Performance improvement

Performance improvement is a method of improving medical care by monitoring the elements of diagnosis, treatment and outcome. It evaluates the performance of both individual providers and the system in which they work. The concepts of such a process have evolved over time. Medical audit is a concept originating in the 19th and early 20th century. It consisted of a system of counting procedures, complications and deaths. Quality assurance was built upon audit by reviewing medical records for documentation of predetermined criteria, which were felt to reflect an acceptable quality of delivery of medical care. This was utilized typically to look for providers who did not live up to expected standards. This approach evolved into the process of performance improvement, also known as continuous quality improvement (CQI), which looked at the effect of factors in the system as well as individual practitioners' actions (52).

Performance improvement for trauma care has followed the same evolution. A variety of techniques have been used specifically in this field.

• Morbidity and mortality conferences: These involve a discussion of deaths and complications in search of preventable factors, primarily in the actions of individual practitioners. Such conferences are utilized in surgery departments around the world, and the peer review process involved in these is the foundation for improvements in medical care through more formal programmes for performance improvement. Typically, all types of cases are discussed at these. Busier trauma centres may have specific morbidity and mortality conferences on trauma alone.

• Preventable death studies: These employ reviews of deaths, either at an individual hospital or within a given system, looking for deaths which are considered, by consensus, preventable. This may include deaths due to airway obstruction or isolated splenic injuries.

• Audit filters: A number of quality-of-care criteria are established. Particular cases that do not meet these criteria are then reviewed on a systematic basis to see whether, indeed, there was a problem with the quality of medical care delivered. These include such factors as patients with abdominal injuries and hypotension who do not undergo laparotomy within one hour of arrival at the emergency department; patients with epidural or subdural haematoma who do not undergo craniotomy within four hours of arrival at an emergency department; and open fractures which are not debrided within eight hours of arrival. Among the audit filters are evaluations of unexpected trauma deaths, such as those occurring with low injury severity scores (53).

• Complications: A long list of potential complications may also be tracked as indicators of the quality of care. This process looks for a rate of complications that is higher than would normally be expected. This includes complications such as pneumonia, wound infections, venous thrombosis and urinary tract infections.

• Risk-adjusted mortality: Through this statistical process, hospitals evaluate the percentage of deaths occurring in patients with low injury severity scores or a low probability of death based on a combination of injury severity scores and trauma scores (TRISS methodology). This allows the hospitals to compare themselves against predetermined national norms. Hospitals with higher risk-adjusted death rates may warrant evaluation of the individual unexpected deaths along with evaluation of their systems of care, to identify elements that might be contributing to such higher risk-adjusted mortality.

For all of the methods noted above, the primary principle is to identify the problems that are arising due to correctable factors. Corrective action is taken to ameliorate these problems. Finally, the effect of these changes is evaluated to assess whether they have been successful in correcting the problem. The last step is known as "closing the loop".

Most of these methods of performance improvement in trauma care depend on reliable, ongoing sources of information about trauma patients. This is typically provided by trauma registries, which are generally considered an integral part of any quality improvement programme (17, 52). In the previously noted process of trauma centre verification, professional societies look closely at the existence and functioning of programmes for performance improvement in trauma care. The publication Resources for optimal care of the injured patient lays out guidelines for what should be in place for a trauma performance improvement programme. These are required at all hospitals that care for injured patients. Likewise, in developing standards to improve trauma care in the United Kingdom, the British Trauma Society mandated that all hospitals caring for major trauma patients should have an audit programme to maintain quality standards in trauma care (54).

There has been some experience with programmes for performance improvement for general medical care in developing countries. In Malawi, audit of antibiotic usage revealed large-scale inappropriate use, which led to the implementation of treatment guidelines (55). In Nigeria, the implementation of a quality-assurance programme in a network of primary health care clinics improved the management of diarrhoea (56).

Some of the best reported use of programmes for performance improvement in low- and middle-income countries relates to the Safe Motherhood Initiative. A specific type of performance improvement for obstetric care is the medical audit of maternal death. This has proved instrumental in improving obstetric care globally (57—61). Pathak et al. demonstrated that most facility-based maternal deaths in Nepal were due to correctable factors, such as delays in treatment at the facilities, inappropriate treatment and lack of blood (57). In Zaria, Nigeria, Ifenne et al. demonstrated that such performance improvement monitoring assisted in reducing the time interval between admission and treatment from 3.7 to 1.6 hours. Similar performance improvement-related improvements in the process of care led to a decrease in the case fatality for obstetric complications from 12.6 percent to 3.6 percent in Kigoma, Tanzania (60).

