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Innovations

Virtual Trauma Center Surveys, Are They Virtually the Same?

Krichten, Amy E. MSN, RN, CEN, TCRN; Gondell, Darlene MSN, RN, CCRN-K, CNRN, TCRN; Over, Anna MSN, RN, TCRN, EMT-I

Author Information
doi: 10.1097/JTN.0000000000000641
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Abstract

The Pennsylvania Trauma Systems Foundation (PTSF) prides itself on more than 35 years of experience with trauma system development. Headquartered in Camp Hill, PA, the PTSF is the accrediting body for trauma centers in Pennsylvania and supports hospitals in advancing trauma care across the Commonwealth. The organizational mission of “optimal outcomes for every injured patient” is augmented by the vision of “committed to zero preventable deaths from injury in PA” (PTSF, 2021). The PTSF services include operational support for trauma registry, performance improvement (PI), and research.

The PTSF was created within the Emergency Medical Services Systems Act of 1985 as the sole authoritative organization to accredit hospitals as trauma centers in Pennsylvania. Based on this mandate, the PTSF establishes trauma center accreditation standards and conducts site survey visits to determine whether a hospital is compliant with those standards, reflected by accreditation outcomes. Per legislative mandate, the PTSF Standards of Accreditation must meet the American College of Surgeons (ACS) requirements at a minimum (Emergency Medical Services Systems Act of 1985). These requirements must be continuously maintained with compliance measured by the PTSF periodically through a survey process. The PTSF, independently of the ACS, accredits four levels of trauma hospitals: Level I, II, III, and IV adult and Level I and II pediatric centers (PTSF, 2021). In a similar fashion to the ACS Committee on Trauma Verification, Review, and Consultation Program, the PTSF accreditation process is designed to help hospitals improve care and patient outcomes (ACS, 2014). The accreditation survey teams are composed of independent, qualified physicians and nurses. The surveyors' observations and recommendations are aggregated into blinded reports presented to the PTSF Board of Directors (BOD) for deliberation and ultimate accreditation decisions.

The COVID-19 pandemic proved a source of disruption, unexpected illness, stress, and adversity. As the reality of COVID-19 unfolded, health care organizations found themselves in the midst of site survey review cycles (Curto & Martin, 2020). Regulatory agencies had to modify appraisal processes while balancing the safety and well-being of those involved (Curto & Martin, 2020). Completion of traditional on-site surveys was not feasible. State restrictions and health and safety concerns created a challenge for our organization. Despite this, the PTSF was determined to maintain a quality accreditation process. The PTSF adapted site survey procedures, developing two different formats: an on-site hybrid format and a 100% virtual format. The primary plan for completing surveys was utilizing the hybrid format, with the secondary plan of instituting the 100% virtual format, if necessary. A pilot study of two reaccreditation virtual surveys was completed to evaluate the logistical aspects, content, and quality of the virtual survey compared with the on-site survey process. The PTSF was given the unique opportunity to aggregate hospitals, surveyors, and accrediting body perspectives.

KEY POINTS

  • Virtual trauma center site surveys are possible and allow for comparable content review.
  • Lost in the virtual surveys are invaluable conversations, educational opportunities, and team collaboration.
  • The logistical workload to accomplish a virtual survey is twofold that of an in-person survey.

OBJECTIVE

The purpose of this article is to describe and evaluate the implementation of a virtual accreditation survey process, including outcomes, for Level I and II trauma centers from the perspective of all parties involved.

METHODS

As a reflection of the COVID-19 safety risk of hospital staff, surveyors, and PTSF staff, the PTSF BOD decided in early 2020 to postpone site surveys (PTSF, 2020). Similar to the ACS, the PTSF granted a 1-year extension for eligible centers (ACS, 2020). The PTSF planned to resume site surveys in June 2021. Scheduling surveys late in the calendar year, coupled with the volume of visits needed, limited the number of days available if further postponements were needed. Therefore, a virtual format was developed as a backup plan if on-site visits were prohibited. In February 2021, the PTSF BOD unanimously approved the pilot of a virtual survey process.

