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OSDH Home > Protective Health > Trauma Division > Continuous Quality Improvement (CQI)
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Quality Improvement

Creating an environment of quality care for Trauma patients

The purpose of continuous quality improvement:

  • Create a system of optimal care for all trauma patients
  • Measure, evaluate, and improve the quality and effectiveness of care
  • Assure trauma standards of care are met and inappropriate variations of care are minimized
  • Prevent and decrease death and disability

CQI is a requirement of Senate Bill 1554: "The Oklahoma Trauma Systems Improvement and Development Act"

This legislation created the:

  • Medical Audit Committee
  • Regional Continuous Quality Improvement Committees

The Regional CQI Committees are sub-committees of the RTABs (Regional Trauma Advisory Boards.) These committees are made up of representatives from Hospitals, EMS Services, Air Services and Physicians. The various roles of the committee members help to deliver a multi-faceted perspective on cases reviewed. The Regional CQI Committees are tasked with review of quality related issues that occur in the Region which are system or process related.

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Regional CQI Committees:

Region 1 (NW)

Region 2/4/7 (combined)(NE/N Central)

Region 6/8 (combined)( Central/OKC)

Region 3 (SW)

Region 5 (SE)

 

The Medical Audit Committee membership is comprised of nine Physicians and Surgeons appointed by the Commissioner of Health. These Physicians and Surgeons come from all over the state and represent rural and urban populations. Their focus is to review cases that are related to clinical issues, sentinel events or adverse outcomes. They are also tasked with the oversite of the work of the Regional Committees.

What is the purpose of a REFERRAL?

  • R-Review of what happened
  • E-Ensure expeditious and expert care was given
  • F-Formulate a time-line of events
  • E-Examine reasoning for decisions
  • R-Regional Plans/T3 Algorithms/patient priority (application of)
  • R-Recommendations from Committee
  • A-Action is required!
  • L-Loop closure letters (how the required actions are communicated)

Recommendations for improvement may include but are not limited to the following elements:

  • COMMUNITICATION!
  • Application of the Trauma Triage and Transport Guidelines
  • Application of the Regional Trauma Plan
  • Consideration of destination choices of ground units (based on the Regional Plan) and the effects on the Critical access and Level 4 facilities when delivering multiple injured patients to the same facility
  • Ground ALS support
  • Utilization of air at the scene
  • PELA sites
  • Do not perform testing at Critical access and level 4 facilities when the conditions discovered cannot be treated or managed at the facility. Priority 1 patients should be brought to these facilities for stabilization ONLY
  • EDUCATION! EDUCATION! EDUCATION! TNCC (Trauma Nursing Core Course), RTTDC Rural Trauma Team Development Course, ATLS (Advanced Trauma Life Support), Education on Regional Plans and T3 Algorithms

It is imperative that all patient care providers know what resources are available in their area. Hospitals, EMS Services, Air services, EMRAs (Emergency Medical Responders) and local first responders should meet together to discuss the best plan of action when responding to trauma scenes in their area. This communication fosters a team approach and will ensure the patient receives the best possible coordinated care, when help is needed.

"The time to plan for an Emergency is before it happens!"

The goal of the State Trauma System is to deliver the best care possible to the Citizens of Oklahoma. This can only be accomplished when, collectively, we work together towards this goal.

If you have a trauma care concern or issue, please submit a referral for review by clicking on the link below.

Please feel free to contact our CQI Coordinator for any concerns or questions.

 

Sandra Terry, RN-BC, BSN

CQI Coordinator - OSDH 

Emergency Systems 

1000 NE 10th

OKC, OK  73117

Office Number: 405-271-4027

Fax: 405-271-1045 (This is a secured fax line for confidential documents.)

sandrat@health.ok.gov

 

"If we won't be better tomorrow than we were today, then what do we need tomorrow for?"    - Rabbi Nahman of Btratslav

 

 

 

 

 

 

Frequently Asked Questions
Q: Who may refer a case?
A: A physician, nurse, or other health care provider, or member of the public may refer a case for quality improvement review.

Q: What may be reported?
A: Any situation involving the care of trauma patients, including patient transfer and referral issues, patient care issues, patient transport problems may be referred for quality improvement review.

Q: What happens after I make a referral?
A: Oklahoma State Department of Health (OSDH) staff will obtain and review relevant records and determine the appropriate reviewing committee/subcommittee. The reviewing committee may make recommendations for trauma system education, refer the case situation for review by an agency/entity’s internal quality improvement process, or identify other system issues, as appropriate.

Q: Will I know the outcome of my report?
A: You will be notified of receipt of your referral. However, the results of the review are confidential and will not be released to the individual making the referral or to the public.

Q: How do I make a referral?
A: Referrals may be made by submitting a completed Oklahoma Trauma System Performance Improvement Process Referral Intake Form (via secure fax line 405/271-1045, or by mail to: CQI Coordinator, OSDH-PHS-Emergency Systems, Oklahoma State Department of Health 1000 N.E. 10th Street, Room 1104, Oklahoma City, Ok 73117-1299.)For question, please contact the CQI Coordinator, Emergency Systems: 405-271-4027.

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