TQIP Conference Outlines Impact of Effective Communication on QI

The 2024 Trauma Quality Improvement Program (TQIP) Annual Conference, held November 12–14 in Denver, Colorado, drew 2,300 in-person and 419 virtual attendees—the meeting’s highest attendance in its 14-year history.

Participants experienced presentations describing the many facets of quality improvement in the trauma care setting. Two Executive Sessions addressed considerations for implementing trauma center activation fees and approaches for leveraging the financial value of trauma programs. Educational programming anchored to the meeting’s theme, “Enhancing Quality through Communication,” included hands-on improvisation workshops and an inspiring trauma survivor story.

On-demand registration remains open through April 14, 2025.

TQIP Update

“Communication in our space is a pain point,” said Avery B. Nathens, MD, PhD, MPH, FACS, FRCSC, Medical Director of ACS Trauma Quality Programs. “You’re here because you want to advance care in your hospitals by working better together as a team.” He cited a 2022 study of the TQIP Mortality Reporting System that revealed nearly half (49%) of 395 deaths during a 2-year period had a communication-related opportunity for improvement.

Dr. Nathens described two approaches for developing a culture of safety in healthcare. The Safety I model assumes events unfold in a linear fashion and focuses on ensuring that as few occurrences as possible can go wrong, while the Safety II model assumes environments are unpredictable and that it is unrealistic to develop standard operating procedures for all potential scenarios.

“The Safety I approach features protocolized care in a fairly narrow bandwidth. It’s tightly regulated. This might make sense in an environment that’s highly predictable with low variability—that’s not our environment,” explained Dr. Nathens, adding that the Safety II model, which is the more resilient approach, views humans as a resource (rather than the cause of problems) capable of an adaptive communication style.

Dr. Nathens also provided an update on trauma quality programs, starting with what he called a re-imagining of TQIP. “Our goal is to identify the clinical content that trauma centers can use to improve trauma care and get a better sense of how we can deliver the reports in a format that is much more actionable.”

This approach is based on feedback culled from stakeholder interviews representing 60 different trauma centers. A notable long-term goal for the reports could include a transition from a hybrid model to a digital first model, he said, a move that would include additional stakeholder input.

Moving from TQIP reports and data collection to the topic of Verification, Review, and Consultation Program standards, Dr. Nathens noted that this year was the first using the Resources for Optimal Care of the Injured Patient (2022 Standards). An estimated 280 site visits have been conducted thus far, with more than 80% of those being reverification visits.

“These standards have been challenging to navigate for many of you, and we are doing our best to make sure there’s clarity around those standards,” he said.

He outlined content updates to the recently released Best Practices Guidelines for the Management of Trauma Brain Injury, and he offered a high-level preview of the Best Practices Guidelines for the Management of Urological Injuries, which is under review and expected to be released in spring 2025.

Dr. Nathens also described the development of the ACS Stop the Bleed course (version 3), which will be available in the first quarter of 2025, and offers a focus on both rural and urban communities with more images and less verbiage to enhance engagement with international learners.

Positioning Your Trauma Center for Success

This year’s Executive Track featured two sessions that offered strategies for achieving fiscal responsibility, managing resource allocation, and connecting quality improvement initiatives to economic growth.

“The financial insolvency of trauma centers is a population-health problem,” said John W. Scott, MD, MPH, FACS, a trauma surgeon and associate professor of surgery in the Department of Surgery at the University of Washington in Seattle.

He also said that some states use taxes and fees to fund their trauma systems—but many do not. Trauma centers lose approximately $1 billion annually, and 339 of 1,125 trauma centers closed between 1990 and 2005, often due to financial distress, leading to several trauma “access deserts” and likely increased mortality.

“The solution that came in 2002 is commonly referred to as ‘trauma activation fees,’” said Dr. Scott. “There’s some promise and there’s some peril regarding trauma activation fees. There’s been a significant reduction in closures, and for many hospitals, the trauma center went from being a cost center to a revenue center.”

The fact that these fees are set by hospitals or states allows administrators to tailor them to specific needs based on the setting.

“So, have they worked? They work—but that’s not the story you hear these days,” said Dr. Scott, referring to mainstream media and peer-reviewed reports that suggest trauma activation fees often are applied when not indicated, outlier trauma centers are charging exorbitant prices, and other concerns.

To mitigate misconceptions regarding trauma activation fees, Dr. Scott recommended benchmarking trauma activation fees against other hospitals in the market and being fully transparent when justifying the fees charged by the center.

Notably, the ACS Board of Regents approved a statement in June 2024 regarding trauma activation fees, in which the College asserts that trauma activation fees are necessary for the viability of trauma centers to ensure optimal care for patients.

