Follow-Up Review Report No. 15-02

May 2015

Georgia Department of Audits and Accounts
Performance Audit Division
Greg S. Griffin, State Auditor Leslie McGuire, Director

Why we did this review
This follow-up review was conducted to determine the extent to which recommendations in our December 2012 special examination (Report #1223) have been addressed.
The original examination answered House Appropriations Committee questions regarding the Commission's success in reaching its original goals, which include:
(1) Increasing the number of Level I, II, and III trauma centers; (2) Improving service delivery and response times; (3) Mitigating uncompensated care through the distribution of formula funds; and (4) Addressing the need for and benefit from providing ambulance purchases.
About the Commission
The Georgia Trauma Care Network Commission was established in 2007 following recommendations from a 2006 Joint Comprehensive State Trauma Services Committee. The Commission's main duties are to distribute funds to trauma centers and EMS providers to compensate for costs of readiness and uncompensated care related to trauma. The Commission is also responsible for establishing a trauma center network to ensure injured patients are cared for at the best available facility.
In fiscal year 2015, the Commission received state appropriations of $16.3 million. The funds approximate fines related to Georgia's super speeder law.

Follow-Up Review
Georgia Trauma Care Network
Commission
Many issues identified in special
examination have been addressed
What we found The Georgia Trauma Care Network Commission (the Commission) has made significant progress in addressing the findings in the December 2012 report. Notable improvements have been made regarding performance measure development, lead agency collaboration, and the use of data to analyze trauma system service delivery.
Since the release of the original report, the Commission and the Department of Public Health's Office of Emergency Medical Services and Trauma (OEMST) have cultivated a more cooperative relationship. Previously, ineffective interactions between the agencies had limited trauma system initiatives. Recent collaboration has led to advances in the areas of performance improvement and role delineation.
In fiscal year 2013, the Commission and OEMST formed an Evaluation Committee to create and monitor trauma system performance measures. Committee members selected the five measures shown in Exhibit 1 on page 2 and identified the necessary data sources for each measure's calculation. The Evaluation Committee plans to further develop its performance improvement program through regional-level analyses, benchmark identification, and the creation of more sophisticated measures.
The Commission and OEMST have also better defined their agency roles. At the time of the original report's release, the absence of a statutorily-defined trauma system lead agency had contributed to an ineffective relationship between the two agencies, both of

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Georgia Trauma Care Network Commission

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which share trauma system responsibilities. While the General Assembly has not modified state law to assign a single lead agency, the trauma system state plan created by OEMST in fiscal year 2014 recognizes both agencies as leaders of different trauma system functions. The Commission is the lead agency for trauma system funding and development, and OEMST is responsible for trauma center designation, emergency medical services (EMS) licensing, and system monitoring. While the current personnel of the two agencies are satisfied with the delineation of responsibilities, unclear and overlapping roles continue to exist. For example, while OEMST designates trauma centers, O.C.G.A. 31-11-102(12) states that the Commission will "establish, maintain, and administer a trauma center network to coordinate the best use of existing trauma facilities in this state." It is not clear if the Commission has the authority to restrict OEMST from performing additional designations should a region need no additional trauma centers. The constructive relationship between the agencies is based on the current leadership, not roles clearly defined in statute or regulation.
Exhibit 1 Trauma System Performance Measures
Performance Measure
Number of individuals trained through Commission funding
Percentage of approved readiness costs funded by the Commission
Percentage of severely injured patients treated at designated trauma centers
Number of regions with Commission-approved plans
Average response time from dispatch to destination for trauma patients
Source: Commission records
Trauma center coverage has continued to improve since the release of the 2012 report. Since fiscal year 2012, designated trauma centers have increased from a total of 21 to 25 (see Appendix A), and Northeast Georgia Medical Center's designation as a Level II trauma center increased coverage in the northeastern region of the state. However, some regions of the state, such as region 9 and parts of regions 5 and 8, still have limited access to definitive care at a Level I or II trauma center.1
The Commission has undertaken efforts to evaluate service delivery and identify areas of the state in need of trauma center coverage. In January 2014, analysis by a Commission consultant showed that severely injured patients have a 9% survival advantage when treated in a designated trauma center and that the percentage of those patients receiving treatment in designated trauma centers had increased from 64% in 2003 to 84% in 2012. The analysis also identified areas where new trauma centers would be most useful. Using the analysis, in January 2015, the Commission voted to limit fiscal year 2016 funding to one additional Level I, II, or III trauma center among the top five non-designated hospitals already serving severely injured patients.
The Commission has also taken steps to evaluate its programs and funding models. Regarding EMS funding, the Commission voted to end the ambulance replacement grant in fiscal year 2013 and EMS uncompensated care funding in fiscal year 2014. While funds from the discontinued programs were reallocated to training for EMS personnel and equipment grants for EMS providers, the Commission is still working to determine the best use of EMS funding. In fiscal year 2015, the Commission closed its Trauma Communications Center in favor of supporting further development of the Resource Availability Display, a web application that shows healthcare providers' current capacity levels for both trauma and non-trauma facilities. Additionally, the Commission is currently reviewing its funding model for designated trauma centers.

