TOPIC Medical Center
Trauma Center Performance Improvement Patient Safety (PIPS) Master Plan
Goal
Sample - The goal of this plan is to provide a framework for the planning and implementation of
performance improvement activities for the TOPIC Level XXX Trauma Center. The plan objective is to
assure the proper support is in place to achieve the goals as outlined in the Trauma Program Purpose
and Organization Structure Policy. The goal of that policy is to ensure the delivery of appropriate and
optimal care to all injured patients coming to TOPIC Hospital Level XXX Trauma Center.
Mission and Vision of the Trauma PIPS Program
Purpose of this section – To state how to integrate the mission and vision of the medical center and/or
facility’s quality department with the mission and vision of the Trauma PIPS program. The mission
statement is a general statement regarding the role of the trauma program and quality improvement as
a service to the patients, community, and region.
Authority/Scope
Purpose of this section – This section should include information on the designated authority for
operating the trauma PIPS program as well as the extent of authority in patient care review. This could
be a bylaw statement which grants authority from a medical staff level. Include all of the people and/or
groups that grant authority to the Trauma Center for their PIPS program activities. Include the role that
person/entity has in the medical facility that gives them the authority to approve the trauma program’s
authority. It is helpful to specify the reporting structure of the trauma PIPS activities (example would be
organizational chart).
Credentialing
Purpose of this section – The credentialing statement for physicians on the trauma call panel should
include criteria to be met for initial and regular review of trauma team privileges as well as who is
responsible for the process. Language needs to include the authority of the Trauma Medical Director to
credential surgeons for trauma call and the authority to remove providers from call if someone is
deemed unable to provide safe care. (See Resources for Optimal Care – Chapter 5) If trauma program
providers include Advanced Practitioners include language on how they will be credentialed for trauma
patient care. (See Resources for Optimal Care – Chapter 11.)
Trauma Patient Population Criteria
Purpose of this section – The trauma patient population criteria should be a concise statement
describing those patients that will be monitored under the trauma performance improvement. It may
include a defined age group, range of ICD 10 diagnosis codes, and regional or state descriptors.
Data Collection and Analysis
Purpose of this section – Data collection and analysis should include a statement regarding all of the
data sources that support the trauma performance improvement process. Also to be included is how
patients and events are identified, data is collected, and where the data is entered and stored. State
methods used for data analysis.
Process for Monitoring Compliance
Purpose of this section – The process for monitoring compliance should include the spectrum of
activities involved in operating the PIPS program. This will include the processes used to ensure
compliance with policies, practice guidelines, standards of care, and current practice.
Review Process
Purpose of this section – State the process the trauma center uses for event review. Include language
on Primary, Secondary, Tertiary, and Quaternary reviews.
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