In a presentation that examined the benefits of avoidable interfacility patient transfers, Zain G. Hashmi, MD, FACS, assistant professor of surgery and director of teletrauma in the Division of Trauma and Acute Care Surgery at The University of Alabama at Birmingham, revealed that nearly 30 million Americans lack timely access to verified trauma centers.

“This reality leads to our current challenge where patients are initially evaluated at a nontrauma center and then transported to a Level I or Level II trauma center,” he said. “A large proportion of these patients are rapidly discharged without any critical interventions. These constitute potentially preventable interfacility transfers or secondary over-triage.”

According to Dr. Hashmi, 20%–50% of all trauma transfers are potentially avoidable, which is notable considering that estimates suggest transfer can cost anywhere from $20,000 to $65,000 per patient care episode.

“When you couple this with Dr. Scott’s data showing that 1 in 7 trauma patients are at risk of catastrophic health expenditures, this incremental cost surpasses most of our patients’ annual incomes, making matters much worse,” he said, asserting that “simply adding more resources is not the solution—the solution, in one word, is communication.”

He called for “purpose-driven communication” to curb potentially avoidable interfacility transfers, specifically through region-based solutions such as participation in the Rural Trauma Team Development Course from the ACS Committee on Trauma, development of subspecialty clinics for nontransferred patients, and enhanced implementation of teletrauma resources.

Jorie Klein, MSN, MHA, BSN, RN, director of the EMS/Trauma Systems Section of the Texas Department of State Health Services, discussed best practices for trauma centers to align with state leadership, specifically via monthly stakeholder calls organized by trauma center level, to discuss costs associated with trauma center readiness, trauma rule amendments, transfers, and region-specific issues.

In a presentation that defined the role of hospital system leadership in advancing trauma system growth, Nirav Patel, MD, FACS, vice chair for quality and patient safety at the University of Arizona College of Medicine in Phoenix, suggested following a reverse engineer model, which involves dismantling current processes to gain an understanding of the business side of hospital administration and provides opportunities to uncover inefficiencies.

“Lead from the bottom line,” said Dr. Patel, underscoring the importance of periodizing top goals when making decisions. “Be micro-ambitious. We try to bite off too much, too fast. Pick your battles and have a phased, multidimension strategic plan.”

Dollars and Sense

ACS Executive Director and CEO Patricia L. Turner, MD, MBA, FACS, provided opening remarks for the second Executive Session, stating that trauma quality verification effectiveness has been shown to reduce mortality by 25%.

“It is also more cost effective when patients are cared for in a Level I trauma center versus a center without a trauma designation,” said Dr. Turner. “Having a plan is the best way to reduce mortality and reduce costs—and we want to help you do this. We hope that all of you will have conversations at your home institutions to help bring forward this notion of enhanced quality for everyone—for every patient at every institution.”

The first step in determining a trauma center’s value is to examine how administrators view it—as a cost center, a profit center, or a value center, according to A. Britton Christmas, MD, MBA, FACS, medical director of trauma at Atrium Health’s F. H. “Sammy” Ross Jr. Trauma Center in Charlotte, North Carolina.

“A value center is what we really want to be because you’re bringing more than just money to the table, but you have to know how to communicate that,” said Dr. Christmas.

He described how quality improvement initiatives not only reduce mortality rates, but they also can lead to decreases in variable costs by improving resource use and aligning incentives.

“This is where you adopt best practices, where your TQIP reports really come in, your guidelines, and standardization—the goal is to reduce errors and increase quality and efficiency,” said Dr. Christmas.

One of the best approaches for achieving buy-in from administrators is to acknowledge when a quality improvement project fails to deliver results. “If you’ve got a quality initiative and it is not going well—dump it and walk away because what it’ll also do is save your credibility when the next ask comes up,” he said.

The two remaining presenters—Trey Eubanks, MD, FACS, president and surgeon-in-chief at Le Bonheur Children’s Hospital in Memphis, Tennessee, and Toni von Wenckstern, MS, RN, vice president of Trauma Service Line and Life Flight at Memorial Hermann Health System in Houston, Texas—provided the CEO’s perspective for setting trauma center priorities, and offered practical approaches for making an effective pitch to the C-suite.

Keynote Address: Developing the Expeditionary Mindset

Jeff B. Evans, PA-C, a practicing emergency medicine physician assistant and expedition guide, delivered the 2024 TQIP Keynote Address in which he described the value of communication and teamwork as demonstrated by his experience guiding the first blind man to the top of Mount Everest.

