As of September 2023, trauma centers verified by the American College of Surgeons are now being surveyed under Resources for Optimal Care of the Injured Patient (2022 Standards) — widely known as the Grey Book.
The challenge for trauma program leaders is that the Grey Book survey experience is a big unknown. What are review teams focusing on? How are reviewers interpreting the new standards? What is the best way to prepare for a successful visit?
To find out, I spoke with two experienced trauma leaders whose centers recently underwent a Grey Book survey: Marco Bonta, MD, MBA, FACS, system chief at OhioHealth Trauma (Columbus, Ohio) and Debra Kitchens, MBA, BSN, RN, CEN, TCRN, NRP, manager of trauma services at Prisma Health-Upstate (Greenville, South Carolina).
Bonta and Kitchens were my special guests during a webinar in November 2023 that focused on Grey Book surveys (if you want to view the webinar on demand, register here). During this event, they told us about their recent site visits and shared the lessons they learned about the survey process.
Here are four lessons these trauma leaders learned about ACS verification visits under the new standards.
1. Get started much earlier on your PRQ
When you access the new Prereview Questionnaire, you will notice one thing right away — the new PRQ is much longer than the old one. All the program information that used to be provided in binders for an in-person visit (or uploaded to a shared drive prior to the virtual visit) must now be submitted digitally via the PRQ at least 45 days in advance of the virtual review.
Kitchens pointed out that the new PRQ emphasizes process documentation. “The old PRQ was more focused on data,” she said. “The new PRQ asks for more guidelines and protocols versus actual data.”
Assembling all this information is a huge task. As just one example, Bonta noted the challenge of providing documentation in support of Standards 4.21 through 4.26, which cover the availability of specialty services. “You have to fill out and submit a call schedule for 12 or 13 different specialties for 365 days with no gaps,” he said. “It’s one of the beastliest parts of the new PRQ.”
In addition, trauma centers undergoing a combined site visit for both their adult and pediatric programs can expect double the work. “It used to be that adding the pediatric program to the PRQ was a matter of filling out one additional sheet,” Kitchens said. “Now, you essentially have to fill out two complete PRQs.”
2. Get ready for a deep dive on your medical charts
Because of how the new Preselected Chart Review (PCR) process is set up, your ACS review team will have access to your medical charts several weeks before your verification visit. That means reviewers will spend more time with your charts than ever before. It also means reviewers will come to your visit ready to take a deep dive into your entire system of care.
Although Bonta’s OhioHealth trauma centers had no deficiencies, he has detected a trend through his consulting work with other trauma programs — reviewers are now focusing on issues that previously received little attention.
“In the past, at least half of the deficiencies that reviewers flagged were PI-related,” he said. “That’s still the case, but now it seems that more ‘arcane’ deficiencies are getting listed, things that surveyors never really examined in previous surveys because they didn’t have time.”
Kitchens also observed this shift: “For example, our surveyors spent time focusing on more details of the OPPE process and gave suggestions on items that should be considered for inclusion,” she said. “OPPEs did not receive as much attention in the past.”
According to both Kitchens and Bonta, the lesson is that trauma surgeons involved in the survey must become intimately acquainted with the 25 charts preselected by the review team.
“The reviewers are at home reading through your charts and thinking carefully about what they want to ask,” Bonta said. “Your trauma surgeons need to be doing the same thing and thinking about how they will address all the issues that may be present.”
3. When selecting charts, think “great PI” not “great saves”
Under the new PCR process, trauma program leaders can select the 63 cases that best represent the care their program provides to injured patients. According to Bonta, program leaders should give careful thought to the charts they put forward.
“The beginner’s mistake is to choose charts for cases where the program is really proud of the clinical outcome, like unexpected survivorship,” Bonta said. “But frankly, those are usually not the best charts to choose. The better charts to choose are the best examples of the PI program, which are probably not the charts where the outcome was the best.”
In the past, his programs steered reviewers toward good examples of PI by placing circular red stickers on select charts: “We would say, choose any chart you want, but the ones with red dots are ones we think are the best representatives of our PI program.”
Under the new survey process, program leaders can achieve the same goal by adding comments to the PCR template.
“In the PCR template, there is a little section labeled ‘Notes’ that allows some free text,” Bonta said. “In preparing for our visit, we were very liberal with that section. We wrote in capital letters ‘PICK ME’ and added comments like ‘Excellent loop closure’ or ‘Practice restriction followed this.’ It lets reviewers know which charts are the best example of your PI program, and it also makes it less likely they will pick a chart you are not very familiar with.”
Kitchens recommends a related strategy. “Each chart you upload to your shared platform must include a Medical Record Face Sheet that is provided by the ACS,” she said. “Page two of the sheet includes sections for summarizing the levels of review. My advice is to take full advantage of these sections. Do not just write ‘Yes’ — provide short but substantive information about the PI you did for the case.”
4. Know the Grey Book inside and out
The Grey Book is new for everybody — both trauma program leaders and ACS reviewers. While you may be struggling to understand some of the requirements, it is also true that your reviewers will not have the familiarity with the 2022 Standards that can only come with years of experience and many site visits.
The implication is that the better you know the Grey Book, the more you will be able to discuss the requirements with your reviewers and (respectfully) question any interpretations that do not seem to align with the text.
In addition, remember that you are being surveyed on Resources for Optimal Care of the Injured Patient, not on the PRQ. “Our reviewer asked us which team member was identified as the lead pediatric registrar,” Kitchens said. “That’s not in the PRQ, but it is in the Grey Book.”
And as always, remember that while deficiencies are spelled out relatively clearly, ACS review teams have significant personal leeway to identify weaknesses.
“If something is not in the Grey Book or asked for in the PRQ then it cannot lead to a deficiency, but it can still be listed as a weakness or an opportunity for improvement,” Kitchens said. “You need to be ready to talk about all your processes and demonstrate what you are doing.”
Listen to a candid discussion
Would you like to hear more about the new survey process? As I noted above, Debra Kitchens and Marco Bonta discussed their experiences at length during a special November 2023 webinar event. To view the webinar on demand, visit the registration page or click the banner below:
