Healthcare consulting

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 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 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:


Detected weaknesses:


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.


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


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.





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

Meet our team

Theresa Radeker

Theresa Radeker, MHA, BSN, RN, TCRN


Theresa is a high-energy and results-driven hospital operations executive, with a proven track record of achievement in trauma program management, project management, service line leadership, hospital administration, physician recruiting, and quality and compliance.

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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. 

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