Performance Improvement

Cedars-Sinai; Trauma PIPS Master Plan

Cedars-Sinai; Trauma PIPS Master Plan

  • Last Updated: 2018
  • Author(s): Cedars-Sinai Medical Center
  • Language(s): English

A. Trauma Population
The patients that will be reviewed for performance improvement and patient safety (PIPS) and included in the hospital Trauma Registry are consistent with the Los Angeles County Trauma System patient inclusion criteria (Appendix 1), and the National Trauma Data Standard (NTDS). Cedars-Sinai Medical Center (CSMC) submits trauma data to the LA County Trauma and Emergency Medical Information System (TEMIS), California EMS Information System (CEMSIS), American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) and the ACS National Trauma Data Bank (NTDB). Data elements included in the CSMC hospital Trauma Registry include those required for each of these 4 entities.B. Standards of Quality Care
Evaluation and monitoring of trauma care delivery at CSMC is based on national, regional and local standards of trauma care.

C. Credentialing Standards for Practitioners – Initial and Ongoing
All surgical staff will be credentialed per CSMC Medical Staff Bylaws and the Department of Surgery Policy & Procedure before being scheduled for trauma call. The Trauma Medical Director (TMD) will complete an initial and annual review of credentials for the trauma call panel. The TMD has the authority to set the qualifications for the trauma service members including initial and ongoing review. The form “Annual Trauma Panel Credentialing-Ongoing Professional Practice Evaluation (OPPE)” will be used for supporting the process (Appendix 2). This form and supporting documents will be kept on file in the office of the Trauma Program Manager (TPM). The trauma physician liaisons from Neurosurgery, Orthopedic Surgery, and Emergency Medicine will also undergo annual review for participation on the trauma call panel.

D. Operational Support
The TMD and the TPM are empowered by the Board of Directors and the Medical Staff to maintain all aspects of Level I trauma hospital requirements, including all PIPS requirements. This is evidenced by the “Resolution” from both the Board and the Medical Executive Committee that is updated every 3 years. The TMD and TPM are responsible for the oversight of the Trauma PI (systems) and QI (peer review) processes. The Trauma Performance Improvement Coordinator works closely with the TMD, TPM, and all departments to maintain the Trauma PIPS Program. The Trauma Registrars support the PIPS process with a concurrent data process. The concurrent data process is dependent on adequate staffing. In the event of an inability to maintain par trauma registry staffing levels, data backlog will occur. All efforts, (administratively), will be implemented to sustain a concurrent data process to meet all Level I trauma hospital data and PIPS requirements.

Deconess; Trauma PI Plan

Deconess; Trauma PI Plan

  • Last Updated: 2005
  • Author(s): Deaconess Trauma Services
  • Language(s): English

Deaconess Hospital’s Trauma Performance Improvement (PI) plan is to measure, evaluate, and improve the process and effectiveness of care rendered to the injured patient including medical oversight of pre-hospital providers, resuscitation, inpatient care, and inter-hospital transfer. This includes a multidisciplinary effort to monitor, assess, and improve both the processes and outcomes of care to the injured. The long-term goal is to decrease death and disability by reducing inappropriate variation in care through progressive cycles of performance review.

Criteria for determining which patients undergo monitoring and evaluation of care is correlated with the American College of Surgeons and hospital-specific indicators. See Trauma Registry Process Guideline for inclusion criteria.

The Performance Improvement consists of internal and external monitoring and evaluation of care provided by EMS, medical, nursing, and ancillary personnel, as well as hospital departments, services, and programs. Monitoring is ongoing and systematic; opportunities to reduce inappropriate variation in care are sought, and strategies to improve care are documented in the registry. The effectiveness of corrective action is evaluated through continuous reassessment and monitoring utilizing an ongoing performance improvement process.

The Trauma Medical Director, Trauma Outreach Medical Director, Trauma Performance Improvement Medical Director, Director of Patient Care Services, Trauma Program Manager, Trauma Data Quality Coding Coordinator(s), Trauma Clinical Operations Supervisor, Trauma Performance Improvement Nurse, and EMS Coordinator(s) address performance issues, which involve multiple services and departments. The Trauma Medical Director(s) leads the Trauma PI process through case reviews, participation in Multidisciplinary Trauma Rounds and review of variances, indicators, complications and complaints. The Trauma Medical Director will review events and determine corrective action if applicable.

