trauma room

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

Matthew Mowry, MSN, RN, TCRN, CEN, NE-BC, Accreditation Specialist

Preparing for Site Survey

Eligible Trauma Centers that elect a virtual survey should refer to the PTSF Policy AC-141 and the Virtual Survey Guidebook

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.

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.