Change management was the theme of the 2021 Trauma Quality Improvement Program (TQIP®) Annual Conference, November 15–17, which drew 3,688 registrants as of late November 2021 to engage in live, virtual sessions focusing on performance improvement, new trauma standards, pediatric trauma readiness, and other topics of interest to trauma medical directors and other trauma care professionals.
All sessions are available on demand until February 17, 2022. This article highlights several popular sessions presented at the 11th annual TQIP conference.
GS01: Opening Session
“There has to be a stepwise approach to change and to quality improvement that is learned, much like we learn other things in how we provide care,” said Avery Nathens, MD, PhD, FACS, FRCSC, Medical Director, American College of Surgeons (ACS) Trauma Quality Programs. He noted, “Change is hard because people overestimate the value of what they have or do and underestimate the value of what they might gain by giving that up.”
Dr. Nathens provided updates regarding key TQIP initiatives, including the Peer Coaching Program; the TQIP Mortality Reporting System; ACS TQIP Best Practices Guidelines, specifically the recently released Best Practices Guidelines for Spine Injury; and how COVID-19 has affected trauma centers.
“Overall, about 2% of TQIP patients had COVID. In the Level III centers, about 1.1% had COVID. The COVID impact was not distributed equally. About 20% of centers had no cases, and a small number of centers, 8%–10%, were COVID positive. This is important to include in the risk adjustment model,” said Dr. Nathens.
GS04: Keynote Address
Chip Heath, PhD, professor of organizational behavior at Stanford University, CA, and coauthor of Switch: How to Change Things When Change Is Hard, presented the Keynote Address and described how to implement lasting change by understanding the two systems that typically dominate human brains: the rational mind and the emotional mind.
“We know some things about change. We know that change is hard. We know change is futile. We know that people resist change and that people hate change. That is a depressing picture for a group of you that is trying to change practices at your hospitals,” Dr. Heath said, noting that messages heard in the larger culture regarding change are often negative. “There’s part of us that sees comfort in the way we originally did things, and there is another part of us that sees the need for change.”
Dr. Heath, citing the work of social psychologist Jonathan Haidt, PhD, described the two independent, “always on” sides of the human mind as “the elephant” (emotional mind) and “the rider” (rational mind), with the elephant typically winning any disagreement between the two. “Sure, the rider can decide if we are going to change, but the elephant has a say in that, and the elephant has a several-ton weight advantage. The rider is not always the hero, and the elephant is not always the villain. Change happens when we align these two sides of our brain.”
“Most journeys of change are long, and you’re going to need the strength, the passion, and energy of the elephant side of yourself,” he added. “Engaging the elephant in the change, bringing that elephant along, making the elephant the energy source behind the change, is going to dramatically improve our odds” of success.
He noted successful change management teams typically “shape the path” for the elephant and the rider to develop a setting and conditions that are receptive to change.
Dr. Heath suggested that change is a continuous process, and successful change occurs when there is clear direction, adequate motivation, and a supportive environment.
GS08: Surviving Columbine: Lessons Learned in Survivor Care and Recovery
Heather Martin was a senior at Columbine High School, Littleton, CO, when two students killed 13 people and wounded 20 others during a mass shooting on April 20, 1999. The incident was, at the time, the worst high school shooting in US history.
In her presentation as the TQIP 2021 trauma survivor speaker, Martin described taking refuge in a small office, along with 60 other students and faculty, for 3 hours during the incident, and the long-term effects of her experiences that day. Although she returned home physically uninjured, this traumatic experience continued to affect her in the following years as she attended college.
“When I got home, surrounded by friends and family, is when I started watching the news coverage. I had not actually seen what happened. I had seen the aftermath. This is where that initial trauma-grief-anger [cycle] really started to bubble up, and that anger only got worse as days, weeks, months, and years passed. That anger just simmered below the surface all the time,” Martin said. “I found myself being really resentful of anyone talking about the shooting who wasn’t there and thought they knew what happened.
“As time passed, even within 1 month, 2 months, I was already telling myself that I should be fine, I should be over this, which led to a lot of embarrassment on my part. I was embarrassed that I was still struggling, that I couldn’t go to the bank by myself, the grocery store by myself. And really what this all stemmed from was my fear of being judged for my recovery and judged for how I was still struggling,” she said.
“After about a year of this, I knew I needed help, but I was also scared to ask for help because, again, I thought people would judge me for struggling.”
Struggling to cope with her anxiety, Martin dropped out of college, developed an eating disorder, and experimented with recreational drugs briefly. After visiting Columbine at the 10-year mark of the shooting in 2009, and seeking treatment from an experienced therapist, she re-enrolled in college, eventually earning her teaching license.
After the shooting at the Aurora, CO, movie theater in July 2012, Martin and some of her Columbine 1999 classmates cofounded The Rebels Project, which focuses on establishing a network of survivors to support others in times of need.
During the question-and-answer session, Martin underscored the importance of trauma-informed care and the skills necessary to recognize the effects of trauma on health and behavior. “Asking questions, listening, and thinking about the root cause to determine why an individual might be acting a certain way [are key],” she said. Martin also suggested healthcare providers have contact information available for therapists who are trained specifically in trauma support and encouraged providers to suggest peer support groups, such as The Rebels Project, which provide both short- and long-term assistance to trauma survivors.
GS16: Closing Session
Dr. Nathens described the process used to develop the 2022 edition of the Resources for Optimal Care of the Injured Patient and highlighted some of the most impactful standards in the updated manual.
“This being our seventh edition means that this is the sixth transition of the standards,” Dr. Nathens said, noting that this isn’t the first time users have experienced change with these standards. “As leaders, you do have the skills to help prepare your team for change,” he said.
“When we started this process, we had a means of getting a lot of information from all of you,” he said, noting that more than 2,000 responses came from chapters to stakeholder surveys regarding the current standards. This feedback was conveyed to 14 workgroups that included representatives from specialty organizations, trauma program managers, Committee on Trauma (COT) members across quality programs, and staff.
The goals of this standards update were to ensure utility, relevance, and effectiveness and to clarify the standards by using direct and quantifiable language, he said, noting that a conscious effort was made to align these standards with other ACS Quality Programs.
The 2022 manual will include 112 standards organized into the nine categories all ACS Quality Programs will use moving forward:
- Institutional Administrative Commitment
- Program Scope and Governance
- Facilities and Equipment Resources
- Personnel and Services Resources
- Patient Care: Expectations and Protocols
- Data Surveillance & Systems
- Performance Improvement Patient Safety
- Education: Professional and Community Outreach
Research
Dr. Nathens identified notable changes to existing standards, as well as entirely new standards added to the 2022 manual, and described applicable levels and definitions and requirements for each.
The manual will be released in March, and the first consultations on the new standards will begin in February 2023, with the first center verification visit anticipated to occur in September 2023.
GS05: Please, Sir, I Want Some More: How to Get More Resources for Your Trauma Program
“The value proposition for trauma care is favorable to hospitals and health systems in multiple contexts,” said Michael Chang, MD, FACS, Chair, Trauma Quality Programs Pillar and Chair, TQIP Committee for the COT, and chief medical officer and associate vice-president for medical affairs, University of South Alabama Health System, Mobile. Revenue and quality are two key domains in which trauma programs add value, according to Dr. Chang.
“At most large hospitals, typically at least 30%–50% of your patients are going to Medicare or will be covered by government payers, so your hospital administration is always going to be paying attention to how you are doing in the context of taking care of patients for whom you are paid by the government,” he said. “As a reminder, commitment to being a trauma center incurs fixed costs, and revenue is maximized by increasing volume, decreasing complications and, therefore, decreasing variable costs. This is what you have to keep in mind as you move forward in your negotiations with your hospital administration.”
In terms of quality, trauma care is protocol-driven and evidence-based with improvements that affect thousands of patients. These improvements typically result in a “halo effect” that improves quality for surrounding programs as well. “There is a direct benefit of basing a trauma center on your performance in the value-based purchasing programs,” added Dr. Chang. “Improving quality drives down your variable costs by decreasing complications and shortening length of stay, which is financially beneficial as well.”
