Category Archives: Performance Improvement

How Often Should My Trauma Operations Committee Meet?

June 2, 2026 The Trauma Pro

In my last post, I discussed how often your multidisciplinary trauma performance improvement committee (PI) should meet. As you know, one other mandatory committee is required of all trauma centers, the Trauma Operations Committee (Ops). In this post, I will:

describe how often your operations committee should meet
help you determine whether your two committees should meet on the same day or separately

How Often?

The short answer to this question is practically the same as for your PI committee, “It depends.” Whereas the PI committee schedule is determined more by the volume of your performance improvement activity, your ops committee is driven by its agenda.

First, look at what items are on your typical agenda:

Reports
Announcements
Policy discussion and revision
Marketing and outreach planning
TQIP report analysis
System issue analysis
Workgroup reports
Other stuff

Now, think back to your previous meetings. Do you sometimes have to cancel due to a lack of agenda items? Do you struggle to keep to the time allotted and frequently go over it? These are your biggest clues that let you know that you need to adjust the meeting frequency,

In general, your ops committee frequency is reasonably predictable from your trauma center level:

Level I – monthly
Moderate to high volume Level II – monthly
Lower volume Level II – bimonthly
Level III – bimonthly to quarterly
Level IV – quarterly

However, the agenda is really what drives meeting frequency. If you have a very active ops committee or are a “young” trauma center, this group may be very busy and need to meet more frequently than this. Base your final decision on your level of “busyness.”

To Combine Or Not Combine?

Combining your PI and Ops committee meetings has several pros and cons.

Pros:

Decreases the number of meetings for everybody by one
Easier scheduling for attendees and venue
Consolidates agenda planning for the trauma admin team

Cons:

May lead to loooong meetings
Frequently results in a less predictable start time for the second meeting
Requires extra administrative effort to maintain separate minutes and content
Often involves required attendees changing between meetings

Consider the logistics and personalities involved in your committees carefully. Do the attendees value shorter meetings with a predictable start time? Or do they just want to power through and take care of all of the business at hand?

Bottom line: First, determine the ideal frequency for your operations committee meeting. Is it the same as your PI committee? If so, consider combining them. If not, you will probably be forced to live with separate meetings. It is possible, however, to be creative. Consider a monthly PI meeting combined with the Ops meeting every other month.

What is the usual combined duration of the two meetings? If it is more than 2 hours, I recommend not combining them. That is just too long for your attendees to stay focused. If you can combine them, then look at the specific attendees for each meeting. Are they mostly the same? If they are, you are more likely to be successful when combining them. Reach out to your attendees to see if they would welcome a single meeting date and time. But warn them that it will routinely be 1.5 to 2 hours in length.

Now, plan your agendas carefully. If you have a substantial number of attendee changes between meetings, figure out how people will know when to show up for the second. It is easiest to have the smaller meeting first, and then add attendees when the second one starts. As for timing, there are two choices: always make each meeting a fixed length, or limit your first meeting to an exact length and allow the second to start at a fixed time and have a variable duration.

Finally, make sure the contents and minutes of the two meetings are separate. This keeps your documentation clean and easier to follow.

How Often Should My Trauma Multidisciplinary Performance Improvement Committee Meet?

May 29, 2026 The Trauma Pro

Every trauma center is required to have two specific committees: a multidisciplinary trauma performance improvement committee (PI) and a trauma operations committee (ops). However, a common question is, “How often do my committees need to meet?” Let’s start with your PI committee.

The answer, of course, is “it depends.” There is no cookie-cutter, one-size-fits-all answer. In this post, I’ll review the six factors you must consider when designing your meeting schedule.

Total Patient Volume

The number of patients seen at your center directly impacts your PI committee meeting schedule. The more patient encounters, the more likely that performance issues will arise and the more likely that some will need to be aired at the full committee meeting.

PI Issue Volume

What is the total number of PI items that your program identifies over time? Busy Level I centers may find five or ten items
every day!

In contrast, an average Level IV center may only find a PI issue to pursue every few weeks. This has a noticeable impact on how often these items need to be escalated, analyzed, and discussed at your PI meeting.

PI Issue Severity

What fraction of your PI cases actually require discussion by the full committee? How many can be processed and closed by the Trauma Program Manager alone (primary review) or with the Trauma Medical Director (secondary review)? Only complex cases that require the input of multiple liaisons actually need to go to the committee.

