THE NEED FOR CHANGE
Before the 1990s, there were in Quebec no regulated prehospital triage system and poor inter-hospital communication and transfer mechanisms. Trauma victims were taken to the nearest hospital, regardless of the severity of the injury and the capacity of the facility, which translated into undue delays, suboptimal transfers, and decreased capacity to intervene properly. Moreover there were no quality standards, control processes, and evaluation mechanisms at the time. Not surprisingly, this situation was associated with an increased rate of mortality and morbidity as compared to other hospitals in Canada and in the United States (Reference Liberman, Mulder, Lavoie and Sampalis1;2). Determined to change this unenviable record, the Quebec government made trauma a provincial priority in 1990 and initiated a series of measures and changes based on best practices and continuous quality monitoring that would transform the Quebec's field of trauma care into becoming one of the best organized systems in the country and beyond (Reference Liberman, Mulder, Lavoie and Sampalis1;2).
Initiated in 1991 and inspired by other high-performing systems in the world, the creation of the Quebec trauma care continuum (TCC) aimed to provide accessible, continuous, efficient, and high quality services for all trauma victims in the province. Its design relied on three key components: (i) the designation of a network of acute care and rehabilitation facilities with specific mandates and responsibilities; (ii) the elaboration of transfer protocols, standing agreements, and governing structures to ensure fluid and optimal patient flow throughout the continuum; and (iii) the close monitoring of several structure, process, and results indicators to facilitate the continuous evaluation and improvement of the network.
None of these three components could have, by itself, allowed the TCC to take form and reach its full potential. Structural elements and coordination mechanisms serve as the backbone of the entire system. However, the continuous evaluation and retroaction process, solidly anchored in evidence-based knowledge, is central to the system's sustainability, responsiveness, and most of all, to its capacity to drive improvements and generate tangible results.
Positioning the Structure and Process Backbone of the Network
Lead by a partnership between the ministère de la Santé et des Services sociaux (MSSS) and the Régie de l'assurance automobile du Québec (RAAQ, which became in 1990 the “SAAQ” for Société de l'assurance automobile du Québec), the TCC was implemented in several phases over a period of 20 years (see reference 3 for a detailed account of the history and key components of the TCC). The first step involved the designation of individual hospitals into one of four levels of a hierarchical system of specialized trauma services developed by the American College of Surgeons based on various criteria pertaining to volume, availability of resources, expertise, etc. (3;Reference Boyd and Cowley4).
A trauma advisory expert group first audited over 70 facilities, using a structured assessment grid based on available evidence (mainly the various standards put forward by the American College of Surgeons) (Reference Boyd and Cowley4) and expert opinions. The assessment criteria included an array of components, for example, admission volumes, transfer number, delays, length of stay, medical staff, technical plateau, staff training, and clinical protocols. Field triage guidelines and prehospital protocols were introduced to ensure the transportation of trauma victims to the designated facility in minimal delays. Over time, the list of evaluation criteria was updated based on evolving literature and practice-based knowledge, leading to a reduction in the number of facilities involved and an adjustment of the levels of designation to meet regional and provincial needs.
Similar designation processes were conducted during that period with rehabilitation facilities as well as consortiums of facilities and centers of expertise, thereby ensuring better flow of services and high expertise for specific patient populations (e.g., traumatic brain injury, spinal cord injury, severe burns, amputations). The overall resulting trauma system is now composed of fifty-nine trauma centers including three adult and two pediatric level 1, five level II, twenty-one level III, and twenty-eight level IV centers. Standardized prehospital protocols ensure that major traumas are directed to these designated hospitals and standing agreements regulate transfers between hospitals and between hospitals and rehabilitation facilities (Reference Moore, Turgeon and Lauzier5).
To ensure the carry-over and strengthening effects of the audits, each trauma designation came with a list of obligations and reporting requirements for the facilities, consortiums, and regional health authorities, such as the maintenance of local and regional trauma committees, the elaboration of various collaboration agreements, and the production of action plans and annual reports. These elements were validated by the evaluation team and the status of completion of each facility was color-coded and posted on the trauma Web site described below. Still today, a permanent trauma committee, now based at the Institut national d'excellence en santé et en services sociaux (see Figure 1), monitors the presence and conformity of these requirements on a continuous basis and advises the MSSS of situations requiring action.
Figure 1. Mission of the Institut national d'excellence en santé et en services sociaux (INESSS).
SETTING UP THE CONTINUOUS MONITORING SYSTEM
One of the key ingredients of the vision and planning of the TCC was the implementation, along with the designation of the first trauma centers, of a centralized trauma registry. This enabled the trauma evaluation team to directly extract and analyze the data of each facility and compare them with other facilities of the same level throughout the province. This gradually led to the development of a centralized assessment-management Web site. Through this Web site, the trauma evaluation team at INESSS can validate the presence and conformity of the different structural elements (e.g., standing agreements, governing structure, protocols, etc.) and processes (e.g., clinical activities) requirements linked to the designation of each facility.
Comprising three levels of accessibility, on the first level the Web site contains information on injury for the general public. On the second level, those involved in the trauma network can access, consult, and extract protocols, procedures, and algorithms produced by their and other facilities, enabling sharing of material and best practices. Finally, a third secure level, accessible to only certain individuals in each facility, provides access to statistics, performance data, and evaluation reports.
PROMOTING QUALITY THROUGH THE MONITORING OF KEY PROCESSES AND RESULTS
Although the original in-person audit model of evaluation was certainly relevant and helpful at the time of the creation of the TCC, it is perhaps less necessary now that the system has reached a certain level of maturity. The continuous evaluation of the trauma system now relies mainly on the exploitation of the trauma registry, the monitoring of quality indicators, and the systematic analyses of these data by governing authorities and key stakeholders in each facility.
