2015 Site Survey Information Required Form

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1 SITE SURVEY INFORMATION Page 1 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

2 SITE SURVEY INFORMATION Page 2 Hospital staff assigned to accompany site surveyor on brief tour of hospital Surveyor Team Member Trauma Surgeon Team Leader** Surveyor Tour Guide 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.

3 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.) Trauma Program Medical Director Chief of Orthopedic Surgery, or Orthopedics Emergency Department Director, or Emergency Medicine Chief of Anesthesiology, or Anesthesiology Chief of Radiology, or Radiology Director and/or co-directors of the intensive care unit(s) where trauma patients are admitted Chief of Pediatrics, or 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

4 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.) Trauma Program Manager Nurse Administrator/Chief Nursing Officer the Emergency Department the Trauma/Surgical ICU the Perioperative Unit (OR/PACU) 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

5 SITE SURVEY INFORMATION - Page 5 Hospital staff to be present during the medical record review. 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.

6 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): 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 NO LATER THAN three weeks prior to your scheduled site survey

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