“Trauma Survey Notebook” is a new article series that will take a close look at the American College of Surgeons (ACS) review process from the perspective of trauma program leaders who have recently undergone a site visit.
The goals of this series are to identify the specific issues that review teams are focusing on, highlight effective approaches to demonstrating compliance, uncover pitfalls to avoid in site review prep, and share trauma program leaders’ recommendations for preparing for a successful site visit.
The first article in this series focuses on Intermountain Health Good Samaritan Hospital, a Level II trauma center in Lafayette, Colorado. Good Samaritan underwent a successful ACS reverification review in October 2024.
I spoke with Stephanie Vega, MBA, BSN, RN, CCRN-K, CSTR, trauma nursing director at Good Samaritan Hospital, to hear about her recent experience with the ACS process and learn her recommendations for ensuring a successful review.
Filling out the PRQ and preparing for the visit
The new Pre-Review Questionnaire (PRQ) is well organized and fairly clear, Vega noted, but filling it out is a major project. Her general recommendation is to access the PRQ as soon as possible and perform an upfront needs assessment. Vega’s specific recommendations include:
Use ACS templates to request data. The PRQ includes downloadable templates for certain information requests, such as board certifications, CME records and registrar education. Vega found that these templates make it easier to manage data requests. “For example, for board certifications, you can just send the template to your medical staff office and ask them to fill it in,” she said.
Keep the terminology straight. There are two terms in the PRQ that are easy to mix up — Reporting Period and Verification Cycle. “In the PRQ, you need to pay attention to what the question is asking for,” Vega said. “If the question is asking for data from your ‘Verification Cycle,’ they want to know about the whole three years. But if it’s for your ‘Reporting Period,’ then the request is for the one-year time frame.” (See Resources for Optimal Care of the Injured Patient: 2022 Standards for the official ACS definitions of these terms.)
Plan to accommodate state reviewers. If your state designation process is coordinated with the ACS verification review, there will likely be extra work. “In Colorado we have to do two applications — one for the state and one for the ACS,” Vega said. “That adds some complexity, because the state reviewers do not have access to QPort. So anything you upload to TQIP you also have to provide in a separate area for your state observers.”
Medical Record Review
When preparing for the Medical Record Review, Vega’s general advice is to pay close attention to the ACS Medical Record Face Sheet, which includes precise instructions. “If you are confused about anything, just reach out to the ACS and ask them for clarity,” she said. “Don’t try to guess. If you have any questions about what you’re supposed to put on there, ask the ACS.”
Be ready to talk about arrival times. ACS reviewers have been focusing on specialist arrival times for several years, and the Good Samaritan site visit was no exception. “I think the biggest area that comes up during the chart review is documentation of arrival times,” Vega said. “When did the neurosurgeon see the patient? When did ortho see the patient? When did they get to IR and make that decision? The reviewers are still really focusing on that.”
Ideally, show that you are monitoring PI issues. One of the non-surgical admission (NSA) charts that the Good Samaritan team submitted for review included documentation confirming that the admission was appropriate based on the patient’s significant medical problems and relatively minor injury. However, Vega also included a graph summarizing the program’s ongoing monitoring of NSAs. “Including the graph showed that we didn’t just look at this case as a one-off — we actually monitor this issue throughout the year and make sure we’re being appropriate for all of our NSA cases. I think having that extra loop closure did provide the reviewers with enough information to say, ‘Okay, these guys really are tracking this issue. They didn’t just look at this one case.’”
Benchmark Report Review
Good Samaritan Hospital participates in the Trauma Quality Improvement Program (TQIP). Vega shared three recommendations for preparing for the benchmark review:
Look beyond your last two reports. Officially, this segment of the visit focuses on the center’s two most recent risk-adjusted benchmark reports. “I think it’s important to know, however, that you can go back further,” Vega said. The Good Samaritan trauma team created a presentation that examined their top three PI initiatives over the last three years, and the presentation incorporated all six of their TQIP reports from that period. “We used those reports from way back to show where we’ve been and where we are now,” she said. “And I think that helps the reviewers see the whole spectrum of your PI process.”
Be honest about the stumbles. “When reviewing your PI work, it’s okay to talk about areas where you thought you would have a good impact but it turned out that you didn’t,” Vega said. “You can list the pitfalls you had — for instance, maybe you had a provider change so you lost traction on a PI project — and talk about how you made a pivot and modified your plan. There’s a lot you can explain in that 30 minutes as you go over the progression of your program and the impact that you’re trying to have.”
Do not just validate the report data. While data quality is important, reviewers want to see that you used your benchmark data to improve some aspect of patient care or program performance. “I think they like to hear that you validated the data, but they don’t want to hear that that’s the only thing you did,” Vega said. “They want to hear that you did something from those reports.”
Document Review
The Grey Book requires trauma centers to develop and maintain an extensive array of policies and guidelines. Vega pointed out that while these policies must cover trauma patients, they do not have to be developed by the trauma program.
