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
PATrauma@ptsf.org
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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2016 Site Survey Information
Required Form
SITE SURVEY INFORMATION – Page 2
Please complete and return Pages 1-6 to the Foundation office
NO LATER THAN three weeks prior to your scheduled site survey
PATrauma@ptsf.org
Hospital staff assigned to accompany site surveyor on brief tour of hospital
Surveyor Team
Member
Surveyor
Tour Guide
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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2016 Site Survey Information
Required Form
SITE SURVEY INFORMATION - Page 3
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
Please complete and return Pages 1-6 to the Foundation office
NO LATER THAN three weeks prior to your scheduled site survey
PATrauma@ptsf.org
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2016 Site Survey Information
Required Form
SITE SURVEY INFORMATION - Page 4
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
Please complete and return Pages 1-6 to the Foundation office
NO LATER THAN three weeks prior to your scheduled site survey
PATrauma@ptsf.org
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2016 Site Survey Information
Required Form
SITE SURVEY INFORMATION - Page 5
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.
Please complete and return Pages 1-6 to the Foundation office
NO LATER THAN three weeks prior to your scheduled site survey
PATrauma@ptsf.org
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2016 Site Survey Information
Required Form
SITE SURVEY INFORMATION PACKET
Page 6 of 6
LEADERSHIP MEETING FORM
Hospital staff to be present during the Leadership Meeting (maximum 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 PATrauma@ptsf.org
NO LATER THAN three weeks prior to your scheduled site
survey
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