Strengthening Trauma Care Across Systems: A Step-Wise Approach to Developing Performance Improvement on a Regional Scale-Handout: Meeting Template Toolkit

Handout: Meeting Template Toolkit

Pdf Summary

The 2025 toolkit produced by TCAA Systems’ Committee provides comprehensive guidance and templates for developing and operating a regional trauma system’s committee focused on trauma case review and performance improvement. It includes key documents such as a committee charter example, process steps, confidentiality and data use agreements, legal requirements for protected “Safe Tables,” the ACS national field triage guidelines, just culture algorithms, and patient safety culture frameworks.<br /><br />The process for developing a System’s Committee involves engaging system leaders, creating a small group to design logistics, developing a charter and audit filters, identifying evidence-based guidelines, establishing document management, inviting members who sign confidentiality agreements, defining case review procedures, and generating actionable quality initiatives.<br /><br />The confidentiality statement outlines confidentiality and privacy protections for trauma case review participants, emphasizing adherence to federal and state laws and restricting data use solely for improvement and education purposes, with no external disclosure.<br /><br />Legal requirements for “Safe Tables” detail protections under the Patient Safety and Quality Improvement Act and associated regulations. Committees must operate via federally-listed Patient Safety Organizations (PSO) within Patient Safety Evaluation Systems (PSES), ensuring patient safety work product (PSWP) is privileged and confidential with narrowly defined exceptions, compliant with HIPAA, and marked/secured appropriately.<br /><br />The ACS 2021 Field Triage Guidelines assist in categorizing trauma patients by injury severity, mechanism, and vital signs to guide transport decisions.<br /><br />The Just Culture algorithm helps classify errors as system flaws, human errors, at-risk behavior, or reckless behavior, guiding appropriate responses that balance accountability with system improvements.<br /><br />The patient safety culture section highlights the importance of fostering trust, transparent reporting, multidisciplinary collaboration, and continuous assessment (eg, via AHRQ surveys) to improve safety outcomes. Initiatives include safe tables, leadership engagement, education, and peer learning collaboratives.<br /><br />The committee charter example defines purpose, scope, objectives, membership, leadership, meeting structure, confidentiality, documentation, and decision processes to standardize trauma system committee function.<br /><br />Sample communications such as welcome letters and requests for case review documentation illustrate practical tools to engage members and support data validation and discussion.<br /><br />Overall, the toolkit equips trauma systems with structured operational, legal, cultural, and clinical frameworks to support effective case review, quality improvement, and regional trauma care coordination.

Keywords

Trauma System Committee

Trauma Case Review

Performance Improvement

Safe Tables

Patient Safety and Quality Improvement Act

ACS Field Triage Guidelines

Just Culture Algorithm

Patient Safety Culture

Committee Charter

Confidentiality Agreements