The Trauma Clinical Operations Supervisor and Trauma Performance Improvement RN abstract data from selected patients’ chart concurrently, they identify and report complications, variances in care, complaints and opportunities for improvement from time of patient injury (EMS Care) through rehab. These issues are reported to the Trauma Medical Director/Trauma Program Manager and the Trauma Service team for concurrent follow-up needs. Each chart is screened again by the Trauma Data Quality Coding Coordinator(s) after discharge as appropriate.

The Trauma Data Quality Coding Coordinator(s) is responsible for report writing, and utilizing the Trauma Registry as the core source of information. He/she enters data into Trauma Base (Trauma Registry), State of Illinois Registry, and State of Indiana Registry assigns AIS codes, ICD-10 Codes and validates / enters E-codes for all injured patients who meet inclusion criteria. Issue, judgment, and action are documented in the patient’s trauma registry information by the Trauma Care Coordinator, Trauma Performance Improvement RN, Trauma Program Manager, and Trauma Data Quality Coding Coordinator(s).

Trauma cases are screened for physician review by the Trauma Program Manager, Trauma Clinical Operations Supervisor, and the Trauma Performance Improvement RN. Cases with complications, variances, or complaints may be reviewed by the Trauma Medical Director(s), Director of Patient Care Services, Trauma Program Manager, Trauma Clinical Operations Supervisor, Trauma Performance Improvement RN, and Trauma Data Quality Coding Coordinators as appropriate, then if warranted, forwarded to the Trauma Peer Review M&M committee. Trauma Services collaborates with the Deaconess Hospital’s Quality Improvement Liaison in screening mortalities, variances in care, and at risk cases. This communication between departments stimulates ideas and processes to ensure quality patient care. A representative from the Performance Improvement department attends the monthly Trauma Peer Review M & M committee meeting and reports back to the Medical Staff Quality Council if necessary.

The Trauma Operational Committee consists of a multidisciplinary team representing all phases of care provided to the injured patient including pre-hospital care. A representative from each of the designated trauma care areas is encouraged to attend and participate. These participants include: EMS, ICU, Medical Surgical, Orthopedic and Neurological Floors, Administration, ED liaison, Trauma Surgeon (TMD) and Trauma Services.

The Trauma Peer Review Committee meets monthly. This meeting is physician led, confidential, and peer protected. Peer physician representation includes Trauma Surgery, Vascular Surgery, Pediatric Intensivist, Emergency Medicine, Pulmonary Critical Care Medicine, Anesthesia, Radiology, Neurosurgery, Orthopaedic Surgery, and other appropriate physician sub-specialists. Cases that require further follow-up or action are referred to the Deaconess Medical Staff Executive Council or other department sections as necessary. Internal CME is available for Physicians at this meeting due to educational content, case reviews, and EBP reviews when indicated.

The Trauma Program Manager coordinates action planning and documentation between the trauma program and the hospital-wide PI program. Trauma Operational Committee and Trauma Peer Review M&M Committee meet monthly. System and process related issues are reviewed at the Trauma Operational Committee. Provider related morbidity and mortality issues as well as select complications are reviewed at Trauma Peer Review M&M Committee. The Trauma Service’s Department is responsible for data processing, analyzing, and reporting variances to the Trauma Operational and Medical Committees. As necessary, cases of educational merit are discussed with EMS, physicians, nurses and ancillary personnel and education credit given in compliance related to patient privacy regulations and peer protection requirements.

Trauma Services utilizes a three tiered system for trauma patient review. Each chart is screened to ensure patient care was delivered appropriately and timely (DVT prophylaxis, GI prophylaxis, c-spine clearance, timelines of treatments-OR, CT, ED, admitting orders, admitting MD, etc.) using a standard form/database. All deaths receive a Level 2 review completed by the Trauma Medical Director(s) and are presented at Trauma Peer Review Committee meeting for a level 3 review.

Geisinger; Trauma Performance Improvement Plan

Geisinger; Trauma Performance Improvement Plan

  • Last Updated: 2016
  • Author(s): Starlett Bixby, BSN, CEN, RN, PHRN
  • Language(s): English

