Tag Archives: performance improvement

How Often Should My Trauma Operations Committee Meet?

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.


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


  • 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?

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
  • 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.

Best Of AAST 2021: Reducing Errors In Trauma Care

Finally, a performance improvement (PI) abstract at AAST!

As many of you know, there are two general types of issues that are encountered in the usual PI processes: provider (peer) vs system. Provider issues are errors of omission or commission by an individual clinician. Examples include a surgeon making a technical error during a procedure, or prescribing the wrong drug or dose for some condition.

One might think that provider issues are the most common type of problem encountered. But they would be wrong. The vast majority of clinicians go to work each day with the idea that they will do their job to the best of their abilities. So how could things go awry?

Because the majority of errors have some degree of system component! They are set up to fail by factors outside their perception and/or control. Let’s look at a surgeon who has several small bowel anastomoses fall apart. His surgery department head chides/educates him, reports him to hospital quality, and proctors his next ten bowel cases. Everything is good, right?

But then, two months later, the stapler company issues a recall because they found a higher than usual number of anastomotic failures with one of their products. So it wasn’t the surgeon after all, like everyone assumed. This is an extreme example, but you get the idea. System issues often look like peer issues, but it’s frequently difficult for many PI programs to recognize or accept this.

A multi-institutional group reviewed the results of a newly implemented Mortality Reporting System (MRS) to analyze a large number of PI opportunities for improvement (OFI). More than 300 trauma centers submitted data to the MRS when a death occurred where an OFI was identified. The reports included details of the incident and mitigation strategies that were applied.


Here are the factoids:

  • A total of 395 deaths were reviewed over a two year period
  • One third of deaths were unanticipated (!!), and a third of those were failure to rescue
  • Half of errors pertained to clinical management, clinical performance, and communication
  • Human failures occurred in about two thirds of cases
  • The most common remedy applied was education, which presumes a “provider issue”
  • System strategies like automation, standardization, and fail-safe approaches were seldom used, implying that system issues were seldom recognized
  • in 7%, the trauma centers could not identify a specific strategy to prevent future harm (!!!)

The authors concluded that most strategies to reduce errors focus on individual performance and do not recognize the value of system-level intervention.

Bottom line: Look at the pyramid chart above (interesting choice for a chart, but very effective). The arrow shows progression from provider focus to systems focus. The pyramid shows how the recognition of and intervention for system issues drops off very rapidly.

I am both shocked and fascinated by the last bullet point. A strategy couldn’t be developed to prevent the same thing from happening again. Now, there are a few rare instances where this could be correct. Your patient could have been struck by a bolt of lightning in her room, or a meteorite could have crashed through the wall. But I doubt it. This 7% illustrates the importance of investigating all the angles to try to determine how the system failed!

For once, I have no critique for an abstract. It is a straightforward descriptive study that reveals an issue that many in PI are not fully aware of. I’ll definitely be listening to this one, and I really look forward to the published paper!


Coming Soon! New Site For Trauma PI!

One of the most common requests I get is to provide more detailed content on Trauma Performance Improvement! To that end I am putting together a collection of print and video content on a new website that will address the things you really want to hear about but can’t find anywhere else.

Here’s a sample listing of some of the topics that will be covered:

  • Writing a good PI plan
  • Loop closure – basic to advanced
  • Involving your TMD
  • PRQ preparation
  • Creating workable practice guidelines
  • Crafting a Massive Transfusion Protocol that works for you
  • How to calculate your optimal number of trauma registrars
  • Preparing for your site survey
  • How to read your TQIP report
  • What is OPPE and how do I do it?
  • Integrating PI with your registry
  • How to interpret the Orange Book

If you want to be one of the first to get access to this content, please fill out the form by clicking here. Your name will be placed on my early bird e-mail list. I’ll provide regular updates on the opening date, and solicit your ideas on specific content you would like to see.

Subscribe to the mailing list now!

Nuances Of The “Unanticipated Mortality” Classification

All trauma centers verified by the American College of Surgeons (ACS) are required to classify trauma patient deaths into one of three categories: unanticipated mortality, mortality with opportunity for improvement, or mortality without opportunity for improvement. I’ve provided some details about each of those over the past several posts. But I do want to provide a little more detail for the much dreaded “unanticipated mortality.”

You may have noticed that unanticipated mortality does not seem to come in the same two flavors as the anticipated mortality: with and without opportunity for improvement. Why is this? Does this imply that all unanticipated mortalities have some opportunity or another? I actually used to think so.

But over time, I’ve changed my mind. It is true that the vast majority of unanticipated mortalities involve one, and many times, several opportunities that may improve the outcome for similar patients in the future. But I have personally seen at least two that did not.

How can this be, you say? Let me give you a far-fetched example. A healthy young male is involved in a car crash, sustaining fractures of a few ribs which are very painful. He is admitted for pain control, and is treated with your usual regimen of analgesics, mobilization, and pulmonary toilet. He admits to no significant medical or surgical history and is taking no medications. As he is sitting in his room waiting for his ride on the day of discharge, a small meteorite plunges through his window and strikes him in the head, killing him instantly.

So where’s the opportunity? Put meteorite shielding around your entire hospital? I think not. Don’t be ridiculous, you say, that’s not a realistic example. But what if, on the day of discharge, he stands up in his room and keels over in PEA arrest? An autopsy is performed, and a massive pulmonary embolism is identified. And let’s say that this patient somehow met your DVT prophylaxis criteria and he was receiving appropriate management per your practice guideline. And when you convey these findings to the family, they seem to recall a pattern of pulmonary embolism deaths and DVT complications in other family members. But nobody mentioned this to you during the history and physical exam. And you treated them exactly according to your protocol.

So what do you think now? Is there an opportunity? I still think not! But you must still pick apart every bit of the patient’s care, trying to identify anything that was not done according to plan or protocol that may have led to this (extremely) adverse outcome. But be aware that over your career as a trauma professional, you will likely run into one or more of these cases that are unanticipated but completely nonpreventable!