PERFORMANCE IMPROVEMENT (PI) MONITORING

Population of Interest

All patients with laser eye exposure/injury.

Intent

1. Patients in the population of interest are identified as having exposure at first role of surgical care.
2. Patients in the population of interest undergo comprehensive evaluation by an eye care provider as soon as possible after exposure events
3. Patients in the population of interest have complete documentation of type of laser injury, severity, treatment, and outcomes.

Performance/Adherence Metrics

1. Number and percentage of patients in the population of interest with documented comprehensive eye exam.
2. Number and percentage of patients in the population of interest with complete documentation of type of laser injury, severity, treatment, and outcomes.

Data Sources

- Individual Medical Record
- DVEIVR
- DoD Trauma Registry

System Reporting & Frequency

The above constitutes the minimum criteria for PI monitoring of this CPG. System reporting will be performed annually; additional PI monitoring and system reporting may be performed as needed.

The system review and data analysis will be performed by the Joint Trauma System (JTS) Chief, JTS Program Manager, and the JTS Performance Improvement Branch.

RESPONSIBILITIES

It is the trauma team leader’s responsibility to ensure familiarity, appropriate compliance and PI monitoring at the local level with this CPG.