Traditional Format

The typical Level I and II trauma center reaccreditation site survey includes two PTSF accreditation staff members facilitating the survey, two trauma surgeon surveyors, and one registered nurse surveyor. The surveyors must be non-PA residents and comply with conflict-of-interest regulations. Site survey day followed a very structured schedule: trauma program overview, previous significant issue and PI overview, physician liaison meeting, nurse and collaborative services meeting, hospital tour, medical record review, and closing leadership meeting (Table 1). The day lasts approximately 11 hr, with about 60% of the time spent reviewing medical records. Multiple hospital staff members participate in the survey, including the trauma program medical director (TPMD), trauma program manager (TPM), trauma program staff, hospital administration, physicians, nurses, collaborative services staff, and three chart navigators.

Table 1. - Typical Level I and II Trauma Center Survey Schedule
0645–0700 Team arrival and introductions
0700–0715 Trauma program overview
0715–0800 Previous significant issue and performance improvement overview
0800–0845 Physician liaison meeting
Nursing and collaborative services meeting
0845–0915 Hospital tour
0915–1200 Medical record review
1200–1230 Private survey team lunch
1230–1630 Medical record review continues
1630–1730 Private survey team meeting—Surveyor report writing
1730–1800 Closing leadership meeting

Virtual Format

When adapting the traditional site survey format into a virtual format, we strived to maintain the essence and quality of the survey. We kept the same structure, content, and participants and adjusted the logistical aspects of the survey. A third PTSF staff member was added so that each surveyor could be paired with a PTSF staff member. A videoconferencing platform of the hospital's choosing was utilized to conduct the survey virtually. The total length of the survey was expanded to 14 hr over 2 days, with time added to each session to allow participants to log into the videoconferencing platform (Table 2). In lieu of a hospital tour, the hospital provided a picture tour or prerecorded video.

Table 2. - Virtual Survey Schedule
Virtual Survey Schedule: Day 1
0800–0900 Private survey team meeting PTSF link #1
0900–0930 Trauma program overview Hospital link #1
0930–1030 Previous significant issue and performance improvement overview Hospital link #2
1030–1115 Physician liaison meeting Hospital link #3
Nursing and collaborative services meeting Hospital link #4
1115–1130 Break
1130–1300 Medical record review Hospital link #5 for lead trauma surgeon surveyor
Hospital link #6 for trauma surgeon surveyor
Hospital link #7 for nurse surveyor
1300–1330 Lunch break
1330–1400 Private survey team meeting PTSF link #2
1400–1700 Medical record review continues Continue medical record review links
Virtual Survey Schedule: Day 2
0730–0800 Private survey team meeting PTSF link #3
0800–1100 Medical record review continues Continue medical record review links
1100–1200 Private survey team meeting—Surveyor report writing PTSF link #4
1200–1230 Closing leadership meeting Link #8
Note. PTSF = Pennsylvania Trauma Systems Foundation.

Participant Composition

In selecting the participants for the pilot project, it was important to consider experience with previous PTSF site surveys. Participation was voluntary. Ultimately, two hospitals were selected to participate in the virtual survey pilot project: one Level I and one Level II adult trauma center. Both trauma centers had experienced TPMD, TPM, PI coordinators, and registrars. The selected surveyors had years of experience surveying with the PTSF and, as recommended by Tomaseski (2020), were in the same time zone to ensure reasonable participation expectations were achievable.

