trauma room

Trauma Accreditation Resources

Educational resources compiled by the Pennsylvania Trauma Systems Foundation to assist Pennsylvania hospitals and medical centers’ pursuits of trauma accreditation are listed below.

Information about how to apply for a site survey, updated copies of the PTSF Standards of Accreditation, and ACS Accreditation Guidelines are listed as well.

If the information that you are looking for is not found here, please contact a member of the PTSF staff—they are always happy to help.

**NEW PENNSYLVANIA TRAUMA PROGRAM NURSE LEADERS**

New Trauma Program Nurse Leader Orientation – Tuesday, March 25, 2025, from 1000 to 1500

PLEASE REGISTER HERE

Educational Videos

It’s Not About the Chest X-Ray – It’s About Consistency!
Tracking and Calculating Trauma Multidisciplinary Peer Review Meeting Attendance PDF

Site Survey Information

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.
64.23K
Accreditation Policy (AC-106)
Transition Period for the Implementation of New or Revised Standards of Accreditation
137.39K
Accreditation Policy (AC-114)
Certificates of Accreditation
148.19K
Accreditation Policy (AC-130)
Process for Becoming an Accredited Trauma Center
217.34K
Accreditation Policy (AC-132)
Media Notification Regarding Trauma Center Status
143.58K
Accreditation Policy (AC-136)
Request for Reconsideration of Board of Directors Decision
148.04K
Accreditation Policy (AC-138)
Process for Trauma Center Accreditation Level Change
173.00K
Accreditation Policy (AC-139)
Level Four Trauma Center Mid-Cycle Panel Review
164.26K
Accreditation Policy (AC-140)
Level I, II & III Trauma Center Accreditation Extension
145.20K
Accreditation Policy (AC-142)
Level I, II and III Survey Process for Exemplary Trauma Centers
189.03K

Site Survey Toolkit

Anesthesiologists Template
List the Anesthesiologists who provide coverage for the survey cycle.
36.79K
Emergency Medicine Template
List the Emergency Medicine Physicians who provide coverage for the survey cycle.
37.11K
Injury Prevention Activities
List the public injury prevention activities for the reporting period.
36.26K
Significant Issues Template
List the Significant Issues for the survey cycle.
23.79K
Trauma Program Manager Continuing Education Template
List the Trauma Program Manager’s continuing education for the survey cycle.
36.15K
Trauma Program Medical Director Continuing Education Template
List the Trauma Program Medical Director's continuing education for the survey cycle.
0.00P
Alternate Pathway Request
Approval Process for use of Non-Board Certified Physicians: Alternate Pathway
270.91K
Applying for a Variance from a Standard
Accreditation Policy (AC-105)
126.69K
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
Pennsylvania Trauma Nursing Core Curriculum
Pennsylvania Trauma Nursing Core Curriculum
363.51K
Site Survey Guidebook (Coming Soon)
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.
0.00P
AFS Survey Eligibility Requirements
To be signed by hospital administration
140.85K
Committee Attendance Log Template
Tracking Template for Multidisciplinary Peer Review PI Meeting Attendance — Required for AFS
92.33K
Education and Credentialing Site Survey Report Template
Education and Credentialing Site Survey Report Template (Word Format)
39.06K
Education and Credentialing Site Survey Report Template
*NEW* Education and Credentialing Site Survey Report Template (Excel Format). Automatic calculations and non-compliant areas turn red to alert non-compliance and the need for a comment to explain.
24.51K
Alternate Pathway Provider Medical Record Form
Institutions with Alternate Pathway providers: Submit one week prior to survey
77.50K
Web-Based Online Trauma Nurse Course
Provided by Conemaugh Health System
373.94K

Standards of Accreditation

Resources for Optimal Care of the Injured Patient
American College of Surgeons Committee on Trauma Resources for Optimal Care of the Injured Patient, 7th Edition "The Gray Book"