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Helping a trauma center improve efficiency and achieve ACS verification

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Interim leadership and trauma services consulting helped to reclaim trauma services verification in six months

A community hospital with trauma services lost its verification status through ACS (American College of Surgeons) after 12 years with 3 highly-successful triennial surveys. 16 required (type 2) deficiencies and 8 weaknesses had been identified.

Philips Blue Jay Consulting provided a performance improvement team with subject matter expertise as a trauma program manager to lead a comprehensive assessment and process improvement implementation work. Activities included data analysis, onsite observations, staff and stakeholder interviews, and more. An action plan was developed including a deep dive on each deficiency.

Results of the engagement included:

The deficiencies and weaknesses were addressed and eliminated.
The hospital regained its Level III Trauma Center ACS Verification within six months.
The trauma services policy and procedure manual was rewritten.

"The Philips Blue Jay Consulting team was instrumental in helping us to secure our Level III Trauma Services status. During our exit interview, the surveyor commented on the significant commitment by all the people that geared it up and did a really great job and how the consultants made our program really impressive.”

- Assistant CNO and Director of Emergency and Trauma Services

US community hospital

Our approach

To understand the challenges, issues, and opportunities for improvement, a team of two consultants performed a comprehensive assessment.

Some of the methods of assessment included:

Data analysis
Onsite observations
Staff and stakeholder interviews

Detected deficiencies:	16
Detected weaknesses:	8

This enabled them to gather further insights in regards to the ACS findings and uncover any potential deficiencies or weaknesses. The consultants worked with the trauma center team including a deep dive on each deficiency, weakness, and recommendation plan was developed to address each of these.

Philips also provided support and guidance on program management processes and methodologies.

Recommendations

Working closely with the client team, an action plan was developed to improve performance and address the identified areas of concern.

The below initiatives were implemented:

Revision of the performance improvement and patient safety program
Update of the injury prevention and education plans
Rewrite of the trauma services policy and procedure manual
Trauma resources business case development and help in obtaining approval of the plan to sustain new programs into the future
Collaboration with the staff to create a dynamic and supportive trauma team
Revision of the committee structure and peer review process to uphold the new processes
New processes to include EMS personnel in field activation decisions

Results*

The hospital’s new trauma program manager and medical director are working as an integrated team along with their supportive staffs. A new collaborative culture has emerged within the entire facility.

The ACS surveyors made a return visit in 6 months and were pleased to see that all type 2 deficiencies (16) and weaknesses (8) had been addressed and were removed.

The hospital is once again a Level III Trauma Center with ACS verification.

Deficiencies:	0
Weaknesses:	0

Becker’s Hospital Review recently interviewed JoAnn Lazarus on performance improvement in the Emergency Department. Read the full interview here.

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

Download case study

Meet our team

JoAnn Lazarus, MSN, RN, CEN, FAEN

Principal and Practice Operations Lead

JoAnn brings 40+ years’ experience in ED leadership and helping hospitals improve efficiency. She has led many change projects in EDs to improve process flow including implementation of fast track and middle track processes with reduction in LWBS.

Recent success

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