Trauma Center Guidelines

Whether you call them clinical practice guidelines, policies, procedures, or numbered memorandums (hereafter called "guidelines"), these documents are critical to trauma patient care. Not only are many guidelines required as part of ACS verification, but more broadly, sound guidelines help standardize how the team responds to and cares for patients. 

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Here are some common situations we see in trauma centers:

• Multiple departments have their own sets of guidelines, which conflict and prevent collaboration across departments

• The process for writing, revising, and approving guidelines in a hospital setting is obscure, time-consuming, and inefficient

• Hospitals operate without guidelines because they think everyone will just know what to do based on their clinical training or even the way the EMR is structured

• The guidelines are printed in hard copy and sit on a shelf, unused and collecting dust

• Department leaders and employees have no idea that certain guidelines exist and could not find them if their life depended on it

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There are more than two dozen guidelines required to meet ACS standards, as well as another 10-20 guidelines that strengthen trauma care and enhance trauma operations. So the lack of guidelines or the lack of ability to demonstrate compliance with policies can tank a verification review. That's where Diligent Consulting can help.

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​​A typical project workplan includes:

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1. Conduct a guideline audit within the hospital to determine what guidelines exist and which guidelines need to be created.

2. Outline the process for guidelines to be reviewed and approved in the hospital.

3. Create a work plan and timeline for collecting, review, revising, and gaining approval for guidelines to ensure all required guidelines are approved within the review window.

4. Write or revise guidelines in collaboration with key stakeholders to ensure they reflect best practice (examples can be provided from our database). We can also help you create algorithms and process charts to improve ease of use.

5. Develop a compliance plan to identify existing guidelines and a manageable cadence for regular review and updating.

6. Establish implementation plan to ensure staff are trained and educated, metrics are established to monitor compliance, and documents are implemented fully.

7. Enhance performance improvement to monitor (in real time and through retrospective review) compliance with guidelines.

8. Work with your EMR and document management systems to embed guidelines and ensure access.

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Contact Diligent Consulting today to learn more.