The next presentation in this session described a hospital resource acquisition success story at MetroHealth System/Case Western Reserve University, Cleveland, OH. In December 2015, a new Level I trauma center entered the Cleveland market and MetroHealth saw significant effects within 1 year, including a 26% decline in trauma activations. “This was very concerning on a lot of levels,” said Bernard Boulanger, MD, MBA, executive vice-president and chief clinical officer. “A fair amount of revenue to the health system was impacted by this decline.” So, he suggested putting together a value proposition.
“We put together a SWOT [strengths, weaknesses, opportunities, threats] analysis in 2016,” said Jeffrey Claridge, MD, FACS, trauma medical director, service line and division director, MetroHealth System/Case Western Reserve University. According to Dr. Claridge, weaknesses included a lack of partnerships and a lack of referral hospitals, whereas opportunities for success focused on MetroHealth’s expertise in emergency general surgery, burn care, and critical care, as well as the facility’s low-cost, high-quality aeromedical service.
MetroHealth’s value proposition to two potential trauma care partners included:
- Reduced costs: Decreased duplication of resources, shared registry personnel and leadership, and more individuals covering call while paying less for full-time employees.
- Leverage trauma care brand: MetroHealth’s brand would result in immediate recognition of trauma care at partner hospital locations and co-branding of both hospital systems would improve recognition and build trust in the community.
- Staff: The partnership would result in dual-boarded faculty to community partners and bring Level I trauma care to local communities that were an hour to an hour-and-a-half away.
“In July 2019, MetroHealth formed two partnerships to collaborate on Level III trauma programs. From 2019 to 2021, MetroHealth’s total trauma activations increased 29%, with more acute transfers and activations—a 27% increase in category 1 and 58% in category 2 activations,” said Dr. Claridge.
In October 2020, MetroHealth expanded the trauma network further by opening an existing hospital in Parma, OH, as a Level III trauma center. The strong financial position afforded by all of these partnerships allowed MetroHealth to invest in trauma resources such as operating room (OR) time, ultrasound equipment, noninvasive monitoring, bronchoscopes, glidescopes, and a multimillion-dollar hybrid OR.
GS06: Maximizing the Value of Your Benchmarking Program
This session focused on how to use both clinical and claims data to maximize the value of a hospital’s benchmarking program.
Dr. Nathens described how institutions can optimize performance improvement using data from TQIP reports. “TQIP is based on valid, reliable, standardized data,” he said. “TQIP explores variability in the data to identify best practices and then promotes structures and processes of high performers.” Dr. Nathens’ presentation covered TQIP patient cohorts that are based on clinical definitions and how the reports use clinical data for risk adjustment. He also provided a real-world example of how a user can drill down on a problem identified in a facility’s TQIP report by examining the clinical data. After a review of clinical and data quality issues are examined and opportunities for improvement are identified, the next step involves employing change management tools to foster sustainable improvement.
Steve Meurer, MBA, MHS, PhD, executive principal, Vizient, Elmhurst, IL, described his organization’s clinical database as a “retrospective patient and physician-level comparative database that has metrics in quality, safety, operations, and finance.” Vizient’s clinical database comprises approximately 900 hospitals, including academic and community hospitals, and users can analyze hospitals by name, allowing them to benchmark against similar institutions. Users also can review risk- and severity-adjusted methodologies that drive the benchmarking data, potentially leading to enhanced stakeholder trust and engagement.
“What we encourage our members to do, when you’re drilling down to understand why you are different, is to spend time and energy in all three aspects of quality and performance: data quality (inclusions and exclusions); throughput (postacute care, length of stay outliers, early deaths); and harm (readmissions within 24 hours, select complications in low-severity patients),” said Mr. Meurer.
“We are getting very sophisticated in our data abilities—the data collection, the data mining, the data analytics,” said Clifford Y. Ko, MD, MS, MSHS, FACS, Director, ACS Division of Research and Optimal Patient Care. “But what is the future if we are going to try to improve trauma care even more than we are currently doing?” Opportunities for improvement include alleviating collection burden, enhancing flexibility and standardization of data variable and case-variable ascertainment, and increasing cross-functionality across registries.
