PTSF Trauma Accreditation Site Survey
Amy Kempinski, MSN, RN, CEN, TCRN, PTSF Vice President
Darlene Gondell, MSN, RN, CCRN-K, CNRN, TCRN, Director of Accreditation
Kristen DiFiore, MSN, RN, TCRN, Accreditation Specialist
Preparing for Site Survey
- Read the Site Survey Guidebook to prepare for the accreditation site visits. Applicable for all trauma levels, accredited or pursuing accreditation
- Complete the Application for Survey (AFS). The PTSF recognizes that the pandemic resulted in temporary changes to standard processes and care. To assist hospitals in completing the AFS, the PTSF created this guide: AFS Responses in the Setting of COVID-19
- AFS User Manual located on the home page of the Central Site Portal
- AFS Attachment and Report List
- Survey Eligibility Requirements signed by hospital administration. The PTSF President will sign the document after the AFS submission.
- Multidisciplinary Peer Review PI Meeting Attendance Log Template, Required for AFS
- Optional Trauma Program Manager Continuing Education Template and Trauma Program Medical Director Continuing Education Template are available on the home page of the Central Site Portal
- Submit the Site Survey Schedule and Participant Form to the PTSF three-weeks prior to site survey
- Three 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
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 & Credentialing Site Survey Report (use the Excel template or Word template)
- The Site Surveyors document their observations from survey day and Medical Record Review in the PTSF Site Surveyor software. Screenshots of the software are available on the home page of the Central Site Portal to assist trauma program staff, specifically those who will be Chart Navigators on survey day, in preparation for the accreditation survey.
What happens after your hospital’s site visit?
The PTSF Board will hold deliberations thoroughly reviewing and discussing applicants to determine successful and unsuccessful accreditation of new and/or existing trauma centers. A blinded vote is made, 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 Accreditation Deliberation Decision