurrent in your chart review that is a type one deficiency criterion deficiency 5 - 23 in level one and two trauma centers that trauma program manager must be full-time and dedicated to the trauma program that's a type two deficiency if you'll remember if you get one type one or any type two or more than three type two you're not moving forward with your verification so that's why these vacancies are so critically important to your program that's why you also cannot just take a leader from another area of scene where ICU directors are also given the trauma program responsibility where the IDI director is also given the trauma program responsibility they cannot possibly split their time between the two especially in level one and two facilities so criterion deficiency 15-9 one full-time equivalent employees dedicated to the registry must be available process of data capturing the NTDs data set for 500 to 750 admitted patients annually that's type 2 so if they can see there and all of these listed here all of these criterion deficiencies listed here are type 2 so all surgeons and physicians on the child trauma call panel must be board-certified in their specialty or follow the alternate pathway so there's an opportunity for at least eight type 2's if you have one physician in each of those specialties as a reminder if any type one or more than three type two deficiencies are identified the facility fails to achieve verification and a focused review must occur six to twelve months from the initial visit at an additional cost so how do you avoid these deficiencies ask the right questions you view the data and know your numbers whether it's a dashboard of key performance indicators whether you run a report of your PRQ tables and understand what is going on in your program clarify the rules or standards with the governing body I participate in a lot of lists our list serves where there are lots of questions about how to interpret different rules I recommend that you always go to the source and get clarifications on on the rules and standards sniffing doubt consult an expert I want to conclude with this that no trauma center should run the risk of a deficit under performance or closure from being ill-prepared for their site visit trauma is very important to the hospital's bottom line but I think it's more important to the community it serves but thank you for giving us your time and attention today I'm going to pass this back to the moderator for any questions that you may have great well thank you dr. Escobar Tucker and Angie for such a fantastic presentation will now begin today's question and answer session please submit any questions you have by typing them into the Q&A box you see on your dashboard we'll try to get through as many questions as we have time for the first question is from an audience member who is asking what key audit measures or key performance metrics were most challenging to achieve well dr. Escobar I'll let you yeah I was gonna say to him I'm sure that from different points of view there's going to be a slightly different answers but though the one that for for me in just intuitively trying to get around was not necessarily documenting the appropriate activation of the trauma surgeon which at the end of the day as long as they showed up to the majors and somebody had noted it even if I just signed it on a piece of paper that was fine for me the difficulty was trying to UM define orthopedic surgery or neurosurgery appropriately responding and how did we document that and we're still working on that the other key piece and then I'll turn it over to Jennifer was what if you disagreed with the site reviewers and so my academic interest lies in child abuse screening and trauma centers and I'm heavily involved in the creation of those kind of screening programs and I disagreed with the site reviewers in a in a certain recommendation regarding a child abuse screening so you know I was prepared to write a rebuttal um because I did not think that we should just implement that particular recommendation um and so so those are the two things as a medical director that that I found challenging and Jennifer yeah Kenny I was making sure what is it still on view so you're right that was one of the the ones that we found so to start off with what we did was we worked on those as I had in the PowerPoint presentation those are key we're all in agreement and these are the ones that we're going to work on what we have done as dr. Escobar said is what we've done is we this house was so amazing that they actually have a subcommittee of our trauma committee that is focused on child child abuse so what we have done in that committee is we have continued to discuss it and look at you know what what exactly the state was wanting from this particular weakness that they identified and the findings around it so what we'll do our next steps are what we're working on is to make sure that we've gotten clarification from the state there was one other and dr. Escobar that we have that we we really weren't sure what the state was saying we didn't necessarily agree with it and on that particular one what I had done is I emailed the state and asked them here's where we don't necessarily agree with you or understand what you're saying so could you please clarify or give us more information and so we were able to partner with them and actually come up with the solution and it is documented now you know in email that this is what we agreed upon that will we do to make that weakness in Angie do you have anything to add No I think just changing the process of evaluating the care and documenting it in a different way was initially a challenge but we quickly were able to overcome that challenge and I think honestly the the P I meetings that I've been able to attend have been very robust discussion and debate and conversation which is very healthy in a program to have that input from in participation from the difference of specialties so I think actually Mary bridges well on their way to to making great improvements in their program wonderful thing to offer Wigan on that question the next audience member is asking did you add anything else to the TPM job description besides the topic course we did and of course ancient doctor is Clark please adding anything instead I forget we as far as with the qualifications