Alternate review pathways

There are more options for review other than the primary and secondary pathways mentioned in the previous paragraph. Typical options would be direct correspondence with a liaison for simple one-service issues or discussion (and good documentation) from a morbidity and mortality conference. The use of these alternatives will reduce the number of potential cases for your PI committee and decrease the overall number of meetings needed.

Age of your Trauma Program

Are you part of a mature, long-standing trauma center? Or is your program newly minted by the American College of Surgeons or state designating agency? Newer centers benefit from sending more items to the PI committee to build engagement of the liaisons and other attendees. More frequent meetings help get them used to the review process and the frank but friendly discussions required for effective PI review.

PI Committee “Leftovers”

How often do you need to table issues or cases until the next meeting because you ran out of time? If you are chronically short of time to discuss all the agenda items, it’s time to either make the meeting longer (groan!) or schedule them more frequently.

Bottom line: These six factors listed above must be considered when choosing your meeting schedule. Here are my starting suggestions for the ideal frequencies for adult trauma centers:

Level I – monthly (but high volume centers may need biweekly)
Moderate to high volume Level II – monthly
Lower volume Level II – bimonthly
Level III – bimonthly to quarterly
Level IV – quarterly

Most pediatric centers admit lower volumes and less complex patients, which usually only warrants a bimonthly meeting.
Remember, these are starting meeting frequencies only.
If you are a new trauma center, consider more frequent meetings for your first year to get your attendees used to and invested in the process. And if you need more cases to fill the meeting or have more hold-overs until the next meeting, adjust your calendar appropriately.

In my next post, I’ll cover this same topic for your trauma operations committee.

Performance Improvement

How To “Track And Trend”

March 24, 2026 The Trauma Pro Leave a comment

One of the most overused terms in trauma performance improvement is “track and trend.” It implies that the event in question will be closely monitored, with the promise of potential future action.

But the reality is that, much of the time, these events are largely ignored, and a running tally is either kept somewhere or will be calculated at some undefined time in the future. The ultimate result is that these events tend to get “swept under the rug” and ignored.

All is not lost! If done correctly, “track and trend” can be very valuable. Here are the key components of an effective “track and trend” process:

A definition of the problem event. Be very specific. For example, the occurrence of VTE interruption in patients with orthopedic injuries requiring surgery.
Occasionally optional: An intervention that has been implemented to address the event and make it “better.” If you have experienced what you believe is a truly one-off event and want to confirm its rarity, an intervention is not necessary. However, this is not a common occurrence. Most events will require some type of intervention, especially if they are serious or seem to be recurring.
A length of time for monitoring. Again, be specific. The length of time must be based on the specific event being tracked. Sometimes the time frame may be brief, e.g., three months. But in this VTE example, a longer time may be required, such as a year.
A threshold goal. This is the new minimum acceptable performance standard. It will be dependent on the event being tracked. Sometimes, guidance can be found in the literature. But most of the time, the current incidence will need to be calculated, and then reduced by an arbitrary amount to arrive at the new threshold. In this example, if the current incidence is 20%, the program may want to drop it to 10%.

In this example, the full “track and trend” text reads like this:

We will track the occurrence of interruption of VTE chemoprophylaxis in patients undergoing operative repair of orthopedic injuries after implementing a new VTE practice guideline. This will be monitored for 12 months, with a goal of an incidence of less than or equal to 10%.

Here is another example. A trauma surgeon took a hypotensive patient to CT scan during a trauma activation, where the patient suffered a cardiac arrest due to inadequate resuscitation. The PI process captured this, and the TMD counseled the surgeon.

Here’s the track and trend text in this case:

After counseling by the TMD, we will track the occurrence of hypotensive patients being taken to CT during trauma activations by Surgeon X for six months, with a goal of no occurrences during that period.

The final part of the track and trend process is to see if the goal was met. If so, create solid documentation for loop closure, and your job is done! If not, it’s time to put on your thinking cap, change the intervention, and start again. Repeat until the final goal is reached.

By implementing this process, the track and trend process can actually be a meaningful part of the PI program.

Performance Improvement

What Is: Unanticipated Return To OR?

March 17, 2026 The Trauma Pro Leave a comment

Important note! As called out in a comment at the bottom of the post, this article is based on the 2025 NTDS Data Dictionary. It has recently been updated to the 2026 version, which I do not currently have access to.

There seems to be quite a bit of confusion about the concept of “unanticipated return to the operating room” among trauma program professionals. Let’s dig into the real definition of this important performance improvement topic.

