How Mary Bridge Children's Hospital enhanced its trauma performance improvement program

To drive performance improvements within its trauma program and the state designation process, Tacoma, Wash.-based Mary Bridge Children's Hospital enlisted the help of Philips healthcare transformation services.

Mary Bridge Children's Hospital, part of MultiCare Health System in Tacoma, Wash., partnered with Philips' healthcare consulting services, which aims to improve clinical care and patient experience, in February 2019 after undergoing a trauma program site review. The hospital chose Philips to build a joint team focused on addressing performance issues within the program.

During a Jan. 14 webinar hosted by Becker's Hospital Review and sponsored by Philips, Mauricio Escobar Jr., MD, pediatric trauma medical director at Mary Bridge Children's Hospital; Jennifer Brown, interim trauma program manager at Mary Bridge Children's Hospital and trauma service line consultant for Philips; and Angela Chisolm, consulting manager for Philips trauma service line; discussed Mary Bridge Children's Hospital's partnership with Philips and how the organizations collaborated to transform performance improvements in the hospital's trauma program.

After undergoing the trauma site review last February, one of Mary Bridge's key findings was to establish an experienced team to tackle performance improvement issues, Dr. Escobar said.

"[Together with Philips,] we essentially rebuilt our trauma program from the ground up," he said. "Although performance improvement was a key finding, there were many elements that had to be addressed. We looked at the program as an opportunity to build from the ground up, and what we came up with is much more robust."

Plan, Do, Study, Act

To rebuild its trauma program, Mary Bridge and Philips settled on using the PDSA methodology. This is defined as planning a change or improvement, doing the improvement, studying the results and examining the data, and acting to sustain performance and spread change.

The team first identified the problem: critical deficiencies in Mary Bridge's trauma program's performance improvement processes such as failure to perform adequate primary and secondary case review as well as missed opportunities for adequate loop closure and feedback to providers. These inefficiencies led to a failure to improve care for the benefit of future patients.

After the problems were defined in April 2019, Mary Bridge and Philips set their goal, which was to resolve the deficiencies in the trauma performance improvement process by Oct. 31 of that year and satisfy the state's trauma requirements to achieve Level II Pediatric Trauma Center status.

While Mary Bridge was able to identify concrete issues with its trauma program, Ms. Chisolm said the problems were not with the hospital's performance improvement capabilities but rather its documentation process.

"Mary Bridge was not making mistakes with their performance improvement," she said. "They just needed to enhance it a bit and document it a little bit better. They were providing excellent patient care, but they needed to gather that information and make a proof point of the data."

Mary Bridge and Philips implemented various interventions, including creating a dashboard of key performance indicators and a performance improvement database to document the trauma program's activities. The team studied the database and used its information to collect, monitor, trend and report quality improvement as well as develop a corrective action plan to implement its new trauma quality improvement program.

Insights learned from the PDSA approach

Using the PDSA approach, the Philips and Mary Bridge team was able to submit its corrective action plan for the trauma program to Washington on Sept. 23, 2019, more than a month before the report was due. The team's proper leadership, assessment and follow through of quality improvement initiatives helped support the early delivery of the plan, Ms. Brown said. 

"It is so important to identify the right stakeholders and have them in the right meetings at the right time," she said. "And to make sure that our team is ready, and they understand what we're going to be doing and making sure those initiatives are carried out."

Ms. Brown added that having an early understanding of the state's quality improvement and designation process standards was vital to ensuring the performance improvement team could properly map out changes necessary for the program.

To view the webinar, click here.

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