How to Get Ready and Stay Ready for Quarterly TQIP Data Submissions

Preparing your quarterly Trauma Quality Improvement Program (TQIP) submission to the American College of Surgeons (ACS) is crucial for trauma centers aiming to improve care by leveraging performance data and comparing it with similar programs nationwide. With data submissions due every three months, it’s always the right time to prepare your TQIP.

Here’s how you can get ready and stay ready for quarterly TQIP data submissions—and use your benchmarking report to prepare for your ACS verification site visit.

Get Ready

Start with Performance Improvement (PI)

The ACS mandates that trauma centers use registry data to support performance improvement. Begin by examining your data there. You may have to create a custom audit filter in your trauma registry to record data validation findings or add a PI module to your dashboard.

ImageTrend Patient Registry™ shows validation and inter-rater reliability rates right in the registry and reports on all fields. You can also automate trending reports on key PI data points.

Include NTDB Measures of Processes of Care

The National Trauma Data Standard systematizes trauma registry data to improve patient outcomes by defining a standard to measure care. Although it is created and maintained by the National Trauma Data Base, it also serves as an operational guide for TQIP. Run NTDB validation reports to check your data.

Evaluate Your TQIP Inclusion Rate

Assess what percentage of patients in your trauma registry are accepted by TQIP. If your inclusion rate is low, determine what is preventing patients from being included. Common problems include insufficient documentation, AIS coding errors, and incomplete data. Look at NTDB and TQIP benchmark reports for data fields that are used the most and more likely to cause exclusion.

Re-Abstract Only Key Data Points

The ACS recommends re-abstracting 5-10% of trauma patient records during validation checks, which can be overwhelming for large hospitals with a high volume of trauma patients.

A sufficient alternative for larger institutions is to focus on key data elements that impact performance the most, like complex procedures, comorbidity, and complications, which shape risk adjustment in TQIP benchmarking. Look for patterns and anomalies. If a data point is pretty consistent and then suddenly isn’t, the chart may not have been abstracted correctly.

… And Stay Ready

Check Your Fields and Filters

The data you have is only as good as the data you collect, so make sure you have the appropriate fields and filters set up in your registry, including PI-related fields. Clean up the fields and check that the required ones are marked that way. This will also save your team time in abstraction and validation.  

Prioritize Reporting

Don’t let reporting take a back seat to abstraction. Many trauma centers deal with registry backlogs, but reporting is a critical part of validation. By spotting the front-end problems, reporting actually improves data quality and reduces time spent abstracting and cleaning up data.

Increase Reporting Frequency

Validating months of data and processing the information once a quarter is not sustainable. Monthly internal reporting and validation will make a big difference in staying prepared for quarterly data submissions and reduce the time and resources required to verify and correct your database (in addition to reducing errors).

Stay Prepared for Your Site Visit

Since 2021, TQIP data has played a more significant role in verification site visits. Your quarterly TQIP benchmark report is a vital tool for site visit preparation, highlighting areas reviewers are likely to focus on. Use your TQIP data to identify and address performance issues early, demonstrating ongoing improvement during your review.

Ensure Continuous Readiness

By following these steps, you can streamline your TQIP data submission process and ensure continuous readiness for ACS verification site visits. Regular preparation and proactive management of your trauma registry data will help improve patient outcomes and maintain high standards of care.

Learn more about TQIP and how our hospital solutions can assist you in maintaining optimal trauma care.