Prepping for your burn center verification site visit−what you need to know.

There are many components of the burn center site visit.

  • Chart reviews
  • Fact-finding review
  • Tour of burn center
  • Review of program activities (PI, CME, outreach prevention and guidelines, and research)
  • Closed discussion of findings and creation of executive summaries
  • Exit interview

What burn centers need to know:

Day #1
  • 1:00 – 5:00 pm: Chart review and Evaluation of Process Improvement
  • If time is available, other areas of the site review may be completed (research, prevention, outreach, etc)
  • 6:00 pm: Review dinner
  • 9:00 – 10:00 pm: If necessary, the review team meets briefly to discuss findings and prepare for Day #2.
Day #2
  • 7:00 am: Breakfast with extended burn center staff and hospital leadership
  • 9:00 am: Tour of burn center and clinical rounds of current inpatients
  • Complete evaluation of PI, research, prevention, outreach and other documentation, as needed
  • 11:00 am: Site reviewer meeting/deliberation – Site review team (30 or more minutes)
  • 11:30 am: Exit interview – Team leader and site reviewers with the burn center members
  • 12:00 pm: Verification visit completed
Role of Burn Center Director
  • arranges transportation for the site reviewers, from the airport to the hotel
  • meets informally with the reviewers, prior to the formal dinner meeting
  • needs to be available throughout the site visit
  • be sure the site reviewer questions are fully answered
  • accommodates a professional, congenial experience for all site visit participants

Refer to the sample agenda for assistance in planning the site visit. Exact times may vary based on site reviewer flight schedules; however, the overall duration of the visit should allow for the following to occur.

Computer resources need to be available for each site reviewer, to evaluate the medical records and charts separately, with assistance from one staff member to facilitate access. The burn center director must be present and other burn surgeons are welcome to participate.

Chart reviews are an important activity in the Re-verification review process. Therefore, to facilitate the onsite review, medical charts/records in the following categories need to be available during the visit. Unless otherwise specified, the records should be patients cared for in the past twelve calendar months. If charts are pulled and tagged, as requested, and conference records pulled ahead of time, the review will be substantially expedited.

1. All Deaths During the Twelve Previous Months, Fiscal or Calendar Year

To facilitate this review:

  1. tag death summary
  2. tag any critical progress notes
  3. have autopsy report readily available
  4. have minutes or summary of conferences, where open, critical, candid discussion took place, readily available
  5. include any recommendations from these conferences
  6. show loop closure, if applicable

2. All Patients Transferred to Another Acute Care Facility During the Past Three Years

To facilitate this review:

  1. tag all pertinent progress notes, indicating the reason for transfer
  2. tag discharge summary
  3. have readily available, any discussion of these transfers during conferences

3. Records of Five Patients with Non-Fatal Complications, Discussed at the Conferences, as Listed Above:

To facilitate this review:

  1. tag discharge summary
  2. tag any critical progress notes relating to the complication(s)
  3. have readily available, minutes or summary of conferences, where open, critical, candid discussion took place
  4. include any recommendations from the conferences
  5. show any loop closure that might have resulted from these conferences

NOTE: One non-fatal rehabilitation chart must be provided, including specific complications or challenges with indication how they were managed by the multi-disciplinary team.

NOTE: Centers applying for both Adult and Pediatric Verification/Re-verification must provide a medical record of at least one pediatric chart during the site visit.

A single patient’s medical record may fulfill more than one of these categories. Patients whose treatment involved the quality assurance program should receive priority for selection. This latter criterion will facilitate evaluation of the quality assurance program for the unit. Please have all quality assurance materials available for the medical records review.

Questions? Contact the ABA Central Office, zemelko@ameriburn.org, or 312-662-6074.