American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Site Visit Outcomes

Effective May 1, 2007, the updated criteria for trauma center verification outlined in the Resources for Optimal Care of the Injured Patient: 2006 go into effect. In addition, the Committee on Trauma (COT) of the American College of Surgeons (ACS) has made substantive changes to the outcomes of a verification site visit in order to better serve the trauma community. These changes also go into effect May 1, 2007, and are detailed below.

Outcomes of Verification

Previously, after completion of a verification or re-verification site visit, a trauma center was either “verified” (certificate for three years) or “not verified.” One of the current missions of the Verification Review Committee (VRC) is to provide guidance and recommendations for trauma programs during the site visit process, while at the same time verifying that the essential criteria of a trauma center are in place. With this emphasis the COT has added a third category as an outcome to a verification site visit. This category is “verified” with a certificate of verification for one year. This category is further described below and in the attached outline entitled Verification Site Visit Outcomes.

Type I and Type II Criteria

One of the most significant changes is the identification of the essential requirements as Type I and Type II criteria (or deficiencies). Type I criteria must be in place at the time of the verification site visit in order to achieve verification. Type II criteria are also required, but are less urgent criteria. If three or less Type II deficiencies are present at the time of the site visit, a one year certificate of verification will be issued, during which time if the trauma center successfully corrects the deficiencies, the period of verification will be extended to three years from the date of the initial verification visit.

If any Type I deficiency or more than three Type II deficiencies are present at the time of the initial verification site visit, the hospital is not verified. As in the past, a successful Focus Review would be required in order to achieve verification. The Focus Review must occur 6 to 12 months from the date of the notification.

Site Visit Report

The format and the executive summary of the site visit report will not change. The final results of the site visit (including identification of Type I and Type II criteria or deficiencies) will be determined by the VRC. The findings will be noted in the VRC’s letter to the hospital after the report has been reviewed by the committee.

This new process will be continually evaluated, and future revisions of specific criteria or requirements included in each category may be necessary.

Frank (Tres) L. Mitchell III, MD, MHA, FACS
Immediate Past Chair, Verification Review Committee