The most basic definition of an unanticipated return to the operating room (let’s call it URTOR for brevity) is an additional operative procedure not part of the original treatment plan. Also, it must occur after any operation for a similar or related previous procedure performed at your hospital. It does NOT include any staged, pre-planned, or incidental procedures that are part of the initial plan. And if it is due to a procedure from an outside hospital, their PI program needs to run it through their PI process. That one’s not on you.

Here are some straightforward examples:

The definitive laparotomy stage of a damage control procedure is not unplanned. Nor is a planned second-look procedure to determine bowel viability.
But if an iatrogenic injury occurs in the ED or ICU that requires operative intervention, that IS a URTOR. This case meets the “prior procedure” caveat that mandates the operative procedure.

Here are some of the other clarifications provided by the ACS that indicate a URTOR:

Missed injuries leading to an operation. For example, a delayed fracture diagnosis leading to an operation is a URTOR.
VATS for retained hemothorax is a URTOR.
Delayed craniectomy for worsening status (neurologic or CT) is a URTOR.

And finally, here is the official algorithm for determining if a trip to OR is a URTOR. Click on the image to see a bigger copy.

Courtesy: ACS TQIP All Hospital Events Algorithms

Bottom Line: Familiarize yourself with the NTDS/TQIP definition of unexpected return to OR. These are important events that must be accurately captured in your trauma performance improvement program!

Performance Improvement

Overtriage And Anti-NFTI

January 23, 2026 The Trauma Pro Leave a comment

In my previous post, I discussed the evils of undertriage and how we can use registry tools to decrease the number of charts reviewed to identify this problematic issue. Now, I’ll move to the opposite extreme: overtriage.

Overtriage is defined as summoning the trauma team when a patient does not meet any criteria for the given activation level. Granted, all trauma centers include a garbage collection criterion, clinician judgment, that lets them activate if criteria are not met, yet they have a bad feeling about the situation. This is a legitimate criterion and recognizes that intangible “gut feeling” trauma professionals may get in certain circumstances.

Overtriage is not as bad as undertriage. The patient is not at risk of life-threatening injuries being missed or treated late. But unneeded trauma activations do take their toll. Every activation summons a large team of people and relies disproportionately on personnel who have other jobs in the emergency department. Each unnecessary activation pulls people away from their other responsibilities for a period of time and disrupts the department’s overall workflow.

Sometimes, overtriage can be allowable. If there is regular personnel turnover on the trauma team, a few extra activations here and there can serve as training exercises. This can be important in trauma centers with trainees and higher nursing turnover. But taken to an extreme, it can wear everyone down, including the trauma surgeon.

There is an extreme case, which I refer to as “ultimate overtriage.” This involves a patient who triggers any level of trauma activation, undergoes a complete evaluation, and then is sent home (in paper clothes) several hours later. Sure, this may happen from time to time. But if it’s a regular occurrence, there is a problem.

I previously wrote about using NFTI (Need For Trauma Intervention) to help identify potential undertriage if patients required certain critical resources. Ultimate overtriage patients are just the opposite. They are anti-NFTI. They didn’t need any of those resources.

As the percentage of anti-NFTI overtriage cases climbs, so does the wear and tear on the trauma team. Typically, the number of highest-level activations is roughly 10% of registry admissions. The number of intermediate-level activations is usually about 25%. But some centers have more total trauma activations than they have trauma admissions! This is clearly a problem!

An ultimate overtriage problem is usually due to poorly designed intermediate-level activation criteria. Typically, there is an over-reliance on mechanism-of-injury criteria. Potential offenders are:

Use of vague qualifiers such as “high-speed”
Inclusion of vehicle intrusion criteria
Upgrading all patients over age xx (e.g., 65) to an activation based on fall or head strike
Vague fall criteria

What to do: First, see if you have a problem. Divide both the number of highest and intermediate-level activations per year by 365 to determine how many of each occur every day. Do the numbers seem reasonable? Most medium-volume centers will have one-ish highest-level and two-ish intermediate-level activations per day. If you are approaching five intermediates per day, you may have a problem unless you are very high-volume.

Next, run a simple registry report. For each activation level over a year-long period, list the total number and the number that were discharged home from the ED. Both percentages should be in the low double-digits. I have visited centers with more than 60% of level 2 activations sent home!

If you determine you have a problem, it’s time to review your activation criteria critically. Either retrospectively or prospectively, look at all trauma activations and identify which criterion was used to trigger it and whether the patient was sent home afterward. Keep a tally. Eventually, patterns will emerge. Some criteria will be completely nonproductive and should be reworked or, preferably, dropped. Do this slowly and carefully over time, and give your trauma team a break!

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