Dr. Ko also outlined important priority areas that are not being sufficiently measured in registries, including patient-centered care, timeliness, efficiency of care, provision of equitable care, and cost.
“There are two areas to consider for the future: improve data collection and address effectiveness beyond safety,” he said, noting that one way to improve data collection is through automation from the electronic health record (EHR), although he noted that automation is hindered by unstructured fields in the EHR, which feature narrative text rather than synoptic reporting.
GS09: Best Practice Guidelines—Spine Injury
Topics covered in this session included an overview of the new Best Practice Guidelines on Spine Injury in Trauma Patients and their implementation, as well as assessment and treatment of spine injury across the continuum of care.
“Spinal column fractures have an incidence rate ranging from 4%–23%, but their impact can be significant, including long-term disability, associated healthcare consequences, and costs,” said session moderator Christine S. Cocanour, MD, FACS, FCCM, professor of surgery, University of California Davis, and Chair of the COT Performance Improvement and Patient Safety Program Subcommittee. “This best practice guideline is intended to serve as an evidence-based practical guide for the evaluation and management of the adult patient with spinal injury. When evidence is poor or absent, then the guideline is based on expert opinion from leaders in neurosurgery and orthopaedic surgery.”
Alexander R. Vaccaro, MD, PhD, FACS, chairman of the board, Rothman Orthopaedics, Philadelphia, PA, described spinal trauma and cord injury classification and management. When describing goals of treatment, he noted that “the bottom line is do no harm, protect the spinal cord, do everything you can to maximize neurologic recovery, achieve/maintain anatomic reduction, and provide a stable spine for early rehabilitation.”
William C. Welch, MD, FACS, FAANS, FICS, professor of neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, identified key factors in an initial spine evaluation and provided an overview of corresponding chapters in the Best Practice Guidelines, including Epidemiology, Pre-Hospital Spinal Motion Restriction, Cervical Collar Clearance, Imaging, and Physical Examination. For example, Dr. Welch noted that the epidemiology chapter describes the differences and associations of spinal cord fracture and spinal cord injury and identifies that motor vehicle-associated trauma and unintentional falls are the most common cause of spinal cord injury.
Addressing the topic of critical care of the spinal cord injured patient, Gregory Schroeder, MD, associate professor, Rothman Orthopaedics, summarized key points of the following topics: neurogenic shock and systemic pressure-directed therapy, pharmacologic management of spinal cord injury, venous thromboembolism prophylaxis, spinal cord injury-induced bradycardia, and ventilator management in high spinal cord injury. Dr. Schroeder also outlined other expectations and recommendations for patients in the intensive care unit in a critical care scenario.
Jorie Klein, MSN, MHA, BSN, RN, director, emergency medical services-trauma systems section, Texas Department of State Health Services, Austin, provided strategies for both best practice guidelines implementation and performance improvement integration, which include conducting a gap analysis and developing an education plan. “With the spinal injury Best Practice Guidelines, the goal is to decrease variations in the standard of care, and to implement processes that begin with the trauma medical director’s and trauma program manager’s leadership activities through the systems committee into all phases of care in the trauma center,” said Klein.
GS10: Fireside Chat with David Hoyt, MD, FACS, Outgoing Executive Director of the ACS
In this session moderated by Dr. Chang, David B. Hoyt, MD, FACS, then-ACS Executive Director, described the evolution of quality initiatives within the COT program and the College’s future role in this area.
“If you look historically, the roots of the College have a focused approach to standards for hospital-based care,” Dr. Hoyt said. “At the hospital level, the COT put out in 1976 what would be called today the ‘optimal resources’ document. It was basically an article in the Bulletin that defined the equipment you needed in the emergency room for the initial care” of the trauma patient.
“Creating a common language is so important when there is a lot of variability in care,” he added, underscoring the importance of patient care standardization.
Dr. Hoyt noted that the four-part ACS quality model of setting standards, building infrastructure, measuring the data, and verifying through external peer review has been essential in creating public trust.
