Interim leadership and trauma services consulting helped to reclaim trauma services verification in six months
A community hospital with trauma services lost its verification status through ACS (American College of Surgeons) after 12 years with 3 highly-successful triennial surveys. 16 required (type 2) deficiencies and 8 weaknesses had been identified.
Philips Blue Jay Consulting provided a performance improvement team with subject matter expertise as a trauma program manager to lead a comprehensive assessment and process improvement implementation work. Activities included data analysis, onsite observations, staff and stakeholder interviews, and more. An action plan was developed including a deep dive on each deficiency.
Results of the engagement included:
The Philips Blue Jay Consulting team was instrumental in helping us to secure our Level III Trauma Services status. During our exit interview, the surveyor commented on the significant commitment by all the people that geared it up and did a really great job and how the consultants made our program really impressive.”
Assistant CNO and Director of Emergency and Trauma Services
US community hospital
Our approach
To understand the challenges, issues, and opportunities for improvement, a team of two consultants performed a comprehensive assessment.
Some of the methods of assessment included:
| Detected deficiencies: | |
| Detected weaknesses: | |
This enabled them to gather further insights in regards to the ACS findings and uncover any potential deficiencies or weaknesses. The consultants worked with the trauma center team including a deep dive on each deficiency, weakness, and recommendation plan was developed to address each of these.
Philips also provided support and guidance on program management processes and methodologies.
Recommendations
Working closely with the client team, an action plan was developed to improve performance and address the identified areas of concern.
The below initiatives were implemented:
Results
The hospital’s new trauma program manager and medical director are working as an integrated team along with their supportive staffs. A new collaborative culture has emerged within the entire facility.
The ACS surveyors made a return visit in 6 months and were pleased to see that all type 2 deficiencies (16) and weaknesses (8) had been addressed and were removed.
The hospital is once again a Level III Trauma Center with ACS verification.
| Deficiencies: | |
| Weaknesses: | |
Meet our team
JoAnn Lazarus, MSN, RN, CEN
Principal, Philips Blue Jay ConsultingJoAnn is a leader for the emergency services team, providing interim leadership and leading process improvement projects. Among her accomplishments include establishing a fast track, a middle track, implementing a SWAT team for the waiting room, and decreasing the walk out rate by 25% in a 100,000-visit level 1 academic trauma center.
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* Results from case studies are not predictive of results in other cases. Results in other cases may vary
