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Performance Improvement


Performance Improvement is foundational to trauma program development and growth.  It acknowledges that defect free care is both aspirational and obtainable.  Learning is continuous as science informs, best practices are shared, and lessons learned improves the care paradigm. 

The 2014 American College of Surgeons Resources for the Optimal Care of the Injured Patient (Orange Book) states that “A trauma center should provide safe, efficient and effective care to the injured patient.  Doing so requires the authority and accountability to continuously measure, evaluate and improve care (performance improvement).”  The Orange Book noted “there is no precise prescription for trauma performance improvement and patient safety (PIPS).”  Performance should aim to meet the six quality aims for patient care: safe, effective, patient centered, timely, efficient and equitable. 

This PI toolkit is designed to provide easy access to some of the tools and resources that have been collected and shared from partners and stakeholders committed to the practice of continuous performance improvement. These partners understand that while there is not a precise prescription for performance improvement; tools, forms and processes can help organize the work, ensure the important components have been addressed and provide visual assists that identify, track and trend issues. We would like to thank those that have shared this information so that we all may commit to the essential work of performance improvement. 

This PI toolkit is a work in progress. As we learn, grow and develop our PI processes we will update, edit and revise the materials accordingly. We invite our partners willing to share tools, processes, and best practices to please submit your materials to


Getting Started:

Having a clear understanding of performance and quality review contributes to building a strong, resilient system that supports the delivery of safe, quality care. Getting Started is organized around the state requirements for Performance Improvement Patient Safety (PIPS). This section includes a power point that walks through the process of evaluating a trauma program, samples of a flow chart and templates that can be tailored to an individual trauma program.







This section includes a compilation of Performance Improvement presentations that have been presented in Michigan.  They represent various perspectives from Montana, Minnesota and Michigan about how PI can be implemented:

PI Tools:

This section includes tools to help with chart review and data abstraction, documentation, forms and job descriptions. The materials shared may be modified to meet the needs of an individual facility.