How to bounce back from a “not quite perfect” site visit


You put in all that work for the site visit from the American College of Surgeons (ACS). Your trauma program staff practically halted work on everything else for the month prior to the review. You slaved and sweated for the two days the reviewers pored through charts, looked at your hospital and scrutinized documentation. And then…

During the exit interview, the reviewers tell you they noted one or more deficiencies! Now what?

First, don’t panic. Yours is not the only program this has happened to. Ten to fifteen percent of trauma centers will receive at least one deficiency during their site visit.

The good news is that, in most cases, you will still be verified or reverified. (And rest assured, no one outside the people attending the exit interview will know. The ACS does not publicize the results of any site review.) The bad news is that you must do more work to make your verification last more than one year.

What is the best way to organize that work? Below I describe some practical steps that trauma program leaders can take after a “not quite perfect” site visit. The first priority, however, is to understand the different ways a program can fall short of ACS criteria.

A closer look at Orange Book deficiencies

There are two types of deficiency listed in Resources for Optimal Care of the Injured Patient (a.k.a. “the Orange Book”). Type I deficiencies are catastrophic failures in the structure and/or function of a trauma center. Examples include things like:

  • There is no trauma medical director
  • The performance improvement (PI) program is nonfunctional
  • There is no surgical commitment to the trauma program

A single one of these deficiencies completely prevents verification. The good news is that these are extremely rare.

Type II deficiencies are less dire but still serious. They may signal anything from a minor CME issue to more serious problems with board certification or PI. They still permit verification, but only for a period of one year and not the usual three — a provisional verification. However, there is one exception to this rule. If a program accrues more than three Type II deficiencies, the center cannot be verified.

Just as there are two types of deficiencies, there are two types of “not quite perfect” site visits. I call them hard and soft fails.

A hard fail occurs when a trauma program receives a single Type I or more than three Type II deficiencies. A hard fail means that the program needs to start over, fix everything and schedule another visit. This may be either a full verification visit or a focused review, depending on the number and severity of the deficiencies. It may take a substantial amount of time to accomplish this, which is why it is so important to try to get everything right the first time.

A soft fail occurs when a program receives three or fewer Type II deficiencies. Soft fails can also be divided into two categories based on how the deficiencies are remedied. The easiest is the “fix by mail” (my terminology), which usually involves documentation problems that were identified at the time of the site visit. In these instances, trauma center structure and function are generally okay. Common issues include CME documentation, committee attendance and physician credentialing requirements.

The second type of soft fail requires a “focus visit.” This is most commonly required if significant issues are noted in the PI program. In a focus visit, a two-physician team must return to your center for a half-day review of specific materials related to the deficiencies. Usually, one or both physicians were part of the original review, so they are very familiar with the program and the deficiencies. This visit typically begins at about 7 a.m. and lasts four hours. It usually involves review of at least 20 charts, which are selected in the same way as the first review.

At the end of the focus visit, an exit interview is held and the findings are once again presented to the trauma program team. If all deficiencies have been remedied, then the center will be verified for the remaining two years.

One last note: During a focus visit, in addition to clearing all deficiencies, there is an expectation that most or all weaknesses be addressed and resolved, too. Weaknesses might include things like the use of locum tenens surgeons, low levels of trauma certification and education in ED or ICU nurses, or use of an electronic trauma flow sheet.

As I noted above, recovering from a soft fail requires additional work. Following is my recommended strategy for bouncing back from a “not quite perfect” site visit:

1. Take notes during the original exit meeting

Assign someone to take detailed notes on what the reviewers say about every deficiency and weakness. It is acceptable to record the exit meeting, but let the reviewers know in advance.

This step is important because it may take up to three months to get your official report from the ACS. And you may not realize it, but the one-year provisional verification clock starts ticking on the day of the exit meeting. If you wait until you get the official report, you may have as little as nine months left to correct all the deficiencies.

2. Convene a work group of key players as soon as possible after the site visit

Attendees should include the trauma medical director (TMD), trauma program manager (TPM) and the hospital administrator who oversees the trauma program. Physician and nursing leaders — such as the chief medical officer, the chief nursing officer, the vice president of surgical services, etc. — are also commonly involved.

Others should attend based on the specific deficiencies and weaknesses identified. Were there problems with a certain specialty or hospital service area? Then the appropriate liaison and/or department head should be invited. Were there issues with the PI program? Include most, if not all, of the members of the multidisciplinary trauma peer review committee.

