JULY 2003
Volume 27 No. 7

Leadership, teamwork pay off in successful trauma survey

When surveyors from the American College of Surgeons came to Stanford in April to determine whether the hospital's trauma program met its criteria for "verification" - the gold standard for trauma programs nationally - David Spain was hoping that the program, which he directs, would come away with only a few easily resolved deficiencies.

But when Spain received the ACS' final report in early June, it was far better than he or his colleagues had expected: zero deficiencies among the 176 evaluation criteria. "I was extremely pleased with what we'd done," Spain said. "It was a huge morale booster."

For Spain and the trauma team, these results confirmed what they already knew: Stanford's Level-I trauma center provides excellent care in compliance with county and national criteria. The challenge was to demonstrate this by getting processes and documentation in order. "It's not enough that you do good work - you have to show it. That's where much of our efforts went," said Janet Neff, trauma program manager since 1990.

The program's faculty and staff spent hundreds of hours preparing for the survey. Beginning in fall 2001, Spain, Neff and trauma clinical coordinator Carol Thomson reviewed ACS' criteria and developed spreadsheets listing more than 200 tasks to complete. These included making sure all physicians on the trauma service had the required CME credits; ensuring around-the-clock coverage by all of the required specialties; testing and refining the on-call paging system; and implementing effective quality-improvement projects.

The tasks were divided among several working groups. Many tasks simply required better documentation of existing processes, but additional work was required in quality improvement - the process of identifying and addressing problem areas. While QI had always been a high priority for Stanford's trauma program, Spain said, it was done rather unsystematically.

So Spain enlisted two SHC quality managers - Pat Smith and Kathy Gelman - to work with the trauma team on following a structured model for identifying and resolving concerns. The model, IMADIM, stands for identify the problem; measure it; assess possible solutions; design a solution; implement it; and monitor with continuing follow-up.

The trauma team began meeting with Smith and Gelman in summer 2002, and together they developed nine projects (see sidebar). It wasn't always easy, given the different cultures of QI - which follows elaborate color-coded schedules - and trauma, which thrives on adrenaline-fueled action. "We're good at jumping in and doing what needs to be done," Spain said, "but we're not always concerned about writing everything down."

Despite the differences, the two camps developed a good working relationship. Smith said what most impressed her about the trauma team was, "they were totally open to learning this new process. They'd ask us, 'How can we do this better?'"

As the site visit approached, the focus shifted to coordinating the required materials and personnel so everyone would know where they should be and when and with what information. "It was like planning a wedding - everything had to be carefully orchestrated," Smith said.

Conducted by two practicing trauma surgeons, the site visit began with a dinner meeting attended by some two dozen SHC administrators, physicians and staff. It continued the next morning with a hospital tour during which the surveyors randomly pulled aside staff, asking questions about clinical care and procedures.

Then came the chart review, where the surveyors spent hours reviewing recent charts on certain types of patients, including those with head trauma and intra-abdominal injuries. The surveyors asked pointed questions: How long did it take to get this patient to the OR? What kinds of CT scans were ordered? Why was a particular medication chosen?

The surveyors presented their positive preliminary findings at the end of their site visit, but the ACS' final report - which is also used by Santa Clara County to confirm Stanford's designation as a Level-I trauma center - wasn't received until early June. The report lists a dozen program strengths, including quality of care; continuing education of the nursing staff; quality-improvement efforts; proactive follow-up to previous deficiencies; and leadership by Spain, Neff, support staff and administrators.

Neff agrees that a critical factor was Spain, who joined Stanford in August 2001 as its first full-time, permanent trauma program director. "David made a huge difference," she said. "He was committed to this effort and made sure we got the support we needed." Spain, meanwhile, credits teamwork by personnel across several disciplines. "This process showed that there are a lot of eager, talented people here who want to help us improve, and if you give them the opportunity, they'll make it happen."

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