Hospital Verification

Table of Contents

The State of Iowa Trauma Coordinator oversees the verification of all Trauma Level III and IV hospitals that are not verified by the American College of Surgeons.  The administrative rules that govern the categorization and verification of each trauma level are in Iowa Administrative Code (IAC 641-134.2 (147A) and (IAC 641-134.2(3) a) and b).  The Resources for the Optimal Care of the Injured Patient 2014 by the American College of Surgeons Committee on Trauma is adopted by reference into rule.  These are the criteria by which Iowa trauma facilities are verified.  The book is available for free download here: Resources for the Optimal Care of the Injured Patient 2014. It is highly recommended that each TPM obtain a copy and familiarize him or herself with its contents.  The criteria are separated by trauma level.  Each TPM should become familiar with their specific trauma level’s criteria. 

The Re-Verification Process

Re-verification is the process by which each trauma care facility receives its trauma verification every three years.  Each trauma care facility’s re-verification due date is found on the verification certificate obtained at the time of the last designation.  The TPM should contact the State of Iowa Trauma Coordinator if a certificate cannot be located.  Six months before the facility’s re-verification due date, the State of Iowa Trauma Coordinator will contact the TPM with an email communication.  This communication will contain the re-verification application, as well as, other reference material needed to successfully fill out the application.  The self-assessment categorization application (SACA) contains all the necessary information needed for re-verification.  The application asks that several policies, procedures, and meeting minutes be included with the application as attachments.  All materials are to be gathered by the TPM and sent to the State of Iowa Trauma Coordinator (preferably electronically, but can be by mail) four months before the facility’s re-verification due date.  The material’s due date will be provided by the State of Iowa Trauma Coordinator in the six-month re-verification notification email. After the TPM sends the application to the State of Iowa Trauma Coordinator, the Trauma Coordinator does an initial review of the materials and communicates with the TPM for any additional materials needed.

All Level III trauma facilities are verified by an on-site visit.  Level IV facilities can opt-in to an on-site visit.  Only Level IV facilities can be verified by a paper review.  After the review is finished, the facility receives a final report from the State of Iowa Trauma Coordinator.  This report contains strengths of the trauma program, any criterion deficiencies, and recommendations for the facility to consider to further develop the trauma program before the next re-verification.   The facility will also receive a verification certificate, which will verify the facility for three years from the current verification certificate end-date.  And, depending on existence of criteria deficiencies, the facility will receive a re-verification letter congratulating it on another successful re-verification.  This process will be detailed in the following sections.

On-site Reviews

An on-site review is conducted on all Level III Facilities.  At a Level III facility, a survey team is comprised of two survey physicians, one of which must be a surgeon and a nurse surveyor (typically a TPM from another facility), and the State of Iowa Trauma Coordinator. A Level III on-site review typically lasts approximately five hours.  During this time, an opening session with hospital administration and board members is conducted, in order for, the survey team to gain an understanding of the support for the trauma program and the goals which it seeks to achieve.  The next session consists of an interview with the TPM and TMD in order to glean the working relationship and see how the facility’s processes and practices are put into practice.  A brief tour of the Emergency Room and Trauma Bays follows, with subsequent trips to Radiology, Lab, the Operating Room, and the ICU.  The team may also request to see various other portions of the hospital, depending on time.  The tour is followed by a chart review. 

The chart review is conducted differently at different sites, depending on the availability of resources.  The survey team asks that 10-15 charts are pulled for a good sampling of trauma patients that may come into contact with the trauma program at any point in time.  Examples of charts to pull include those trauma patients with an ISS>15, deaths, transfers out, pediatric patients, and patients that go straight to the OR.  The TPM and TMD can present these cases in whatever method deemed appropriate by the facility.   Many TPM’s and TMD’s project the electronic medical record on a large screen and walk the survey team through the hospital course of the patient.  Others, present case studies on patients incorporating the process improvement strategies utilized and loop closure.  The method of delivery is left up to the TPM and TMD and the facility.

