If you have recently learned that your state is planning to adopt and/or will require trauma centers to obtain ACS (American College of Surgeons) verification, take heart. Last week, we spoke with Dan Hamilton, public information associate, at the ACS regarding the process and what administrators and other hospital leaders should know about it. Read on to learn about the first steps for verification and what you should do to prepare.
The consultation/verification process
Once you have completed the application for a site visit, as well as the prereview questionnaire (PRQ), two surgeons will be selected to conduct the review at your facility, and a date—agreed to by all parties—will be determined. Next, according to documentation from the ACS, the state or provincial chair of the ACS Committee on Trauma (COT) and region chief of the Regional Committees on Trauma will be informed. Unless you present a special request to the contrary, reviewers will be from out of state or province.
During the site visit, your organization must provide requested medical records. An explanation of the documents needed will be furnished two to three weeks or more prior to the visit, allowing ample time to assemble medical records for the reviewers’ assessment.
The following measures, as outlined by the ACS, are followed to ensure consistency:
- Completion of the PRQ, which may be done online, to provide site visitors with greater knowledge of your hospital’s current trauma care capabilities, and the performance of your facility and staff
- Furnishing guidelines for the review to all site visitors
- Preparation of a planned agenda to ensure the review is conducted efficiently
- Establishment of a lead reviewer, a standard practice for every site visit team
- A report written in a standardized format
- The Verification Review Committee’s (VRC) final review of all reports
Typically comprised of the review team, trauma director, trauma program manager, and a hospital administrator, these gatherings are held to aid an effective review process. However, others may be asked to participate, too, if they can supply additional information to clarify the PRQ and/or shed further light on standing trauma center activities. Hospital decision makers should know that the meeting will include conversations on issues ranging from the overall trauma program to distinctive features of the institution.
Roughly six to eight hours are required for the on-site review, and each trauma care area of your facility may be visited. What’s more, evaluating records of trauma patients and drawing a relationship between patient care and the performance improvement program is a key component of the review. An exit interview will take place at the end of the visit so reviewers can go over their findings and conclusions. Then, a report will be created—capturing dialog from the exit interview—and sent to the VRC. After the report is reviewed, the VRC will establish if there are deficiencies and whether a hospital can be verified. If your facility receives verification, it will be added to a list of currently verified hospitals, which is maintained online and updated monthly.
More information can be found in the Resources for Optimal Care of the Injured Patient – Sixth Edition, the ACS COT’s manual, which may be downloaded or ordered online. For your trauma center’s locum tenens staffing and permanent placement needs—as well as our consulting, project and resource management, and transition program services—please visit our website or speak with a Medicus Healthcare Solutions business development executive by calling 855-301-0563.