PTSF Trauma Accreditation Survey
Darlene Gondell, MSN, RN, CCRN-K, CNRN, TCRN, Director of Accreditation
Annalisa Negrea, BSN, RN, CEN, Manager of Accreditation
Jen Lau, MSN, RN, CNML, CEN, CPEN, Manager of Accreditation
Allison Saia, BA Accreditation Coordinator
Preparing for Survey
- Read the Survey Guidebook to prepare for the accreditation visits. Applicable for all trauma levels, accredited or pursuing accreditation.
- Watch the Trauma Center Preparation: 2026 Survey Preparation video if your center is having a site survey.
- Required for TPMs and TPMDs at pursuing centers within a year of the 1st survey.
- Required for TPMS and TPMDs at accredited trauma centers within a year of their 1st survey in the role.
- Recommended for all TPMs, TPMDs, TPICs and Mentors having a site survey in 2026.
- Please reach out to Allison Saia, Accreditation Coordinator, for the access code.
- Complete the Application for Survey (AFS) – provided to each hospital with a 2025 accreditation survey
- AFS User’s Manual
- AFS Attachment and Report List
- Survey Eligibility Requirements signed by hospital administration. The PTSF President signs the document after the AFS submission.
- Required for AFS
- Multidisciplinary Peer Review PI Meeting Attendance Log Template
- Over-Undertriage Template (Instructional video for each version available in TraumaHQ Library)
- Over-Undertriage Template – Excel Version
- Over-Undertriage Template – Power BI Version (Located in TraumaHQ Library)
- Optional for AFS
- Submit the Site Survey Schedule and Participant Form to the PTSF three-weeks prior to site survey. Provided to individual hospitals.
- Four weeks prior to survey, the PTSF will communicate the Medical Records Selection.
- Institutions with Alternate Pathway providers will submit the Alternate Pathway Provider Medical Record Form one week prior to survey.
Eligible Trauma Centers that elect a virtual survey should refer to the PTSF Policy AC-141 and the Virtual Survey Guidebook (Coming Soon).
Trauma Centers elevating their level of trauma center accreditation should refer to the PTSF Policy AC-138.
Level IV Trauma Centers with a Mid-Cycle Panel Review will follow the process outlined in the PTSF Policy AC-139.
What happens on survey day?
On survey day, the trauma surveyors—our “outside” trauma experts and fact finders—enter information and comments relevant to the care of the injured patient and the compliance with the PTSF Standards of Accreditation (Standards) into the electronic survey software. Information in the survey software, reports, trauma program documents/policies, timeliness charts, and the clarification letter from the trauma program will be blinded to remove all identifiers. All blinded survey/accreditation information is presented to the PTSF Board.
- Opening Conference
- Physician, Nursing & Collaborative Services Group Meeting(s)
- Significant Issue Presentation (if applicable) and Performance Improvement Overview
- Hospital Tour
- Medical Record Review
- Closing Leadership Meeting
- Provide the PTSF Staff with the Education and Credentialing Site Survey Report (use the Excel Template or Word Template)
- The Site Surveyors document their observations from survey day and Medical Record Review. (Screenshots Coming Soon)
What happens after your hospital’s site visit?
The PTSF Board holds deliberations to thoroughly review and discuss applicants to determine successful and unsuccessful accreditation of new and/or existing trauma centers. All hospital materials are redacted for a confidential vote, and the majority vote determines whether a hospital receives accreditation/reaccreditation, the duration of the accreditation, the status of previously cited significant issues, any new significant issues, strengths, and opportunities for improvement.
- An Accreditation Report will be sent to you outlining status of previous significant issues, new significant issues, strengths, opportunities for improvement, queries, and medical record review. Refer to the Site Survey Guidebook for details.
- Significant Issue Action Plan Template
- PTSF will award hospitals with Certificates of Accreditation
- In 2020 the Board of Directors approved extending the length of certificates for Level I-III Trauma Centers that meet criteria outlined in the PTSF Policy AC-140
- Hospitals have the option to request reconsideration of the Board of Directors Decision AC-136