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

The Verification, Review, and Consultation Process

Before Site Visit

Submit online site visit application

  • The site visit application is available online.
  • Following submission of the application, the trauma center will receive an email confirmation receipt.

Complete Pre-Review Questionnaire (PRQ)

The PRQ allows the reviewers to have a better understanding of the existing trauma care capabilities and the performance of the hospital and medical staff before beginning the review.

  • Trauma center will receive access to the online PRQ within 10 days of application submission.
  • The online PRQ must be completed and submitted 30 days before the scheduled site visit date.

Review Site Visit Confirmation

  • The dates provided on the online application will be the tentative site visit dates until confirmed by ACS. If for any reason the dates must be changed, the trauma program manager will be notified in advance by ACS staff.
  • A confirmation email will be sent to the trauma center approximately 120 days before the scheduled site visit date. The confirmation will include the names and contact information of the reviewers, along with the review agenda.
  • The ACS Committee on Trauma (COT) Region Chiefs and State Chairs and the State Department of Health/Emergency Medical Service agency will be notified of the scheduled site visit.

Prepare for Site Visit

  • The trauma center is required to provide medical records at the time of the scheduled site visit. The Site Visit Agenda provides a detailed description of the medical records required at the time of the on-site visit. It also contains all logistical information needed for the site visit.

On-Site Visit

The following is an example of the on-site site visit schedule. For more detailed information, please refer to the On-site Visit Agenda.

Day 1

11:00 am–5:00 pm

Chart audit and evaluation of Performance Improvement and Patient Safety (PIPS)

6:00– 8:30 pm

Review meeting

Day 2

7:00–8:00 am

Hospital tour

8:00–9:00 am

Additional assessments, examples could be:

  • Injury prevention documents
  • Review of other documentation

9:00–10:00 am

Review Team Closed Meeting (30-60) minutes

10:00 am–12:00 pm

Exit Interview (30-60) minutes

Virtual Visit

The following is an example of the virtual site visit schedule. For more detailed information, please refer to the Virtual Site Visit Agenda.

Day 1

8:00–8:30 am

Introductions                                                                    

8:30 am–12:30 pm

Chart audit

 

1:30–3:00 pm

Review of Program Documents

 

3:00–4:30 pm

Review Meeting

Day 2

8:00–9:30 am

Hospital tour

 

9:30–10:00 am

Review Team Closed Meeting

10:00–10:30 am

Meeting with TMD and TPM

10:30–11:30 am

Exit Interview

Chart Audit – Reviewers will evaluate care of the trauma patient through review of the medical record and correlating the patient’s care with the performance improvement program.

Review Meeting - This meeting is intended to discuss the pre-review questionnaire, the overall trauma program, specific concerns, unique features of the institution, and the local trauma system. During on-site visits, the review meeting is a working dinner. For more information refer to the appropriate Site Visit Agenda.

Hospital Tour - The tour will highlight all areas of the hospital where trauma care is provided and will follow the path of the trauma patient through your institution. Specifics of the hospital tour are outlined in the appropriate Site Visit Agenda. Reviewers may tailor the tour to the needs of the center.

Exit Interview - The visit concludes with an exit interview to share the preliminary findings of the reviewers with the trauma center leadership team.  Reviewers will communicate the Deficiencies, Strengths, Opportunities for Improvement, and Recommendations. The final decisions regarding deficiencies will be made by the Verification Review Committee (VRC) and may differ from the findings stated at the exit interview.

Post Site Visit

  • Final Report - The reviewers prepare a report that reflects the Deficiencies, Strengths, Opportunities for Improvement, and Recommendations uncovered during the site visit. This report is forwarded to the VRC Committee. The Committee reviews this report and confirms the presence or absence of deficiencies. Review by the VRC committee ensures accurate interpretation of the findings, well-documented conclusions, and consistency in the final report.
  • Trauma centers that are successfully verified will be added to the list of currently verified trauma centers on the VRC website.
  • Trauma centers that do not attain verification must undergo a focused review to ensure all deficiencies have been addressed. If the program disagrees with the site visit findings in the final report, an appeal may be submitted.

The Appeal Process

The trauma center may submit a written appeal addressed to the VRC Chairs within 90 days following receipt of final report. The appeal letter along with supporting documentation must be emailed to cotvrc@facs.org.