Self-Assessment Survey: Research & Data

CATRAC has organized the DSHS Self-Assessment tool by four categories:

1. Emergency Healthcare Systems Plan

2. Research & Data

3. System Requirements

4. RAC Administrative requirements

The Self-Assessment tool has been broken into four surveys. You are currently taking the Research & Data portion of the Self-Assessment Survey.

The following survey is the exact language from the Self-Assessment tool presented by each category. Please score each element according to service line using the 0-5 scale to the best of your ability. The accuracy of identifying gaps in the region relies on the accuracy of this survey.

The Element number corresponds directly to the RAC Self-Assessment Scoring Tool.

Taking this survey on a mobile device is not recommended.

Question Title

* First and last name

Question Title

* Agency/Facility

Question Title

* What service line are you representing? (check all that apply)

Prehospital- Ground Service Line

Prehospital- Air Medical Service Line

Hospital- Trauma Service Line

Hospital- Cardiac Service Line

Hospital- Stroke Service Line

Hospital- Perinatal Service Line

LTACH/Rehab/Psych/FSED/Specialty facility

Non-designated Hospital

Question Title

* Email address

Question Title

* Element 1: EPIDEMIOLOGY

Be sure to read each rating description as they vary for each question.

There is a thorough description of the epidemiology of trauma, prehospital, perinatal, stroke, cardiac, and emergency healthcare incidence of prehospital transport, hospital admissions, and mortality in the regional population-based data, to include data specific to urban and rural data, and diverse populations to assist in defining regional priorities.

0. Not known or N/A

1. There is no data description of the epidemiology of trauma, prehospital, perinatal, stroke, cardiac, and emergency healthcare incidence of prehospital transport, hospital admission, mortality in the region.

2. Reported admissions and mortality data have been used to describe the statewide incidence of trauma, prehospital, perinatal, stroke, cardiac, and emergency healthcare deaths, aggregating all etiologies, but no regional data is available.

3. The RAC has access to the minimal data sets established to develop an epidemiology history of the incidence of prehospital transport, hospital admissions, and mortality for trauma, perinatal, stroke, and cardiac disease.

4. In addition to #3, mortality data is aggregated in a confidential process by reporting entities and is shared with specific committees of the RAC.

5. In addition to #4, stakeholders use the data to develop strategies and prioritize needs for the rural and urban areas, to include measures for diverse populations, to define key initiatives, prevention, and awareness programs.

Please rate each service line below.

	0	1	2	3	4	5
PREHOSPITAL	PREHOSPITAL 0	PREHOSPITAL 1	PREHOSPITAL 2	PREHOSPITAL 3	PREHOSPITAL 4	PREHOSPITAL 5
TRAUMA	TRAUMA 0	TRAUMA 1	TRAUMA 2	TRAUMA 3	TRAUMA 4	TRAUMA 5
PERINATAL	PERINATAL 0	PERINATAL 1	PERINATAL 2	PERINATAL 3	PERINATAL 4	PERINATAL 5
STROKE	STROKE 0	STROKE 1	STROKE 2	STROKE 3	STROKE 4	STROKE 5
CARDIAC	CARDIAC 0	CARDIAC 1	CARDIAC 2	CARDIAC 3	CARDIAC 4	CARDIAC 5

Question Title

* Element 2: EPIDEMIOLOGY

There is a description of trauma, prehospital, perinatal, stroke, cardiac, and emergency healthcare incidence and prevalence within the regional jurisdiction, including the distribution by specific populations (pediatric, geriatric, specialty populations, distinct cultural/ethnic populations, rural, and others), from available data resources.

Be sure to read each rating description as they vary for each question.

0. Not known or N/A

1. There is no written description of trauma, prehospital, perinatal, stroke, cardiac, and emergency healthcare incidence or prevalence within the regional system jurisdiction.

2. One or more population-based data sources describe the trauma, prehospital, perinatal, stroke, cardiac, and emergency healthcare incidence and prevalence patterns within the region, but data is not current.

3. One or more population-based data sources and one or more clinical data sources are used to describe the trauma, prehospital, perinatal, stroke, cardiac, and emergency healthcare incidence within the region.

4. In addition to #3, the regional information is updated at least annually.

5. In addition to #4, hospital discharge data, EMS data, medical examiner data, fatality review teams, and other sources are linked and used by stakeholders to describe trauma, prehospital, perinatal, stroke, cardiac, and emergency healthcare incidence and prevalence within the region annually.

Please rate each service line below.

