Trauma centers receive survey deficiencies for many reasons — inadequate specialty coverage, insufficient registry staffing, ineffective PI processes and other compliance challenges. But the root cause of all these problems goes deeper than any specific compliance issue.
In my experience, the underlying cause of most trauma program deficiencies is lack of informed leadership commitment at the senior or executive level.
This will not be a revelation to most trauma program leaders. Inadequate executive support is an ongoing challenge in the world of trauma, and everyone knows that the solution is to “engage” executive leaders. But exactly how do you begin engaging an executive group that has already demonstrated its ability to be underinformed and disconnected?
I propose adopting a fresh approach — mentoring up.
Mentoring up is a leadership development concept that flips the traditional hierarchy by pairing junior staff (who become the mentors) with senior leaders (who become the mentees).
While traditional mentorship focuses on long-term career guidance for juniors, mentoring up (also known as “reverse mentoring”) is often shorter and it aims to shore up specific knowledge gaps among senior-level professionals.
For example, in a mentoring-up relationship a younger leader (or any individual who is further down the org chart) may help an executive leader understand new technologies, new regulatory requirements or new perspectives on healthcare operations.
The concept of reverse mentoring has been in the business world since the late 90s, and the idea of mentoring up has more recently become an important part of academic career development.
My goal in this article is to show how trauma program leaders can use mentoring up to inform and educate hospital executives, clinical department heads and other key administrators and to empower them to provide true leadership support for the trauma center.
Effective mentoring-up behaviors include proactive communication, regular briefings using dashboards, and clearly articulating what senior leadership must do — not simply what trauma leaders have done.
The mentoring-up approach positions trauma leaders as facilitators and diplomats, acting as the “glue” that connects clinical operations, standards compliance and leadership engagement.
Mentoring executives about their leadership responsibilities
Standard 1.1 of Resources for Optimal Care of the Injured Patient: 2022 Standards underscores that trauma center leadership must demonstrate visible and ongoing commitment to the trauma program.
Unfortunately, many executive and senior leaders have only a limited understanding of what the trauma program is and what support it needs. This leads to a range of problems in resource allocation and organizational accountability.
To mentor executives and other key individuals about trauma center leadership responsibilities, focus on the following points:
The complexity and interdependence of trauma center operations. Many executive leaders do not fully grasp that the trauma center is not just the trauma program or the clinical trauma service but the entire hospital. So as a starting point for mentoring up, make sure all executives understand how departments and functions throughout the hospital contribute to the care of injured patients.
The organizational impact of verification or state designation. All hospital leadership teams are proud of their trauma center status, but executives periodically need to be reminded that ACS verification or state designation is not just a participation trophy, it is a core element of the hospital’s care mission. The literature has demonstrated that trauma center verification leads to significant reductions in morbidity and mortality both nationally and at the state trauma system level. In light of this, the key role of leaders is to ensure that resources are immediately available for timely trauma interventions (the “golden hour”) and that the organization provides standardized, high-quality care with improved protocols.
The president/CEO is the head of the trauma center. While the TMD and TPM lead the trauma program, responsibility for the trauma center is ultimately the responsibility of the president or CEO. A subtle but important point here is that the trauma center verification letter is sent to the hospital CEO with a cc to the TMD and TPM. This underscores the fact that the TMD and TPM are largely facilitators whose role is to ensure each department is aware of the relevant standards and expectations. It is the CEO’s responsibility to hold various officers, vice presidents and directors accountable for trauma center standards. For example, if there is a deficiency in physician attendance, the CMO should be made aware and lean in to assist in gaining compliance. If ED nursing documentation is a deficiency, it is the ED leadership and the CNO who are responsible for resolution and sustainment.
Mentoring executives and functional leaders about the importance of trauma data
ACS Standard 4.31 defines requirements for trauma registry staffing, trauma registry training and data quality expectations. Leadership at many levels must ensure staffing is adequate, appropriately trained and supported — onsite or offsite.
When mentoring executives and functional leaders on trauma data issues, focus on:
Clarifying the operational importance of accurate trauma data. One effective approach is to show how registry data drives not only the trauma PIPS process but also resource planning and other executive-level decision‑making.
