ACS Standard 7.3: What Trauma Programs Need to Know

The American College of Surgeons (ACS) recently updated Standard 7.3, a component of the revised Commission on Cancer (CoC) accreditation standards. This update emphasizes quality improvement initiatives that enhance patient care by incorporating Social Determinants of Health (SDOH) and patient-centered approaches in cancer treatment.

While the ACS Commission on Trauma (COT) operates separately from the CoC, this update is still relevant to trauma program leadership and the broader hospital system.

What’s in the ACS Standard 7.3 Update?

The updated standard encourages programs to develop quality improvement initiatives in cancer care that focus on:

• Cultural competency – Ensuring healthcare providers respect and accommodate diverse cultural backgrounds and language needs.
• Health equity interventions – Identifying and reducing disparities in cancer care to ensure all patients have equitable access to services.
• Individualized shared decision-making (SDM) – Supporting informed, collaborative treatment choices that empower patients.

Why Should Trauma Programs Pay Attention to ACS Standard 7.3?

Even though trauma centers are not directly audited under CoC standards, aligning your program with these initiatives can improve patient outcomes and operational efficiency.

Historically, trauma care and oncology care have operated in silos at many hospitals, leading to gaps in treatment, inefficiencies, and missed opportunities for data-driven insights.

However, cancer programs are already collecting key data points—such as demographics, care timelines, and outcomes—that trauma registries also track. Integrating this data can enhance care coordination and research.

Impact on Patient Outcomes

Cancer patients are particularly vulnerable to trauma, facing unique challenges that impact treatment and recovery. High-quality data on trauma and cancer patient overlap is essential for optimizing care, reducing delays, and improving patient outcomes during acute incidents.

With more robust datasets, hospitals could answer critical questions about best practices, ideal treatment timelines, and procedural optimizations for cancer patients experiencing traumatic injuries.

Integrated Hospital Quality Improvement

Leading hospitals are moving toward interdisciplinary quality improvement efforts, leveraging data across departments. Trauma programs play a key role in these system-wide efforts, and collaboration with oncology, emergency medicine, and hospital leadership is essential.

New Trauma Protocols in 2022

In 2022, the ACS introduced major updates to the Resources for Optimal Care of the Injured Patient (Seventh Edition), which emphasized:

• Developing new clinical protocols, including those for cancer patients with traumatic injuries.
• Setting benchmarks for specialist response times to ensure timely, coordinated care.

Aligning with Standard 7.3 can complement these trauma-specific protocols, reinforcing a hospital-wide commitment to data-driven performance improvement.

Aligning with ACS Standards

Hospitals that proactively engage in interdisciplinary quality initiatives will be better positioned for future accreditation requirements. The ACS continues to advocate for data integration and equity-focused initiatives, recognizing that healthcare is increasingly interconnected.

To get a clear picture of how this update can shape your requirements in the future, it’s important to understand ACS’s mission and history. The 2024 update to Standard 7.3 is similar to the 2022 trauma standards update in that they both emphasize data-driven performance improvement and patient-centric approaches. The ACS also has a track record of extending requirements from one Commission’s standards update to others in subsequent years.

How can your trauma PIPS process contribute?

Trauma Performance Improvement and Patient Safety (PIPS) programs can incorporate cancer-specific data points to track surgical delays and consult times—for example, for trauma patients with cancer. When considering the overarching goals of the hospital system, choose data points that can illuminate challenges and help resolve them. What are your health system’s mission and priorities? How can this initiative support the hospital system’s goals?

Expand trauma registry fields to capture cancer history, treatment status, and outcomes—supporting your trauma team directly as well. Align with Standard 7.3 and incorporate equity-based data, such as demographics (race, ethnicity, primary language, socioeconomic status, etc.), into your review.

A review could find, for example, that trauma patients with active cancer experience extended stays due to delays in oncology clearance, leading to worse outcomes. This issue could also disproportionately affect certain groups. The PI team can use these insights to develop new protocols for coordinating care.

Before expanding data collection, collaborate with interdepartmental colleagues. Secure buy-in from the start to ensure alignment and discuss how to track this data uniformly and effectively.

Get connected: Work with the cancer program’s quality improvement teams to integrate data from the trauma and cancer registries. This could involve sharing key points or setting up a cross-departmental reporting mechanism. Interoperability enables bidirectional data exchange using HL7, FHIR, or other standardized interfaces for seamless data sharing.

Standardize definitions: Align your data dictionaries to ensure consistent metrics across the board. If you’re tracking apples, everyone needs to agree on what an apple is in order to recognize and use the data effectively.

Hold regular reviews: Collect and report data in interdisciplinary performance improvement reviews, ensuring that shared quality initiatives (such as cultural competency and equitable access in the case of Standard 7.3) are addressed in meetings with key stakeholders. If necessary, establish a joint PI committee to review cross-departmental quality data.

Specialized tools, like the state-of-the-art PI and complications module included as a standard feature in ImageTrend Patient Registry, can play a major role in organizing, analyzing, and managing data.

The Future of Trauma-Cancer Collaboration

Any time we bridge the gap in healthcare information and communication, hospital workflows improve along with patient care and outcomes. While trauma centers are not yet required to comply with ACS Standard 7.3, aligning with its principles can prepare them for future accreditation changes and reinforce their role in providing equitable, high-quality care.

“Trauma data isn’t about filling out a report.”

It’s about driving meaningful improvements in care. Talk to an expert today to see how ImageTrend Patient Registry™ and its state-of-the-art PI and Complications Module can help your program track custom data points, monitor trends in real-time, and support equity-focused quality initiatives.