Community-based trauma systems in the United States: An examination of structural development

Objective: To examine the organizational, political, and community characteristics that facilitate or impede community progress in developing a coordinative network of health services for trauma delivery. Study Setting/Design: A comparative case study design was used to examine trauma network development in 6 U.S. cities with a population of 1 000 000 or more. Five key coordinative activities were selected for study. Each study site varied in the set of activities that had been implemented. Data Sources: Information on the structure and composition of local trauma coordinating councils; interviews with a common set of informants in each site using a semi-structured interview protocol. Study Methods: The literature on interorganizational community structures and local policy development was drawn upon to create a conceptual framework for assessing the development of a coordinative service network. Analytical techniques included network analysis to understand the linkages across organizations in overseeing trauma network operations, assessment of leadership structures to identify central actors and organizations, and pattern matching techniques of case study analysis to identify factors that affected trauma network development. Principal Findings: Leaders capitalized on local events and were instrumental in keeping network development on the top of the political agenda. Successful leaders spent substantial time and energy documenting problems, assessing the needs and understanding of stakeholders, educating stakeholders and politicians, and creating trust and shared understanding of values. Conclusions: Prior research has documented the importance of central actors and organizations in developing coordinative networks. The unique contribution of our research is its insights on how central actors and organizations are more likely to motivate collaboration in situations where they lack control over the allocation of payments across involved organizations. Our research suggests that under these circumstances central players should focus their time and energy educating stakeholders and developing a shared understanding rather than using their centrality to impose a particular coordinative structure. To date, U.S. trauma networks have served as models for other industrialized countries, and thus, lessons learned in the U.S. about implementing interorganizational networks of trauma care can assist other countries achieve more effective coordination and avoid mistakes that impede progress. (C) 1998 Elsevier Science Ltd. All rights reserved.