1 Georgia trauma centers are designated as Level I, II, III, or IV, with Level I centers offering the most comprehensive level of care.

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Commission and Department of Public Health Responses: The Commission and the Department of Public Health both expressed agreement with the current status of the findings as presented.
The following table summarizes the findings and recommendations in our 2012 report and actions taken to address them. A copy of the 2012 special examination report #12-23 may be accessed at http://www.audits.ga.gov/rsaAudits/Download/15584.

Georgia Trauma Care Network Commission

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Georgia Trauma Care Network Commission Follow-Up Review, May 2015

Original Findings/Recommendations
Data to measure improvement is limited; however, an increase in the number of trauma centers and in the percent of trauma patients going to trauma centers indicates improvement.
We recommended that the Commission and OEMST collaborate to develop a performance improvement program, including the creation of performance measures that consider both statewide and regional performance. We also recommended that the Commission utilize data already collected by OEMST to track trauma system outcomes.

Current Status
Fully Addressed The Commission and OEMST have established a forum for leading performance improvement initiatives, including the creation of performance measures that utilize available data sources.
In 2013, the Commission collaborated with OEMST to form an Evaluation Committee tasked with developing and monitoring trauma system performance measures. The Evaluation Committee is composed of trauma system stakeholders. Committee members received assistance from the Governor's Office of Planning and Budget to develop the performance measures shown in Exhibit 1 on page 2. The measures utilize available data sources, such as the Georgia EMS Information Systems.
According to the Commission, the Evaluation Committee is in the early stages of analyzing performance measures at the regional level. Additionally, the Evaluation Committee will continue to assess data needs, develop more sophisticated measures, and work toward establishing benchmarks. The Committee should also work to improve data quality by implementing processes to collect, maintain, and accurately quantify performance data.

The Commission's actions to improve trauma care are closely aligned with criteria set by the American College of Surgeons and other states; however, further improvements are needed.
We recommended that the Commission and OEMST continue to use the American College of Surgeons' (ACS) recommendations to guide trauma system activities. In particular, ACS recommended establishing a single lead agency in statute, which would require action by the General Assembly. In the absence of a statutory change, we recommended that the Commission and OEMST clarify each entity's roles and responsibilities.

Partially Addressed The Commission and OEMST have continued to implement ACS recommendations. They have taken action to define their roles and responsibilities; however, further clarification is needed in some areas.
The Commission and OEMST have demonstrated progress in implementing ACS recommendations in four of five major areas noted in the original report: structure, system development, operations, and performance measurement. Regarding structure, the General Assembly did not modify state law to identify a lead trauma system agency, but the Commission and OEMST did use existing state statute to define their roles as dual lead agencies. These roles are described in the 2014 trauma system state plan. The plan identifies the Commission as being responsible for trauma system funding and development, while OEMST is responsible for trauma center designation and system monitoring. However, the state plan does not provide sufficient clarification in the areas where the Commission and OEMST share responsibilities. For example, the state plan does not address how the Commission's role as system development lead agency intersects with OEMST's responsibility to recruit and designate trauma centers. It is important to note that the two agencies have cultivated a cooperative relationship since the issuance of the original report, including the creation of processes that have not been formally documented.
Progress has also been shown in three other areas. Regarding system development, the Commission aided in the creation of seven additional regional trauma advisory committees (RTAC), so that each of the 10 EMS regions now has an RTAC. Regarding operations, the Commission and OEMST collaborated on the trauma system state plan, which provides a guiding document for trauma system stakeholders statewide. Regarding performance measurement, the Evaluation

