trauma room

Trauma Accreditation Resources

Below you will find information resources and documents put together by the Pennsylvania Trauma Systems Foundation to educate and assist Pennsylvania hospitals and medical center’s pursuits of trauma accreditation.

You’ll find information about how to apply for a site survey, as well the PTSF’s standards of accreditation, including ACS accreditation guidelines.

If the information that you’re looking for can’t be found here, please don’t hesitate to contact a member of our PTSF support staff—they’re always happy to help.

**NEW PENNSYLVANIA TRAUMA PROGRAM NURSE LEADERS**

Save-The-Date for the next Trauma Program Nurse Leader Orientation on November 10, 2021 10 am-2:30 pm. Registration will be available in the Fall

It’s Not About the Chest X-Ray – It’s About Consistency!

ATLS Presentation by Dr. Eric Bradburn, Trauma Program Medical Director at Penn Medicine Lancaster General Hospital on 4/20/2021

Site Survey Information

PTSF Hybrid Survey Webinar
This webinar will assist Pennsylvania hospitals in preparing for a 2021 PTSF trauma accreditation survey. Details of the hybrid format and PTSFs COVID-19 risk mitigation plan for survey day will be presented.
25.58M
Application for Survey
Sign in to access the PTSF Application for Survey
 
Guide to Understanding the Accreditation Report
Guide to Understanding the Accreditation Report
215.27K
Significant Issue Action Plan Template
Required template for submitting an action plan for each Significant Issue identified during the accreditation process. Submit to PTSF Accreditation Staff by the due date listed on the accreditation report cover letter.
59.59K
Site Surveyor Orientation Guide
This Guidebook was developed for Site Surveyors to use as a tool when completing consultative visits and/or site survey accreditation visits.
1.34M
Accreditation Policy (AC-106)
Transition Period for the Implementation of New or Revised Standards of Accreditation
81.93K
Accreditation Policy (AC-114)
Certificates of Accreditation
85.53K
Accreditation Policy (AC-130)
Process for Becoming an Accredited Trauma Center
123.95K
Accreditation Policy (AC-132)
Media Notification Regarding Trauma Center Status
90.52K
Accreditation Policy (AC-136)
Request for Reconsideration of Accreditation Deliberation Decision
89.17K
Accreditation Policy (AC-138)
Process for Elevating Trauma Center Accreditation Level
105.99K
Accreditation Policy (AC-139)
Level Four Trauma Center Mid-Cycle Panel Review
108.33K
Accreditation Policy (AC-140)
Level I, II & III Trauma Center Accreditation Extension--this new policy was adopted by the PTSF Board of Directors on July 23, 2020. Trauma centers surveyed in 2020 that meet the criteria outlined in this policy will be eligible to apply for the one-year extension beginning in spring of 2022. Specific date(s) will be outlined in Accreditation Reports moving forward for eligible trauma centers.
129.11K
2021 AFS Changes Template
For Hospitals whose Site Survey was postposed from 2020 due to the COVID-19 pandemic and will be completed in 2021. Previously submitted 2020 AFS will be utilized in the site survey process and optional changes made to the AFS will be communicated to PTSF Staff on this template.
20.92K

Site Survey Toolkit

Site Survey Guidebook
This Guidebook was developed to assist trauma program staff with their preparation for accreditation site visits. This document is written for all trauma levels, including both pursuing and accredited trauma centers.
475.56K
Site Survey Screen Shots
**2021 Survey Now Available** Screen shots of the questions answered by the Site Surveyors during Medical Record Review. These documents were developed to assist trauma program staff, specifically useful for Chart Navigators, in preparation for the accreditation survey. Located in the Support section of the Central Site Portal.
 
Application for Survey (AFS) User Manual
This Manual was developed to assist trauma program staff with their preparation for completing the Application for Survey. Includes answers to FAQ. Located in the Support section of the Central Site Portal
 
AFS Attachment and Report List
A list of reports, data and attachments that will be needed for the completion of the Application for Survey
178.93K
AFS Responses in the Setting of COVID-19 FAQ
A list of frequently asked questions and answers to offer guidance for responses within the AFS to best demonstrate the effects of the pandemic within the trauma program.
128.93K
AFS Survey Eligibility Requirements
To be signed by hospital administration
80.48K
Committee Attendance Log Template
Template for tracking Multidisciplinary Peer Review PI Meeting attendance, and Required for AFS
77.42K
2021 Hybrid Site Survey Information Form – Levels I, II & III
Submit to PTSF 3-weeks prior to site survey. This form has now been combined with the contact form. You will only need to complete this form.
44.27K
2021 Hybrid Site Survey Information Form – Level IV
Submit to PTSF 3-weeks prior to site survey. This form has now been combined with the contact form. You will only need to complete this form.
41.39K
Education & Credentialing Site Survey Report Template
Education & Credentialing Site Survey Report Template in Word format
30.07K
Education & Credentialing Site Survey Report Template
*NEW* Education & Credentialing Site Survey Report Template in Excel format with automatic calculations and non-compliant areas turning red to alert non-compliance and the need for a comment to explain
15.05K
Alternate Pathway Provider Medical Record Form
Institutions with Alternate Pathway providers: Submit one week prior to survey
77.50K
Trauma Program Medical Director Continuing Education Template
Optional attachment for the AFS. Located in the Support section of the Central Site Portal
 
Trauma Program Manager Continuing Education Template
Optional attachment for the AFS. Located in the Support section of the Central Site Portal.
 

Standards of Accreditation

Trauma Center Mentor & Mentee Collaboration: How to Make it Work
Presentation at the 2020 PTSF Annual Conference. Presented By: Peter Thomas, DO, Rebecca Wilde-Onia, MSN, RN, CCRN, & Stephanie Noll, MSN, RN, CNL
1.17M
Standards Comparison by Trauma Level
2020 Standards Comparison by Trauma Level
212.37K
Pennsylvania Trauma Nursing Core Curriculum
Pennsylvania Trauma Nursing Core Curriculum
398.49K
Applying for a Variance from a Standard
Accreditation Policy (AC-105) (Rev. 07.01.2019)
29.76K
Alternate Pathway Request
Approval Process for use of Non-Board Certified Physicians: Alternate Pathway (PTSF Board of Directors Revised, 07.11.2019)
65.72K
Senate Bill No. 922
Section of the Bill that applies to PTSF and Level 3 Funding
190.54K
Resources for Optimal Care of the Injured Patient
American College of Surgeons Committee on Trauma Resources for Optimal Care of the Injured Patient, 6th Edition "The Orange Book"
 
Letter of Intent and Letter of Request Templates
Letter of Intent (LOI) to Pursue Trauma Center accreditation, and Letter of Request (LOR) for Site Survey
80.70K
Trauma Nurse Course Delivery Information
Clarification of trauma nurse course delivery
46.50K
Web-Based Online Trauma Nurse Course
Provided by Conemaugh Health System
117.40K