After agreeing to lead Erik Weihenmayer up the earth’s highest mountain, Evans was discouraged by colleagues who feared both would perish as a result of the extreme altitude—which can lead to oxygen deprivation, increased heart rate, and fatigue—as well as the risk of frostbite and perilous falls.

There were many events during their arduous ascent that pushed both climbers to their physical and mental limits, but Evans described one incident in particular that demonstrated what he called the “expeditionary mindset,” a style of leadership that is tethered to building trust among team members.

While it is fairly common to use climbing ladders to cross hazardous sections of Mount Everest, at one point, they were unable to use a ladder to cross one of the shorter gaps that was approximately 3 to 6 feet in length.

“When I encounter those, I usually just jump,” said Evans, noting that Weihenmayer had no choice but to put faith in his guide and literally jump blindly across a crevasse that was thousands of feet deep.

“Trust is developed over time by sharing a difficult objective, whatever that may be. The worthy objectives are the ones that really take us to uncomfortable situations where we are forced to lean into each other and that is when trust is developed,” he explained.

According to Evans, the expeditionary mindset approach to leadership duplicates the skills of the mountain guide to lead teams. Managers adhering to this model have the ability to adequately assess resources, consider how the team is acclimating as they move, recognize potential “storms” (stressors) that could impede progress, and then determine the best way to move forward in a safe and efficient way.

After an almost-3-month climb, the team made it to the top of Mount Everest where they spent a total of 20 minutes before beginning their descent.

“The view is completely overrated,” joked Weihenmayer. But his wisecrack actually took on a new meaning for Evans regarding the secret to successful team building.

“Life doesn’t take place on the summit. It takes place on the sides of the ‘mountain,’” he said. “On our journey, I learned a lot about trust and communication, but I didn’t learn any of that during those 20 minutes on the summit. The sides of the mountain are where we fall down and that is where we stand back up, brush ourselves off, and recalibrate. It’s when we check in with our people—are you good? Okay. Let’s go.”

Surviving Survival: The Trauma Patient Perspective

Geralyn Ritter was returning from a business trip in May 2015, when Amtrak 188 derailed just outside of Philadelphia. The crash killed eight individuals and injured hundreds more, including Ritter who suffered abdominal, chest, pelvic, and orthopaedic injuries so severe she was not expected to live.

In a matter of moments, Ritter went from being an influential senior executive at one of America’s largest companies to an immobilized intensive care unit patient on a ventilator, completely dependent on others for her care.

“I had about six of my more-than-25 surgical procedures in the first 10 days, and I didn’t realize how the survival journey was just getting started,” admitted Ritter, who outlined ways her care could have been improved. Specifically, she suggested that enhanced counseling for postdischarge would have set realistic expectations for inpatient rehabilitation, pain management (level and duration), physical limitations/return to work, and mental health risks.

“One of the biggest surprises during my recovery had to do with the importance of focusing on mental health,” she said. “I had started to think of myself as this collection of broken parts, and one of my doctors told me she recommends that all her trauma patients receive treatment for post-traumatic stress disorder (PTSD).”

Ritter asked caregivers to keep in mind that PTSD is “not often associated with accidental trauma—at least in the minds of the patients themselves—and that stigma around the condition persists.” She also suggested helping patients find a balance between “optimism and cold hard realism” is essential for building resilience.

Using Improv to Improve Communication

After Michael Smith, MD, was given improv lessons as a surprise gift, he quickly realized the potential of incorporating those skills into his work as a physician and educator.

In 2018, Dr. Smith—an associate professor and academic hospitalist at the University of Nebraska Medical Center in Omaha—developed five workshops for faculty development at his institution, and since then, he has led hundreds of improv workshops for healthcare professionals across the US.

At the TQIP Annual Conference, Dr. Smith co-led three breakout sessions focused on enhanced interdisciplinary communication, communication in the trauma bay, and communication with families.

“The same skills that I use to create humor with my improv scene partners all come from connection,” explained Dr. Smith. “I use those same skills in some of the most serious situations in the hospital, whether it’s a palliative care discussion or a serious diagnosis discussion—those same skills help me connect with patients and build a reality together.”

According to Dr. Smith, improv skills that can enhance communication in healthcare include the ability to ignore distractions and focus on the person in front of you, and enhanced active listening, which allows clinicians to temporarily deactivate the urge to share their own opinions in order to absorb what a patient or colleague is saying in the moment.

“People won’t care about what you know—until they know that you care,” he said.

The 2024 TQIP Annual Conference on-demand content (general and breakout sessions) will be available for both in-person and on-demand registrants this month.

The 2025 TQIP Annual Conference will take place November 8–10, in Chicago, Illinois.