Trauma ODM AMN Healthcare RCS

This is one in a series of blogs meant to inter-relate to each other. Please see the first blog in this series published:

Blog #1 –

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

Blog #2 –

Coordinating Trauma Performance Improvement (PI) and Hospital-wide Quality Assurance (QA) Departments

How To Transition Individual Performance Improvement to Systemic Performance Improvement.

Trauma Performance Improvement (PI) is a process that identifies trauma patients who are treated at your facility with the focus of evaluating and improving the multidisciplinary processes of care.  It is a continuous cycle of monitoring to recognize issues, attempt to correct them, then re-monitor (loop closure) to assure your corrective action plan was successful.  Loop closure is commonly stated as one of the weak links in a trauma service’s PI process, it is defined as; a loop of assessing the corrective action to see if it achieved the established goal and the resultant feedback to stakeholders. If the corrective action was not achieved, it can be refined or reassessed with new parameters, and then continue on through the loop once more. The process can be a method that takes several iterations to attain the desired outcomes, but is a continual loop of setting a measurable goal, assessing the achievable outcomes and communicating results to the originating committee or stakeholders.  After the re-monitoring proves success, the goal can be documented as achieved.

  • Individual or patient specific PI is an issue that upon initial review appears to only effect the patient currently under review.
  • Systemic PI focuses on issues that are determined to effect multiple patients, i.e. elective OR cases getting priority over trauma or acute care concerns, delays in access to CT and timely response of results, etc…

Each event starts out as a patient specific occurrence, and documentation must be readily available to show the event as it effected the index patient.  The cause, corrective action plan and loop closure method process should follow the standard PI plan process. 

  • Primary review

At this level of review the PI coordinator or Trauma Program Manager (TPM) will initiate a primary review to establish the accuracy of the audit filter failure. This individual will gather information and timelines for the identified event to confirm the concern is valid and occurred as reported.

Some events (audit filter failures) have mandated progression to further review, such as mortalities or cases where action is needed to prevent event recurrence. Other events, though triggering an audit filter, may be deemed trivial and not require elevated review.

  • Secondary review

At this review level, the initial reviewer sends the case for physician review; typically, this involves the trauma medical director or a dedicated PI physician that is a member of the trauma service. The physician reviewer digs deeper into the event’s clinical situation, determining if policies, procedures and clinical practice management guidelines (CPG) were followed with no omitted steps, standards of care were met and clinical judgement was sound, or if opportunities for improvement existed. The decisions to be made at this level are: Was care appropriate? Is there opportunity for improvement? Is further action needed, such as education? Is this a recurring issue? Is further review warranted? And what can we do to keep the next patient from suffering the same complication.

If the physician reviewer determines care was appropriate, the case is closed; if further review is indicated, the case is referred for committee-level tertiary review. Whether the case is closed or sent for further review, accurate and complete documentation of the secondary review is critical.

  • Tertiary review

At this level, event review is conducted by a multidisciplinary committee. Tertiary review is always conducted with mortalities or high-stakes events, such as sentinel events, etc.  The Multidisciplinary committee is chaired by the Trauma Medical Director (TMD) with membership from the discipline liaisons, (Neurosurgery, Orthopedic Surgery, Emergency Medicine, Critical Care Medicine, Pediatric Surgery or Geriatrics) as appropriately determined by the patient population makeup. Tertiary review is more in-depth, considering all detailed event aspects, allowing for attendees’ questions and perspectives. This level’s decision to be made is: Was there opportunity for improvement in this patient’s care? If so, what actions or system fixes might prevent recurrence? What follow-up is needed?

This committee determines an action plan for the identified event and determines responsible individuals. Tertiary review documentation involves event decisions made and follow-up plans. Documentation, as with previous levels of review, is critical, as is loop closure.

  • Systematic review

Primary review investigations should delve into whether this concern is a patient specific occurrence or if this represents a common issue with patients suffering this type of injury,   i.e. does this issue involves a lack of resources during a limited timeframe, or is it a broader problem? Are the solutions department specific or does the proposed correction require the involvement of department heads and leadership? Or does the solution require a monetary investment in equipment or additional staffing hours?

These questions may be discussed in each involved department, division or unit, but Trauma PI must maintain a leadership role in forming and monitoring the corrective action plan.  The systemic issues must be documented thoroughly and should be benchmarked and trended for several quarters to validate loop closure.


Society of Trauma Nurses. (2014). Trauma Outcomes & Performance Improvement Course. Lexington, KY.

Trauma Performance Improvement Reference Manual, Performance Improvement Subcommittee of the American College of Surgeons Committee on Trauma