Implementing a trauma data quality plan using ACS Standard 6.1

Authored by:
Angie Chisolm, MBA/HCM, BSN, RN, CFRN, TCRN
President and Managing Partner

High-quality data is the foundation for effective trauma care improvement. The American College of Surgeons (ACS) Standard 6.1 emphasizes the importance of establishing a comprehensive trauma data quality plan. This standard ensures that trauma registries maintain accurate, reliable, and actionable data to support decision-making and performance improvement. Here’s a roadmap to implement a robust data quality plan aligned with ACS Standard 6.1.

  1. Define data quality goals:  Start by setting clear objectives for your trauma data quality plan. These should align with ACS guidelines and focus on accuracy, completeness, and timeliness. For example, aim for a 95% or higher accuracy rate in registry abstraction and ensure all cases are entered within 30 days of patient discharge.
  2. Establish data validation processes:  Regular data validation is critical to meet ACS Standard 6.1. Implement the following processes:
    • Audits: Conduct periodic random audits of trauma registry records to verify accuracy and consistency. Inter-rater reliability (IRR) is a form of audit focused on assessing consistency among different abstractors. IRR evaluates whether multiple registry staff members interpret and record information from source documents in a consistent manner. This process helps identify variability in data abstraction, uncover training needs, and improve the overall reliability of the data collection process.
    • Logic checks: Use software tools to identify discrepancies, such as mismatches between patient outcomes and injury severity scores. For instance, flag cases where a low ISS is recorded for a patient who experienced unexpected mortality, as this might indicate potential errors in scoring or incomplete documentation of injuries. Another example of a logic check is to identify cases where the number of recorded ICU days is greater than zero, but there is no documentation of an ICU admission. This discrepancy could indicate either a missing ICU admission record or an error in the recorded ICU days.
    • Benchmark comparisons: Compare your data against national or state benchmarks to identify outliers or errors. 
  3. Provide ongoing training for registry staff:  Ensure your trauma registry staff are well-versed in coding standards, data entry protocols, and the use of registry software. Offer ongoing training and certification opportunities to maintain high levels of proficiency. The ACS Trauma Quality Improvement Program (TQIP) training resources are excellent tools for this purpose.
  4. Integrate multidisciplinary collaboration:  Data quality improves when clinical and administrative teams collaborate. Regularly engage trauma surgeons, nurses, and performance improvement staff to review data and address discrepancies. Their insights can help bridge gaps between clinical practice and data abstraction.
  5. Monitor key performance indicators (KPIs):  Develop KPIs to track the effectiveness of your data quality plan and incorporate these metrics into your quality dashboard to facilitate monitoring and ensure compliance. Examples include:
    • Percentage of records completed within the required timeframe
    • Accuracy rate of abstraction audits (inter-rater reliability measures)
    • Number of logic errors identified and resolved

    6. Regularly report these metrics to your trauma program leadership and use them to guide quality improvement initiatives.

  6. Create a culture of accountability:  Data quality is a shared responsibility. Foster a culture where staff understand the importance of accurate data and feel empowered to flag concerns. Recognize and reward efforts that contribute to maintaining high data quality standards.
  7. Leverage technology for efficiency:  Use trauma registry software and automated tools to streamline data validation and reporting. Many software solutions offer built-in quality assurance features to help meet ACS requirements more efficiently.

By implementing a trauma data quality plan aligned with ACS Standard 6.1, trauma centers can ensure the integrity of their data, drive meaningful performance improvements, and ultimately enhance patient outcomes. 

Visit our resources webpage to download an example of a Data Quality Plan.