Demonstrating the negative impacts of registry delays or errors. Executives and directors need to understand how delays in trauma registry data can affect quality metrics, finances and public reporting. Budget support for the trauma registry is often overlooked simply because the C-suite does not understand that appropriate staffing, staff training, data validation and timing of data submission all require significant resources.
Ensuring department leaders understand their role in supporting registry operations. Trauma programs require a direct line of communication with IT to ensure trauma registry updates and interfaces are working appropriately. Ideally, a specific IT staff member will be assigned to the trauma program to provide prompt support. In addition, HR leaders need to understand registry staffing ratio requirements and the importance of hiring appropriately trained staff.
Mentoring specialty service leaders about their role in trauma care and standards compliance
Several ACS standards emphasize timely and coordinated clinical care, specialty coverage and availability of essential trauma resources. The challenge is that many specialty leaders have a limited view of their service’s role in trauma center operations and trauma patient care.
Mentoring up can address this challenge by:
Reinforcing expectations for 24/7 readiness and rapid response. Start by ensuring that each department head recognizes that trauma care is not optional work — it is a defined responsibility embedded in ACS standards and tied to verification status.
Developing shared accountability for quality outcomes. A key message is that all injured patients are trauma patients whether they are on the trauma service, the orthopedic service, the neurosurgical service or the hospitalist service. Therefore, every service that cares for injured patients has a shared responsibility to adhere to trauma clinical practice guidelines and participate in trauma performance improvement.
Ensuring specialty services understand specific trauma requirements. In many instances, service leaders simply misunderstand trauma compliance expectations. Often, however, a service misinterprets what a standard actually requires. For example, service leaders may agree that specialists must be “available 24/7” — but their patients are nearly always transferred out after 5 p.m. Provide data and education, but this situation may require oversight by the CMO or COO to ensure compliance.
Mentoring all administrative and clinical leaders about their role in trauma PIPS
ACS Standards 7.1–7.10 outline the structure and execution of a fully functional performance improvement and patient safety (PIPS) program. Unfortunately, many administrative and clinical leaders outside the trauma program do not appreciate the importance of their involvement in trauma PI.
Key mentoring-up strategies for ensuring strong PI include:
Sharing regular gap analyses. Keep all administrative and clinical leaders informed on the PI process by regularly sharing a gap analysis. This can be as simple as an Excel spreadsheet with each standard coded green, yellow or red to show leaders where compliance risk exists and where intervention is required. For even better results, each standard should designate one person (not necessarily the TMD or TPM) who is responsible for ensuring compliance.
Aligning PIPS findings with hospital-wide quality and risk initiatives. The most recent revision of Resources for Optimal Care of the Injured Patient clarifies the relationship between the trauma PIPS program and the hospital’s overarching quality department (see Standard 7.1). This is important, because PI is one key way that trauma benefits the entire hospital. For example, if trauma patients are experiencing a high DVT rate, perhaps due to holding doses of chemoprophylaxis, the rest of the hospital might be experiencing the same issue. If so, a unified hospital-wide effort is essential to improving performance for both trauma and non-trauma patients.
Reinforcing leadership responsibility to resolve OFIs or non-compliance issues when barriers exceed trauma’s scope. It often happens that the trauma leadership team identifies a resolution (loop closure) but relevant departments or specialties are not providing adequate support to ensure implementation. In these cases, the C-suite may be required to lean in. Oftentimes, executives only find out about loop closure barriers after they have received an adverse site survey report. Communicating about barriers on an ongoing/scheduled basis, not just in survey years, is important to resolving issues that may take an extended period of time to resolve.
It’s not asking for permission
Mentoring up is not about asking for permission. It is about guiding leadership to fully understand their defined responsibilities under ACS standards and holding department heads responsible for compliance with the standards that are relevant to them.
When trauma leaders mentor up effectively, organizations experience stronger collaboration, faster resolution of compliance gaps, an enhanced culture of accountability and improved patient outcomes.
By mastering the art of mentoring up, trauma centers create a leadership structure that supports sustained readiness, high reliability and consistent success in ACS verification.