3. Create a comprehensive action plan that addresses every deficiency and weakness cited

Each deficiency and weakness should have its own entry in the action plan. More complex items (e.g., PI) may need further breakdown into more manageable steps. The action plan should be readily available to everyone in the work group, at all times. An electronically shareable version is preferred so that all members can access it at any time to check progress and review open items.

4. Assign a specific, manageable completion date to each item in the action plan…

Be realistic with these assignments. Yes, you do want them done as quickly as possible. But deadlines that are too aggressive may be difficult to achieve, and may slow down other related or even unrelated items. Never forget, though, that the one-year clock is ticking.

5. …but make completion dates for performance improvement issues as early as possible

Not only do PI issues need to be fixed, a meaningful number of patient encounters have to occur between the time the fix is in place and the day the reviewers return.

Let’s say your PI program is revamped and finally functioning well in May, but the ACS reviewers are scheduled to return in July. Only a month or so of “improved” charts will be available for their review. They will have no choice but to look at charts from the “old” system, and your program will run the risk of failing again.

6. Make one person responsible for monitoring the plan and all communications

Although this could be the TPM, he or she will generally have better things to do. Assign a skilled administrative assistant to monitor action plan activities, updates and group communication.

7. Convene your group of key players frequently

Work not monitored is work not done. Meeting every two weeks or so is ideal. Any less frequently, and unexpected delays may not be noticed quickly enough. But meeting more often than twice a month runs the risk of wearing your team out.

8. Provide written/emailed updates

Written action plan updates should go out to all areas touched by the trauma program (which is just about every part of the hospital), all high-level administrators and most managers. Have updates shared at weekly huddles or other planned get-togethers. This helps build and maintain morale and momentum throughout the hospital, and demonstrates the energy and commitment to fix the issues identified during the site survey.

9. Check off each item as it is completed, and share with everybody

When everything is complete, double-check and then celebrate!

10. Compile information to provide to the ACS

List each deficiency, and provide a detailed, step-by-step description of what was done to correct it.

  • “Fix by mail”: Add documentation demonstrating the correction of each issue, such as attendance records, CME certifications, etc. Send this to the Verification Review Committee (VRC) office as requested.
  • “Focus visit”: In addition to the deficiency documentation, do the same for each weakness, recognizing that some may not be complete by the time the reviewers return. Send this to the VRC office when the actual review is scheduled.

Here are a few tips on managing the most common deficiencies:

CME deficiencies: Create a reliable reporting system

A single physician in one required specialty who is a single CME short will generate one deficiency. And there are five required specialties, so it is possible to kill your trauma program if more than three physicians are short. Most of the time, physicians actually have obtained the needed education. They just don’t want to take the time to dig up the certificate or make sure it is trauma-related.

Develop a regular reporting system so that certificates are collected throughout the year, not just in the month before a site visit. Involve the CMO, department heads or other administrators to apply pressure from above. Or consider removing the non-compliant surgeon from the call panel until his or her CME documentation is up to date.

Committee attendance deficiencies: Intervene with department heads, liaisons

According to ACS criteria, trauma surgeons and physician liaisons must attend at least 50% of multidisciplinary trauma PI committee meetings. The TMD should personally meet with any surgeon or liaison who falls short of attendance requirements. For trauma surgeons, the department head may be called upon to address non-compliance. Otherwise, the only other option is removal from the call panel. When working with subspecialty liaisons, the TMD should convey the importance of their attendance at multidisciplinary PI meetings. If a liaison is unable to commit to regular attendance, another physician should be selected.

PI deficiencies: Identify and attack specific issues

PI deficiencies are the most complicated issues to address effectively. These deficiencies may be due to data collection, problems identifying quality issues, inadequate resolution and, most commonly, poor documentation. For general recommendations on strengthening your performance improvement efforts, read 9 tips for running an effective trauma PIPS program.

Quick recovery

Yes, it’s aggravating and embarrassing to encounter problems during your site visit. Careful planning and attention to detail are the keys to avoiding a “not quite perfect” visit in the first place. But if it happens to you, don’t despair. By applying these tips, you can recover and clear up your program’s deficiencies quickly.

Michael McGonigal, MD is the director of trauma services at Regions Hospital in St. Paul, Minn. He is also the author of The Trauma Professional’s Blog, which provides injury care education to thousands of trauma providers worldwide.

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