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 270 Washington Street, SW, Suite 1-156 Atlanta, Georgia 30334 Phone: (404) 657-5220 www.audits.ga.gov Georgia Trauma Care Network Commission 2 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. Georgia Trauma Care Network Commission 3 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 4 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 5 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 6 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.