Types of Site Visits and VRC Review Teams

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

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 non-compliant standards and/or opportunities for improvement identified during the consultation visit, and ensure that corrective actions have been in practice during the reporting year.

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 certificate will be issued consistent with the verification outcome. If during a verification site visit the trauma center is cited with any non-compliant standards, the center must demonstrate these have been addressed through a corrective action review.

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

Corrective Action Review Site Visit

A corrective action review by site visit is needed when medical record review is required to ensure the non-compliant standards have been addressed. This may occur for non-compliant standards including, but not limited to, those evaluating the performance improvement and patient safety (PIPS) process. The corrective action review site visit can be scheduled no earlier than 6 months from the date of the initial site visit. The hospital must submit a corrective action PRQ with required documentation at least 45 days in advance of the scheduled corrective action site visit.

The corrective action review site visit 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.

Corrective Action by Documentation

A corrective action review by documentation is appropriate when the resolution of non-compliant standards may be supported with documentation—such as orthopaedic surgeon back-up call schedule, or peer review meeting attendance—and does not require chart audit. The hospital must submit a corrective action PRQ with required documentation according to the deadline provided 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.

*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.