"Trauma centers should promote a culture of patient safety that acknowledges the multidisciplinary aspect of trauma care and empowers all team members. This effort should include...awareness of high-risk or error-prone situations in the care of the trauma patient."1 This quote from the recently released Orange Book concisely summarizes the intent and future direction of the performance improvement process for trauma care. Hospitals that embrace this concept encourage and empower all staff to speak up when concerns for patient safety arise. Events, both actual or near misses, are reported without fear of repercussion or punishment so prevention and mitigation efforts can limit their occurrence and/or soften their consequence. Hierarchies are flattened, team interaction encouraged, and careful review of patient care expected. The antiquated model of blame, complete with finger pointing and open reprimands, is replaced with the thoughtful question, "If faced with this same situation in the future is there anything we might consider doing differently?"

Many believe that by embracing the Institute for Healthcare Improvement's recommendations to develop a culture of safety,2 the American College of Surgeons Committee on Trauma (ACSCOT) is advocating for a complete change in the way trauma centers conduct performance improvement. In some ways that statement is correct. To view performance improvement in a constructive light is truly a complete change for staff at many trauma centers. Adding additional categories to event reviews is also a change from the current process. These categories will be discussed later. However, the performance improvement process itself (which includes event identification, levels of review, determination, action plans, and event resolution) as taught in the Society of Trauma Nurses Trauma Outcomes Performance Improvement Course (TOPIC) has not changed and continues to be the foundation of any trauma quality program.

Integral to updates in the ACSCOT trauma performance improvement process is the addition of the International Patient Safety Event Taxonomy.3 This taxonomy, also referred to as the Joint Commission Taxonomy, provides a robust classification system that aids in identifying things that go wrong in health care, the reason why they occur, and preventive strategies which can minimize future occurrences.4 The categories include impact (harm to the patient), type (the processes that were faulty or failed surrounding the event), domain (the setting and its characteristics), and cause (human and/or system factors that led to the event). The last category of the taxonomy is prevention and mitigation, which encompasses the current action planning and event resolution ("loop closure") as taught in TOPIC. The use of this taxonomy is facilitated by adding fields to current trauma registry software programs, which allow for reports that identify opportunities for improvement in a more specific manner. This can certainly aid busy trauma centers with finite resources in prioritizing trauma projects to those areas that seem to be most problematic.

At the October 2014 ACSCOT Performance Improvement Patient Safety (PIPS) Committee meeting, the use of the patient safety taxonomy in trauma performance improvement was endorsed. There was also the recognition that the taxonomy in its current state needed to be "traumafied." A small workgroup was formed with representatives of Trauma Quality Improvement Program, National Trauma Databank, and the Society of Trauma Nurses to bring this about. Members from this group are currently working to standardize definitions for levels of harm for National Trauma Databank complications and have future plans to use this same methodology when looking at common trauma system metrics (eg, surgeon arrival to trauma bay and emergency medical services scene time). The use of standardized language in performance improvement will also increase the depth to which trauma centers can benchmark their programs compared with others. Benchmarked data can be made available to site reviewers for hospitals undergoing American College of Surgeons (ACS) verification visits, providing objective information on the performance of that center. This provides a real opportunity to support the purpose of ACS designation-the recognition of centers for quality.

It will be important for all leadership in trauma centers to stay abreast of the changes coming to the trauma PIPS process. One of the best venues for assuring a center meets the current criteria requirements for passing ACS verification visits is application of the principles taught in a TOPIC course. The principles that drive a culture of patient safety are explained along with practical use of the Institute for Healthcare patient safety taxonomy. The ideal way to attend a TOPIC course is to have a trauma medical director and trauma program manager go together and hear firsthand how to bring real change to their program. Physicians will be provided practical ways in which to engage other providers in the trauma quality process. Trauma program managers will be given tools to use to support and enhance the trauma PIPS program. Another place to watch for PIPS updates will be the Trauma Performance Improvement Reference Manual located on the ACS Web site.5 As the PIPS chapter for the Resources for Optimal Care "Orange Book" continues to be molded into a true trauma culture of safety document, references and tools will be added to this site.

It is going to take time and great effort from all of us to migrate to this Trauma Culture of Safety, but the change that is coming is exciting. In the end, the ultimate winner from all these endeavors will be the one we all strive to serve best...our patients.

REFERENCES