The importance of a formal, written PI plan cannot be overemphasized. The PI plan should be a dynamic document, developed as the result of an integrated multidisciplinary effort, which should be reevaluated and updated periodically to encompass key changes within the hospital trauma system and trauma care standards. Recommended distribution of the plan might include hospital quality improvement staff, nursing leadership, physician leadership from medical divisions involved in trauma care, and trauma program staff. This plan could be used as part of the orientation process for new hospital leadership, which will be responsible for trauma patient care. The PI plan should include the following:

The PI plan should consider state, regional, and national standards related to trauma care. The American College of Surgeons document titled Trauma Performance Improvement, A How to Handbook provides practitioners with an operational manual for establishing and maintaining a trauma PI program.¹

The trauma program’s medical director sets the tone for the PI program, by leadership and active participation. Although tasks may be delegated to other personnel, the medical director is accountable for the PI activities.

Under various titles, the trauma nurse coordinator, program manager, or program administrator shares the responsibility for the PI program. In centers with high volumes of patients, the PI activities may be delegated to a PI coordinator, who is responsible for collecting and reporting data as well as for providing links with other hospital departments.

The attending physician staff should also have an active role in PI, which includes identifying problems, attendance at meetings, reviewing medical records, and participating in the peer review process. Ensuring physician attendance at PI meetings can be difficult. To facilitate attendance, a set calendar of meetings should be established on a routine day and time that are convenient for team members considering their clinical responsibilities. It may be helpful to incorporate trauma PI committees into existing hospital and departmental forums such as departmental morbidity and mortality conferences. There should be records of attendance to comply with the American College of Surgeons’ (ACS) standard for participation in multidisciplinary peer review forums.

The roles and responsibilities of the personnel involved in the PI program should be part of the respective job descriptions, and these should be included in the PI plan.

The PI process can follow any one of a number of models, just one of which is outlined in the subsequent text.

FOCUS-PDCA, also called the Shewhart cycle

Regardless of which model is utilized, the institution should have a systematic way to identify problems, analyze the issues, and take corrective action if indicated, and then reevaluate.

The trauma registry is a fundamental component of the center or trauma system, and there should be a strong interface between the registry and the PI program. Registry reports can provide information on audit filters; therefore, it is helpful to have the current registry data. This allows for real-time evaluation of care with impact to the patient at point of service. The utility of current audit filters has not been determined definitively. Research has been done on whether the audit filters have consistent links to improved outcomes.²

Literature suggests that although some have found existing audit filters to be useful, others have found them labor intensive and costly.³

Occurrences or complications can also be identified by registry reports, so an up-to-date registry is valuable. It is imperative that standard definitions for complications be adopted, so that occurrence rates can be compared or benchmarked with other institutions.

If the trauma center practices evidence-based medicine, in which high quality research leads to clinical guidelines, protocols, or algorithms, then variations in practice can be tracked and integrated into the PI process.