Philosophy of the Trauma Program

  1. Geisigner Health System is an integrated health services organization widely recognized for its innovative use of the electronic health record and the development of innovative care delivery models such as Proven Health Navigator and ProvenCare®, Acute/Chronic Programs. As one of the nation’s largest health service organizations, Geisinger serves more than three million residents throughout 45 counties in central, south-central, and northeast Pennsylvania, and also in New Jersey with the addition of AtlantiCare, a National Malcolm Balridge Award recipient. The physician-led system is comprised of approximately 30,000 employees, including nearly 16,000 physicians, 12 hospital campuses, two research centers, and a 510,000-member health plan, all of which leverage an estimated $8.9 billion positive impact on the Pennsylvania economy. Geisinger has repeatedly garnered national accolades for integration, quality, and service. In addition to fulfilling its patient care mission, Geisinger has a long-standing commitment to medical education, research, and community service.
  2. Geisinger Health System has had a long tradition in the provision of trauma care and has been recognized as a regional resource trauma center since 1986. Geisinger Health System and the Janet Weis Children’s Hospital are committed to the provision of adult and pediatric trauma care which fostered them to gain accreditation as a Level One Trauma Center with Additional Qualifications in Pediatric Trauma in 1996. The Janet Weis Children’s Hospital has been accredited as a Level Two Trauma Center since 2011. To accomplish these goals, Geisinger requires strong leadership with authority to coordinate the multidisciplinary team. The need to coordinate prevention programs and to direct research activities among many different specialties providing care to the trauma patient will impact the future direction of adult and pediatric trauma care in the country.
  3. Geisinger Health System has and continues to be successful in its attention to traumatized patients by providing coordinated care throughout Geisinger departments and divisions. Geisinger Health System complies with the Pennsylvania Trauma Systems Foundation (PTSF) standards for Trauma Center Accreditation and is designated as a Level I Regional Resource Trauma Center by the Pennsylvania Trauma Systems Foundation. In 2012, Geisinger Health System became part of the American College of Surgeons Trauma Quality Improvement Program (ACS TQIP). By utilizing ACS TQIP, Geisinger Health System is elevating the quality of care currently being delivered by members of the multidisciplinary team through the use of risk adjusted benchmarking based upon national comparisons. ACS TQIP also provides education and training to help Geisinger Health System trauma program to improve the quality of data and accurately interpret our benchmark reports.
  4. The Division of Trauma Surgery falls under the Division of General Surgery. The expansion of our services includes not only adult and pediatric trauma, but emergency general surgery and surgical critical care. This service will permit enhanced patient services and facilitate a robust learning environment for residents and medical students.
Harborview; Trauma Quality Improvement Plan

Harborview; Trauma Quality Improvement Plan

  • Last Updated: 2018
  • Author(s): Harborview Medical Center
  • Language(s): English

Harborview Medical Center provides trauma care to adults and children serving as a Level I adult and pediatric trauma center. Harborview is committed to providing the highest level of definitive care for injured patients, from resuscitation through rehabilitation. As the only Level I facility in a four-state region (Washington, Alaska, Montana and Idaho), Harborview participates in a regional system designed to ensure that every injured patient has access to the appropriate level of trauma care as soon as possible.

The goals of the trauma quality improvement program at Harborview Medical Center are:

  1. To provide a method of peer review oversight and evaluation of all aspects of adult and pediatric trauma care from pre-hospital care to rehabilitation.
  2. To assist in providing the highest level of care and service to trauma patients, their families, pre-hospital agencies, referring providers and medical centers in the region. This includes peer review and feedback for care provided across the continuum of the trauma system.
  3. To design, measure, assess and improve patient care processes and triage of adult and pediatric trauma care within the system.
  4. To measure, assess and improve patient outcomes following traumatic injury. This includes establishing and implementing evidence-based guidelines for trauma care.
  5. To evaluate and improve satisfaction of patients, patient families, staff, community, and licensing and accrediting agencies with the quality of trauma care at Harborview Medical Center.
  6. To provide a forum that encourages presentation of errors or potential errors that is protected from legal disclosure, that is available to all health care providers, with the goal of system improvement rather than blame assignment.
  7. The trauma Quality Improvement plan provides a mechanism for implementing these goals within the broader context of the hospital-wide Quality Improvement program and seeks to integrate with hospital Quality Improvement initiatives.


