Virtual Trauma Center Survey Presentation in Florida
Trauma Center
Virtual Survey Presentation
September 29, 2021
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Department of Health
Trauma Centers that Participated
The 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 City
•
Gaylen Tips, RN, Holmes Regional Medical Center, Melbourne
•
Cory Hewitt, RN, Ocala Regional Medical Center, Ocala
•
Jami Rothenburg, RN, Broward Health North, Deerfield Beach
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Madonna Stotsenburg, RN, St. Mary’s Medical Center, West Palm Beach
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, RN
Survey Teams
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Pre-survey questionnaire received from the trauma center 60 days prior to day of the survey.
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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.
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Orientation meeting with the Trauma Section staff and the survey team.
•
Compiling the deficiency report.
Elements that Remained
What went VIRTUAL?
Elements that went Virtual
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:
•
Helipad
•
EMS Bay arrival area and pathway to the Trauma Bay
•
Radio room in the ED
Equipment Videos
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
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:
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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 Services
The trauma medical director and trauma program manager coordinate with the different people in each
department 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
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
EST
8:45 - 9:00 am
Surveyors connect to virtual meeting invite
9:00 - 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
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)
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; XII
12:15-12:45 pm
Peer Meeting: Discuss medical records review, policies and procedures
related to the specialty and other issues requiring clarification
12:45-1:15 pm
Survey team closed meeting to discuss findings
Virtual Day Agenda (continued)
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 review
1:45
-2:15pm
Exit conference with key hospital personnel
Virtual Day Agenda
(continued)
A special thank you to the following Trauma Section staff for assisting in the design and
implementation of the virtual surveys:
Bernadette Behmke
Government Operations Consultant
Carma Harvey
Information Technology Analyst
Shayla Cole
Government Analyst I
Thanks to DOH Staff
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Thank you!
The Department of Health in Florida organized a successful virtual survey for trauma centers, with Trauma Section Administrator Kate Kocevar leading the presentation. Participating trauma centers and program managers were recognized for their dedication. Survey teams, including medical professionals and RNs, worked diligently to ensure a smooth survey process. The virtual survey maintained key elements while leveraging technology for tasks like equipment videos.
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Presentation Transcript
Department of Health Division of Emergency Preparedness and Community Support Bureau of Emergency Medical Oversight Trauma Section Trauma Center Virtual Survey Presentation September 29, 2021
Department of Health Presented by: Kate Kocevar, Trauma Section Administrator 2
Trauma Centers that Participated The 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 City Gaylen Tips, RN, Holmes Regional Medical Center, Melbourne Cory Hewitt, RN, Ocala Regional Medical Center, Ocala Jami Rothenburg, RN, Broward Health North, Deerfield Beach Madonna Stotsenburg, RN, St. Mary s Medical Center, West Palm Beach 3
Survey Teams 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, RN 4
Elements that Remained Elements of the virtual survey that REMAINED the same as an on-site survey Pre-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. 5
Elements that went Virtual What went VIRTUAL? 6
Equipment Videos 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: Helipad EMS Bay arrival area and pathway to the Trauma Bay Radio room in the ED 7
Remote Medical Record Review 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. 8
Relay Virtual Facility Tour Live 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 Services The trauma medical director and trauma program manager coordinate with the different people in each department to provide a virtual observation of their respective area and field surveyor s questions to provide detail and/or clarification. 9
Pre-Appointed Meetings 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. 10
Virtual Day Agenda EST 8:45 - 9:00 am Surveyors connect to virtual meeting invite 9:00 - 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 11
Virtual Day Agenda (continued) 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. 12
Virtual Day Agenda (continued) 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; XII 12:15-12:45 pm Peer Meeting: Discuss medical records review, policies and procedures related to the specialty and other issues requiring clarification 12:45-1:15 pm Survey team closed meeting to discuss findings 13
Virtual Day Agenda (continued) 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 review 1:45-2:15pm Exit conference with key hospital personnel 14
Thanks to DOH Staff A special thank you to the following Trauma Section staff for assisting in the design and implementation of the virtual surveys: Bernadette Behmke Government Operations Consultant Carma Harvey Information Technology Analyst Shayla Cole Government Analyst I 15
Thank you! Questions or Comments? 16
