This study was designed to document the reasons hospitals have been unsuccessfully peer reviewed as potential trauma centers.Method: 120 trauma center reviews were performed by a peer review program between September 1987 and December 1992 using the American College of Surgeons (ACS) criteria. Fifty-four hospitals had criteria deficiencies. These reviews were studied for criteria deficiencies for each hospital with documentation of frequency and relationship to re-review outcome.Results: There are 108 ACS criteria. The 54 hospitals had various combinations of 28 different criteria deficiencies. Deficiencies ranged from 1 to 15 per hospital. Thirty-one hospitals underwent a second review. Twenty-five hospitals had corrected the deficiencies and were verified. No hospital with over 8 deficiencies was subsequently verified. The Quality Improvement program was the most common deficiency (74%) and was correctable (50%). Other frequent deficiencies were no trauma service (46%), no surgeons in ED (41%), inadequate neurosurgeon response (35%), no trauma corrdinator (31%), no trauma registry (28%), lack of surgical commitment (26%), and lack of 24 hour OR availability (24%). The lack of surgeon or hospital commitment accounted for most of the 28 criteria deficiencies. Subsequent verification was notably poorer for hospitals seeking verification for the purpose of designation versus verification only (29% versus 75%). Only 1 hospital with a prior ACS consultation visit failed the first verification review.Conclusions: A limited but critical set of criteria enable a hospital to function as a trauma center. Trauma quality improvement is a poorly understood but a correctable issue. Surgical and hospital commitment are essential for verification. Prior consultation may be of benefit.