The more you know about the trauma survey process, the better able you will be to prepare for a successful review.
At the recent Virtual Summit for Level III, IV & V Trauma Centers, a pair of trauma leaders looked at the survey process from two different points of view.
The trauma program leadership perspective was provided by Jennifer Marcotte, BSN, RN, CEN, TCRN, trauma program manager at Southern New Hampshire Health, a Level III-N trauma center in Nashua, New Hampshire.
And the state survey perspective was supplied by Darlene Gondell, MSN, RN, CCRN-K, CNRN, TCRN, director of accreditation for the Pennsylvania Trauma Systems Foundation (PTSF).
During their session, Marcotte and Gondell shared a range of practical tips for preparing for a successful trauma center survey, whether you are reviewed by the American College of Surgeons or your state designating authority.
1. Start with an honest gap analysis
Begin by creating a document that lists every standard you will be surveyed on. In the document, note whether the requirement is met, in progress or not met. Marcotte emphasized the need to be honest about your program’s current compliance.
“Say you want to impress your senior leadership, so you mark ‘OR availability’ as met because you’ve never had any problem with getting your patients to the OR,” she said. “Then you spend two months focusing only on those items that you’ve marked as in progress or not met. When survey day finally arrives, the review team finds that you don’t have a process outlined to track your OR times. Now you have to explain what happened not just to the survey team but to your senior leadership team as well.”
“I cannot emphasize enough how important a gap analysis is. It isn’t just for showing your senior leadership, nor is it simply for identifying your gaps,” she said. “If done correctly, a proper gap analysis will serve to keep you on track with all the standards you have to meet for your survey.”
2. Make the application perfect
“Your application is your surveyor’s first impression of your program, so make sure you’re giving the best impression that you can give,” Gondell said.
If any of the responses in your application have outliers, include an explanation. “That lets the surveyor know that you saw there was an outlier and are addressing it,” she said. “They won’t have to ask you about it on survey day, and they will have confidence in your ability to do PI.”
In addition, pay attention to detail. “Double-check spelling and math. If the surveyors are looking at your application, and things are a little off, it’s going give them the opinion that you’re not very well organized,” she said.
“Ask someone who knows nothing about trauma to read your application,” she said. “They can proofread it for clarity, spelling and grammar, and they can let you know what doesn’t make sense.”
3. Lean on external resources for education
“One of my top priorities during our review year was to schedule as many trauma grand rounds as possible,” Marcotte said. “I looked internally for speakers, and I did find a few, but what worked very well for me was reaching out to the tertiary centers, where we typically transfer our patients, and I just made the ask.”
“Our final survey cited professional education as a strength,” she said, “and it didn’t cost us a penny.”
4. Highlight key moments in patient timelines
Marcotte encouraged program leaders to organize medical records for easier review.
“Highlight some key moments in the patient timeline, things like the first set of vital signs, a FAST exam, a needle decompression, transport to the OR, etc.,” she said. “The easier you make it for surveyors, the happier they will be. And if they’re happy during your review, they will be happy when they write your report.”
5. Perform a mock survey
Gondell encouraged the use of mock surveys, ideally led by individuals from outside your center. The mock surveyors should mirror the survey day, with pre-review of your application, the same slate of meetings, and a review of the same medical records you submitted to surveyors.
“It is really eye-opening because it can help you figure out whether there are logistical things that need to change or whether you don’t have all the right information you need,” she said.
6. Designate a behind-the-scenes helper
“Designate a go-to resource person, someone who isn’t part of the survey, who can help keep things running behind the scenes on survey day,” Gondell said. “They could be the one to make sure people are arriving on time and call people if they’re running late. They can pull up presentations for you and also take care of any last-minute surveyor requests. Having a resource person allows the TPM and the TMD to remain with the surveyors all day.”
7. Give surveyors a good welcome
“Don’t have surveyors driving around your parking lot in the morning trying to find a parking spot,” Gondell said. “Instead, put cones out near the front and save a few parking spots for them. Or have a valet waiting for the surveyors. That really decreases the survey team’s stress level and makes it a really nice start of their day.”
In addition, representatives from trauma should be outside waiting for surveyors to arrive. “Especially the program manager and medical director — if they’re waiting outside, it just looks like they’re excited that the survey day is here and want to greet the survey team. That makes the surveyors feel pretty good.”
8. Nail the opening presentation
According to Marcotte, the opening presentation should set the tone for the entire survey.
“During the opening presentation, let the review team know all about your hospital, the demographics of your surrounding area, who is included in your catchment area, plus some basic information about your program, things like volumes, your transfers, your non-surgical
admits, your Cribari and NFTI analyses.”
If there are any weaknesses in your program, identify them. “Don’t try to hide anything,” she said. “It’s better to put it out there up front than have the review team find a skeleton hidden in the closet.”
9. Have a hospital leader take part
Gondell recommends asking a hospital leader to open the day with welcoming comments.
“I’ve seen surveys where a hospital board member shares a personal story as to why their hospital is a trauma center,” she said. “That can be really impactful and leaves an impression on the surveyors. It lets surveyors know how important trauma center designation is to your community, and that looks really great for your center.”
10. Demonstrate resolution with data
“If you happen to have previously cited issues from a prior survey, you’re going to have to present these,” Gondell said. “But be concise and to the point — it must be really easy for reviewers to follow what was done and to see that you have resolved the issue.”
“But don’t just put a slide there, saying, ‘this issue is resolved,’” she said. “That means nothing and it might actually bother the surveyors that you just decided to tell them the issue was resolved as opposed to giving them data to support that. Data is the best way to show that you resolved an issue.”
11. If numbers are low, show quarterly data
“At level III, IV and V trauma centers, you might have a lower patient volume, so there are smaller sample sizes,” Gondell said. The result can be graphs with a chaotic sawtooth pattern.
“If that is your situation, it typically looks better when you present data quarterly rather than monthly.” She pointed out that the same data, when presented quarterly, can be easier to read and can more clearly demonstrate underlying trends.
12. Engage frontline staff
When preparing for the facility tour, make sure to engage and work closely with frontline staff.
“Frontline staff and department leaders are the ones that the survey team will want to talk to about processes and procedures,” Marcotte said. “Every area they visit is subject to interrogation, so make sure your staff know what to expect and how to answer the questions.”
She recommended finding out which staff members will be working on survey day. “If you know in advance who is working the day of the survey, you can meet with them separately to set them up for success.”
During her program’s recent survey, Marcotte was surprised by the way reviewers were questioning the staff.
“I imagined really quick questions about different things like where a piece of equipment might be or who to call for certain instances,” she said. “But instead, what we got was an evolving case scenario with a patient who began to progressively decompensate as the reviewer moved throughout the hospital. The takeaway here is to be prepared for literally any line of questioning.”
13. Practice, practice, practice
“Practice until you can’t get it wrong — that’s my new favorite line,” Marcotte said.
Everyone involved in the survey should practice their presentations and the hospital tour repeatedly.
“I am ditching the ‘practice makes perfect’ saying. Nothing is ever perfect but you can practice enough that you feel prepared for literally anything.”