Looking at nationwide improvements in maternal care, Koblinsky et al. point out an interesting contrast which is of some relevance to the Essential Trauma Care Project (62). Some countries (Malaysia, Sri Lanka) have reduced the maternal mortality rate to well below 100 deaths per 100000 live births through fairly simple measures. These have included an increased use of midwives for home delivery, and an increased use of hospitals with basic (non-surgical) obstetric care. Accompanying these increases in resources were improvements in organization of the system for emergency obstetric care through a process of tiered oversight. This included programmes for performance improvement and reviews of maternal deaths. In contrast, a study in urban Mexico City in the 1980s revealed that almost all births in the city took place in hospitals. The maternal mortality rate was relatively high, at 114 deaths per 100000 live births. Eighty five percent of these deaths were deemed preventable and were associated with a lack of quality assurance, a lack of organization and suboptimal use of resources (62, 63).

Several articles have specifically addressed quality improvement programmes in surgery departments in developing countries. In Saudi Arabia, Ashoor et al. reported on the development of a quality assurance programme for an oto-laryngology unit. They reported that this programme helped with their resource utilization, including minimizing cancelled cases (64). In Pakistan, Noorani et al. reported on the implementation on a locally designed, inexpensive surgical audit system. They demonstrated improved reporting of chest and wound infections, which led to development of protocols for improved antibiotic prophylaxis (65).

Many of the preceding authors report on the problems of implementing a quality improvement programme in a developing country. These included the lack of an organized data collection system and computers for analysis, failure by governments to provide the necessary initial resources, resistance to the introduction of such a programme by clinicians, for fear of reprisal, and difficulty with definitions of "quality of care" within different societies. However, none of these problems was insurmountable and all of the studies indicated successful implementation of programmes that did lead to improvements in the quality of medical care provided. Moreover, the implementation of a more formal performance improvement process was generally felt to improve upon the existing system of periodic case review meetings (55, 56, 64, 65).

One of the few and best reports on the implementation and effectiveness of a performance improvement programme for trauma care in a developing country comes from the Khon Kaen region of Thailand. At the major hospital in this region, a trauma registry was established in the mid-1990s. This indicated a very high rate of potentially preventable deaths. A trauma audit committee reviewed the process of care on expired cases. A variety of problems were identified, both in the actions of individual practitioners and in the system. This included difficulties in the referral system, the emergency department, the operating theatres and the intensive care unit. One of the difficulties that was noted was inadequate resuscitation for patients in shock, both during referral and in the emergency department. In addition, there was a high incidence of delay in operations for head injuries. Throughout all of this, there were felt to be difficulties with record-keeping and communication among hospital personnel. Corrective action included improving communication by introducing walkie-talkies within the hospital, stationing fully trained surgeons in the emergency department during peak periods, improved orientation about trauma care for new junior doctors joining the surgery team, and improved reporting on trauma care through hospital meetings. Using the trauma registry, they were able to demonstrate that these improvements increased compliance with medical audit filters. These improvements in process were associated with a decline in mortality. Overall mortality among admitted trauma cases decreased from 6.1% to 4.4% (66).

Experience from other countries indicates that such successes should be eminently reproducible. As previously described, a review of trauma admissions at the main hospital in Kumasi, Ghana, revealed notable deficiencies in the process of care, despite availability of resources. These included low use of chest tubes, low use of crystalloid and blood for resuscitation, and prolonged times to emergency surgery. All such items should be readily amenable to improvement through the improved organization provided by programmes for performance improvement (16).

In conclusion, it remains to be determined what types of programmes for performance improvement might play a role in promoting the Guidelines for essential trauma care. Formal programmes for performance improvement are especially likely to play a role at larger hospitals with high trauma volumes. Progress might come in the form of improved record-keeping and establishing basic trauma registries (67), and augmenting existing morbidity and mortality conferences by tracking unexpected and preventable deaths. Elements of performance improvement that might be instituted at smaller general practitioner (GP) hospitals still need to be defined. Formal programmes for performance improvement in trauma care are less likely to be indicated. Rather, broader systems for processing management information that address both efficiency and quality assurance for a broad range of issues are likely to be found appropriate (49). However, there is almost certainly a role for monitoring the process of trauma care as a means of assuring the provision of standards for essential trauma care at all levels of care.

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