Trauma quality improvement: The Pietermaritzburg Metropolitan Trauma Service experience with the development of a comprehensive structure to facilitate quality improvement in rural trauma and acute care in KwaZulu-Natal, South Africa

Abstract

Strategic planning is a systematic process designed to assist organi sational decision-making by taking account of the micro environment(s) within an organisation, as well as the macroenvironment in which the organisation exists. [1][2][3][4][5] Healthcare systems are complex and tightly coupled. Strategic planning within such a system, without an overarching framework to provide a structure for quality improvement programmes, risks becoming ad hoc, haphazard, ineffectual and even counterproductive. The strategic planning process must identify the organisation's vision and mission or the system's aims and objectives. The mission statement explains the reasons for the healthcare system's existence. The vision statement identifies a potential more ideal 'future state' that the system aspires to achieve. Situational analysis follows and analyses the external environment to identify threats and opportunities, then looks inwards to assess the organisation's resources and capabilities. [1][2][3][4][5][6] The stage of synthesis follows, in which the strategic plan is crafted. The plan must then be implemented, and after that outcomes must be audited. There are a number of generic strategic planning tools that are of relevance to developing a structured systemic approach to quality improvement programmes. These include the SWOT analysis, the balanced scorecard, and strategic drift and gap analysis. SWOTThis acronym stands for Strengths, Weaknesses, Opportunities and Threats (SWOT) and identifies internal strengths and weaknesses, and threats and opportunities in the external environment, that may affect the organisation. The balanced scorecardThe balanced scorecard is a forward-looking management system that views the organisation from four perspectives, namely learning and growth, process, the customer point of view, and results. Strategic drift and gap analysisThe final outcome of a strategic plan is a result of the interaction of the external environment and three internal factors, namely the plan, the leadership and the culture of the organisation. A gap analysis model helps identify reasons for the strategic gap.

Analysis of 5 years of morbidity and mortality conferences in a metropolitan South African trauma service

“…This has remained constant with the introduction of the HEMR, which reported human error as a cause of 33% of all adverse events. [1][2][3][4] These findings highlight the need for both general error awareness training and specific interventions for a number of common clinical scenarios and procedures. [16,17] In addition modern taxonomies of error and modern classifications of morbidity must be used to help staff understand where in the process of care error intervened.…”

“…It is apparent that educational courses in isolation will not reduce the incidence of surgical morbidity and they need to be included as part of a multifaceted quality improvement programme. [3] This is analogous to the fact that good traffic regulations by themselves will not reduce traffic-related accidents and a combination of enforcement and mechanical interventions such as traffic calming speed humps are required to improve traffic safety. The development of preoperative 'tickbox' style checklists has been shown to help reduce operative mortality and may have a major role to play in reducing morbidity associated with these common procedures.…”

“…[1][2][3][4][5] The culture of surgical practice is, however, often inimical to the open and transparent reporting of surgical adverse events, error and morbidity. This creates difficulties in developing strategies to address human error and to reduce surgical and trauma-related morbidity.…”

“…This has run since then and has been a predominantly paperbased system which relied on self-reporting. [3][4][5] However, selfreporting of morbidity is generally believed to result in a significant underestimation of morbidity. Subsequent to the institution of the MMC in 2007 we introduced a hybrid electronic medical record system (HEMR) with a dedicated interface for capturing morbidity in 2012.…”

An electronic colonoscopy record system enables detailed quality assessment and benchmarking of an endoscopic service

“…The development of our electronic medical record systems enabled us to keep detailed electronic records of all endoscopic procedures. [6,7] By keeping these data in a relational database, we can perform detailed audits of colonoscopies at our institution. We aimed to use data from such an audit to benchmark our results against international quality guidelines and to provide individual endoscopists with a procedural logbook.…”