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 dozens of guidelines required as part of ACS verification, but more broadly, sound guidelines help standardize how the team responds to and cares for patients.

Have you faced any of these problems in your trauma center?

No two people can agree on the process for getting guidelines approved and dozens of departments/committees all want a chance to weigh in on the content (or participate in wordsmithing)
Multiple departments have their own sets of guidelines, which conflict and prevent collaboration across departments
The process for writing, revising, and approving guidelines is obscure, time-consuming, and inefficient
Hospitals think they are ok to operate without guidelines because they assume everyone will "just know what to do"
The guidelines are printed in hard copy and are collecting dust on shelf, unused and forgotten

There are more than two dozen guidelines required to meet ACS Level I/II 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.

How Can Diligent Consulting Help?

Conduct a hospital-wide guideline audit to determine what trauma-related guidelines exist and which guidelines need to be created.
Outline and agree upon the process for guidelines to be reviewed and approved in the hospital. Be mindful of other credentialing bodies and departments that must have a seat at the table.
Create a work plan and timeline for collecting, review, revising, and gaining approval for guidelines to ensure all documents are approved within the review window.
Write or revise guidelines in collaboration with key stakeholders to ensure they reflect best practice. We can also help you create algorithms and process charts to improve ease of use.
Develop a compliance plan to identify guidelines and set a manageable cadence for regular review and updating.
Establish implementation plans to ensure staff are trained and educated, metrics are established to monitor compliance, and documents are posted and accessible.
Enhance performance improvement to monitor (in real time and through retrospective review) compliance with guidelines.
Work with your EMR and document management systems to embed guidelines and ensure access hospital-wide.

Who Can Benefit from This Service?

Trauma program leaders
Hospital c-suite administrators
Compliance and legal managers in hospital

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