TQIP requirements for patient care and data quality

Authored by:  
Angie Chisolm, MBA/HCM, BSN, RN, CFRN, TCRN
President and Managing Partner

Keeping up with the latest standards is crucial for ensuring optimal patient care and data quality in trauma centers. The updated American College of Surgeons (ACS) standards for participation in risk-adjusted benchmarking programs bring forth two requirements:

  • Trauma centers must leverage benchmarking results to identify opportunities for improvement in both patient care and registry data quality.
  • Data validation protocol – when faced with outlier results or fluctuations in reporting periods within your Trauma Quality Improvement Program (TQIP) report, initiating a thorough data validation process is paramount. 

Here’s a step-by-step guide:

  1. Drill down – Access the patient list for the affected cohort using the TQIP driller.
  2. Review and verify – Examine each case to ensure adherence to National Trauma Data Standard (NTDS) complication definitions.
  3. Compare records – Cross-reference TQIP submissions with trauma registry records. Identify any discrepancies and address inclusion issues by re-abstracting patient records if necessary.
  4. Correct data – Address gaps or coding errors by re-abstracting patient charts.
  5. Resubmit if necessary – Significant registry corrections may warrant resubmission of patient data to TQIP.

Validating and correcting data not only ensures accuracy but also facilitates meaningful comparisons with peer institutions. Should outliers persist even after validation, it signals the need for addressing underlying care issues.

Once you have used the box plots and trend charts to identify possible data issues, leverage the TQIP data tables to explore and unearth potential care issues. Here’s how to delve deeper into your TQIP report:

  • Exploring patient characteristics: Start by examining the ‘patient characteristics’ tables. Notice the mean age of your shock cohort, which surpasses the average for all TQIP hospitals. This disparity hints at a potential geriatric care concern. Additionally, scrutinize the “selected mechanisms of injury by cohort” table to uncover patterns like elevated fall injuries, highlighting the geriatric nature of the issue.
  • Analyzing hospital events: Next, explore the ‘hospital events’ tables. Observe any discrepancies in event rates, such as the notable increase in DVT and PE occurrences among your shock patients compared to the broader dataset. Such findings shed light on specific areas requiring attention within your care protocols.
  • Evaluating processes of care: Finally, navigate to the ‘processes of care’ tables. Here, focus on VTE prophylaxis rates among shock patients. Discovering that a substantial portion receives no prophylaxis underscores potential gaps in care delivery. Compare these rates to the average across all hospitals to gauge performance and identify opportunities for improvement.

Interpreting these insights prompts critical questions, such as the adequacy of VTE prophylaxis in geriatric shock patients.

Navigating the wealth of data in TQIP reports requires a methodical approach. By following these steps, trauma centers can harness benchmarking data to drive continuous improvement in patient outcomes and data integrity.