TRAUMA SERVICE
PERFORMANCE IMPROVEMENT PLAN
AUTHORITY/SCOPE
The Board of Directors of ______________________ (hospital) authorizes the Trauma
Committee to implement and sustain a Performance Improvement (PI) Plan. The PI Plan is
to be consistent with the provision of quality care and services for all trauma patients within
the scope of services.
The Chief Executive Officer authorizes the Trauma Committee, its Director, and its members
to participate in the Trauma Service PI Program.
The Executive Committee of the Medical Staff delegates responsibility to the Trauma
Committee, its Director, and its members to participate in the Trauma Service PI Program.
The Trauma Committee, chaired by the Trauma Medical Director, meets quarterly and
evaluates the collected trauma data, takes appropriate action, and reports to the Executive
Committee.
The Trauma Coordinator collects the trauma data and reports to the Trauma Committee.
PURPOSE AND RATIONALE
The Trauma PI Plan is established according to the fiscal year and is reviewed annually for
efficiency and effectiveness to:
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Improve the quality of pediatric through geriatric trauma patient care
Reduce morbidity and mortality
Ensure that the scope and nature of the Trauma Services are appropriate and responsive
to the to the needs of all trauma patients and other customers
Demonstrate a commitment to continuous performance improvement through systematic
means for measuring, monitoring, and managing outcomes
Sustain compliance to current regulations and accreditation standards, including Trauma
Region and Illinois Department of Public Health PI initiatives
Abide by the guiding principles of the (hospital) PI Plan
TRAUMA SERVICE PERFORMANCE IMPROVEMENT PLAN
Trauma Service
PI Plan
The Trauma PI Plan consists of statistical data collection of all pediatric through geriatric
trauma patients and quarterly focused outcome analysis review as delineated on page one
regarding all:
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Trauma-related deaths excluding DOA (dead on arrival) and DIE #C (no vital signs on
admission and never achieves vital signs despite resuscitation)
 Internal review by Trauma Medical Director
 External review by region peer group includes assessment of:
 Potential problem with Medical Management
 Potential problem with Systems
 Patient death not preventable
 Patient death possibly preventable
 Patient death preventable
Region Peer Review Form
 Trauma morbidities/complications (sent monthly to region)
 Trauma surgeon response times > 30 minutes for Category I patients sent to region and
includes assessment of:
 Care managed appropriately
 Physician arrival time did not negatively impact patient outcome
Region Trauma Surgeon Response Time
Trauma Surgeon/ Sub-Specialist Times
 Trauma surgeon response times > 12 hours for Category II patients
 Trauma transfers (greater than two hours from ED arrival to higher level of care reported
to region)
Region Transfers to a Higher Level of Care > 2 Hours
 Category I trauma patients
 Patients with an ISS of 15 or greater
 Inappropriate categorizations
 Missed significant injuries
 Missed C-spine injuries
 Re-admissions within 30 days
 Open fractures to OR > 8 hours post ED arrival
 Intra-cranial injuries to CT > 2 hours post ED arrival (excluding concussions)
 Epidural or subdural hemorrhages to OR > 4 hours post ED arrival
 Intra-abdominal injuries requiring OR to OR > 2 hours post ED arrival
 Cranial, thoracic, abdominal, or vascular injuries to OR > 24 hours post ED arrival
 AMA’s
 Deviations from trauma plan with potential impact on care (i.e. sub-specialist call)
Trauma PI
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Trauma Service
PI Plan
Factors contributing to morbidity and mortality are included in appropriate reports reviewed
internally and/or externally as required.
Additional Region PI initiatives other than those listed above include:
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Region Database
Monthly Trauma Service Summary (from trauma registry)
Pre-hospital Airway Management of Category I patients
Unplanned ICU Admissions
Other opportunities for improvement of the Trauma Service may be identified through
collaboration of the Trauma Committee, the Trauma Medical Director, and the Trauma
Coordinator. These initiatives may be measured, monitored, and/or managed on a quarterly
basis as necessary.
OUTCOMES MEASUREMENT AGGREGATE
PI Outcomes Measurement Aggregate
Surgical Services PI on Category I Trauma Surgery
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