Georgia Trauma Care Network Commission

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Georgia Trauma Care Network Commission Follow-Up Review, May 2015

Original Findings/Recommendations
While the number of designated trauma centers has increased since 2007, there are still areas of the state in which injured patients must be transported long distances to receive definitive care at a Level I or II trauma center. We recommended that the Commission and OEMST determine the number and level of designated trauma centers needed in Georgia based on geography, population density, and hospitals' capabilities. As additional trauma centers are added, we recommended that the Commission invest its limited funding in trauma centers having the greatest impact on the system.

Current Status Committee described in the previous finding has created trauma system performance measures.
The fifth area noted in the original report, financing, has yet to be addressed. The General Assembly has considered legislation to provide additional funding for the trauma system, but none has passed.
Fully Addressed While portions of the state are still significant distances from Level I or II trauma care, the Commission has identified areas most in need of trauma center coverage.
The Commission hired a consultant to assess the effectiveness of the Georgia trauma system in providing access to trauma services. The study analyzed data from 2003 to 2012 and identified the top non-designated hospitals serving severely injured patients. The Commission compared this list to the locations of existing trauma centers to identify areas of the state serving trauma patients without designated trauma centers. As shown in Appendix A, patients in some regions must travel long distances to receive Level I or II trauma care.
Based on this analysis, the Commission decided to limit fiscal year 2016 funding to one additional Level I, II, or III trauma center among the top five non-designated hospitals noted in the study. The number one hospital on the list, Northeast Georgia Medical Center, had become a designated trauma center in fiscal year 2014. As shown in Appendix A, the four remaining hospitals eligible for Commission funding in fiscal year 2016 are located in the southern part of the state.

The Commission has mitigated approximately 24% of uncompensated care costs incurred by trauma centers and 65% incurred by participating EMS providers.
No Recommendations

No Recommendations to Address
The Commission indicated that it is considering a new trauma center funding model. The Commission's evaluation is still in the early stages, and any change will not go into effect until fiscal year 2018. Additionally, the Commission discontinued EMS uncompensated care funding in fiscal year 2014. The funding was redirected as described in the following finding.

The extent to which the Commission's ambulance replacement grant program benefits trauma patients is unclear.
We recommended that the Commission evaluate the ambulance replacement program's impact on trauma patients to determine whether it is the best use of EMS distribution funds.

Partially Addressed The Commission discontinued the ambulance replacement grant program and reallocated funds to training and equipment; however, it has not yet determined the best use of EMS funds.
In fiscal year 2013, the Commission voted to end the ambulance replacement grant program. Following the recommendation of the Commission's EMS Subcommittee, the funding from the ambulance replacement grant and EMS uncompensated care were reallocated to training and equipment. The funding provides training for EMS leadership and first responders and provides grants to ambulance companies for trauma care equipment. Funds budgeted for training and equipment increased from approximately $750,000 in fiscal year 2012 to $1.5 million and $2 million in fiscal years 2013 and 2014, respectively. However, the budgeted training and equipment funds for fiscal years 2013 and 2014 have not been fully expended. As of April 2015, approximately 91% of the fiscal year

Georgia Trauma Care Network Commission

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Georgia Trauma Care Network Commission Follow-Up Review, May 2015

Original Findings/Recommendations

Current Status 2013 funds and 4% of the fiscal year 2014 funds have been expended.
The Commission is still working to determine the best use of EMS funding. The EMS Subcommittee has not yet reached a consensus on funding needs. Commission leadership indicated that the funding could be directed to regional EMS priorities, as determined by the RTACs. They noted that the Commission had recently funded specific regional EMS projects, such as a Disaster Assistance Response Team in Region 1.

