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!
Site Survey Information
Sign in to access the PTSF Application for Survey
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.
Transition Period for the Implementation of New or Revised Standards of Accreditation
Certificates of Accreditation
Process for Becoming an Accredited Trauma Center
Media Notification Regarding Trauma Center Status
Request for Reconsideration of Accreditation Deliberation Decision
Process for Elevating Trauma Center Accreditation Level
Level Four Trauma Center Mid-Cycle Panel Review
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.
Site Survey Toolkit
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.
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.
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
A list of reports, data and attachments that will be needed for the completion of the Application for Survey
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.
To be signed by hospital administration
Template for tracking Multidisciplinary Peer Review PI Meeting attendance, and Required for AFS
Education & Credentialing Site Survey Report Template in Word format
*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
Institutions with Alternate Pathway providers: Submit one week prior to survey
Optional attachment for the AFS. Located in the Support section of the Central Site Portal
Optional attachment for the AFS. Located in the Support section of the Central Site Portal.
Standards of Accreditation
Approval Process for use of Non-Board Certified Physicians: Alternate Pathway
Accreditation Policy (AC-105)
Letter of Intent (LOI) to Pursue Trauma Center accreditation, and Letter of Request (LOR) for Site Survey
Pennsylvania Trauma Nursing Core Curriculum
American College of Surgeons Committee on Trauma Resources for Optimal Care of the Injured Patient, 7th Edition "The Gray Book"
Section of the Bill that applies to PTSF and Level 3 Funding
Presentation at the 2020 PTSF Annual Conference. Presented By: Peter Thomas, DO, Rebecca Wilde-Onia, MSN, RN, CCRN, & Stephanie Noll, MSN, RN, CNL
Provided by Conemaugh Health System