The American College of Surgeons (ACS) has notified Flagstaff Medical Center in Flagstaff, Arizona, that it is no longer verified as a Level II trauma center. The decision was the outcome of an in-person reverification site visit in which the hospital was found to be non-compliant with five standards in Resources for Optimal Care of the Injured Patient: 2022 Standards.
According to a press statement from Northern Arizona Healthcare (NAH), the nonprofit system that owns Flagstaff Medical Center (FMC), the hospital’s trauma program was non-compliant with:
- Two trauma registrar staffing standards: ACS reviewers cited the hospital for “two standards for staffing in the record-keeping role of trauma registrars.” The statement noted that NAH, like healthcare organizations nationwide, is contending with a shortage of trauma registrars.
- Two surgeon response standards: The hospital was cited for “two standards for documentation regarding when certain surgeons were called to care for a patient, when they arrived, and how long it took for them to arrive at FMC”.
- One PIPS standards: “Our process for following up on issues needs to better define system issues and their resolution,” according to the statement. “We are already implementing new processes to ensure this occurs.”
Little room for error on compliance
According to Resources for Optimal Care of the Injured Patient, a trauma center must be compliant with all Type I and Type II standards at the time of site visit in order to receive full three-year verification. However, a center can be non-compliant with up to three Type II standards and still receive a one-year verification.
According to the ACS document, trauma centers that fail a verification visit must undergo a Corrective Action Review.
Hospital will apply for new review
Flagstaff Medical Center is still designated as a Level I trauma center by the Arizona Department of Health Services.
According to the NAH statement, FMC staff are currently in the process of resolving the trauma program’s standards compliance issues, and they anticipate applying for a new site survey.