For planning purposes, the review will last at least six hours.

Please note: Pending reviewer’s travel arrangements, it may be requested that chart reviews begin on the day before the review, prior to the pre-review dinner. Please make arrangements to accommodate this request should it be made.

Hotel arrangements must be made and paid for each reviewer. For a single center site visit, hotel arrangements can be made for one night. For a joint site visit, hotel arrangements may be made up to two nights depending on reviewers travel schedule.

Reviewers will arrive at hospital approximately twenty minutes before review actually starts. Coffee with Hospital Administration, Burn Unit Director, and Burn Unit Nurses.

Emergency Department – 20 minutes

  1. Review Emergency Department facility, resuscitation area, equipment, protocols, flow sheet, staffing, on-call schedule…
  2. Interview Emergency Department physician and Emergency Department nurse

Operating Room/ Recovery Room – 15 minutes

  1. Interview Operating Room Head Nurse and Anesthesiologist
  2. Check Operating Room Schedule

Burn Unit – 30 to 45 minutes

  1. Inspect facility
  2. Review flow sheets
  3. Interview nurse

Blood Bank/ Labratories/ Rehabilitaiton – May be visited

  1. Inspect facility
  2. Interview technicians

Hospital Administrator / Chief of Surgery / Chief of Staff, Burn Service Attending Staff Surgeons should be available for questions. DO NOT SCHEDULE INTERVIEWS!

After allowing 1-1/2 to 2 hours for the above…

Review of Quality Assurance Documents / Patient Chart Review – 2-1/2 to 3 hours Executive Closed Session for Reviewers Only for approximately thirty minutes.

Exit Interview – 30 to 45 minutes

Hospital Administrator, Chief of Burn Service, and others as desired.

Available at time of review

  1. Listing of Hospital’s involvement from one year in the following:
    • Continuing education for physicians, nurses, rehabilitation therapists, public…
    • Research activities including reprints and copies of submitted articles, protocols of present studies
  2. Copy of on-call schedule for three moths prior to review
    • Burn Service on-call schedule for the attendings
    • Burn Service resident on in-house physician on-call coverage
  3. Policy and procedure documentation for Pre-hospital, Emergency Department, and Burn Unit/Center
  4. Quality Assurance Documents:
    • Minutes of Burn Service CQI Committee meetings for one year
    • Quality assurance programs relating to burn service for one year
    • Specific examples of “closure of the loop” in the QA programs
  5. Specific burn service patient charts will be requested either before the review or from the Burn Service Registry at the time of the review

Available during review for interview

  • Hospital Administrator
  • Burn Service Chief
  • Trauma Service Chief
  • Emergency Dept. Medical Director
  • Director of the Critical Care Unit
  • Medical/Technical Director of Skin Bank
  • Infection Control Director
  • Burn Unit Nurse Manager/QA Nurse for Burn Services
  • Chief of Staff
  • Chief of Surgery Service
  • Chief of Anesthesia Service
  • Chief of Rehabilitation Service
  • Medical Records Technician
  • Burn Registry Manager