5 Findings

2 Fully Addressed 2 Partially Addressed 0 Not Addressed 1 No Recommendations

Appendix A Georgia Trauma Centers

Dade

Walk er

Catoosa Whitfield

Murr ay

Fannin

Union

Towns

Rabun

0 to 25 miles

7

Gilmer

White

26-50 miles

Chattooga Chattooga
20 8
FFllooyydd

1 Gordon Bartow

Pi ck ens Cherokee

Lumpkin Daws on
Forsy th Forsy th

2
2146
HHaallll

Habersham Stephens

Banks

Franklin

Jack son

Madis on

Hart El ber t

Polk

10
CCoobbbb

Gwinnett

Barr ow

13

Polk Haralson

Paulding

3 11 12

9

13

Douglas 226 2 Dekalb

167
Walton

Clark e

Oc onee

Oglethor pe

10 1292

18
Wi lk es Wilkes

Lincoln

Carroll

Fulton

Clayton Clayton

Henry

Newton

Morgan

Greene

Taliaferro

Columbia

McDuffie

19

Heard

Coweta

Fayette

Henry
25
Butts

Jasper

PuPtuntanmam

Warren

Ric hmond
237 5

426

Meriwether

Troup

SpSapldailndging Lamar
Pike Monroe

Jones

Baldwin

Hanc oc k

Gl as cock

Washington

Jeffer son

6 Burke

Harris
Mus cogee
14

Upson

Talbot

7

Taylor

Crawford

BBibibb
4

Twiggs

Wi lk inson

Peach HoHuosutosnton

Bleckley

Chattahoochee

Marion Sc hl ey

Mac on Dooly

Pul as ki
178

Dodge

Stewart

Webster

Sumter

Quitman Clay

Terrell Lee
Randolph

Calhoun

Dougherty 2370

21
Crisp
8
Worth

Wi lc ox
Turner
31

Ben Hill Irwin

5
Laurens

Johns on
214

Treutlen

Emanuel

Wheeler

25
Toombs

Telfair

Jeff Davis

Appling

Coffee

Bacon

Jenkins

Sc reven

Candler

Bulloch

Ev ans

Tattnall

Effingham
23

Br yan

6 Chatham

9 Long Wayne

Liberty McIntosh

Early

Baker

Miller

Mitchell

Colquitt

Tift Berr ien
Cook

Atkinson

Pierce

Ware

Br antley

Glynn
29

Seminole

Decatur

Grady

15
Thomas

Br ooks

Lanier

28
Lowndes

Cli nc h Ec hol s

Charlton

Camden

Level I Trauma Centers: 1 Atlanta Medical Center 2 Grady Memorial Hospital 3 Children's Healthcare of Atlanta at Eglestonx 4 Medical Center of Central Georgia* 5 Georgia Regents Medical Center* 6 Memorial Health University Medical Center*
Level II Trauma Centers: 7 Hamilton Medical Center 8 Floyd Medical Center 9 Gwinnett Medical Center 10 North Fulton Hospital 11 Wellstar Kennestone Hospital 12 Children's Healthcare of Atlanta at Scottish Ritex 13 Athens Regional Medical Center 14 Medical Center - Columbus

Level II (Cont.): 15 John D. Archbold Memorial Hospital 16 Northeast Georgia Medical Center
Level III Trauma Centers: 17 Clearview Regional Medical Center 18 Taylor Regional Hospital 19 Trinity Hospital of Augusta 20 Redmond Regional Medical Center
Level IV Trauma Centers:1 21 Crisp Regional Hospital 22 Morgan Memorial Hospital 23 Effingham Health System 24 Emmanuel Medical Center 25 Meadows Regional Medical Center

Burn Centers: 26 Grady Burn Center 27 Joseph M. Still Burn Center
Top Non-Designated Hospitals Treating the Severely Injured2 28 South Georgia Medical Center 29 Southeast Georgia Health System 30 Phoebe Putney Memorial Hospital 31 Tift Regional Medical Center
x Pediatric center *Adult trauma center with pediatric commitment Designated after fiscal year 2012

1In fiscal year 2014, two other hospitals lost their level IV trauma center status due to hospital closure and voluntary de-designation. 2The Commission decided to limit fiscal year 2016 funding to one additional Level I,II, or III trauma center from this list. Source: Commission, OEMST documents; Microsoft MapPoint

The Performance Audit Division was established in 1971 to conduct in-depth reviews of state-funded programs. Our reviews determine if programs are meeting goals and objectives; measure program results and effectiveness; identify alternate methods to meet goals; evaluate efficiency of resource allocation; assess compliance with laws and regulations; and provide credible management information to decision-makers. For more information, contact
us at (404) 657-5220 or visit our website at www.audits.ga.gov.