Implementation

Although all participants had previous experience with the PTSF survey process, the logistical aspects of the virtual format were new. Preparation and trial runs were necessary to ensure the virtual survey day ran smoothly. To aid in legal and the Health Insurance Portability and Accountability Act (HIPAA) compliance, the PTSF allowed each hospital to select a secure videoconferencing platform that minimized technology concerns for the center's Information Technology (IT) and regulatory compliance departments. A separate link was assigned for each session on the survey schedule to allow participants to connect early and begin promptly when the surveyors joined. A video meeting coordinator role was added to the virtual format. This person was a hospital staff member and was responsible for ensuring the remote participants were connected to each meeting on time, with audio and video functioning properly. The video meeting coordinator could not be the TPMD or TPM; we recommend IT personnel or an administrative assistant for this role.

A primary schedule with meeting links was generated for the hospital and PTSF staff. Each surveyor received an individualized schedule with links to the meetings and medical record review to which they were assigned. Private meetings between PTSF staff and surveyors were hosted from PTSF web-based platforms. Preparation meetings were conducted with the surveyors prior to survey day to explain the proposed process and commitment expectations. The surveyors were required to sign a heightened HIPAA agreement with the assistance of legal counsel to ensure confidentiality was maintained. To aid in the sharing of important documents with the surveyors, the PTSF utilized a secure web-based document-sharing platform. Surveyors were required to test each component on the computers they would use on the survey day. This preparation allowed troubleshooting issues before survey day to ensure connectivity and logistical understanding.

The virtual format required each surveyor to have access to two computers or a computer with two monitors on survey day; one for the PTSF site survey software and the second for the videoconferencing platform. In addition, they were required to have high-speed, secure internet connectivity and video and microphone capabilities. During medical record review, each surveyor and their PTSF support person was given a link for the videoconferencing platform that connected them to a chart navigator at the hospital who shared their screen. In the traditional format, the medical record review included paper documents generated from the hospital's PI database and additional supporting PI documents, such as follow-up letters and evidence of loop closure. For the virtual format, PI documents were required to be formatted in portable document format (PDF) for easy access by chart navigators. When a surveyor reviewed an individual chart, the chart navigator had the electronic medical record and PI documents shared on the screen. The surveyor was able to take control of the mouse to scroll through the content easily, which improved the efficiency of the review over time.

RESULTS

Hospital Comments

After each pilot, the PTSF connected with trauma program leadership to debrief on the logistical aspects of the virtual survey. Accreditation-related content was not addressed at this meeting. Overall, the response from each trauma center was positive. Both disclosed they felt they had ample time to present the required information. Use of the videoconferencing platform did not prohibit them from providing material to the surveyors or PTSF staff. They shared their concerns prior to the survey day related to the possibility of issues with the videoconferencing platform, internet connectivity, and the increased time required to prepare for the survey. Most importantly, they missed the interactive team dialogue typically embedded throughout the day when in person.

Surveyor Comments

A debrief occurred with the surveyors and PTSF staff immediately after each survey. Overall, they were impressed with the logistics and efficiency of the virtual process. They noted that the time to review one medical record increased from an average of 30 min to minimally 45 min per record. They missed the survey team collaboration and ability to share thoughts with each other in real time. They also felt the frustrating impact of having to request to speak with the TPMD or TPM during medical record review. They appreciated completing the survey process from the comfort of their own home or office without the burden of travel time and expense reimbursement. Ultimately, they voiced they had enough information to make meaningful recommendations and complete the required reports for the BOD. Again, most notably missed was the ability to effectively communicate, educate, and share best practices.

Board of Directors Comments

The deliberation packet for the BOD was identical to a site survey in the traditional on-site format. The BOD noted they could not identify whether hospitals they were deliberating on were completed in the virtual or traditional formats, as the reports and surveyor feedback were comparable. Neither pilot hospital requested reconsideration from the BOD accreditation decisions, signifying agreement with the determinations.

