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The Genesis of a Trauma Performance Improvement Plan

Pidgeon, Kristopher MSHA, RN, CEN, NREMT-P

doi: 10.1097/JTN.0000000000000166

The purpose of this article is to assist the trauma medical and program director with developing a performance improvement and patients safety plan (PIPS), which is a required component of a successful trauma verification process by the American College of Surgeons. This article will review trauma quality standards and will describe in detail the required elements of a successful trauma center's performance improvement plan including a written comprehensive plan that outlines the mission and vision of the PIPS Program, authority of the PIPS Program, PIPS Program Committee reporting structure to the other hospital committees, list of required PIPS multidisciplinary team members, the operational components of the utilized data management system (trauma registry), list of indicators/audit filters, levels of review, peer determinations, corrective action plan with implementation, event resolution, and reevaluation. Strategies to develop a successful trauma performance improvement plan are presented.

Burn and Trauma Services, Kendall Regional Medical Center, Miami, Florida.

Correspondence: Kristopher Pidgeon, MSHA, RN, CEN, NREMT-P, Burn and Trauma Services, Kendall Regional Medical Center, 11750 SW 40 St, Miami, FL 33175 (

The author declares no conflict of interest.

Copyright © 2015 by the Society of Trauma Nurses.