	0	1	2	3	4	5
PREHOSPITAL	PREHOSPITAL 0	PREHOSPITAL 1	PREHOSPITAL 2	PREHOSPITAL 3	PREHOSPITAL 4	PREHOSPITAL 5
TRAUMA	TRAUMA 0	TRAUMA 1	TRAUMA 2	TRAUMA 3	TRAUMA 4	TRAUMA 5
PERINATAL	PERINATAL 0	PERINATAL 1	PERINATAL 2	PERINATAL 3	PERINATAL 4	PERINATAL 5
STROKE	STROKE 0	STROKE 1	STROKE 2	STROKE 3	STROKE 4	STROKE 5
CARDIAC	CARDIAC 0	CARDIAC 1	CARDIAC 2	CARDIAC 3	CARDIAC 4	CARDIAC 5

Question Title

* Element 4: EPIDEMIOLOGY- SURVEILLANCE

There is an established regional trauma, perinatal, stroke, and cardiac surveillance process that can, in part, be used to support performance measures.

Be sure to read each rating description as they vary for each question.

0. Not known or N/A

1. There is no established region-wide trauma, perinatal, stroke, cardiac, and disease surveillance process.

2. There is a regional trauma, prehospital, perinatal, stroke, cardiac, and disease data collection process, but not all hospitals in the service area contribute to the database.

3. There is a regional trauma, perinatal, stroke, cardiac, and cardiac data initiative with all designated hospitals in the region contributing data for the incidence of prehospital transports, hospital admissions, and mortality only.

4. In addition to #3, the hospital data is used in conjunction with the EMS data system or hospital discharge data.

5. In addition to #4, the regional data is accessible, electronically and has consistent data definitions, with the identified EMS wristband identifier, and processes in place to support report writing. The data supports prevention strategies, coalition building, public awareness, surveillance, and performance improvement with stakeholder input to define priorities and initiatives. Processes for sharing and linkage of data exist between EMS systems, public health systems, and the trauma and emergency health care system participants with this data being used to monitor, investigate, and diagnose regional community health risks.

Please rate each service line below.

	0	1	2	3	4	5
PREHOSPITAL	PREHOSPITAL 0	PREHOSPITAL 1	PREHOSPITAL 2	PREHOSPITAL 3	PREHOSPITAL 4	PREHOSPITAL 5
TRAUMA	TRAUMA 0	TRAUMA 1	TRAUMA 2	TRAUMA 3	TRAUMA 4	TRAUMA 5
PERINATAL	PERINATAL 0	PERINATAL 1	PERINATAL 2	PERINATAL 3	PERINATAL 4	PERINATAL 5
STROKE	STROKE 0	STROKE 1	STROKE 2	STROKE 3	STROKE 4	STROKE 5
CARDIAC	CARDIAC 0	CARDIAC 1	CARDIAC 2	CARDIAC 3	CARDIAC 4	CARDIAC 5

Question Title

* Element 7: SYSTEM PLAN

The regional trauma and emergency health care system plan clearly describes how the regional stakeholders will implement and manage the defined criteria and contract requirements to ensure there is documentation of compliance with data analysis.

Be sure to read each rating description as they vary for each question.

0. Not known or N/A

1. There is an outdated regional trauma and emergency health care system plan posted on the website.

2. The regional trauma and emergency health care system plan does not address or incorporate the regional trauma and emergency health care system criteria or the contract requirements.

3. The regional trauma and emergency health care system plan define the compliance to the RAC criteria and contract requirements to include objectives for system evaluation.

4. In addition to #3, the system plan objectives are monitored and analyzed quarterly and annually, then shared with regional stakeholders.

5. In addition to #4, the regional data is included in the RAC annual report reflecting the system’s performance and outcomes and posted on the regional public website, then shared with public health, local officials, the business community stakeholders, and the department.

Please rate each service line below.

	0	1	2	3	4	5
PREHOSPITAL	PREHOSPITAL 0	PREHOSPITAL 1	PREHOSPITAL 2	PREHOSPITAL 3	PREHOSPITAL 4	PREHOSPITAL 5
TRAUMA	TRAUMA 0	TRAUMA 1	TRAUMA 2	TRAUMA 3	TRAUMA 4	TRAUMA 5
PERINATAL	PERINATAL 0	PERINATAL 1	PERINATAL 2	PERINATAL 3	PERINATAL 4	PERINATAL 5
STROKE	STROKE 0	STROKE 1	STROKE 2	STROKE 3	STROKE 4	STROKE 5
CARDIAC	CARDIAC 0	CARDIAC 1	CARDIAC 2	CARDIAC 3	CARDIAC 4	CARDIAC 5

Question Title

* Element 18: PREHOSPITAL

There are recommended regional prehospital triage criteria to establish appropriate destination and transport of patients with acute trauma, perinatal, stroke, cardiac, or other time-sensitive disease processes. Prehospital triage criteria are regularly evaluated by the regional medical advisory committee/process, prehospital providers, and designated facilities to identify system gaps.

