For Registrar, TPM

Surface potential PI issues through registry case review.

For TPM, TMD, Trauma team

Surface potential issues from overnight activity and active trauma cases.

For TPM, ICU team

Surface potential issues from ICU trauma cases and care concerns.

For TPM, Nursing team

Surface potential issues from inpatient trauma cases and care concerns.

For TPM, ED liaison

Surface potential issues from emergency department entries relevant to trauma care.

For TMD, TPM, PIM

Validate the potential issue and determine the appropriate review outcome.

For TPM, TMD

Review clinical questions, documentation, and proposed next steps.

For TPM, Relevant specialty, Nursing leadership

Obtain focused review from the involved clinical discipline.

For TPM, TMD, Relevant stakeholders

Review cases requiring focused discussion beyond the initial review.

For PI Committee, TMD, TPM

Review PI cases, actions, and loop-closure progress.

For TMD, Trauma faculty, TPM

Review mortality and significant clinical cases.

For PI Committee, Clinical disciplines

Review care across teams and services.

For EMS liaison, TPM, Prehospital partners

Review prehospital trauma care and handoff concerns.

For TPM, Operations leadership

Review process, systems, and resource issues.

For TPM, TMD, Data / quality team

Review TQIP findings, trends, and improvement priorities.

For Hospital Quality, Risk Management, TPM

Review cases requiring hospital quality or risk-management involvement.

For Hospital administration, TMD, TPM

Review cases requiring executive oversight or organizational action.

For External reviewer, Subject matter expert, TPM

Obtain independent expertise when needed.

For Regional trauma council, TPM, TMD

Coordinate review across the regional trauma system.

Provide targeted education and document completion.

Address the issue with the responsible individual and document follow-up.

Monitor similar cases over the coordinator-defined interval against a stated goal.

Update the guideline or pathway that contributed to the issue.

Link the case to a related PI project and track its outcome.

Revise the applicable policy and document adoption.

For PI assignee, TPM

Implement the action and confirm near-term effectiveness for this case before closure.

For TPM, PI Committee

Record the action, effectiveness review, and closure rationale.

Close the case record after loop closure is documented.

For PI Coordinator, TPM, PI Committee

Review performance data, watch for drift, and check for new barriers after closure.

Document that performance remains at or above target.

Open a new improvement cycle when compliance falls below target.