The second article in the “Trauma Survey Notebook” series focuses on NYC Health + Hospitals/Elmhurst, a Level I trauma center in Queens, New York. Elmhurst Hospital underwent a successful ACS reverification review in January 2025.
I spoke with Carrie Garcia, RN, trauma program director at Elmhurst Hospital. She detailed her recent experience with the ACS survey process and shared her thoughts on how to ensure a good survey outcome.
This interview has been edited and condensed for clarity.
Filling out the PRQ and preparing for the visit
Garcia began working at Elmhurst mid-way through its verification Reporting Period, so her immediate priority was to begin work on the Pre-Review Questionnaire (PRQ). The first step is to get organized:
Create a responsibility structure. “I went through the PRQ and assigned a responsible party for each element,” she said. “That person might need to reach out to another department for a type of information or an updated policy. Ultimately, he or she was responsible for bringing the data or policy back to me. I myself was the responsible party for several PRQ questions, but as the trauma program director I was also the ‘keeper of the keys’ who kept the entire effort on track and in order.”
Don’t be wordy, but don’t be vague. “On the one hand, you don’t want to over-share and open a door due to confusion,” Garcia said. “On the other hand, you don’t want to reviewers to read your PRQ and walk away sort of scratching their heads because of ‘over sharing.’ You just want to be clear, concise and complete. Try to answer everything that the question is asking, not anything more and not anything less.”
Review and update all CPGs. Most of the required policies already existed, but many of them needed to be updated. “Our TMD worked with one of our PI personnel to go through each of our policies and clinical practice guidelines, which was a huge undertaking,” she said. “They had to update many of them with current references, and they also had to make sure the verbiage was current. For example, we had some policies that referenced our old EMR.”
Make sure your PI process is clear to reviewers. Garcia adapted an existing spreadsheet tool to strengthen the center’s process for documenting and tracking the PI process: “To this tool, I added a sheet that functions as an ongoing primary review board,” she said. “I also updated our process for showing loop closure.”
Medical Record Review
In preparing for the Medical Record Review, Garcia divided the work between registry staff, injury prevention staff, the PI team and herself.
Vet charts for completeness. After using registry reports to identify potential charts for inclusion, Garcia assessed each one. “I vetted each chart to make sure all the key elements were there before sending it to the TMD for the final decision,” she said. “I looked to make sure a chart had PI follow-up and loop closure, that all the notes were intact, that the flowsheet looked good, that there was an ACR, etc. As I had arrived mid reporting year and had made changes to the PI process, it allowed me the opportunity to familiarize myself with the program on a facility level as well as a program level. I wanted to ensure that the charts selected would be a representation of the work performed at our facility.”
Read More: Trauma Survey Notebook: ACS Level II reverification review in Colorado
Ensure a clear pathway through each chart. “Everyone on the team had different roles to play as far as creating the records themselves, but there was always a second or third set of eyes on each section, specifically PI to ensure that everything was complete,” Garcia said. “I wanted to limit the number of times the reviewers had to ask questions like ‘Show me the initial GCS’ or ‘Show me the initial BP.’ A message that has been shared at many conferences is ‘Make the chart easy to follow for your reviewers.’ Ensuring a clear pathway through the chart will save the reviewers time, so they can evaluate the care that is given to the trauma patients at your trauma center.”
Create a table of contents for PI. In addition to creating a table of contents for each record, Garcia and team also created a table of contents for each PI section. “Anything in a chart’s PI section was listed on the table of contents in order — the minutes, anywhere the patient showed up within audit filters, the PI that was done, any follow-up emails, and so on,” she said. “That way, if the reviewers wanted to see any specific PI items when they were looking at the record, they could just jump ahead to that item. It just made it easier for them to maneuver though the records. Our reviewers actually complimented our charts, stating that they were very easy to review.”
Benchmark Report Review
The best way to prepare for the Benchmark Report Review is to become very familiar with your center’s latest Trauma Quality Improvement Program (TQIP) report.
Demonstrate thorough review. It is particularly important to show that your team has responded to any outlier findings. “We were an outlier on isolated hip fractures in geriatric patients, so we had done a large PI project around that,” Garcia said. “And what we did was develop a ‘hip alert’ which acts like a bell to ensure that things move a little bit faster for the patients who fit a certain criteria.”
Document Review
Garcia’s only takeaway from the Document Review is, once again, the importance of careful preparation. “I don’t know how much time the reviewers spend actually looking through these policies and procedures, but I imagine that there are key elements that they’re looking for. So it’s important to not just throw something on a piece of paper.”
Review Meeting
Elmhurst received no deficiencies from their ACS review team. According to Garcia, the Review Meeting focused on suggestions for improving program performance.
Reviewers are currently focusing on MTP. “I would say that massive transfusion protocol was a big initiative for this review, and since our visit I have heard the same thing from other facilities,” she said. “For us, the reviewers suggested that we create more consistent documentation on the medications given along with the MTP. I have heard that at other facilities, they’ve asked for wastage rates as well as the use of adjuncts.”
Hospital Tour
The Elmhurst Hospital site visit was conducted virtually. According to Garcia, the trauma program team combined a tablets-on-wheels setup with a choreographed coverage strategy to remove any lag time between tour stops. Other lessons:
Communicate early. “We made sure to let staff in units we would be visiting know about the upcoming tour,” Garcia said. “Closer to the date, we spoke with the staff members who were actually going to be working that day as well as their leadership — to answer any questions they may have and alleviate any stress they may be experiencing.”
Practice repeatedly. “We practiced our run-through a minimum of five times, if not more,” she said. In addition, Garcia appointed a logistic coordinator who took part in all run-throughs. “I wanted to simulate the process as close to the actual event as I could. I also involved remote staff so they could share any suggestions during our five-minute debrief after each run-through. I wanted to ensure the team was flawless, confident and well prepared.”
Know your Wi-Fi. “Because we had practiced so many times, we knew the spots in each room where the Wi-Fi was the best and where it wasn’t.”
Exit Interview and Final Report
According to Garcia, the ACS review team used the Exit Interview to compliment the Elmhurst trauma program for overall excellence: “They said we’re really functioning well as a mature trauma center, and that we really should commend ourselves as being a leader in our region if not in trauma nationwide.”
Be specific about PI monitoring. Garcia took the opportunity to ask the nurse reviewer whether she had any suggestions for improving the program’s PI work. “She suggested adding specific wording to describe the plan for monitoring. For example, ‘We will monitor this CPG for X months, and if compliance remains above 80% we will go to once a year.’”
Coincidentally, Garcia had heard the reviewer make the same recommendation at a previous TQIP Conference and had already implemented the suggested practice. “So I was able to show the reviewer that, based on her TQIP presentation, we had already incorporated that idea into our PIPS plan and minutes,” Garcia said.
Overall recommendations
Garcia has one overall recommendation for trauma leaders preparing for a site review:
Start early. “You probably already have the answer to every question in the PRQ, but putting the answers on paper is not as quick and easy as one may think,” she said. “Develop a plan, be prepared and know you are not alone.”