“Our motto is ‘to heal all with skill and fidelity.’ Fidelity really means trust,” he said. “We have two professional responsibilities: one is to keep ourselves trained to become master surgeons, and the other is to create the public trust. We create the public trust by living up to our standards, by measuring our performance against those standards, and letting someone else judge whether we are meeting those standards.”
Dr. Hoyt closed by summarizing the overarching goals of healthcare today, which include reducing variability, achieving high-quality care, and lowering costs, all in the interest of “reducing the complexity of care and decision-making.”
“The future should really be to have the expectations of the principles in the ‘Red Book’ or the Quality Verification Program used by all specialties,” Dr. Hoyt said. “The College’s responsibility is to simplify that process.”
GS12: Pediatric Readiness in Adult Trauma Centers
Aaron Jensen, MD, MS, MEd, associate trauma medical director, University of California San Francisco Benioff Children’s Hospital, Oakland, outlined two new pediatric verification standards that will be included in the forthcoming edition of Resources for Optimal Care of the Injured Patient, including one that governs evaluating pediatric readiness, and another that outlines the necessary equipment and facilities required to treat pediatric patients in an adult trauma center.
“Pediatric readiness means that an emergency department has the processes, staff, and equipment to treat children, including the ability to recognize when a child may need more specialized care,” said Marianne Gausche-Hill, MD, FACEP, FAAP, FAEMS, medical director, Los Angeles County Emergency Medical Services (EMS) Agency, Hermosa Beach, CA. “Pediatric readiness is a commitment to comply with national guidelines for pediatric readiness through structural, process, and administrative changes that promote pediatric quality of care.”
Dr. Gausche-Hill described the challenges in maintaining pediatric readiness in emergency departments, including:
- Lack of standardized dosing due to broad range in patient size
- Inability of children to communicate complaints or provide a medical history
- Limited ongoing exposure of many emergency department care providers to critically ill and injured children, which can mean a failure to or delay in recognizing signs of illness or injury
These challenges are particularly concerning, as children account for 5%–10% of all EMS patients, according to Dr. Gausche-Hill. Additionally, children make 25−27 million visits to the emergency department annually, with “83% cared for in general hospital EDs and not in pediatric-specific hospitals.”
“Unintentional injury, for decades, has been the leading cause of death and years of potential life lost in children,” said Craig Newgard, MD, MPH, professor of emergency medicine, Oregon Health & Science University, Portland. “One might assume that if you are in a high-resource trauma center, you have a high [pediatric] readiness score, which is partially true, but not entirely. Even within Level I and Level II centers, there is significant variation by volume, geographic location, and whether there is a pediatric emergency care coordinator present.” Analyzing the National Trauma Data Bank® (NTDB®) data,, researchers have shown that approximately one-third of major trauma centers have low pediatric readiness scores.
“High emergency department readiness improves short- and long-term survival among children with critical illness and trauma,” noted Dr. Newgard, adding that readiness is, indeed, obtainable for Level III and Level IV adult trauma centers.
Katherine Remick, MD, FAAP, FACEP, FAEMS, associate professor, Dell Medical School, The University of Texas at Austin, summarized the mission of the EMS for Children Innovation and Improvement Center, which is to “accelerate improvements in quality of care and outcomes for children who are in need of emergency care.” The organization strives to “link tools, efforts, and entities to effectively decrease child and youth mortality and morbidity sustained as a result of illness or injury,” she said.
Aspen Di Ioli, RN, PHN, CEN, TCRN, MICN, Pomona Valley Hospital Medical Center, La Verne, CA, spoke about what inspired her to become a pediatric emergency care coordinator (PECC), described the typical responsibilities of the PECC, and offered strategies for successfully pitching this role to hospital administrators at an adult trauma center.
Other notable sessions
Other sessions of interest included GS11: Using Data to Effect Lasting Change, which outlined how to use data to effect change at the trauma system, trauma center, and individual provider levels, and GS15: Tales from the Mortality Reporting System, which summarized how this project collects and studies structured mortality review data across TQIP centers to decrease deaths after traumatic injury.
The 13th TQIP Annual Conference is scheduled to take place December 11–13, in Phoenix, AZ.