  1. Integrate and coordinate all trauma quality and performance improvement activities under the direction of the multidisciplinary Trauma Council, the Chief of Trauma Surgery and the Medical Director of Emergency Services.
  2. Ensure that confidentiality of patient and provider information is maintained according to the standards of RCW 70.41.200 and 70.168.090
  3. Provide feedback to prehospital EMS and air medical services and referring hospitals regarding patient care issues during transfer and transport.
  4. Evaluate specific cases or problems identified in the monitoring process by peer review, through Departmental Mortality and Morbidity conferences, the multidisciplinary Trauma Council and provide an educational forum (Trauma Conference) for wide-spread dissemination of practice guidelines.
  5. Use results from internal and external data collection measurement activities (e.g. audit filters) to study and improve processes and outcomes.
  6. Develop standards of quality care for both adult and pediatric trauma.
  7. Provide a process to monitor compliance with or adherence to the standards.
  8. Provide processes for loop closure in correcting problems or deficiencies and measuring the effectiveness of corrective actions.
  9. Identify, evaluate and impact pediatric Quality Improvement issues through the Harborview Pediatric Council.
  10. Identify, and evaluate transitional and long-term outcomes of trauma care through the Harborview Rehab Council for adult trauma care and through the coordinated activities of the Harborview Pediatric Council and Seattle Children’s Hospital for pediatric care.
  11. Use comparative data to benchmark performance of adult and pediatric trauma care to that of other Level 1 trauma centers.
  12. Identify, evaluate and impact regional quality assurance issues through the Regional Trauma Quality Assurance Committees.
  13. Partner with the Washington State Department of Health and EMS and Trauma Steering committee to implement evidence-based guidelines for trauma care statewide and evaluate system effectiveness and efficiency


  1. The trauma Quality Improvement program applies to evaluation across the continuum from pre-hospital care to rehabilitation and re-integration of the patient into their community. The Quality Improvement program is applied to the full scope of trauma service including Prehospital care, resuscitation and evaluation, operative interventions, intensive care, short-term acute care and long-term/transitional care for adult trauma patients.
  2. For pediatric trauma patients, Harborview is equipped to provide all resuscitation and evaluation, operative interventions, intensive care and short-term acute care services. In some cases, children require highly specific pediatric sub-specialty care, long-term/transitional care or pediatric inpatient rehabilitation services. For these patients, care is transferred to Seattle Children’s Hospital (SCH). The Quality Improvement program applies both to the initial resuscitation and acute phases of pediatric trauma care, as well as the long-term/transitional care through coordinated quality and performance improvement evaluations with SCH.
  3. As the sole Level 1 trauma center for the region the scope of this QI program extends to the regional trauma system where we provide feedback to referring hospitals and serve as a resource for development of statewide patient care guidelines and assistance with QI initiatives and education across the region.
Kentucky Trauma Hospital Resource Manual

Kentucky Trauma Hospital Resource Manual

  • Last Updated: 2012
  • Author(s): Kentucky Cabinet for Health and Family Services
  • Language(s): English

Performance Improvement

Every Kentucky Trauma Center hospital is expected to measure, evaluate and improve its performance with respect to numerous objectives in health care from patient care standards to fiscal solvency to materials management. A successful performance improvement process is designed to identify weaknesses within an organization that prevent the organization from providing the optimal care it is capable of providing.

The process used to facilitate performance improvement may be referred to by other names, such as quality assurance or continuous quality improvement. Regardless of by what means your facility employs, it is important that there be a process in place to provide an intentional process, or loop, to continuously identify shortcomings in patient care, determine the likely cause, employ a plan to correct it, then evaluate whether or not the shortcoming has been resolved, thus ―closing the loop.‖ A PI program will assist your facility to constantly improve itself by identifying and confronting problems within the institution. The process can be applied to virtually any element of performance within the hospital.

PI Structure

While the required PI components must be in place in a trauma hospital, the structure is left to the discretion of the facility and will depend on the facility size and available resources. It is anticipated that hospitals have an existing PI structure in place. The trauma program PI activities ideally are incorporated into that structure. The description of the PI process contained herein is not meant to be prescriptive, but illustrative. It is understood that facilities will accomplish PI in a variety of ways. Trauma center are expected to be able to demonstrate the effectiveness of their program.

The trauma program should have a standing trauma PI team, usually made up of the trauma program manager/coordinator, the trauma services medical director and possibly the trauma program registrar. All information and reports pertaining to trauma program performance are funneled through this team. The data is then either used by the team to address system concerns or referred to one or more PI committees to address patient care concerns.

Both system and patient care-related issues can be identified via several methods.

  • Chart abstraction
  • Emails
  • Hallway conversations
  • Hospital information/database systems/registries
  • Individual patient charts
  • Multidisciplinary committee meetings
  • Patient relations inquiries/complaints
  • Personal observations
  • Rounds
  • Staff reports
Mississippi Trauma Care System; PI and Patient Safety Plan

Mississippi Trauma Care System; PI and Patient Safety Plan

  • Last Updated: 2018
  • Author(s): Mississippi Trauma Care System
  • Language(s): English

A systems approach to trauma care provides the best means to protect the public from premature death and prolonged disability. Trauma systems reduce death and disability by identifying causes of injury and promoting activities to prevent injury from occurring, and by assuring that the resources required for optimal care are available. A major goal of trauma care systems is to provide care that is efficacious, safe, and cost-effective.