Leverage existing hospital policies. “We have hospital guidelines that are aimed at treating older adults, so I included those in my measures of compliance for Standard 5.6,” Vega said. “For example, I included our delirium management order set and our delirium prevention strategies, which are hospital-wide guidelines.” The hospital also has organization-wide policies on how to identify vulnerable older adults, medication reconciliation guidelines, and geriatric consult guidelines, all of which help satisfy ACS requirements for geriatric trauma protocols. “There doesn’t have to be a specific trauma program policy around all these things,” she said. “As long as your hospital has policies that cover all those points, that’s evidence of compliance with the standard.”
Summarize related policies in one document. When using a variety of policies and protocols to demonstrate compliance with a standard, Vega recommends tying them all together in a single document. “For our geriatric trauma protocols, we have a document that summarizes all the relevant protocols and links to them,” she said. “It’s basically a summary of how we care for older trauma patients.”
Review Meeting
During the Review Meeting, the survey team paid special attention to orthopedic OR availability. Specific questions covered room availability, callback times and processes for monitoring compliance. The reviewers also drilled down on activation response, anesthesia coverage and pediatric readiness.
Hospital Tour
The Good Samaritan site visit was conducted virtually. One of Vega’s main goals was to avoid excessive “downtime” between stops.
Use multiple camera operators. “Our tour was set to span three different levels, so we chose to manage the tour using three different workstations operated by people on three different floors,” Vega said. “We started out in the ED with one person, and that person went to the trauma bay and also to CT. When it was time to go to the OR, the first person walked to the trauma elevators and turned off their monitor. Then the person on the second floor turned on their monitor and walked from the trauma elevator to the OR. When the reviewers wanted to go to the blood bank, there was a similar transition to the basement.”
Exit Interview and Final Report
During the exit interview, the ACS review team commended Good Samaritan for several program strengths, including:
- Administrative commitment
- Program leadership (the TMD, the ED director and Vega herself)
- Disaster management planning
- The injury prevention program
- OR availability (both regular trauma and orthopedic surgery)
- Feedback loops for prehospital providers
- Education
Reviewers also noted favorably the hospital’s Multidisciplinary Massive Transfusion Protocol (MTP) Committee. “This group meets every month to review all our MTPs — not just trauma hemorrhages, but our OB hemorrhages and GI hemorrhages as well,” Vega said. “Our approach to MTP is not siloed. We look at it globally from a systems perspective.”
In addition, the review team commended Good Samaritan for achieving a significant reduction in trauma diversions.
Opportunities for improvement included documentation of orthopedic surgery, neurosurgery and interventional radiology response times and contingency planning for patients who require cardiopulmonary bypass.
Based on her recent experience with the ACS review, Vega recommends that trauma program leaders pay attention to the following issues:
Strengthen PI for FAST exams. “One thing that ACS reviewers are honing in on is the PI process for FAST exams,” Vega said. “This is an issue for nearly all trauma centers, and it just continues to pop up because there’s no great way to save 100% of your FAST images. The reviewers want to see that you have some quality process to provide oversight on FAST exams and that there is a mechanism for providing feedback when there’s disagreement on the read.”
Carefully manage registrar education requirements. “We had a new registrar who started in July who had the required ICD-10 education, but not the AIS education,” Vega explained. “The challenge was that the next AIS course was not until November, which was after our survey.” Trauma program leaders and review team members discussed the issue extensively. Vega pointed out that for this individual, taking the AIS course in time for the survey was technically impossible. She also noted that the registrar started after the program’s reporting period, so was technically not covered by the requirement. “The reviewers accepted these points, but it was a lot of discussion,” she said. “And as soon as I got our team member’s AIS course certificate in November, I immediately sent it to the review team.”
Overall recommendations
Vega shared several overall recommendations for preparing for and hosting a successful ACS site review:
Involve IT early. “Get your IT department involved early on,” she said. At Good Samaritan, simply giving ACS reviewers access to the hospital SharePoint required clearances from IT. “We had to do a business-to-business application agreement because their email addresses are outside of our institution.”
Put together a visit support team. Vega recommends having an experienced trauma registrar available to run reports quickly on the day of the site visit. Ideally, your site visit team will also include someone who is very familiar with trauma program processes and policies. “Have someone available as support, like another program manager from within your system,” she said. “Because I was new to the institution, there were a couple policies that I knew existed but couldn’t find. One of my colleagues was able to find that for me while I was focused on other parts of the survey.”
Take advantage of the feedback opportunity. “After your survey is over and you get your report, you have an opportunity to provide feedback,” Vega said. “This is not an opportunity to contest the reviewers’ determination or their report, but if there is anything you think the Verification Review Committee (VRC) should be aware of regarding the PRQ, the visit or the surveyors, the feedback area is your spot to communicate that.”