Annual VRC Reviewer Update Webinar November 16, …web4.facs.org/TQIPFiles/2016 VRC Reviewer Update.pdfAnnual VRC Reviewer Update Webinar November 16, ... All rights reserved Worldwide

© American College of Surgeons 2016. All rights reserved Worldwide.

Annual VRC Reviewer Update

Webinar

November 16, 2016


Rosemary Kozar, MD, Chair R. Todd Maxson, MD, Vice Chair Tammy Morgan, Manager, Trauma Center Programs Julia McMurray, Operations Manager Molly Lozada, Program Manager, Verification


Program Staffing Updates

Program Updates: ◦ Program Growth ◦ Report Process ◦ Verification Education ◦ Clarification Document

New Reviewer Editors New Reviewer Process Pilot Study for Physician to Physician Contact Pediatric Collaboration Performance Improvement/Patient Safety


Tammy Morgan, Manager, Trauma Center Programs

Julia McMurray, Operations Manager

Molly Lozada, Program Manager Verification

Megan Hudgins, Program Coordinator

Rachel Tanchez, Scheduling Coordinator

Anita Johnson, Program Assistant


Program Updates



Adult Level I 89 Adult Level I, Level I Peds 23 Adult Level II 170 Adult Level III 79 Level I Pediatric 25 Level II Pediatric 4 Level I/II Adult w/Level II Pediatric 34 TOTAL 424


0

50

100

150

200

250

1985 1990 1995 2000 2005 2010 2015 2020

Num

ber o

f Vis

its

Total Visits

Adult Visits

Pediatric Visits


2016 Visits Total scheduled–233 2017 Visits Pending–289 2018 Visits Pending-14


Report Process


‣ Average turnaround time (1/1/2016 – 6/30/2016): 90 business days (14-16 weeks)

‣ Delays are due to the demand and current report structure process; however, times are improving due to the help of a temp. These % are for completed reports.


Challenges ◦ Delays

Action Plan ◦ Additional resources


All medical cases must be standardized & grammatically correct. ◦ Tutorial coming

All Deficiencies, Strengths and Weaknesses must have

a: ◦ Reviewer comment or recommendation and match the

body of the report. ◦ Lead reviewer must review report for accuracy before

submitting to ACS office. ◦ Must go back into the hospital’s PRQ and modify

answers to match the report.


Verification Education


Report Writer – Tutorial

◦ Assist reviewers prepare the site visit report

◦ Launched 9/1/2016

◦ 144 registered, 61 have completed tutorial w/average

quiz score of 94% ◦ All reviewers must complete.


Purpose: Help frame discussions about TQIP participation and results, and to foster consistent understanding among reviewers and hospitals about the components of TQIP

We need your input! ◦ Are the primers helpful? ◦ Areas for improvement?


Monthly Q&A Verification webinars ◦ Launched June 2016 ◦ Help decreased volume of emails to Molly’s personal

inbox and redirect emails to [email protected]. ◦ Archives of recordings are available on the VRC

Repository webpage at: www.facs.org/quality-programs/trauma/vrc/resources. I will launch a newsletter for reviewers …what format is preferred.

mailto:[email protected]

http://www.facs.org/quality-programs/trauma/vrc/resources




Standardize Medical Case Reviews Develop a New Reviewer Training

A Trauma Program Manager’s Guide to Becoming a

Verified Trauma Center

Work with the Info Tech Committee (Dr. Chris Dente) to develop an IEP process/repository for all trauma centers


Clarification Document

Updates



www.facs.org/quality-programs/trauma/vrc/resources



Must be present the day of chart review.


1. Completed a residency training program in anesthesia. Equivalency will be determined by the ASA representatives on the COT in conjunction with the ASA Committee on Trauma and Emergency Preparedness. In states such as CA where this is verified by the state, documentation of approval must be supplied and forwarded to the VRC.

2. ATLS; 3. 48 hours of trauma CMEs (IEP or external); 4. 50% of the trauma performance improvement meetings; 5. Membership/attendance trauma meetings; 6. M&M PIPS review by the TMD; 7. Licensed to practice medicine/unrestricted surgical privileges. 8. Not required to have an onsite visit by specialist reviewer.


There must be a representative (TMD or designee) from the adult program or from the pediatric program, attend the other program’s meeting, and ensure dissemination of communication is sent to the other panel members.


To meet the external CME requirement, will allow 33 hours of board certification or recertification to count as trauma or critical care external CME for all specialties:

◦ Trauma Surgeons ◦ Orthopaedic Surgeons ◦ Neurosurgeons ◦ Emergency Medicine


All Critical Care CME count.

IEP time must be equivalent to 16 hours annually or 48 hours in three years. ◦ Must be TRAUMA or CCM related (not cancer!!).

Proration ◦ All providers must have one year (16 hours) of CME. ◦ New centers, all providers must have one year (16

hours) minimum of CME.


May be used as an outreach activity.


New Reviewer Editors


Trauma Surgeons: Dr. Roxie Albrecht Dr. Robert Letton Dr. Christoph Kaufmann

Nurse Reviewers: Alice Gervasini, PhD, RN Tracey McDonald, RN


Evaluate the overall quality of the document. ◦ Critical information missing. ◦ Deficiencies or weaknesses not listed. ◦ Explain and support every criterion deficiency. ◦ Link each weakness and deficiency to a recommendation. ◦ Discrepancies between sections of the report or within

tables.

Grammar and spelling. Standardize the chart review format.


Criteria for New Reviewers


1. Be a fellow in good standing of the ACS. 2. Be in active practice and have expertise in the areas of trauma

care, trauma center operations and trauma systems. 3. Display excellent integrity and communication skills. 4. Be an active medical staff in good standing at an ACS verified

trauma center. 5. Be a current or former trauma medical director or a current

assistant/associate TMD, Trauma PI leadership position, or hold some other leadership position within their facility in Acute Care Surgery such as division chief in an ACS verified trauma center.

6. Be a current or past member of the national Committee on Trauma, Regional, or local state Committee.

7. Obtain two letters of nomination: • One from a current Verification reviewer. • One from a national COT member, COT Region Chief, or COT State

Chair.


‣ Coming soon!

‣ Will work with liaisons to create appropriate criteria for neurosurgeon and orthopaedic surgeon reviewers.


CD 4-1: Direct physician to physician contact is essential (interhospital transfer).

Two Level II centers in Ohio requested permission for 6 month pilot to have APPs answer transfer calls.

APP speaks with transferring ED MDs, decide on activation level, and selectively include trauma MD at receiving center.

Update will be provided to VRC after 6 month study of comparing transferring centers satisfaction, triage accuracy, and time to transfer.


Achieving successful pediatric verification in the absence of pediatric specialists while ensuring quality of care.

Pilot was approved with 3 Level II pediatric centers; will continue through next year.

Allow the collaborative relationship to be an alternative to

a pediatric surgeon on staff at the candidate hospitals.

New centers not in the program would receive the CD and then the recommendation would be to consider application to the pediatric collaborative.


Performance Improvement/ Patient Safety



Taxonomy Stratification Cardiac Arrest Organ/Space Surgical

Site Infection Decubitus Ulcer Osteomyelitis

Deep Vein Thrombosis Pulmonary Embolism

Myocardial Infarction Severe Sepsis


https://www.facs.org/quality-programs/trauma/vrc/public-comment









Documents

Annual VRC Reviewer Update Webinar November 16, …web4.facs.org/TQIPFiles/2016 VRC Reviewer Update.pdfAnnual VRC Reviewer Update Webinar November 16, ... All rights reserved Worldwide