Trauma Center Virtual Survey Presentation - PowerPoint Presentation

1. Trauma CenterVirtual Survey PresentationSeptember 29, 2021Department of HealthDivision of Emergency Preparedness and Community SupportBureau of Emergency Medical OversightTrauma Section

2. Presented by:Kate Kocevar, Trauma Section AdministratorDepartment of Health

3. Trauma Centers that ParticipatedThe success of the virtual surveys in Florida is attributed to the following trauma centers and trauma program managers whose dedication and commitment to working with the Department of Health, Trauma Section staff, during the initial design and quality improvement phases of the virtual surveys: Candi Schultz, RN, Bay Medical Center, Panama CityGaylen Tips, RN, Holmes Regional Medical Center, MelbourneCory Hewitt, RN, Ocala Regional Medical Center, OcalaJami Rothenburg, RN, Broward Health North, Deerfield BeachMadonna Stotsenburg, RN, St. Mary’s Medical Center, West Palm Beach

4. A special thanks to the survey teams who diligently worked with the Department of Health, Trauma Section staff and the trauma centers to ensure all components of the virtual survey were in order to achieve the best outcome on the day of the survey. Surveyors:Dr. Marco Bonta; Dr. Fred Luchette; Dr. John McVicker; Dr. Chris Colwell; Dr. John Moorhead; Dr. John Nichols Amy Koestner, RN; Marla Vanore, RN; Susan Cox, RN.; Bonnie Wirth, RNSurvey Teams

5. Elements of the virtual survey that REMAINED the same as an on-site surveyPre-survey questionnaire received from the trauma center 60 days prior to day of the survey.Medical record list received from the trauma center 60 days prior to day of the survey.Trauma Registry reports received from the trauma center 14 days prior to the day of the survey.Orientation meeting with the Trauma Section staff and the survey team. Compiling the deficiency report. Elements that Remained

6. What went VIRTUAL?Elements that went Virtual

7. Two weeks prior to the survey, the trauma center provides the survey team separate videos of the equipment required by the Department of Health Pamphlet 150-9, Standard IX, Equipment.Additional areas that are required to be included in the emergency department (ED) video:HelipadEMS Bay arrival area and pathway to the Trauma BayRadio room in the EDEquipment Videos

8. Electronic access to the medical records:Trauma program manager works with their staff to determine who shall act as a navigator for the surveyor.Trauma program navigator(s) is then assigned to each surveyor.Surveyor provides trauma program staff with date/time available to review the medical records.Six days prior to the virtual survey, the surveyor will review their chosen medical records with the navigator(s), via WebEx, Microsoft Teams, etc. Any supporting trauma program staff may also be enlisted to interact during the review such as a physician, trauma performance improvement coordinator, trauma nurse, or trauma registrar.Remote Medical Record Review

9. Virtual tour observation with the trauma program manager and trauma medical director that will allow direct observation of requirements within the following Department of Health Pamphlet 150-9, Trauma Center Standards:   Standard V Emergency Department Standard VI Operating Room and Post-Anesthesia Recovery Area Standard VII Intensive Care Unit Standard IX Equipment Standard XI Acute Hemodialysis Capability Standard XII Radiological ServicesThe trauma medical director and trauma program manager coordinate with the different people in eachdepartment to provide a virtual observation of their respective area and field surveyor’s questions to provide detail and/or clarification. Relay Virtual Facility Tour Live

10. Two weeks prior to the site survey, the trauma center is responsible for sending meeting invites to the surveyors and Department of Health staff who will participate in the survey.The Department of Health sends a meeting invite to the survey team for the 12:45 pm-1:15 pm, survey team closed meeting.All these meeting are done via Web meeting applications, i.e., WebEx , Google Meets, Microsoft Teams, etc.Pre-Appointed Meetings

11. EST8:45 - 9:00 am Surveyors connect to virtual meeting invite9:00 - 9:30 am Trauma center team provides introduction of the trauma program and the hospital 9:30 - 9:45 am Department of Health provides standard introduction and a brief overview of the virtual processes, expectations and outcomes Virtual Day Agenda

12. 9:45 -10:45 am A review of the trauma center’s quality management program by the trauma medical director and trauma program manager of the following: Briefly go over the process and discuss who is involved. Discuss two examples where an issue was identified, an improvement plan was developed, and outcomes tracked. Discuss two individual physician (peer review) cases.Discuss two systems-related cases.  Discuss two problems that led to a new policy or procedure or modification of an existing policy or procedure. Virtual Day Agenda (continued)

13. 10:45-12:00 pm Virtual Tour: Direct observation of the hospital facility including compliance with the requirements of these Standards: V; VI; VII; IX; XI; XII12:15-12:45 pm Peer Meeting: Discuss medical records review, policies and procedures related to the specialty and other issues requiring clarification12:45-1:15 pm Survey team closed meeting to discuss findingsVirtual Day Agenda (continued)

14. 1:15-1:45pm Survey team meets with the trauma medical director and trauma program manager to communicate any issues or deficiencies discovered during the survey review1:45-2:15pm Exit conference with key hospital personnelVirtual Day Agenda (continued)

15. A special thank you to the following Trauma Section staff for assisting in the design and implementation of the virtual surveys: Bernadette BehmkeGovernment Operations Consultant Carma HarveyInformation Technology AnalystShayla ColeGovernment Analyst IThanks to DOH Staff

16. Questions or Comments? Thank you!