Customer story

Transforming a trauma performance improvement program at a Level II pediatric trauma center 

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Trauma Consulting Services help resolve site survey deficiencies to retain Level II pediatric trauma center status


Following a regularly scheduled trauma site survey in early 2019, the survey team identified critical deficiencies in Mary Bridge Children’s Hospital’s Level II trauma program performance improvement (PI) processes. Failure to perform adequate primary and secondary case review as well as missed opportunities for loop closure and feedback to providers, led to a failure to improve care for the benefit of future patients. 


Philips led an interim leadership and performance improvement consulting engagement to develop a comprehensive corrective action plan that improved performance to meet state trauma designation standards.


As a result of the interim leadership and performance improvement engagement, Mary Bridge Children’s Hospital:

A comprehensive and collaborative approach to improve performance and maintain Washington State designation status


Our approach


The Plan-Do-Study-Act (PDSA) methodology was utilized to implement and test change:

  • PLAN a change or improvement
  • DO the improvement, make the change
  • STUDY the results and examine data
  • ACT to sustain performance and spread change


The goal was to resolve the identified deficiencies in the trauma PI process by fall 2019 and satisfy Washington State trauma requirements to retain Level II Pediatric Trauma Center status. The transformation team consisted of the trauma medical director, trauma registrars, senior hospital leadership, key department stakeholders, and interim trauma program manager.



The team developed the corrective action plan to resolve the identified deficiencies, created a dashboard to monitor Key Performance Indicators (KPIs), implemented a PI database to document activities, and joined the TQIP benchmarking database.  



The corrective action plan was implemented, which included multiple improvement activities to reach target goals. Lessons learned include:  early identification and involvement of key stakeholders, assessing readiness for change, education on new Washington trauma center standards, and continuous feedback and communication of progress was imperative. 



A plan for continuous PI monitoring and documentation of activities was implemented to sustain performance. Identified weaknesses, or opportunities for improvement, were addressed through an ongoing proactive action plan. Following a gap analysis, maintenance of trauma center standards compliance is evident. Active recruitment for a permanent trauma program manager continues.  



By utilizing effective project management techniques and engaging the key stakeholders, the team was able to submit the corrective action results ahead of the deadline. More importantly, the state trauma surveyors accepted the hospital’s report showing resolution of the identified deficiencies and satisfying the state’s requirements for Level II Pediatric Trauma Center designation.



*Results from case studies are not predictive of results in other cases. Results in other cases may vary
Mary Bridge Children’s Hospital, part of MultiCare Health System, is a 82-bed pediatric hospital located in Tacoma, Washington. It is the region’s only children’s hospital and state-designated Level II Pediatric Trauma Center for Western Washington.

Meet our team

Beth Fuller

Angie Chisolm, MBA, BSN, RN, CFRN, TCRN

Consulting Manager

Angie is a nationally recognized expert in trauma program and emergency services management. She is a results-driven leader with expertise in trauma program operations, providing mentoring and consulting focused on coding and billing, site survey readiness, performance improvement, and operational efficiency. 
Beth Fuller

Jennifer Brown, MSN, BSHA, RN-BC, CNL, NEA-BC 


Jennifer brings 20+ years of emergency department and trauma program experience for pediatrics and adults in community and academic settings. Her approach involves collaboration and innovation using proven methods and evidence based practice.

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