Burn Center Verification Review Program
Effective October 1, 2019
The ABA verification criteria are listed below. Criteria numbers listed with a “P” are applicable only to those centers requesting pediatric verification (or both adult and pediatric verification).
Potential criteria deficiencies ultimately determine verification status.
- If a burn center is found to have one Type 1 Criterion Deficiency (CD), this will result in automatic loss of (re)verification, and additional documentation may be requested.
- Three or more Type 2Criteria Deficiencies (CD) are equal to one Type 1 CD, and will result in loss of (re)verification. Additional documentation may be requested.
Use the Print or Excel button below to download a copy of these criteria.
| Criterion Category | # | Criterion | Criterion Level |
|---|---|---|---|
| Section 01: Burn Center Administration | 1.1. (1) | The burn center hospital is currently accredited by the Joint Commission or equivalent. | 1 |
| Section 01: Burn Center Administration | 1.2. (2) | The burn center has an identifiable medical and administrative commitment to the care of the patient with burns. | 1 |
| Section 01: Burn Center Administration | 1.3. (3) | The burn center hospital maintains a specialized unit dedicated to acute burn care. | 1 |
| Section 01: Burn Center Administration | 1.4. (4) | The burn center has designated ICU capable beds. | 1 |
| Section 01: Burn Center Administration | 1.5. (5) | The burn center maintains an appropriate policy and procedure manual that is easily accessible by the burn team and reviewed regularly with appropriate documentation by the burn center director and the nurse leader. | 1 |
| Section 01: Burn Center Administration | 1.6. (6) | Multi-disciplinary patient care conferences are held and documented at least weekly. | 1 |
| Section 01: Burn Center Administration | 1.7. (7) | Renal dialysis, radiological services, including computed tomography scanning, and clinical laboratory services are available 24 hours per day. | 2 |
| Section 01: Burn Center Administration | 1.8. (10) | The burn center hospital's policies and procedures regarding the use of allograft tissues are in compliance with all federal, state, and The Joint Commission (or equivalent) requirements, and, when feasible and appropriate, with standards of the American Association of Tissue Banks (or equivalent). | 1 |
| Section 01: Burn Center Administration | 1.9. (11) | The burn center has liaisons with a designated trauma center to coordinate care of patients with multi-trauma. | 1 |
| Section 02: Burn Center Volume | 2.1 (12.) | The burn center must have a sufficient volume of acute burn admissions on an ongoing basis. | 1 |
| Section 02: Burn Center Volume | 2.2. (13.) | Majority of admissions to the burn center are burn patients. | 1 |
| Section 02: Burn Center Volume | 2.3. (15.) | The burn center maintains and average daily census of 3 or more patients with acute burns. | 1 |
| Section 02: Burn Center Volume | 2.4. (16.) | No more than 5% of all patients with a primary diagnosis of a burn injury are admitted to another service per year (e.g. geriatrics, pediatrics, medicine). | 1 |
| Section 02: Burn Center Volume | 2.5 (88.) | No more than 5% of hospital admissions are transferred to another acute care facility. | 1 |
| Section 03: Burn Center Director | 3.1 (26.) | The burn center director is a licensed surgeon (MD or DO) with board certification by American Board of Surgery or American Board of Plastic Surgery (or equivalent for international burn centers in which case a surgeon must co-manage the center). | 1 |
| Section 03: Burn Center Director | 3.2 (27.) | The burn center director has completed a one-year fellowship in burn treatment and/or has experience in the care of patients with acute burn injuries for two or more years during the previous five years. | 1 |
| Section 03: Burn Center Director | 3.3 (28.) | The burn center director has ABLS (or equivalent) training. | 1 |
| Section 03: Burn Center Director | 3.4 (29.) | The burn center director is responsible for the direction of burn center administrative functions. | 1 |
| Section 03: Burn Center Director | 3.5 (30.) | The burn center director is responsible for the creation of policies and procedures within the burn center specifying all aspects of care for burned patients. | 1 |