Be sure to read each rating description as they vary for each question.

0. Not known or N/A

1. There are no recommended regional prehospital triage criteria to ensure that patients with acute trauma, perinatal, stroke, cardiac, or other time-sensitive disease processes are transported to the appropriate facility.

2. There are differing triage criteria for acute trauma, perinatal, stroke, cardiac, and other time-sensitive disease processes are used by prehospital providers. Appropriateness of triage criteria and subsequent transportation are not evaluated.

3. Regional triage criteria for patients with acute trauma, perinatal, stroke, cardiac, and other time-sensitive disease processes are developed, approved by the EMS medical directors or advisory process, and implemented for a system approach.

4. In addition to #3, the triage criteria are utilized by prehospital providers and monitored through the system performance improvement process.

5. In addition to #4, the effectiveness the triage criteria are evaluated through outcomes, transfers, and double transfers. These reports are generated quarterly and reviewed by the medical advisory process.

Please rate each service line below.

	0	1	2	3	4	5
PREHOSPITAL	PREHOSPITAL 0	PREHOSPITAL 1	PREHOSPITAL 2	PREHOSPITAL 3	PREHOSPITAL 4	PREHOSPITAL 5
TRAUMA	TRAUMA 0	TRAUMA 1	TRAUMA 2	TRAUMA 3	TRAUMA 4	TRAUMA 5
PERINATAL	PERINATAL 0	PERINATAL 1	PERINATAL 2	PERINATAL 3	PERINATAL 4	PERINATAL 5
STROKE	STROKE 0	STROKE 1	STROKE 2	STROKE 3	STROKE 4	STROKE 5
CARDIAC	CARDIAC 0	CARDIAC 1	CARDIAC 2	CARDIAC 3	CARDIAC 4	CARDIAC 5

Question Title

* Element 23: SYSTEM COORDINATION AND PATIENT FLOW

Specific populations that may have defined needs are identified for trauma, maternal, neonatal, perinatal, stroke, cardiac, and other time-sensitive disease processes in the regional plan. Examples of unique populations include but are not limited to pediatric, geriatric, bariatric, homeless, behavioral health, and the non-English speaking population in all geographic areas of the region to include the rural and remote areas.

Be sure to read each rating description as they vary for each question.

0. Not known or N/A

1. There has been no consideration of the specific needs of unique populations.

2. The regional stakeholders have not prioritized the specific populations and their potential needs in the regional plan.

3. The regional stakeholders have identified specific populations and defined if specific resources or guidelines are needed for routine response and this is integrated into the trauma and emergency healthcare system plan.

4. In addition to #3, measures to monitor the effectiveness of these resources or guidelines.

5. In addition to #4, routine monitoring, review, and reporting of outcomes are integrated into the system performance improvement process and shared with stakeholders.

Please rate each service line below.

	0	1	2	3	4	5
PREHOSPITAL	PREHOSPITAL 0	PREHOSPITAL 1	PREHOSPITAL 2	PREHOSPITAL 3	PREHOSPITAL 4	PREHOSPITAL 5
TRAUMA	TRAUMA 0	TRAUMA 1	TRAUMA 2	TRAUMA 3	TRAUMA 4	TRAUMA 5
PERINATAL	PERINATAL 0	PERINATAL 1	PERINATAL 2	PERINATAL 3	PERINATAL 4	PERINATAL 5
STROKE	STROKE 0	STROKE 1	STROKE 2	STROKE 3	STROKE 4	STROKE 5
CARDIAC	CARDIAC 0	CARDIAC 1	CARDIAC 2	CARDIAC 3	CARDIAC 4	CARDIAC 5

Question Title

* Element 25: PREVENTION, COALITION, AND OUTREACH

The region conducts at least one multidisciplinary trauma, prehospital, maternal, neonatal, stroke, cardiac, and emergency healthcare system conference or educational case review annually that is designed to engage regional stakeholders, disseminate evidence-based practices, and provides a focus on the system approach to patient management and outcomes.

Be sure to read each rating description as they vary for each question.

0. Not known or N/A

1. There are no multidisciplinary conferences or educational case review conducted with the region.

2. There are infrequent multidisciplinary educational opportunities provided by the region.

3. A regional multidisciplinary conference or educational case review for trauma, maternal, neonatal, perinatal, stroke, cardiac, or other time sensitive disease process educational opportunity is scheduled at least annually, with attendance monitored and reviewed. An alternate plan for the RAC is to support an educational lecture at another RAC’s conference, or to share a list of all educational opportunities each quarter.

4. In addition to #3, educational opportunities are defined through a needs assessment, or stakeholder request, or the system performance improvement process, and attendance is monitored.