Performance Improvement and Patient Safety (PIPS) in an organized trauma system consists of multiple layers of continuous monitoring and evaluation of care to identify opportunities for improvement. This progressive cycle of evaluation extends from the performance improvement (PI) programs of hospitals and emergency medical services (EMS) agencies to review committees established at the state and regional levels, and evaluation programs within the MSDH including the Mississippi Trauma Registry (MTR).

This model emphasizes a continuous, multidisciplinary, multi-layered effort to monitor, measure, assess, and improve the process and outcomes of trauma care. Regardless of the hospital, service, or region, care processes and the clinical management of trauma patients must be evaluated using an established methodology with pre-defined measures based on national or state recognized standards. This review should include comparison and benchmarking of services, hospitals, and regions with state or national data obtained through trauma registries, mortality studies, and outcomes-related research.

This plan was developed to assist and guide trauma committees responsible for PIPS within agencies, institutions, or regional and state systems. Each section provides PIPS advice for each level of responsibility and is written to stand separately as a guide for that level. As a result, there is some duplication of information throughout the manual. The appendices offer explicit examples and language for PIPS activities which may be adapted. Adhering to the processes described will provide a foundation for a successful trauma center and system PIPS program but is not considered a replacement for a consensus process under the direction of a Trauma Medical Director and Trauma Program Manager. Mississippi Trauma Care System

Other resources to consult as efforts to implement trauma PI statewide evolve include:

  • “PIPS Reference Manual” (ACS 2002)
  • “Resources for Optimal Care of the Injured Patient” (ACS 2014)
  • Advanced Trauma Life Support Manual (ATLS)
  • Evidenced based practice guidelines or reviews
  • American College of Surgeons
  • Eastern Association for the Surgery of Trauma (EAST)
  • US Department to Health and Human Services
  • Agency for Healthcare Research and Quality (Evidenced-based Practice Program)
  • National Guideline Clearinghouse

Together with this plan, the advice of those resources should result in activities necessary for improving trauma care locally, regionally, and state-wide. Seeking the regular advice of professionals with expertise in trauma PI is strongly recommended to assure that PIPS processes meet contemporary theory and comply with State law governing protection of clinical care review.

It is acknowledged that modifications and adaptations of this model will occur to allow for the unique characteristics of trauma care provision in each MS Trauma Care Region.

Ransom Memorial Hospital; Trauma Program PI Plan

Ransom Memorial Hospital; Trauma Program PI Plan

  • Last Updated: 2015
  • Author(s): Kansas Department of Health and Environment
  • Language(s): English

The Trauma Program Performance Improvement (PI) Plan is designed to ensure efficient, cost effective, high quality patient care that is facilitated by continuous, systematic and objective data analysis and multidisciplinary peer review to identify opportunities to improve patient safety through all phases of trauma care. The ultimate goal is to reduce mortality and morbidity in the Trauma patient population. The plan is to provide specialized, effective care to all injured patients presenting to this facility.

South Dakota Trauma System Manual

South Dakota Trauma System Manual

  • Last Updated: 2016
  • Author(s): South Dakota Department of Health
  • Language(s): English

Legislation enacted in 2008 enabled the Department of Health, with input from the Department of Public Safety, to develop, implement, and administer a trauma care system, including a statewide trauma registry that involves all hospitals and emergency medical services within the state.

A trauma system is an organized response to managing and improving the care of severely injured people. It spans the continuum-of-care from prevention, pre-hospital care, acute care to rehabilitation. It has been established to ensure that injured people are promptly transported to and treated at facilities appropriate to the severity of their injury. A trauma system also provides a foundation for disaster preparedness and response. As part of its day-to-day activities, a trauma system coordinates the movement and care of severely injured people.

Following legislation in 2008 and subsequent Administrative Rules adoption in 2009, every healthcare facility in South Dakota has been designated as a Trauma Hospital; thirty-one presentations have overviewed the development and vision of the trauma system; every ambulance service has completed a trauma transportation plan; and, standards including Trauma Alert Patient and Trauma Team Activation criteria have been implemented. A state trauma website has been developed and a state trauma registry has been implemented to capture data meeting inclusion criteria for subsequent analysis.

The successful efforts of many have ensured trauma care in South Dakota meets state and national standards for the safety and care of the injured patient. Through ongoing development and performance improvement, the state Trauma System will continually advance as healthcare facilities further mature and improve upon individual trauma systems.

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