Patient Safety PIPS AMN RCS

Basic Steps to Make Process Improvement and Patient Safety (PIPS) Function

The objective of a Performance Improvement and Patient Safety (PIPS) program is to improve patient outcomes, eliminate problems, and reduce patient variance in care. Per the ACS COT (American College of Surgeons – Committee on Trauma) 2014 Resources for Optimal Care of the Injured Patient, “There is no precise prescription for trauma performance improvement and patient safety (PIPS). However, the American College of Surgeons Committee on Trauma (ACS-COT) calls for each trauma program to demonstrate a continuous process of monitoring, assessment, and management directed at improving care. These performance improvement activities are concordant with the Institute of Medicine’s six quality aims for patient care: safe, effective, patient centered, timely, efficient, and equitable.”

Some of the methods the Trauma Registry can use to influence the objectives of PIPS are;

Trauma registry concurrence

This is one of the first steps necessary to make the program work effectively. If abstraction in the registry does not begin concurrently (i.e., 48 hours post admission) it is difficult to begin to document patient care and critically review clinical processes. Additionally, it is a requirement of the ACS-COT to have the NTDS (National Trauma Data Standard) core data set record completed within 60 days of discharge on 80% of the patients in the registry. CD 15-4 According to the ACS-COT “the PIPS program must be supported by a reliable method of data collection that consistently obtains the information necessary to identify opportunities for improvement” CD 15-3

Use of Audit Filters by registrar

Some Audit Filters are mandatory, such as those set by the ACS COT, others may be set by your state or TQIP collaborative. In addition, develop tools that will analyze the data from your particular program. In all instances see if the audit filter(s) were met. If the audit filter is not met, then answer the question why wasn’t it met? Finally, judge the deviation as either acceptable or unacceptable. Examples of mandatory Audit Filters from the ACS COT include Trauma Surgeon response time to the highest-level trauma activation, trauma team activation criteria, over and undertriage, and admissions to non-surgical service. For other required Audit Filters please refer to the ACS COT 2014 Resources for Optimal Care of the Injured Patient and the 2020 National Trauma Data Standard (NTDS). Some examples of program-specific audit filters might include failed non-operative management, operative management not warranted, the patient leaves the ED with GCS < 8 and no definitive airway, etc.

Support of the PIPS process 

As identified in the trauma PIPS plan, the database can be utilized to report trends or baseline on monthly dashboards.  The dashboards will allow the trauma operational committee to view audit filter variations as individual occurrences or systemic concerns.  This deeper review is of value to correct/improve the quality of care on a large scale.


In future blogs we will investigate and connect systemic PIPS with the concept of “Trauma; the barometer of Hospital quality of care.”

Rob Clements, ASN, CSTR

Susan Schmunk, CAISS, CSTR