American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Trauma Quality Improvement Program

Trauma Quality Improvement ProgramThe Current State of the ACS TQIP

TQIP Experiencing Steady Growth

Not only do all 50 states now have a fully enrolled Trauma Quality Improvement Program (TQIP) site in their state, but TQIP also has participants in Canada, Germany, and Qatar. TQIP is standardizing the way trauma data is collected, measured, and analyzed to generate quality improvement strategies and ultimately reduce disparities in trauma care across the nation.  There are more than 700 trauma centers participating in TQIP, with 466 Adult Level I and II TQIP participants, 125 Pediatric TQIP participants, and 120 Level III TQIP participants. 

Implementation of Start-Up Year for All Levels of TQIP

After the success of the pilot year for Level III centers, which proved to be a great learning opportunity for both participating centers and the TQIP team, TQIP has decided to implement the Start-Up Year for new centers across all levels of TQIP. Effective January 1, 2017, all newly enrolled TQIP centers will participate in a Start-Up Year in an effort to improve data quality and ensure that reports are useful to centers from their first report cycle and onward. The Start-Up Year will provide a special emphasis on education and will allow new TQIP centers to begin to submit data quarterly. This enables centers to gain additional experience with both the data submission process and reviewing their validator reports.

State & Regional Collaboratives

Individual State Collaborative Lunches were held during last year’s TQIP Annual Meeting in Orlando, serving as an opportunity for state trauma leaders and hospitals to discuss their Collaboratives’ short-term and long-term goals in utilizing Collaborative data for trauma system improvement. Participating states included California, Florida, Georgia, North Carolina, Pennsylvania, and Texas, as well as TQIP sites in Canada. TQIP will once again be providing the opportunity for Collaboratives to meet during this year’s TQIP Annual Meeting in Chicago, November 11–13. In March 2017, the COT Region III became the newest fully onboard TQIP Collaborative, joining Florida, Georgia, Michigan, Texas, Pennsylvania, HCA, and LA County California. TQIP is currently working on Collaborative development for the state of California (as well as several counties within the state), North Carolina, the U.S. Department of Defense, and Canada.

For more information about TQIP Collaboratives, visit or e-mail

Upcoming ACS Trauma Quality Program Transition

As you know, ACS Quality Programs, including Trauma, have partnered with QuintilesIMS to build a comprehensive and integrated system for patient and facility data collection and report delivery, with the overarching goal of improving trauma care and advancing data quality. We are pleased to announce that the new platform for the ACS Trauma Quality Program will be launched in July 2017.

The new data collection platform will introduce a number of innovative features including modernized data collection and validation processes, dynamic submission frequency reports that allow patient-level drilldown to help identify issues at the point of submission, and improvements to the reporting applications released in conjunction with each TQIP report.

After June 30, 2017, we will no longer use the current data center for participation in the ACS Trauma Quality Program. In addition, we will not accept updates to facility information on the current data center after June 2, 2017. As we move toward the launch of the new platform, we will provide updates, instructions, and training to help you and your team make the transition and get the most from the new system. Please be assured that we are committed to providing continuous service and support throughout the transition to our new system.

Thanks very much for your participation. Please contact us at with comments and questions

2017 TQIP Annual Scientific Meeting and Training

2017 TQIP Meeting

We are excited to be holding the 2017 American College of Surgeons Trauma Quality Improvement Program’s (TQIP) Scientific Meeting and Training in Chicago, IL, November 11–13, 2017. The meeting will be conveniently located at the Hilton Chicago near many of the city’s main attractions.

Last year, we had 1,579 conference attendees representing over 500 hospitals and Collaboratives. The conference program offered exciting insight into a variety of topics, including the Palliative Care Best Practice Guidelines and a round table discussion on Lessons Learned from the Orlando Mass Shooting. J. Wayne Meredith, MD, FACS, gave the keynote address: TQIP: Where Have We Been? Where Can We Go?  Thank you to all of our speakers and attendees who contributed to another very successful meeting!

The 2017 TQIP Annual Scientific Meeting and Training will include registry-specific, trauma medical director, and trauma program manager-directed breakout sessions to make sure everyone receives the knowledge most useful and pertinent to their role on the TQIP team. We will also have tracks for our Level III TQIP participants and our pediatric providers. Topics of note this year include TQIP Collaboratives, preventable death, and the continued Integration of Verification, TQIP, and PIPS.  The TQIP Best Practices project team will present on Imaging for Trauma Patients (adult and pediatric), with a panel of experts to match. 

We are very pleased to announce that our Keynote Speaker is Lenworth M. Jacobs, Jr., MD, FACS, Chairman of the Hartford Consensus.

