trauma room

PTSF Trauma Accreditation Site Survey

Amy Krichten, MSN, RN, CEN, TCRN, Director of Accreditation

Darlene Gondell, MSN, RN, CCRN-K, CNRN, TCRN, Manager of Accreditation

Preparing for Site Survey

Trauma Centers elevating their level of trauma center accreditation should refer to PTSF Policy AC-138

Level IV Trauma Centers with a Mid-Cycle Panel Review will follow the process outlined in PTSF Policy AC-139

PTSF Accreditation Staff provide education on the accreditation process and site surveys to all pursuing hospital’s trauma program staff and new trauma program leadership at accredited trauma centers. Contact PTSF Staff to request additional accreditation education sessions

Prepare for the 2022 Hybrid Survey

Due to the ongoing COVID-19 pandemic the 2022 site survey process will be completed in the hybrid format. This video will outline what the PTSF hybrid survey format will look like and how to prepare for it. If you have any questions please contact the PTSF Accreditation Team.

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 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.