2016 Site Survey Information Required Form

2016 Site Survey Information Required Form SITE SURVEY INFORMATION Page 1 Please complete and return Pages 1-6 to the Foundation office NO LATER THAN three weeks prior to your scheduled site survey [email protected]

Applicant Hospital:

Site Survey Date:

Information on where Foundation staff should park the van:

Person who will meet survey team upon arrival:

Location where hospital staff will meet the survey team:

Room where Opening conference will be held:

Room where Physician conference will be held:

Room where Nursing conference will be held:

Room where Significant Issues will be discussed:

Room for Medical Record/PI Review:

Room where Lunch will be served:

Room for interviews and focused PI reviews:

Room where Leadership Meeting will be held:

Using Electronic Medical Records: Yes No

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Please complete and return Pages 1-6 to the Foundation office NO LATER THAN three weeks prior to your scheduled site survey [email protected]

Hospital staff assigned to accompany site surveyor on brief tour of hospital Surveyor Team Surveyor Tour Guide Member Trauma Surgeon Team Leader**

Trauma Surgeon**

Registered Nurse

Emergency Physician

Neurosurgeon

Person identified to assist PTSF staff during set-up:

** REMINDER: For Adult and Pediatric Level I, II, centers, the trauma surgeon surveyors will not tour together. Please assign separate surgeons to accompany the trauma surgeon surveyors on the hospital tour.

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PHYSICIAN CONFERENCE FORM Please list physician staff who will participate in the Physician Conference. Limit attendance to 20 persons. (The titles listed below are suggestions. Attendee list is based upon your level of accreditation and members of your administration and trauma team.) Title Name Trauma Program Medical Director

Chief of Orthopedic Surgery, or trauma designee from the Department of Orthopedics Emergency Department Director, or trauma designee from the Department of Emergency Medicine Chief of Anesthesiology, or trauma designee from the Department of Anesthesiology Chief of Radiology, or trauma designee from the Department of Radiology Director and/or co-directors of the intensive care unit(s) where trauma patients are admitted Chief of Pediatrics, or trauma designee from the Department of Pediatrics Physician responsible for trauma rehabilitation Surgeon Accountable for the Pediatric Trauma Patient Population (if applicable) or designee from Department of Pediatrics.

Chief of Neurosurgery, or trauma designee from Department of Neurosurgery Advanced Practitioner accountable to trauma population if applicable Optional: second trauma surgeon Optional: member of hospital administration

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NURSING CONFERENCE FORM Please list nursing staff who will participate in the Nurse Conference. Limit attendees to 20 persons (The titles listed below are suggestions only. Attendee list is based upon your level of accreditation and members of your administration and trauma team.) Title Name Trauma Program Manager

Nurse Administrator/Chief Nursing

Officer Nurse Manager, or trauma designee from

the Emergency Department Nurse Manager, or trauma designee from

the Trauma/Surgical ICU Nurse Manager, or trauma designee from

the Perioperative Unit (OR/PACU) Nurse Manager, or trauma designee from the surgical floor(s) that provide care to the trauma patient(s) Nurse Manager of Pediatrics, or trauma designee that provides care to the pediatric trauma patients Nurse Educator Primarily responsible for

nursing trauma education. Case Manager Providing services to the trauma program/patient Manager, or Designee for trauma

rehabilitation Nurse accountable for the overall trauma performance improvement program

Advanced Practice Nurse(s) accountable to the Trauma Program.

Injury Prevention Coordinator or designee Pre-hospital/EMS/Flight Team

Representative (One individual) Social Services/Social Work/Chaplain

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Hospital staff to be present during the medical record review. Name Title

Note: A physician and nurse should be in the medical record review room at all times. These are usually the Trauma Medical Director and Trauma Program Manager.

In the event an electronic medical record (EMR) is used one additional staff member per surveyor should be available to assist with navigation of the EMR.

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LEADERSHIP MEETING FORM Hospital staff to be present during the Leadership Meeting ( ma x i mum of ten – those listed below are recommended at a minimum) : Title Name Trauma Program Medical Director Trauma Program Manager PI Coordinator Trauma Program Administrator CEO Emergency Medicine Director Specialty services related to significant issues, if applicable

Please complete and return Pages 1-6 to [email protected] NO LATER THAN three w eeks prior to y our scheduled site survey

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