Quality improvement (QI) is a central tenant of trauma center accreditation in most countries, but its effectiveness is largely unknown. We sought to explore opportunities for improving trauma QI. Methods: We performed a qualitative research study using grounded theory analyses of interviews with medical directors and program managers from 75 verified trauma centers sampled from the United States (n = 51), Canada (n = 14), and Australasia (Australia and New Zealand [n = 10]) to explore experiences with trauma QI activities and identify opportunities for improvement. Results: Most trauma centers indicated that they perceived trauma QI to be important and devoted personnel for QI (data entry, data analyst, educator, nurse practitioner). Programs identified 5 principal opportunities to improve trauma QI: (1) ensure resource adequacy (human resources, registry maintenance, financial support, institutional support), (2) encourage stakeholder participation (engagement, communication, coordination), (3) ensure clinical relevance, (4) incorporate evidence-based tools, and (5) require provider and QI program accountability. Conclusions: Quality improvement programs exist as accreditation requirements in most centers. However, trauma QI practices depend on a range of local and regional factors, and concrete opportunities for improvement that address impact and sustainability exist.