3 Commonly Misunderstood ACS Grey Book PI Standards for Trauma Centers

The Grey Book by the American College of Surgeons (ACS) clarified many trauma center requirements when it was first released in 2022, but some performance improvement (PI) standards still require careful interpretation.

Ensure you understand what the ACS requires of your trauma program to maintain verification, provide quality patient care, and strengthen your PI plan.

1. PIPS Audit Filters (Standard 7.2)

The Grey Book tells us that all trauma centers must have a written Performance Improvement and Patient Safety (PIPS) plan that includes all 30 audit filters outlined in the resources section. But you can’t just set it and forget it. Standard 7.2 implies that you are actively monitoring (and improving, if needed) these items.

It’s not enough to include these filters in your review—to copy and paste without active oversight. Even if your program consistently meets or exceeds a quality metric, the ACS wants to see that you’re tracking it.

TIP: Create a workflow or process to regularly review the required audit filters and reports as a part of your ongoing PI program. Integrate all 30 filters to your PIPS dashboard, including any additional program-specific data points you track.

2. Hospice Transfers (Standard 7.7)

Many trauma program leaders still mistakenly believe that discharging a patient to hospice is the same as discharging to a skilled nursing facility (SNF) or a long-term care facility, as far as the registry is concerned. The fact of the matter is that cases discharged to hospice have to be treated the same as trauma-related mortalities.

Standard 7.7 mandates that you look for opportunities for improvements (OFIs) in care for those discharged to hospice, just as you already do for those who die in the hospital. The standard also requires you to classify potential OFIs as either “mortality with opportunity for improvement” (such as failure to follow standard protocols) or “mortality without opportunity for improvement.”

Patients who come from hospice are the exception. It’s important to understand the rationale behind the standard, which is to measure actual mortality performance. Patients who arrive at the trauma center from hospice can be labeled as discharged back home and shouldn’t influence mortality benchmarking since their “clinical course” hasn’t changed.

TIP: TQIP is aligned with this standard, so it should be applied by all trauma centers that submit quarterly data to TQIP. This will also be taken into consideration during your ACS verification review.

3. PI Staffing (Standard 4.35)

The Grey Book finally quantified the ACS rules for staffing, setting a clear standard, if only it weren’t so often misunderstood: Standard 4.35 sets a threshold, not a ratio.

The Grey Book specifies that a trauma center must have at least 0.5 FTE dedicated PI staff if its annual registry has more than 500 patients and at least 1 FTE dedicated PI staff if it’s greater than 1,000 patients. This doesn’t mean you must have 4 FTEs if your registry has 4,000 patients per year in order to satisfy this standard. In this case, the standard still requires just 1 FTE dedicated to PI.

We stress “at least” above because your goal should be adequate staffing above the minimum requirements. For one, it may take additional personnel to meet the full breadth of ACS standards.

TIP: You could hire additional dedicated PI staff if the patient volume calls for it. Otherwise, you can spread PI responsibilities across your trauma team. To supplement the one mandated PI professional, the registrars, for example, can pick up some PI tasks.