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

Types of Site Visits and VRC Review Teams

The American College of Surgeons Committee on Trauma (ACS COT) will provide a hospital consultation, verification, or reverification visit at the request of the hospital or state authority.

Consultation

A consultation visit is optional but highly recommended for a trauma center’s initial visit. This review is most beneficial to centers preparing to undergo their first verification review, as it will provide recommendations to educate and aid the trauma center in preparing for and attaining verification. Following the visit, the center will receive its final report outlining the review team’s findings regarding center’s compliance with standards, any strengths, areas for improvement, and recommendations for how the center can become ACS-verified.

The standard consultation review team consists of two surgeons and a nurse reviewer. The review team composition will vary based on the trauma center patient population. For example, pediatric trauma centers will have two surgeons—at least one of whom will be a pediatric surgeon—and a nurse who may be a pediatric nurse.

The center must schedule the initial verification visit a minimum of 12 months after the consultation visit. This time will allow the hospital to collect new registry data and medical records, address deficiencies (CDs) and/or opportunities for improvement identified during the consultation visit, and ensure that corrective actions have been in practice during the reporting year.

Verification/Reverification

There are several types of visits that a trauma center can undergo to successfully be verified.

A verification site visit is for trauma centers:

  • Seeking to be verified for the first time
  • Restoring verification after a lapse in status
  • Upgrading current verification level

A reverification site visit is for currently verified programs that are planning to maintain their level status. A

Verification Outcomes

Visit Results

Verification Outcomes

No CDs identified

Verified, 3-year certificate

Up to 3 Type II CDs identified

Verified, 1-year certificate, to extend an additional 2 years upon successful completion of a focused review

Any Type I CDs

Not verified

Greater than 3 Type II CDs

Not verified

A certificate will be issued consistent with the verification outcome. If during a verification site visit the trauma center is cited with any CDs, the center must demonstrate the CDs have been addressed through a focused review.

Types of Focused Reviews

To ensure trauma centers are compliant with the standards that were cited during their verification/reverification site visit, the program must undergo a focused visit. The type of focused visit, on-site or by mail, will be determined by the CDs identified.

On-Site Focused Review

An on-site focused review is needed when medical record review is required to ensure the CDs have been addressed. This may occur for CDs including, but not limited to, those evaluating the performance improvement and patient safety (PIPS) process. The on-site focused review can be scheduled no earlier than 6 months from the date of the initial site visit. The hospital must submit a corrective action plan documenting how the CDs and opportunities for improvement have been addressed. The corrective action plan must be submitted to the VRC office (COTVRC@facs.org) 30 days prior to the scheduled on-site focused review.

The on-site focused review will last approximately five hours over the course of one day, with a team of two reviewers. Typically, a reviewer from the verification/reverification visit will return.

Focused by Mail (Email)

A focused by mail is appropriate when the resolution of CDs may be supported with documentation—such as orthopaedic surgeon back-up call schedule, peer review meeting attendance—and does not require chart audit.

The trauma program must submit a corrective action plan signed by the Trauma Medical Director, along with the supporting documentation (for example, copies of back-up schedule, peer review attendance sign-in sheets). All documentation must be submitted to the VRC office (COTVRC@facs.org) 30 days prior to the date noted in the verification/reverification letter (typically within 12 months of initial visit).

Walk-Through

When a hospital or program moves to a new building or physical location, a walk-through visit is required if the move takes place within that first year of their verification/reverification cycle. A reviewer from the most recent site visit will conduct the walk-through to ensure the program has all the necessary staffing and physical resources, such as operating room, radiology, blood bank, etc.

Site Visit Review Teams

Site Visit Type

Standard Review Team

Consultation 2 trauma surgeons, 1 nurse*
Verification/Reverification 2 trauma surgeons
Combined Visits (Adult Level I or II with pediatric Level II) 2 trauma surgeons, 1 pediatric surgeon
On-Site Focused Visit 2 trauma surgeons or 1 trauma surgeon and 1 nurse*
Concurrent Adult Level I & Pediatric Level I (consultation/verification/reverification) 2 review teams:
  • Adult Program: 2 trauma surgeons
  • Pediatric Program: 1 pediatric surgeon, 1 trauma surgeon

*For pediatric trauma centers, at least one reviewer will be a pediatric surgeon and the nurse reviewer may be pediatric nurse.

Additional reviewers may be required on consultation, verification, and reverification visits based on the regulations set forth by the state department of health or EMS agency. In some instances, trauma programs may request specialty reviewers (orthopaedic surgeon, neurosurgeon, emergency physician) to evaluate those specific services. There is an extra cost per additional reviewer.