A National Trauma Care System Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury (2016) / Chapter Skim
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3 A Framework for a Learning Trauma Care System
3 A Framework for a Learning Trauma Care System
Pages 119-146
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From page 119... ...
CHARACTERISTICS OF A LEARNING HEALTH SYSTEM The Institute of Medicine (IOM) defines a continuously learning health system as one "in which science, informatics, incentives, and culture are aligned for continuous improvement and innovation, with best practices seamlessly embedded in the delivery process and new knowledge captured as an integral by-product of the delivery experience" (IOM, 2013, p.
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In developing a framework for a learning trauma care system (described later in this chapter) , the committee built upon the components of a continuously learning health system characterized in the 2013 IOM report Best Care at Lower Cost (see Table 3-1)
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Supportive A learning health system constantly refines complex care operations and system processes through ongoing team training and skill building, systems analysis and competencies information development, and creation of the feedback loops for continuous learning and system improvement. SOURCE: Adapted from IOM, 2013, p.
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. Setting Crisp, Quantifiable Aims In a typical learning system, there exists a vague notion that the aim for the system is to facilitate learning.
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are predominant as an educational model, a preponderance of evidence shows that optimal learning in adults does Box 3-1 L EARNING SYSTEM MODEL: PROJECT ECHO Project Extension for Community Healthcare Outcomes (ECHO) , a program that began at the University of New Mexico School of Medicine in 2003, connects primary care clinicians practicing in local communities with specially care teams to better man age patients with chronic conditions that require complex care (Arora et al., 2014)
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In high-performing learning systems, however, the generation of performance data extends down to the level of the team or individual practitioner. Like having clear and quantifiable aims, performance data that show progress at the provider level can generate excitement and inspire corrective action far better than aggregate data showing only system performance.
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Encouraging Experimentation and Improvisation Strict adherence to what one has been taught leads to system stagnation. Continuous learning and associated improvements in care occur through experimentation in the field, and exceptional learning systems encourage (and even require)
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A rapidly learning health system leverages recent advances in health information technology to access and apply evidence in real time, drawing knowledge from both traditional clinical research and patient care experiences. The combination of these forms of knowledge generation works to advance the rapid adoption of best care practices.
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Digital Capture of the Trauma Patient Care Experience In a learning trauma care system, knowledge develops as a natural byproduct of care processes such that each patient experience yields information on the effectiveness, quality, and value of the trauma care delivered. To this end, patient care experiences across the continuum of care are digitally
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Coordinated The supply of knowledge is continuously and reliably expanded and Performance improved through the systematic capture and translation of information Improvement and generated by coordinated performance improvement and research Research to Generate activities. Evidence-Based Best Trauma Care Practices Processes and Tools for Trauma care providers have access to tools such as continuously updated Timely Dissemination clinical practice guidelines and clinical decision support tools to capture, of Trauma Knowledge organize, and disseminate the best available information to guide decision making and reduce variation in care and outcomes.
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Trauma registries, which collect disease-specific clinical data in a uniform format, are an important tool for knowledge generation in a learning trauma care system. In such a system, data from hospital-based registries are collated into a regional registry that includes data from all hospitals
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Adhering to such standards increases the value of state trauma management information systems by providing national benchmarks and allows the lead agency to evaluate the performance of the entire system. To support optimal learning, clinical quality of care, and continuous improvement, data systems (which capture the trauma data included in registries)
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4 Military and civilian trauma systems have developed and use numerous clinical practice guidelines. For these clinical processes, steps 1 and 2 are already complete.
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An example of a civilian health system that has successfully utilized this bottom-up approach is described in Box 3-3. Coordinated Performance Improvement and Research to Generate Evidence-Based Best Trauma Care Practices A core aim of a learning health system is to expand and improve the supply of knowledge available to address health care questions.
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Because clinical processes are standardized, variance is measured, and c linical outcomes are monitored, routine patient care can result in new evidence about best practices. With nearly 100 percent of patients contributing to the knowl edge base, Intermountain can quickly adjust the practice guidelines to reduce errors and costs while improving patient outcomes (IOM, 2011)
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In a learning trauma care system, such information sharing is supported by technological solutions, a culture of sharing, and a conducive regulatory environment. Processes and Tools for Timely Dissemination of Trauma Knowledge Although the continual pursuit of new knowledge through research and performance improvement is a critical aspect of a learning trauma care system, the generation of evidence on best care practices is not sufficient to drive improvements in patient outcomes.
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Instead, trauma care providers have access to clinical practice guidelines and clinical decision support tools that capture, organize, and disseminate the best available information on trauma care practices to guide decision making at the point of care and reduce un arranted variation w in care and outcomes. In the context of trauma, where rapid problem solving can make the difference between life and death, it is critical for providers to have just-intime, synchronous access to experts in trauma care delivery -- for example, through telemedicine -- who can provide guidance to address questions and challenges at the point of care.
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Patient-Centered Trauma Care In a learning health system, the central focus is on those being served. A learning trauma care system ensures patient-centeredness by structuring trauma care around the patient experience and proactively engaging patients, families, and communities.
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The way in which news of a sudden traumatic injury or death is delivered can significantly impact how patients and family members cope with their lives moving forward. The 2nd Trauma Course was developed by the American Trauma Society to help trauma providers deliver such information in the most effective and supportive manner possible.8 Patient-centered trauma care focuses holistically on the needs of the individual patient, combining immediate treatment processes with attention to longer-term needs such as pain management and, importantly, emotional support (Bradford et al., 2011; Gajewski and Granville, 2006; Marks et al., 2005; Wegener et al., 2009; Williams et al., 2002)
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A patient-centered approach ensures that this unique perspective is leveraged to further improve the functioning and design of the trauma care system. Patient and family participation in trauma research, for example, is an important feature of a learning trauma care system (Faden et al., 2013)
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Transparency and Aligned Incentives for Quality Trauma Care A learning trauma care system has leadership that is committed to transparency and aligns incentives to ensure that learning takes place and is sustainable, while at the same time minimizing waste and variability in practice that contribute to suboptimal outcomes. Transparency -- "ensuring that complete, timely, and understandable information is available to support wise decisions" -- empowers providers and organizations to improve their performance over time (IOM, 2013, p.
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Aligned Authority and Accountability for Trauma System Leadership Strong, visible leadership is prerequisite to creating and sustaining a learning trauma care system that supports innovation and continuous improvements in care. The success of a learning trauma care system depends on the existence of defined leadership with comprehensive authority to maintain the system's infrastructure, oversight, planning, and future development; create and enforce policy; and serve as a point of accountability.
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2015. National Trauma Data Bank.
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• Coordinated Performance Improvement and Research to Generate Evidence-Based Best Trauma Care Practices − data from the care experience translated into new care policies and procedures Are through a top-down or bottom-up approach? − Does this translation happen in real time, as is the goal of some high-performing systems?
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2013. An ethics framework for a learning health care system: A departure from traditional research ethics and clinical ethics.
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2013. Best care at lower cost: The path to continuously learning health care in America.
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2008. A national US study of posttraumatic stress disorder, depression, and work and functional outcomes after hospitalization for traumatic injury.
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