Consultation Verification Program
The American College of Surgeons’ long history of activities directed toward the improvement of trauma care was enhanced substantially in 1987 with the creation of the Consultation/Verification Program. This program validates the resources for trauma care at trauma centers. The program is administered by the Consultation/Verification Ad Hoc Committee of the American College of Surgeons (ACS) Committee on Trauma (COT), commonly referred to as the Verification Review Committee (VRC).
Resources for Optimal Care of the Injured Patient outlines the resources necessary for optimal care and is used as a guide for the development of trauma centers throughout the United States. It is the document by which trauma centers are reviewed by the ACS-approved site surveyors.
The designation of trauma facilities is a geopolitical process by which empowered entities, government or otherwise, are authorized to designate. The ACS does not designate trauma centers; instead, it verifies the presence of the resources listed in Resources for Optimal Care of the Injured Patient.
The ACS Consultation/Verification Program is designed to assist hospitals in the evaluation and improvement of trauma care and provide objective, external review of institutional capability and performance. These functions are accomplished by an on-site review of the hospital by a peer review team, experienced in the field of trauma care. The team assesses commitment, readiness, resources, policies, patient care, performance improvement, and other relevant features of the program as outlined in Resources for Optimal Care of the Injured Patient.
Consultation
The ACS-COT will provide a hospital consultation visit, at the request of a hospital, community, or state authority, to assess trauma care or to prepare for a verification review. The standard core 2-surgeon team or a multidisciplinary team may be requested.
A consultation visit follows the same format as a verification review. It provides recommendations and aids the facility in attaining verification.
Verification
Trauma center verification is the process by which the ACS confirms that the hospital is performing as a trauma center and meets the criteria contained in Resources for Optimal Care of the Injured Patient.
To support trauma system development, the VRC requires approval of the designating authority if one exists. If the hospital does not fall under a designating authority, it may directly request a verification site visit. A verification review process results in a report outlining the findings and, if successful, a certificate of verification. This certificate is valid for 3 years, after which a reverification site visit may be requested.
If, during a verification review, a hospital is found to have criterion deficiencies, it must demonstrate that they have been corrected before a certificate is issued. If the deficiencies are significant, at the discretion of the VRC, an on-site focus review may be necessary, in which a 2-surgeon team returns to the facility. Generally, one member of the original team is involved in this review process. The focus review usually is accomplished in no less than 6 months and not more than 1 year from the time of the notification of the results of the initial review.
When the correction of deficiencies can be demonstrated by submitting data forwarded to ACS, the focus review can be completed without an on-site review. The information submitted must be signed by the trauma medical director and the hospital chief executive officer. If the deficiencies can be corrected and their correction can be demonstrated in writing, a certificate will be issued.
If a hospital has previously been verified and criterion deficiencies are identified at the time of the reverification visit, the verification status may be extended for up to 6 months. During this time, the hospital must document the corrections of all identified deficiencies. If all deficiencies are not corrected, further extensions will not be considered.
Multidisciplinary review
The on-site review usually is conducted by 2 surgeons (core team) from the ACS-COT. In some cases, there may be a requirement or desire that trauma center capability be evaluated by a multidisciplinary team. The ACS-COT can assist in this process. The multidisciplinary team is led by 2 general surgeons. Other members may include a neurosurgeon, an orthopaedic surgeon, an emergency department physician, a trauma program manager, or any other person as requested by the designating agency or the hospital.
The Consultation/Verification Process
Following the receipt of a request (application for site visit) and the completion of the prereview questionnaire (PRQ), a review team of 2 surgeons is selected. A mutually acceptable date for the review will be established. The ACS-COT state or provincial chair and region chief of the Regional Committees on Trauma will be notified. All reviewers will be from out-of-state or province unless there is a special request for an in-state or province reviewer. General surgeon reviewers are selected from present and past members of the ACS-COT, state chairs, region chiefs, and other specially qualified surgeons. The hospital is required to provide medical records needed at the time of the visit. A description of the medical records needed to conduct a site visit will be provided to allow the hospital 2 to 3 weeks or more to identify the charts and pull the records.
Consistency of the review process is facilitated by the following:
- A prereview questionnaire that allows site visitors to have a better understanding of the existing trauma care capabilities and the performance of the hospital and medical staff before beginning the review. This questionnaire may be completed online by the hospital.
- Guidelines for the site visitors: A document describing the guidelines for a review is provided to all site visitors. This document is designed to ensure that reviews are conducted consistently. It defines the process of the review and elements of appropriate conduct by a reviewer.
- An organized agenda is prepared for the review so that all reviews are performed in an efficient manner.
- Every site visit team is led by the lead reviewer. These reviewers have been on multiple reviews and are approved by the VRC.
- The report is written in a standardized format.
- A final review of all reports is made by the VRC.
Prereview Meetings
A prereview meeting facilitates an efficient on-site review process. The review team generally meets with the trauma director, trauma program manager, and a hospital administrator. Other individuals may be invited who are needed to clarify the prereview questionnaire and describe existing trauma center activities. The meeting is intended to include discussion of the overall trauma program, clarification of the prereview questionnaire, specific concerns, unique features of the institution, discussion of the local trauma system, and clarification of the review process.
In some cases, it may be beneficial to change the order of the site visit and begin with the review of patient charts before the prereview meeting. This change usually is allowed in hospitals that have been verified previously and only with the approval of the hospital and the reviewers.
The on-site review requires approximately 6 to 8 hours. All trauma care areas of the hospital may be visited. Emphasis is placed on evaluating medical records of trauma patients and correlating patient care with the performance improvement program. The visit concludes with an exit interview to discuss the reviewers’ findings and conclusions. The reviewers prepare a report that reflects the statements made at the exit interview. This report is forwarded to the VRC.
The VRC reviews this report and determines the presence or absence of deficiencies and whether a hospital can be verified. The VRC has the authority to issue final approval. This process ensures accurate interpretation of the findings, well-documented conclusions, and consistency and professionalism in the final report. This final process may modify the conclusions of the individual site reviewers’ report to ensure consistent interpretation of the resources documented.
Confidentiality of the entire review process ensures an institution that the program is designed to be a constructive process in which a hospital can place its trust.
If verified, a hospital will be included on a list of currently verified hospitals available online at http://www.facs.org/trauma/verified.html. This list is updated every month.
The Appeal Process
If the hospital does not agree with the review process, the reviewers’ findings, or the final report, it may appeal in writing to the VRC Office, 633 N. St. Clair, Chicago, IL, 60611. The VRC may require additional documentation, a new review team may be sent for another review, or the issue may be referred to the ACS-COT Executive Committee.
Verification Quality Assurance Process
Based on the feedback from institutions, the Consultation/Verification Program has been valuable. Many favorable unsolicited comments are frequently received. Changes have been made in certain areas such as the revision of the prereview questionnaire, and, on rare occasions, reviewers have been counseled. The biggest concern occurs when the institution is told one thing at the exit interview and additional deficiencies appear in the final report. A concentrated effort is made at the time of the review to inform the hospital that the VRC makes the final decision.
The program is sensitive to the needs of the hospitals, especially needs that have been precipitated by the current socioeconomic conditions prevalent in health care today. This quality assurance process has been extremely helpful in accomplishing this goal.
Application Forms and Site Visit Information
Requests for verification or consultation information should be addressed to:
American College of Surgeons
Verification Review Program
633 N Saint Clair St
Chicago, IL 60611-3211
Office Phone 312-202-5456
These forms and information are also available from the American College of Surgeons Website at http://www.facs.org/trauma/verificationhosp.html
Consultation/Verification Programs for Hospitals
Revised June 7, 2007