Clarifying the path to trauma center reverification  

    Demonstrating a commitment to continued improvement  


    A non-profit faith-based medical center in the western Unites States was looking to understand the root causes related to identified deficiencies following a failed ACS trauma center verification survey, and put corrective actions into place to remediate them. A Philips trauma center performance improvement consultant led an engagement to provide strategic guidance and hands-on support in an effort to help the trauma center achieve clinical excellence and operational efficiency. 

    Passed ACS Verification and Trauma Level 2 Reverification
    Passed ACS verification and trauma level 2 reverification

    Assessing the situation 


    The trauma center staff had been struggling to maintain and adequately document performance improvement activities that properly mapped against internal metrics and industry standards. Difficulty in prioritization, follow-through, and adherence to new processes, put them at a disadvantage when it came time for their ACS verification survey.  


    The initial job was to assess the current situation and determine trauma center shortfalls. In a review of the trauma center’s people, places, processes, and operations, limitations to optimal quality and patient outcomes were identified. This was accomplished through interviews with staff, department leaders, and administration, in addition to onsite observations of departmental processes, meetings, communication, and trauma team activations. 

    Performance Improvement Plan (PIPS) approach 


    At the core of this approach is a ‘360o view’ of trauma center operations. It began with a look back at the trauma center’s 2018 action plan. That plan described the areas of deficiency, and actions necessary for improvement. By comparing the goals of that action plan with the current situation, a gap analysis was conducted to create a future state and the set of metrics toward which the trauma center must work to succeed.   


    Assessment discoveries were used as the basis against which performance improvement recommendations were developed.  The Philips consultant was tasked with holding the trauma team accountable to performance metrics and standards and remained onsite to drive the process. 



    By exposing limitations to optimal quality and patient outcomes and conducting a reevaluation of trauma center clinical processes, Philips and the trauma team were able to spark significant performance improvement. As a result, the trauma center was able to pass the next ACS verification survey with no deficiencies.  

    *Results from case studies are not predictive of results in other cases. Results in other cases may vary. 

    Meet our team 

    Beth Fuller

    Angie Chisolm, MBA/HCM, 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. 

    You are about to visit a Philips global content page

    You are about to visit the Philips USA website.

    Recent success

    Contact information

    * This field is mandatory

    Contact details


    Company details


    You are about to visit a Philips global content page

    You are about to visit the Philips USA website.

    Our site can best be viewed with the latest version of Microsoft Edge, Google Chrome or Firefox.