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Performance Improvement

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Trauma Performance Improvement:

  • Trauma PI is a process that identifies trauma patients, who arrive to the Royal Medical Service in order to evaluate and improve the multidisciplinary process of care. 
  • It is a continuous cycle of monitoring to recognize issues, attempt to correct them, then re-monitor to assure your corrective action plan was successful.  

Responsibilities of Trauma PI :

1-Identification of Trauma-patients via : 

daily-meetings and rounds , which include trauma health care  team, to review all admissions, transfers and referrals. 

2-performing audit filters; patient care review

Once information has been abstracted, it is analyzed, and the identified events are reviewed in the context of bit falls  in care or process and discuss opportunities for improvement.

3-follow up discharged trauma patient in the multidisciplinary  trauma clinic. 


Levels of event review :

• Three levels of review; Data is collected and organized for review under the direction of the Trauma Medical Director and the Trauma Program Manager.

• Major complications, deaths, complex polytrauma-cases, system issues and unexpected outcomes must be reviewed.

• Levels of review can be determined by the degree of harm to the patient.

1-Primary level of review (Event Validation):which is designated to trauma performance improvement  staff ;occur during morning report, patient care rounds, chart review, and direct staff and patient interaction ; changes in patients plan of care or implementation of clinical guidelines may be influenced immediately.

2-Secondary level of review (committee review): Requires additional review, which includes trauma team; PI committee (Liaison officers) Trauma Program Manager and Staff. Issues are validated, additional information collected, analyzed, and in some cases the issue may be close.

3-Tertiary level of review(multidisciplinary level) : data is collected organized for review under the direction of trauma medical director .


Cases are reviewed, determinations made ,corrective actions developed , implementations followed and loop closure is completed.