5. In addition to #4, these educational programs are inclusive to all healthcare stakeholders. Continuing education and continuing medical education credits are provided. If the RAC cannot support the educational opportunities, it is partnering with other RACs to provide educational opportunities or disseminate upcoming educational programs.

Please rate each service line below.

	0	1	2	3	4	5
PREHOSPITAL	PREHOSPITAL 0	PREHOSPITAL 1	PREHOSPITAL 2	PREHOSPITAL 3	PREHOSPITAL 4	PREHOSPITAL 5
TRAUMA	TRAUMA 0	TRAUMA 1	TRAUMA 2	TRAUMA 3	TRAUMA 4	TRAUMA 5
PERINATAL	PERINATAL 0	PERINATAL 1	PERINATAL 2	PERINATAL 3	PERINATAL 4	PERINATAL 5
STROKE	STROKE 0	STROKE 1	STROKE 2	STROKE 3	STROKE 4	STROKE 5
CARDIAC	CARDIAC 0	CARDIAC 1	CARDIAC 2	CARDIAC 3	CARDIAC 4	CARDIAC 5

Question Title

* Element 32: DATA MANAGEMENT

Data collection by the region through State EMS or Trauma Center Registry and/or regional registries or other data sources are utilized to develop regional goals that are data-driven with objectives that correlate with the regional system performance improvement plan.

Be sure to read each rating description as they vary for each question.

0. Not known or N/A

1. Regional data is not available through the state or a regional registry.

2. There are limited mechanisms for data collection that can be accessed to provide a timely data to assist with developing regional goals.

3. The State EMS or Trauma Center Registry data for the region, regional data, and the regional self-assessment provide data to assist with developing goals with define measurable objectives that support the regional performance improvement plan.

4. In addition to #3, the data is used to evaluate the system performance, changes in trends, and identify opportunities for improvements.

5. In addition to #4, the region has guidelines in place to share unidentified data with committees and regional stakeholders. These reports are included in the annual regional strategic planning.

Please rate each service line below.

	0	1	2	3	4	5
PREHOSPITAL	PREHOSPITAL 0	PREHOSPITAL 1	PREHOSPITAL 2	PREHOSPITAL 3	PREHOSPITAL 4	PREHOSPITAL 5
TRAUMA	TRAUMA 0	TRAUMA 1	TRAUMA 2	TRAUMA 3	TRAUMA 4	TRAUMA 5
PERINATAL	PERINATAL 0	PERINATAL 1	PERINATAL 2	PERINATAL 3	PERINATAL 4	PERINATAL 5
STROKE	STROKE 0	STROKE 1	STROKE 2	STROKE 3	STROKE 4	STROKE 5
CARDIAC	CARDIAC 0	CARDIAC 1	CARDIAC 2	CARDIAC 3	CARDIAC 4	CARDIAC 5

Question Title

* Element 33: REGIONAL RESEARCH

The regional trauma and emergency health care system has developed mechanisms to engage the regional general membership and other system stakeholders in regional research projects.

Be sure to read each rating description as they vary for each question.

0. Not known or N/A

1. There is no evidence that regional data is available to support research projects.

2. Data is available through the RAC, but it is sporadic and lacks current data, validation of data, and a coordinated effort to support research activities.

3. The regional trauma and emergency health care system has developed mechanisms to engage the regional general membership and other system stakeholders in research projects. RAC leaders can demonstrate routine interface with the general medical community regarding trauma, prehospital, maternal, neonatal, stroke, and cardiac care updates and performance improvements initiatives.

4. In addition to #3, research is a routine agenda item for the committee and general membership meetings.

5. In addition to #4, a structured process to discuss regional research ideas and projects with the general membership and other system stakeholders in the region is documented and disseminated to stakeholders. Guidelines specifically addressing abstracts, presentations, and publications of research projects funded by the RAC are documented and shared with all stakeholders. All research projects and findings are reported through the RAC committees and general membership meetings before abstracts, presentations, and/or publications are completed.

Please rate each service line below.

	0	1	2	3	4	5
PREHOSPITAL	PREHOSPITAL 0	PREHOSPITAL 1	PREHOSPITAL 2	PREHOSPITAL 3	PREHOSPITAL 4	PREHOSPITAL 5
TRAUMA	TRAUMA 0	TRAUMA 1	TRAUMA 2	TRAUMA 3	TRAUMA 4	TRAUMA 5
PERINATAL	PERINATAL 0	PERINATAL 1	PERINATAL 2	PERINATAL 3	PERINATAL 4	PERINATAL 5
STROKE	STROKE 0	STROKE 1	STROKE 2	STROKE 3	STROKE 4	STROKE 5
CARDIAC	CARDIAC 0	CARDIAC 1	CARDIAC 2	CARDIAC 3	CARDIAC 4	CARDIAC 5