trauma room

Trauma Accreditation Resources

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

You will also find information about how to apply for a site survey, updated copies of the PTSF Standards of Accreditation, and ACS accreditation guidelines.

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**

Save-The-Date for the next Trauma Program Nurse Leader Orientation on Wednesday, November 9th, 2022 from 10 am-3:00 pm. Click here to Register!

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

Application for Survey
Sign in to access the PTSF Application for Survey
 
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
81.93K
Accreditation Policy (AC-114)
Certificates of Accreditation
85.53K
Accreditation Policy (AC-130)
Process for Becoming an Accredited Trauma Center
151.19K
Accreditation Policy (AC-132)
Media Notification Regarding Trauma Center Status
90.52K
Accreditation Policy (AC-136)
Request for Reconsideration of Accreditation Deliberation Decision
147.34K
Accreditation Policy (AC-138)
Process for Elevating Trauma Center Accreditation Level
195.04K
Accreditation Policy (AC-139)
Level Four Trauma Center Mid-Cycle Panel Review
176.88K
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.
239.28K

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.
1.08M
Site Survey Screen Shots
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
91.99K
Committee Attendance Log Template
Template for tracking Multidisciplinary Peer Review PI Meeting attendance, and Required for AFS
86.58K
Education & Credentialing Site Survey Report Template
Education & Credentialing Site Survey Report Template in Word format
37.79K
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
25.82K
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

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)
88.58K
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
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"
 
Senate Bill No. 922
Section of the Bill that applies to PTSF and Level 3 Funding
190.54K
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
Web-Based Online Trauma Nurse Course
Provided by Conemaugh Health System
373.94K