What questions should you ask of your trauma program leadership to ensure compliance with trauma center standards? Below are some of the common ACS criterion deficiencies (CD) that, if not addressed, can lead to poor performance during the site survey:

Trauma registry data must be collected and analyzed by every trauma center and should be concurrent. At a minimum, 80 percent of cases must be entered within 60 days of discharge. This ensures accuracy and offers a good measure of productivity. Strategies for monitoring data validity are also essential and ensure registry compliance. One approach is to re-abstract 5-10 percent of patient records per month. Finally, trauma centers should use a risk adjusted benchmarking system to measure performance and outcomes. It’s important trauma center staff understands this system and that reporting against benchmark improvement is part of regular improvement planning.


Performance improvement, particularly problem resolution, outcome improvements and assurance of safety or “loop closure” must be readily identifiable through methods of monitoring, reevaluation, benchmarking and documentation. In Level I, II and III trauma centers, representation from general surgery, and liaisons to the trauma program from emergency medicine, orthopedics, anesthesiology and critical care must be identified and participate actively in the trauma performance improvement and patient safety (PIPS) program with at least 50 percent attendance at multidisciplinary trauma peer review committee. For Level I and II centers, neurosurgery and radiology must also be represented.

Physician qualifications are also critical. Centers are encouraged to perform a physician qualification inventory on each specialty on the trauma call panel to ensure only physicians with proper credentials are listed. In Level I and II trauma centers, the trauma medical director, trauma program manager and liaisons to the trauma program in emergency medicine, orthopedics, critical care and neurosurgery must obtain 16 hours annually or 48 hours in three years of verifiable, external, trauma-related education (continuing medical education [CME] or CE, as appropriate to the discipline).

Finally, trauma program managers alongside the trauma medical director hold the responsibility of the program. Hospitals must create an environment of trust so trauma program managers feel safe and encouraged to share their concerns and needs and directors have the visibility necessary to guide performance. This culture is built through active engagement and collaboration with program stakeholders.

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