Call for Abstracts Opened May 1

On May 1, we started accepting abstract submissions for the TQIP Annual Scientific Meeting and Training. This is your chance to share with other TQIP centers all the interesting initiatives you have put in place at your hospital. We want to know what internal PI efforts you have embarked on and how you have been using TQIP in your center. Registry staff, we strongly encourage you to present any data quality initiatives you have put in place that have made a difference in your centers. Abstracts may be chosen for oral presentations or posters. Determinations will be made based on subject matter, strength of PI process including loop closure, and the use and strength of data. Those who had posters and presentations last year are encouraged to resubmit with additional outcome data or loop closures.

For more information about the TQIP Annual Scientific Meeting and Training, including submitting abstracts, please visit the meeting website or contact TQIP staff at

Update on the TQIP Committee Spring Meeting

The Trauma Quality Improvement Program (TQIP) Committee saw record attendance (standing room only) at this year’s spring meeting. Attendees and committee members were introduced to the Committee’s new work group structure and invited to sign up for one of the work groups’ post-meeting. These work groups will concentrate on important areas of focus for TQIP: Pediatrics, Collaboratives, Level III TQIP, Quality Measures, Orthopaedics, and the National Trauma Data Standard. Each work group is being led by an expert in the field and has a charter defining its purpose, mission, and approved projects.

Projects to come out of these work groups include a toolkit for developing a TQIP Collaborative, the development of six trauma quality measures based on TQIP data that can be used to populate the SSR and be transmitted to CMS, the identification of postdischarge outcome measures for pediatrics, identifying important outcomes for the Level III TQIP report, the creation of an orthopaedic section in the TQIP benchmark report, and more. Each work group will report out to the full committee at our spring and fall TQIP committee meetings.

For more information about the new TQIP committee work group structure, please e-mail

TQIP National Physician Identifier (NPI) and the SSR

To TQIP Medical Directors and Surgeons, 

The ACS Committee on Trauma has developed trauma quality measures to allow for surgeons to submit data through the Surgeon Specific Registry (SSR). Submitting trauma quality measures data through the SSR will help surgeons meet the requirements of the Centers for Medicare and Medicaid Services (CMS) Quality Payment Program’s (QPP) Merit-Based Incentive Payment System (MIPS), allowing them to avoid a negative 4 percent payment adjustment in 2019 based on their performance in 2017. In previous years, few trauma surgeons have taken advantage of the opportunity to use the SSR for the PQRS program, as it required additional data entry and the measures applied to relatively few patients. 

As of January 2017, the National Trauma Data Standard has been modified so that the National Physician Identifier (NPI) can be captured if entered by your trauma registrar. We are currently modifying the SSR along with our performance measures to allow TQIP data to flow directly into the SSR and then, with approval and minimal effort on your part, to CMS. We anticipate having this implemented in early 2018. This would mitigate the need to enter performance measures data directly into the SSR and allow you to meet the MIPS requirements. This will dramatically ease participation in the MIPS program for surgeons, and we anticipate that it will increase the number of physicians reporting through this mechanism. 

As defined, the NPI will be that of the admitting trauma surgeon. The performance measures we develop will be aligned to reflect the care provided by the admitting trauma surgeon. It is important to note two aspects of this process. First, submission of the NPI is not a mandatory field. If you want this data point entered, you must communicate with your registrar to ensure it is collected and submitted. The trauma registry vendors should have modified your registry to allow for this data collection as of January 2017. The second important point is that submission of any surgeon’s data to the SSR and then on to CMS will not occur unless you request this specifically. The process for requesting that your data flow into the SSR will be announced at a later date.

For more information on CMS Quality Payment Programs, please refer to the ACS FAQ about MIPS and  CMS MIPS Participation Fact Sheet.


Avery B. Nathens, MD, PhD, FACS
Medical Director, Trauma Quality Programs
American College of Surgeons

National Trauma Data BankThe Annual NTDB Call for Admission Year 2016 Data Is Now Open

The National Trauma Data Bank® (NTDB®) officially opened the annual call for admission year 2016 data on April 3, 2017. The NTDB remains the largest aggregation of U.S. trauma registry data ever assembled. Registry data that is collected from the NTDB is compiled annually and disseminated in the forms of hospital benchmark reports, data quality reports, and research data sets. At the opening of the Call for Data, the NTDB contained more than 7 million records. Last year, the call for Admission Year 2015 data resulted in over 860,000 records submitted from 747 facilities. We expect a great deal of participation again this year.

The NTDB annual Call for Data will close on June 1, at 12:00 midnight (CDT).

Questions about NTDB? E-mail