PTSF Staff Comments

The workload from the facilitator's perspective was almost double. The increased workload included additional preparation prior to survey day scheduling and participating in presurvey meetings with PTSF staff, surveyors, hospital staff, and their IT departments. Furthermore, input by legal counsel related to confidentiality and remote setting guidance was obtained. This legal input not only was essential in maintaining the integrity of the process but also had financial implications during the planning stage. Apart from the negative implications, there were also positive ones. The health and safety of surveyors, PTSF, and hospital staff were paramount throughout this process.

DISCUSSION

The PTSF's long-standing reliable survey process was not immune to the disruption of the COVID-19 pandemic and required the development of a virtual format as a backup plan. The pilot project to test the virtual survey format identified unique benefits and disadvantages. Conducting a virtual survey required dependence on videoconferencing platforms. There were heightened concerns that internet connectivity or other technical issues could occur and impact the ability to complete the survey. This concern was not unique to the PTSF's pilot project but was experienced by others who had participated in virtual regulatory surveys (Chen et al., 2021). If videoconferencing platforms are to be used for important health care meetings, it is crucial that participants can communicate effectively, as missed or misunderstood communications could have catastrophic consequences, especially in meetings about patient management (Taylor et al., 2020).

A reliable internet connection cannot be understated. Technical difficulties can be distracting, and there is a danger of attendees missing information (Taylor et al., 2020). The surveyors and PTSF staff connected to Wi-Fi with hot spot routers on standby to reduce connectivity lapses during the survey. Minimal technological issues occurred during the pilot project. There were occasions of dyssynchronous sound and video and occurrences of late participants due to connection issues; however, all were eventually able to log in. Although these issues were minimal and did not affect the survey's outcome, the possibility of technological issues will continue to exist.

As with others who participated in virtual surveys, the most important lesson learned from preparing for a virtual visit was the need for comprehensive technical support and collaboration with IT (McMahon, 2021). Hospital staff should be familiar with the electronic health record and the functionality of the virtual platform. An on-site coordinator is key (McMahon, 2021). Having someone from the hospital, other than the TPMD or TPM, to assist in the logistics and interaction with the videoconferencing platform was essential. This person was crucial in organizing all presurvey and survey-day administrative components (McMahon, 2021).

When translating the traditional survey schedule to the virtual format, each session was evaluated, and the decision was made to keep, extend, or remove the session. Based on previous negative experiences with live virtual tours, such as noise control, patient confidentiality, difficulty with technology, and length of time required to navigate campuses, the option to keep the hospital tour was not entertained. In lieu of a live hospital tour, the PTSF allowed the hospital to present pictures or a prerecorded video of the hospital campus. The typical 30-min tour was limited to less than 5 min and made the footprint of the facility nearly impossible to discern. Although this portrayed the physical plant, the exposure to bedside caregivers and the invaluable interaction surveyors could have with them were lost.

Because of the extra time needed to navigate a medical record remotely, the medical record review session had to be extended. Traditionally, medical record review took place in one large room with all participants present, encouraging free-flowing conversations, questions and answers, and education provided by the surveyors, allowing the surveyors to hear discussions between their colleagues and hospital staff. The hospital staff could collaborate to provide input as needed, allowing for information exchange and universal education. The virtual format prevented this type of open dialogue.

The virtual format, and the need for each surveyor to have a unique virtual meeting link, hindered dialogue during medical record review. At one hospital, each chart navigator was in a separate office. At the other hospital, they were in the same room with a headset on, disallowing the TPMD and TPM from participating in conversations. When a surveyor had a question, the chart navigator had to find the TPMD or TPM, who may have been in a different room, and relay the question appropriately, which meant that questions had to be repeated to multiple people before the answer was obtained. The team lost the esprit de corps typically present when everyone was in person.

During medical record review, the video of the participants was either smaller in size or eliminated to maximize screen layout and document visibility. As with other documented outcomes from virtual events, lost was nonverbal communication (Chen et al., 2021). Although body language might introduce bias regarding how engaged participants are, the limited exposure in the virtual format may heighten this impact (Chen et al., 2021). Lack of nonverbal communication makes people more difficult to read because you cannot see their facial expressions, and other nonverbal nuances are lost (Taylor et al., 2020).