| Section 03: Burn Center Director | 3.6 (31.) | The burn center director is responsible for ensuring that all burn center team members conform to the burn center’s locally established policies and procedures. | 1 |
| Section 03: Burn Center Director | 3.7 (33.) | The burn center director is responsible for the approval of privileges for physicians participating in the burn service based on medical staff credentialing process. | 1 |
| Section 03: Burn Center Director | 3.8 (34.) | The burn center director is responsible for the development and active participation in internal and external continuing medical education programs in the care and prevention of burn injuries. | 1 |
| Section 03: Burn Center Director | 3.9 (36.) | The burn center director is responsible for the communications on a regular basis with referring physicians regarding patients who have been transferred. | 1 |
| Section 03: Burn Center Director | 3.10 (37.) | In the event that the burn center director is not available, an accessible burn center staff surgeon is designated for administrative or clinical decisions. | 1 |
| Section 03: Burn Center Director | 3.11 (38.) | The burn center director regularly participates in regional, national or international burn meetings. | 1 |
| Section 03: Burn Center Director | 3.12P | The burn center director demonstrates CME or evidence of education in pediatric burn care annually (i.e. Pediatric Advanced Life Support, pediatric topic review, local regional meetings, invited speakers, journal clubs etc.) | 2 |
| Section 03: Burn Center Director | 3.13 (39.) | The burn center director has directed the total burn care of 50 or more acutely burned patients annually over a three-year period. | 1 |
| Section 03: Burn Center Director | 3.14P | The burn center director is involved in at least 25 pediatric cases annually. | 2 |
| Section 03: Burn Center Director | 3.15 (40.) | The burn center director demonstrates ongoing involvement in burn-related research, community education, continuing medical education, prevention efforts and local regional or national burn advocacy. | 1 |
| Section 04: Burn Surgeons | 4.1 (41.) | Burn surgeons are licensed surgeons with board certification by American Board of Surgery, American Board of Plastic Surgery or equivalent based on review by Verification Committee. | 1 |
| Section 04: Burn Surgeons | 4.2 (42.) | Burn surgeons have demonstrated expertise in burn treatment, by two or more years of mentored experience in the management of patients with acute burn injuries. | 1 |
| Section 04: Burn Surgeons | 4.3 (45.) | Each burn surgeon has participated, including primary decision-making, in the care of sufficient acutely burned patients annually. | 1 |
| Section 04: Burn Surgeons | 4.4 (43.) | Each burn surgeon must participate in continuing medical education in burn treatment. | 1 |
| Section 04: Burn Surgeons | 4.5 (44.) | Burn surgeons have had ABLS (or equivalent) training. | 2 |
| Section 04: Burn Surgeons | 4.6 (49.) | Assigned burn center medical staff are promptly available on a 24-hour basis. | 1 |
| Section 04: Burn Surgeons | 4.7 (46.) | The burn center maintains an on-call schedule for residents, qualified healthcare professionals and burn surgeons for continuous responsibility of burn patients. | 1 |
| Section 04: Burn Surgeons | 4.8 (109) | For centers that have residents involved in care of the burn patients an orientation program is provided for new residents. | 2 |
| Section 04: Burn Surgeons | 4.9P | Burn center has physicians who are board certified or eligible for certification in one of the following: · pediatric critical care medicine · pediatric surgery or surgical critical care | 2 |
| Section 04: Burn Surgeons | 4.10P | Burn surgeons have pediatric burn fellowship training or mentored clinical experience in pediatric burn surgery. | 2 |
| Section 04: Burn Surgeons | 4.11P | All burn surgeons demonstrate CME in pediatric care or equivalent internal burn education in pediatric burn care annually. | 2 |
| Section 05: Advanced Practice Providers | 5.1 (47.) | All advanced practice providers who are routinely responsible for the care of burn patients conform to burn center criteria documenting appropriate training, patient care experience, continuing medical education, and commitment to the care of the burned patient. | 1 |