After the case presentation, the survey team will hold a closed meeting to discuss the application and the findings.  Subsequently, an open presentation to discuss the findings of the survey team is held, which anyone whom the trauma program deems appropriate to attend is allowed to do so.  It is highly encouraged to have hospital administration and if possible, board members attend this final presentation, so that those stakeholders can better understand the needs of the trauma program and the resources that should be allocated to it. 

An on-site visit has slight differences at a Level IV facility.  The survey team consists of either a Trauma Surgeon or an Emergency Physician and a nurse surveyor, along with the State of Iowa Trauma Coordinator.   The time allocated for a facility tour is decreased due to the smaller size (generally) and fewer departments.  There is also less time allocated to chart review, where only 5-10 charts are reviewed.  There is still a presentation of findings at the end of the day to which trauma programs are encouraged to invite the administration and board. 

The site visits exist as a platform to exchange information and educate both sides of the table.  The survey team members are there to verify the contents of the SACA and provide education and support to the facility’s trauma program.  The goal is to make sure the trauma program at any particular facility has the resources and education it needs to provide the best possible evidence-based care that it can to injured patients in the community. The survey team also gets the chance to learn about the facility and how it fits into the trauma system as a whole.

Paper Reviews

Level IV facilities can decide to proceed with a paper review if an on-site review would put undue stress on the facility for staffing purposes or otherwise.  A paper review is conducted by a nurse survey team member and the State of Iowa Trauma Coordinator.  During the review period the TPM at the facility being reviewed may be contacted by either the survey team member or the State of Iowa Trauma Coordinator for clarification or interview.  The survey team member and the State of Iowa Trauma Coordinator corroborate their findings and then present the facility with a final report and certificate.  While this is a satisfactory way to re-verify as a facility, it does not afford the Level IV facility the readily available access to trauma experts in the state as does an on-site review.  It also gives a limited perspective, what can be shown on paper, to the survey team members and does not allow the facility the opportunity to elaborate on their processes, procedures, and how care is given at their facility. 

Disciplinary Action

Disciplinary action is decided upon in conjunction with recommendations from the survey team members, the State of Iowa Trauma Coordinator, the Bureau Chief of the Bureau of Emergency and Trauma Services, and the Assistant Attorney General’s office. 

With the adoption of the Resources for the Optimal Care of the Injured Patient 2014, a criterion deficiency is separated into one of three types.

  • Type I –The trauma care facility can rectify the deficiency by a plan of correction and a focused site visit in three months.
  • Type II – The trauma care facility can rectify the deficiency with a paper report in 6-12 months.
  • Type IIB – The trauma care facility can rectify the deficiency with a focused site visit in 6 – 12 months.

Whether a criterion is I, II or IIB will be determined by the Bureau of Emergency and Trauma Services with recommendations from the Verification Subcommittee of TSAC based upon standards put forth by the American College of Surgeons Committee on Trauma in the Resources for the Optimal Care of the Injured Patient 2014. Questions concerning re-verification and the disciplinary process should be directed to the State of Iowa Trauma Coordinator.

Level III Criteria

Level IV Criteria

Resources Repository

The American College of Surgeons Verification Review Consultation (COT-VRC) Committee has put together a resources repository for materials related to verification as trauma center.  The resources include: alternate pathway criteria, verification change log, clarification document, application information to apply to the American College of Surgeons for verification, educational webinars and tutorials, and supplementary materials, guidelines, and samples.  The COT-VRC also hosts monthly webinars for trauma centers to clarify questions regarding criteria and verification.  To receive notification regarding these monthly webinars email: cotvrc@facs.org.  It is highly recommended to participate in the webinars or watch them at your convenience as they are recorded and posted to the website.  Following along with the webinars will ensure the TPM and facility stay in compliance with the most up-to-date criteria changes and information. 

ACS COT-VRC website: https://www.facs.org/quality-programs/trauma/vrc/resources