and we did believe that and working with our CNO and a CNN this person need to be a master's level prepared nurse and have current certification in TCR in a trauma course for nurses and and of course having added a topic course that we had also with that we also wanted them to have prior experience in the role of the trauma program manager no I think this is doctor yeah I think Jennifer really really really nailed that for us and for me I think that one of the huge lessons I took away from this site review is the absolute critical nature of the dyad relationship between the trauma program manager in the trauma medical director and while over the years I have absolutely learned a lot about trauma program management I am by no means as smart as my trauma program manager so it took quite a bit to realize that and add to the job description those qualifications that although I can talk about P I and Qi I don't live in it you know I'm not elbows deep into the actual way that we noted loop closure I thought we were doing everything just fine and and then clearly we couldn't demonstrate that we were and those were the extra qualifications that I think were critical one other piece that Jennifer didn't address was that but Angie mentioned was being careful not to add too much to the trauma program management manager Job Description you there's a there's a tendency to want to combine positions to save on FTE at the organization level and that is that is absolutely not in the trauma program managers or the trauma programs best interests so the trauma program manager at a level one or level two should not also be the you know the injury prevention person or the Registrar or etc etc and I think we really clarified that within the rewriting of the Job Description perfect thank you for elaborating on that this next question is is the trauma registry the best place to document case summaries of closed p i-- cases I can I can take that Jennifer I had experience across the country in very different formats and platforms with trauma registry or P I capture and documentation into a database and there believe it or not there are many places who use Excel spreadsheets to capture their p i-- and you can't query an excel spreadsheet which is why i lean towards the database whether it's a homegrown Access database or sequel database or whether you purchase one it is just so important to have your information in a place where you can query and research whether or not the registry is the most appropriate place depends on the type of registry that you have and the platform that you have we've worked with the digital innovations product at Mary bridge the state of Washington works with that product and so they do have a separate database that's integrated in the registry I think that's the key is if it can be integrated where you're not duplicating efforts and you're not abstracting records twice because you're doing it once with the PI and once with the Registrar but yet work together I think that's a better model and it creates more efficiency that way absolutely thank you so much for weighing in there another audience member is asking if you're able to provide a little bit more detail on the insights and challenges for key stakeholders who are involved in the project over time perhaps I can I can take this one um be I can't stress enough that this is a 14 to 18-month project we're at a bit of a disadvantage this cycle because we had some significant changes which actually ended up being for the better in in the state in terms of the requirements they completely change the application dates started getting pushed out and so through actually no fault of our own but again I believe in the end was better for the state we actually didn't have a target date until quite late so we were already behind the eight ball if you will in regards to key stakeholders I I think it is it is imperative that the trauma medical director have and the trauma program manager have the ear of your senior administration your CEO your CMO your CNO your CEO as well as the board and so although this was a little bit higher level preparation leading to the site review we I presented to the board the year prior I worked very closely in reviewing the application with the then-current Toronto program manager we're good to see a no and preparing for that what I did not see coming was the fact that we were unable to present the PI and Qi work that we were already doing in a digestible fashion that really demonstrated that loop closure and that was something that I didn't see coming because I think we use an Excel spreadsheet honestly and that was unfortunate but and so that's been in preparation in terms of the key stakeholders I partnered very closely with all of my c-suite which by the way when we unfortunately underwent the site review that we did undergo I was able to be on the phone the next day with my CEO and my CMO and start working to a plan it is a record time that we were able to sign with Phillip bluej within probably a couple of weeks of that site review knowing what was coming the notes that I had by discussion offline with the site reviewers and with the state and so they were everyone was already prepared to support us and I think that that was that's invaluable I don't know if how many of you have ever had that experience were within a couple of weeks you have that contract signed and we were getting to work within a month that was that was incredible that was because of that you know investment yeah dr. escolar I think you bring up a very two good points actually and that is the reason as I said in the slide deck of how we were able to achieve that deadline successfully we were able to submit the information ahead of time because of that quick action but two things that you said that I think is worth noting is the reporting structure the trauma program is so important the trauma program should report to the c-suite and not up through any other Avenue you you must have the ear of those senior leaders in order to get the support that you need when you need it and the second thing you said that I thought was notable is that you know that you're providing excellent care you see it every day you see it in your patient outcomes and you took it for granted that you could prove that through the p.i process because you knew the care