Title
a. Authorize the Interim Chief Executive Officer for Natividad Medical Center (NMC) or a designee to execute a retroactive non-standard agreement with American College of Surgeons (“ACS”) for participation in the Trauma Quality Improvement Program (TQIP) to support trauma data benchmarking and quality improvement activities at NMC for a maximum County obligation of $122,540 for the term of July 1, 2026 through June 30, 2031.
b. Approve the NMC’s Interim Chief Executive Officer’s recommendation to accept non-standard contract provisions within the agreement.
c. Authorize the Interim Chief Executive Officer for Natividad Medical Center or a designee to execute up to three (3) future amendments that do not exceed 10% ($12,254) of the original agreement, do not significantly change the scope of services, and do not increase the total not to exceed amount over $134,794.
Report
RECOMMENDATION:
It is recommended the Board of Supervisors:
a. Authorize the Interim Chief Executive Officer for Natividad Medical Center (NMC) or a designee to execute a retroactive non-standard agreement with American College of Surgeons (“ACS”) for participation in the Trauma Quality Improvement Program (TQIP) to support trauma data benchmarking and quality improvement activities at NMC for a maximum County obligation of $122,540 for the term of July 1, 2026 through June 30, 2031.
b. Approve the NMC’s Interim Chief Executive Officer’s recommendation to accept non-standard contract provisions within the agreement.
c. Authorize the Interim Chief Executive Officer for Natividad Medical Center or a designee to execute up to three (3) future amendments that do not exceed 10% ($12,254) of the original agreement, do not significantly change the scope of services, and do not increase the total not to exceed amount over $134,794.
SUMMARY:
Natividad Medical Center will receive trauma quality improvement services through the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP). The program provides a standardized, national framework for evaluating trauma care and outcomes through the collection and analysis of trauma patient data. Through participation in ACS TQIP, Natividad Medical Center will receive comparative performance information, risk-adjusted benchmarking, and quality improvement resources designed to help identify opportunities to improve trauma care and patient outcomes.
Trauma registry data will be maintained and submitted in accordance with ACS TQIP requirements, and the trauma program will review available reports and benchmarking information to identify opportunities for improvement. Findings will be incorporated into the trauma program's performance improvement and patient safety activities, as appropriate.
DISCUSSION
Natividad Medical Center is verified by the American College of Surgeons (ACS) as an adult level II trauma center. In order to maintain verification, the trauma center must meet specific requirements established by the ACS and published in The Optimal Care of the Injured Patient document. Participation in ACS TQIP provides Natividad Medical Center with an established, nationally recognized framework for evaluating the quality of trauma care. The program allows Natividad Medical Center to compare risk-adjusted trauma outcomes and performance against other participating trauma centers, helping the organization identify areas where care processes can be strengthened.
ACS TQIP further benefits Natividad Medical Center by providing access to standardized trauma quality measures, data analysis, and educational resources that can assist clinicians and trauma program staff in evaluating and improving the delivery of trauma care.
OTHER AGENCY INVOLVEMENT:
The Office of County Counsel has reviewed and approved this participation agreement as to form, and the Auditor-Controller has reviewed and approved as to payment provisions. The participation agreement has also been reviewed and approved by NMC’s Finance Committee and by its Board of Trustees on October 2, 2026.
FINANCING:
The cost for this participation agreement is $122,540 of which $24,000 is included in the FY 2026-27 Adopted Budget. Amounts for remaining years of the agreement will be included in those budgets as appropriate. There is no impact on the General Fund with this action.
BOARD OF SUPERVISORS STRATEGIC PLAN GOALS SECTION:
ACS TQIP supports improvements in patient care by providing trauma centers with objective data regarding clinical outcomes and opportunities for improvement. The ability to compare outcomes and care processes with national benchmarks helps Natividad Medical Center identify opportunities to improve the timeliness, consistency, safety, and effectiveness of trauma care.
_X_ Well-Being and Quality of Life
__ Sustainable Infrastructure for Present and Future
__ Safe and Resilient Communities
__ Diverse and Thriving Economy
__ Administrative
Prepared by: Chelsi Mettler, RN, Interim Trauma Program Manager, 831-772-7326
Approved by: Nancy Buscher, Interim Chief Executive Officer, 783-2553
Attachment(s):
Board Report
American College of Surgeons for Trauma Quality Improvement Program Participation Agreement
Attachments on file with the Clerk of the Board