North Texas Research Forum 2025
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Division
North Texas
Hospital
Medical City Plano
Specialty
General Surgery
Document Type
Presentation
Publication Date
2025
Keywords
trauma, patient safety, quality improvement
Disciplines
Medicine and Health Sciences | Quality Improvement | Surgery | Trauma
Abstract
In preparation for our facility’s initial ACS verification visit, a Trauma Consultative Site visit in 2021 identified the need for a streamlined process to communicate issues to the Trauma Program that were recognized during patient care. This was especially true on weekends and nights when issues were most likely to occur. A recent literature review revealed implementation of electronic communication tools increased reporting of performance improvement and patient safety (PIPS) events and improved tracking and resolution of events. The authors of that study used a virtual chatroom accessible from cell phone to post PIPS events. One perceived drawback to this method is that reporting cannot be done anonymously if so desired.1 We sought to improve reporting in our facility by providing a rapid, easily accessible, user-friendly, and potentially anonymous method of reporting that any staff member could access. A reporting platform was created to input information regarding PIPS concerns. A QR code was designed which allows providers and staff to input information into a HIPAA compliant access point site, hosted in a Microsoft Forms platform. The report can be made anonymously. The share point site is then accessible by the Trauma Services department to capture all these PIPS issues. The access point notifies the trauma coordinators and the Trauma Program director in real time and the issues are processed within our Trauma PIPS Review Policy. Once addressed, the PI issue is then archived. Information collected includes patient name (if applicable), type and details of the issue, unit of the hospital where occurring, and reporter’s name (not required). Of note, this product is a patient safety work product document. It is protected from disclosure pursuant to the provisions of the Patient Safety and Quality Improvement Act (42 CFR Part 3) and other state and federal laws. Unauthorized disclosure or duplication is absolutely prohibited. A QR code-based reporting system is an accessible and easy to use platform for PIPS reporting, additionally with the benefit of anonymity if needed. A more efficient process can result in increased reporting and optimization of the process to identify and rectify issues. Since implementation of the QR code in March 2022, we have been able to measure the effects of the change by examining the number of PIPS issues submitted each month. On average, fourteen reports have been received each month, with the most commonly reporting departments being the trauma surgeons and the emergency department. The change was implemented and continues to be sustained by distributing flyers in the work areas of trauma staff including, but not limited to: call rooms, the OR lounge, emergency department, radiology, surgical units, and ICU. Given the positive response from the staff and the improved PIPS reporting, this hospital system is now offering the application to all other trauma programs, with launch recently at a Level 1 trauma/burn facility. As the process rolls out in other hospitals, we intend to continue to evaluate the effect with pre-and post-rollout monitoring.
Original Publisher
HCA Healthcare Graduate Medical Education
Recommended Citation
Miller, April; Taveras, Luis; Kim, Elizabeth; and Galt, Kathy, "There’s a QR Code For That: Trauma Performance Improvement, Patient Safety, and Peer Review" (2025). North Texas Research Forum 2025. 9.
https://scholarlycommons.hcahealthcare.com/northtexas2025/9