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PI - Regulatory Compliance & Standards


Committee Chair
Victoria Myers, BSN, RN, TCRN


Committee Co-Chair
Crystal Jones, BSN, RN, TCRN

Mission and Purpose

The STN Performance Improvement Special Interest Group (PI SIG) Regulatory Compliance and Standards Subcommittee serves as a collaborative forum dedicated to advancing trauma program compliance, regulatory preparedness, and performance improvement excellence. The subcommittee supports trauma professionals by translating trauma center standards into actionable strategies, fostering peer-to-peer learning, and developing practical resources that promote survey readiness, sustainable compliance, and effective performance improvement programs.

Primary Focus Areas

The subcommittee focuses on topics identified through member feedback and national trends, with particular emphasis on frequently cited ACS standards and survey preparedness. Work is informed by challenges and educational needs identified through the STN PI SIG membership survey and ongoing discussions with trauma professionals across all trauma center levels.

Current Projects and Initiatives

Over the past year, the subcommittee has conducted reviews of commonly cited ACS standards and facilitated collaborative discussions on strategies for monitoring, documenting, and sustaining compliance. A major area of emphasis has been ACS Standard 7.3 (Documented Effectiveness of the PIPS Program) with subgroup work centered on helping trauma programs define what effective PI documentation looks like in practice. This includes clarifying expectations for event identification, effective use of audit filters, demonstrated loop closure, corrective actions, and sustained improvement measured over time. Additional ACS standards address include:

  • Surgical Specialty Response Times (ACS Standards 5.17 and 5.21)
  • Mental Health Screening (ACS Standard 5.29)
  • Alcohol Misuse Screening and Intervention (ACS Standards 5.30 and 5.31)
  • Trauma Multidisciplinary PIPS Committee Attendance (ACS Standard 7.6)
  • Trauma Registry Requirements (ACS Standards 4.31, 4.32, 4.33, and 6.2)

The group is also assembling examples, templates, monitoring strategies, and best practices that can be adapted by trauma centers to strengthen compliance efforts and support site visit preparation.

Future Goals and Opportunities for Member Involvement

The subcommittee will continue expanding its resource library and developing practical tools to assist trauma professionals with implementation of ACS standards, performance improvement processes, and verification readiness. Future priorities include additional standards-specific guidance documents, survey readiness resources, policy and monitoring tool examples, and sharing innovative approaches used by trauma centers nationwide. Members are encouraged to participate in discussions, contribute resources and examples, share lessons learned from site visits, and assist with development and peer review of future educational and compliance materials.

This ongoing collaboration aims to strengthen the collective knowledge of the trauma community while promoting consistent, sustainable, and evidence-informed approaches to regulatory compliance and trauma performance improvement.

Crystal Jones is a Performance Improvement Coordinator at Vanderbilt University Medical Center, an ACS-verified Level I Adult Trauma Center in Nashville, Tennessee. She began her nursing career in VUMC's Trauma ICU and has worked across multiple Level I trauma centers throughout Tennessee. Her experience includes roles as a Clinical Staff Leader, Trauma Educator, and PI Coordinator. Crystal is a member of the Society of Trauma Nurses (STN) TACTIC Committee and serves as ATCN Faculty.

Victoria Myers is the Trauma Performance Improvement Coordinator at ECU Health Medical Center, a Level I Adult Trauma Center in Greenville, North Carolina. With more than ten years of nursing experience and a background in the Surgical-Trauma Intensive Care Unit, she is passionate about nursing education, regulatory compliance, and data-driven performance improvement. Victoria also serves as ATCN Faculty, a member of the STN Clinical Committee and participates in various state level performance improvement committees and initiatives.