Each year, Trauma Registry data are extracted and analyzed at the provincial level as well as site by site. Reports layering out either 3 or 5 years of cumulative data are produced for each facility every year for level I and II centers and every 3–5 years for level III and IV data, depending on patient volume. These reports include descriptive statistics pertaining to the socio-demographic profile of the patients, patient volume, the origin and discharge destination of patients, length of stay, etc. Thirteen process indicators (Table 1) as well as twelve outcome indicators (Table 2), developed through a rigorous methodological protocol (Reference Moore, Lavoie, Bourgeois and Lapointe6–Reference Moore, Lavoie and Sirois12) are calculated, and these results are tabulated in graphs positioning each facility among all designated sites in the province (see example in Figure 2).
Table 1. Process Indicators
GCS, Glasgow Coma Scale; ICU, intensive care unit; ISS, Injury Severity Score.
Table 2. Outcomes Indicators
ISS, Injury Severity Score; LOS, length of stay.
Figure 2. Adjusted mortality rate of all trauma facilities.
These graphs allow knowledge users to monitor provincial averages and identify facility outliers. Upon the reception of their data, the local trauma committee of each facility is required to analyze their statistics and indicators and submit a commented analysis grid and associated action plan to the trauma evaluation team. Programs experiencing particular difficulties or persistent poor performance are discussed with the ministry and relevant authorities. Specific visits can be conducted to further explore the potential sources of problems (structure or process elements) and help orient solutions. This continuous “assessment-retroaction-correction-reassessment” cycle is what essentially drives changes within each facility and allows the administrators and clinicians to continuously review and improve their processes.
THE IMPACT
Almost 25 years have passed since major changes have been initiated in the province of Quebec. A total of four full cycles of assessments have been completed with acute care centers, in addition to several evaluations of the designated consortia and centers of expertise. Although other factors certainly also contributed to the positive evolution of the trauma system and its outcomes during that period (e.g., aggressive prevention campaigns by the SAAQ), the process of monitoring and reporting on structural elements, organizational and clinical processes, as well as various clinical results have brought on incremental changes and improvement within the network. Transfer and communication protocols have been refined where delays and obstacles were shown to persist, adapted trajectories have been put in place to respond to specific needs, numerous clinical protocols were developed and implemented to better respect the established standards of care, to decrease complications and ultimately improve outcomes such as mortality.
The results of these combined efforts are eloquent and serve as a great testimony to the vision and innovative leadership demonstrated by a nucleus of real champions of change, but also to the powerful effect of continuous evaluation and reporting. (i) Between 1992 and 2002, the incidence of in-hospital mortality from major trauma decreased from 51.8 percent down to 8.6 percent (Reference Liberman, Mulder, Lavoie and Sampalis1) (although methodological limitations and differences in the two measurement periods are recognized by the authors). (ii) An additional 24 percent drop in in-hospital mortality was observed between 1999 and 2012, from 5.8 percent to 4.2 percent, accompanied by a 16 percent decrease in average length of stay (15.5 to 11.5 days) but no change in the incidence of complications or unplanned readmissions. These changes translate into 186 lives saved per year and cost savings, due to shorter LOS, of 6.3 million CD$ per year (Reference Moore, Turgeon and Lauzier5). (iii) The risk-adjusted incidence of in-hospital mortality following major injury between 2006 and 2012 (7 percent) was the lowest of all Canadian provinces (Reference Moore, Evans and Hameed13).
In addition to the various publications produced over the years on the development and validation of the Quebec quality framework described above, these outstanding achievements have been recognized by different authorities, serving as a specific example of the World Health Organization's manuscript on “Success stories and lessons from around the world” (2), receiving praise by the Auditor General of the province (14), in addition to numerous awards and distinctions granted to specific individuals having played key roles in the TCC's inception.
CHALLENGES AND FUTURE PERSPECTIVES
Transforming, step by step and over such a long period of time, a complex and multi-faceted system requires a lot of energy and will but ensuring its sustainability over time certainly comprises other important challenges. Financial strains, competing priorities, and changing environments make it more difficult to keep the different supporting structures as dynamic and proactive as when they were created. Governing bodies and hospitals are faced with emerging healthcare needs and priorities (e.g., aging population, cancer, and stroke, etc.) and may perceive a well-integrated and high-performing system as something that requires less investment.
In response to these growing concerns, the trauma evaluation team at INESSS has made significant efforts over the past few years to simplify and lighten the mechanisms used to evaluate the conformity of the different structure and processes components. As mentioned above, the ongoing development and monitoring of key indicators now serve as the primary method used for controlling quality and promoting continuous improvement. Facilities take on a more active role in this process and should gradually be able to take ownership of the quality improvement process within their organization, provided continuous support and some level of control are maintained centrally.
Not being as involved in system coordination activities and facility audits, the INESSS trauma evaluation unit can invest more time and resources in projects aimed at better supporting the network, such as the development of clinical guidelines, algorithms, and best practice implementation initiatives. It is hoped that this revamped process will ensure long-lasting results for all trauma victims and will inspire other jurisdictions and other sectors of activities. The successful story of the TCC, the lessons learned, and the adjustments made over time are incredibly rich sources of information that should guide decisions and reorganization efforts of numerous other fields of the healthcare system in great need of quality improvement and optimized performance.
CONFLICTS OF INTEREST
The authors have nothing to disclose.