| Section 05: Advanced Practice Providers | 5.2 (48.) | All advanced practice providers participating in the burn service are credentialed by the hospital medical staff credentialing process and are approved by the burn center director. | 1 |
| Section 06: Nursing | 6.1 (52.) | The burn nurse leader or equivalent is a licensed Registered Nurse (RN) with a minimum of a baccalaureate degree in nursing. | 2 |
| Section 06: Nursing | 6.2 (53.) | There is at least one nurse leader or equivalent who is administratively responsible for the nursing care provided within the burn center. | 1 |
| Section 06: Nursing | 6.3 (54.) | A burn nurse leader or equivalent must have sufficient experience in burns and nursing leadership to lead the staff and manage the nursing program of the burn center. | 1 |
| Section 06: Nursing | 6.4 (55.) | A metric-based staffing system is in place to determine nurse-staffing needs for patients in the burn center. | 2 |
| Section 06: Nursing | 6.5 (56.) | There is a burn-specific competency-based training and continuing educational program for all nurses assigned to the burn center. | 1 |
| Section 06: Nursing | 6.6 (57.) | The burn nurse leader or equivalent routinely participates in multi-disciplinary patient care rounds and there is dissemination to the nursing staff. | 1 |
| Section 06: Nursing | 6.7 (58.) | The burn nurse leader or designee attends burn-specific continuing educational opportunities at least once every two years. These requirements can be addressed by attending regional, national or international burn meetings; being an ABLS Instructor; and being involved in the ABA. | 1 |
| Section 06: Nursing | 6.8 (59.) | There is nurse representation within burn center quality improvement processes. | 1 |
| Section 06: Nursing | 6.9P | Nurses have pediatric certification or participate in pediatric specific continuing education or equivalent internal burn programming in pediatric burn care annually. | 2 |
| Section 07: Therapy | 7.1 (60.) | A comprehensive rehabilitation program is designed for burned patients within 24 hours of admission. | 1 |
| Section 07: Therapy | 7.2 (61.) | Physical and occupational therapists in the burn center are appropriately licensed in their respective disciplines and demonstrate ongoing continuing education in burn rehabilitation. | 1 |
| Section 07: Therapy | 7.3 (62.) | Therapy staffing is based upon burn center inpatient and therapy specific outpatient activity with at least one designated full-time equivalent burn physical therapist and one occupational therapist, but more depending on center volume. | 1 |
| Section 07: Therapy | 7.4 (63.) | Inpatients with an active rehabilitation plan must have care delivered as prescribed in the evaluation which should determine duration and frequency based on acuity, include goals, outcome and plan for follow up. | 1 |
| Section 07: Therapy | 7.5 (64.) | Burn therapy services are provided 7 days per week for care of burn inpatients. | 1 |
| Section 07: Therapy | 7.6 (65.) | Burn therapists participate in multi-disciplinary rounds and quality improvement. | 1 |
| Section 07: Therapy | 7.7 (66.) | Therapists assigned to the burn center must show evidence of ongoing burn specific competency training. | 1 |
| Section 07: Therapy | 7.8 (67.) | Therapists must participate in burn-related CEU activity on a regular basis. | 1 |
| Section 07: Therapy | 7.9P | Therapy staff participates in pediatric specific continuing education. | 2 |
| Section 07: Therapy | 7.10P | Therapy department has pediatric age-appropriate therapeutic equipment. | 2 |
| Section 08: Burn Team Members & Consultants | 8.1 (68.) | Social service consultation is available to the burn service, as needed. | 1 |
| Section 08: Burn Team Members & Consultants | 8.2 (69.) | A dietitian with adequate critical care and burn experience is available on a daily basis for consultation. | 1 |
| Section 08: Burn Team Members & Consultants | 8.3P | A pediatric dietitian with adequate critical care and burn experience is available on a daily basis for consultation. | 2 |
| Section 08: Burn Team Members & