Each trauma center shall prepare a written Performance Improvement and Patient Safety

Each trauma center shall prepare a written Performance Improvement and Patient Safety (PIPS) Plan. There is no precise prescription for the PIPS plan; however, the trauma program must demonstrate a continuous process of monitoring, assessment, and management directed at improving care. A trauma PIPS plan shall practice a multi- disciplinary and multi-departmental approach to reviewing the quality of patient care across departments and divisions. The trauma PIPS program shall integrate with the hospital quality and patient safety effort and have a clearly defined reporting structure and method for provision of feedback.