Gearing up for success - a new trauma program manager’s guide to mastering their first trauma survey

As a new trauma program manager preparing for your first American College of Surgeons (ACS) trauma verification/re-verification or state designation/redesignation, there are several key steps to ensure a successful review. Firstly, familiarize yourself thoroughly with the ACS guidelines and standards for trauma centers or your state standards for trauma centers paying particular attention to the requirements for your level of verification (Level I, II, III) or state designation (Level I, II, III, or IV). If this is not your trauma center’s first verification/designation be sure and review previous verification/designation reports and ensure all deficiencies have been corrected.

Secondly, ensure that all necessary documentation, policies, and clinical practice guidelines are in place and up-to-date. This includes protocols for patient care, performance improvement and patient safety plan (PIPS), performance improvement processes showing loop closure, staff education and training, outreach activities, along with thorough documentation for PIPS meeting minutes. Working closely with the trauma medical director, administrative leadership, and other key stakeholders (ancillary departments) to ensure alignment and compliance across all departments.

Lastly, conduct a comprehensive mock survey to simulate the ACS verification or state designation process. This allows you to identify any potential gaps or deficiencies in your program and address them proactively. Engage staff members and medical staff from all departments to participate in the mock survey to ensure a comprehensive assessment.  By thoroughly preparing and addressing any areas of improvement, you can approach your first ACS trauma verification or state designation with confidence and increase the likelihood of a successful outcome. Also, you may want to consider enlisting an external source to support your mock survey, as it can provide valuable insights and ensure an objective perspective.

Feel free to reach out to discuss how I can support your mock survey process and contribute to your program’s success.

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