Although cost savings may be applicable, no formal cost analysis was done to evaluate the magnitude of eliminating travel and lodging expenses and minimizing surveyors' time away from primary employment. Additional expenses were accrued related to legal consultation fees and staff workload. Staff resources required for the virtual logistics were double those of the on-site survey.

CONCLUSION

This pilot project confirmed that the PTSF virtual format met the goals of an accreditation survey and maintained the high quality of the accreditation process. Despite this, the traditional format is preferable. Invaluable survey team collaboration and collegiality were diminished in the virtual format as surveyors had limited opportunities to speak to each other and other participants. The hospital missed opportunities to learn from the trauma experts.

We believe there is a place for the virtual format, however, not as a permanent replacement for on-site surveys. Knowing that a virtual survey maintains the quality and responsibility of the survey process ensures it is a viable option for circumstances when an on-site survey is not feasible, preventing the catastrophic need to cancel and reschedule a survey. These circumstances can include the inability to travel due to weather or other unforeseen emergencies. The ability to conduct a high-quality virtual accreditation survey was demonstrated in this pilot project. The full financial implications were not explored. The workload appreciated by the PTSF and hospital staff was twofold. Although the outcome met the goals, the benefits of the interpersonal interactions, education, dialogue with experts, and invaluable discussion related to trauma program opportunities were lost.

Acknowledgments

The authors thank the participating trauma center staff, surveyors, and Board of Directors. The authors also acknowledge the contribution of Juliet Altenburg, PTSF Executive Director, for supporting this project and assistance with the manuscript.

REFERENCES

American College of Surgeons (ACS). (2014). Resources for optimal care of the injured patient. https://www.facs.org/-/media/files/quality-programs/trauma/vrc-resources/resources-for-optimal-care.ashx
American College of Surgeons (ACS). (2020). Clarification of the verification extension and site visit postponement. https://www.facs.org/quality-programs/trauma/tqp/center-programs/vrc/postponement
Chen H., Tseng J., Chaer R., Spain D., Stewart J., Dent D., Ibanez B., Barry C., Jones A., Buyske J. (2021). Outcomes of the first virtual general surgery certifying exam of the American Board of Surgery. Annals of Surgery, 274(3), 467–472. https://doi.org/10.1097/SLA.0000000000004988
Curto C., Martin D. M. (2020). The Magnet® site visit: Going virtual in response to COVID-19. Journal of Nursing Administration, 50(11), 555–556. https://doi.org/10.1097/NNA.0000000000000934
Emergency Medical Services System Act of 1985, Title 35: Section 81 (1985). https://www.legis.state.pa.us/cfdocs/legis/LI/consCheck.cfm?txtType=HTM&ttl=35&div=0&chpt=81
McMahon M. F. (2021). Preparing for an American College of Surgeons virtual trauma reverification site visit: One center's experience. Journal of Trauma Nursing, 28(3), 203–208. https://doi.org/10.1097/JTN.0000000000000584
Pennsylvania Trauma Systems Foundation (PTSF). (2020). COVID19-coronavirus resources & information. https://www.ptsf.org/documents/#4
Pennsylvania Trauma Systems Foundation (PTSF). (2021). History. https://www.ptsf.org/about-us
Taylor M. J., Shikaislami C., McNicholas C., Taylor D., Reed J., Vlaev I. (2020). Using virtual worlds as a platform for collaborative meetings in healthcare: A feasibility study. BMC Health Services Research, 20(1), 1–10. https://doi.org/10.1186/s12913-020-05290-7
Tomaseski C. (2020). The inside scoop of a virtual site visit. American Nurse. https://www.myamericannurse.com/the-inside-scoop-of-a-virtual-site-visit
Keywords:

Designation; Site survey; Trauma center accreditation; Verification; Virtual survey

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