was there and I think that's the missing link for so many programs that struggle with their PI and their loop closure is just that documentation which is labor-intensive but the documentation to prove that what you're seeing is accurate information yeah all great points to call up our audience so things are both there another audience member is asking about the dashboard and they are saying could you give a few examples of the categories or the list of audit filters that were on your dashboard yeah I can answer that this is Jennifer from what we did was the the state of Washington gives you certain they determine certain audits that they want to see within your within your dashboard or within your program and so those of course are the ones that definitely want to have on there and so of course the in addition of that is volume and then also what we did is that under so he found his recommendations we added those to the dashboard as well and then other things that we felt that we needed to work on an example of one of the audits that the state of Washington wants to see is the ad length of stay of patients who are transferred to an outside facility so for instance Mary bridge does that have a burn a burn unit so there's another hospital that burn patients or transferred to so to make sure that we're you know we're getting there with it is time dominator everything else the bar for eg I would just add that most states have discretionary audit filters and non-discretionary all except audit filters listed the ACS also provides you with recommendations for audit filters so there are some standards out there but you also want to look inward at your own program and understand where your problem areas are and number one of those go on your dashboard so you can keep track of your improvement and I'd also suggest that one thing that can happen is you comma program can sometimes end up being an independent silo which is where you have some real difficulties being able to tell your story and why the trauma program is so important so you your hospital is all ready to have quality departments and others that will also have automatic filters such as hey you know quality CLABSI hap use etc to coordinate and collaborate and it really broadens the view of what trauma brings to the hospital across other system quality improvements so I would you know highly encourage you to have your quality person as well be a member of the trauma of the multidisciplinary trauma committee perfect thank you all for elaborating on that this next question is asking how are you able to narrow the identified deficiencies to the most pressing one was that something that played out in the assessment process or not we were very fortunate in that the report was presented to us in a tiered fashion Jennifer correct me if I'm wrong but there was the you know you've got to address these or we're not going to be redesignated and these are the suggestions what as most have probably found is that the suggestions become the requirements the next cycle so we really wanted to address every single one but the pressing ones we wanted to address basically that first page that they sent us that were threats to the program and and as Jennifer mentioned I'm going to let Jennifer finish that part of the story we did submit by the end of September well before the due date and Jennifer would you like to give the result of that yes the the state because when they came back and Italy to what they had done they were just so complimentary of the work that we had accomplished and the fact that even in what we sent them for the case summaries included examples of actual patients that they had brought up as areas of recommendations they weren't the most critical but that we had already started working on those so each state is a little bit different and so again the way the state of Washington has it laid out is you have those things that are you know critical you've got to get it done now here are how they call it highly recommended and they recommended and so we we've actually had a lot of fun and we've really worked through I believe we've we've looked at every one of them we have plans around each other each of those and even if one of the plans or dr. Escobar pointed out they're actually two of them that we didn't necessarily agree with the state or understand and again we're continuing to work on those and we want to again where those things that this state recommend is I think it's so important to show that you get into the last minute address like oh my goodness we've got a survey coming up that we started that immediately so the next survey cycle is in 2022 and those things are already taking place wonderful well before we go ahead and end today's presentation I just want to turn the floor back over to dr. Escobar Jennifer and Angie are there any final thoughts that you'd like to share with the audience I think that the role of the trauma program manager is is sacrosanct in in the trauma program and I just caution the listeners to not combine first of all I cannot stress enough Angie's point the the trauma Department needs to report directly to the c-suite the second is in the era of cost savings I cannot stress enough that there should not be a dilution of the role of the trauma program manager or addition of additional duties to that role because P iqi is the end-all be-all to prove that we are delivering quality trauma care and we have to be able to demonstrate that and that ultimately resides with the trauma leadership the only final thought that I would share is is thanks to dr. Escobar and his team and the leadership at Mary bridge for being so willing to change that made our job quite a bit easier and we've very much enjoyed working with that team that's true they have saved been wonderful to work with no I don't have any novel remarks but yeah I did notice there are several questions left I think if we could probably email those folks with feedback to those questions absolutely we'll make sure everyone's questions are answered after the presentation so thank you that is all the time that we have left for today I want to thank dr. Escobar Jennifer and Angie for their excellent presentation and to Phillips for sponsoring today's webinar enjoy the rest of your day and we look forward to having you join us for future webinars thank you you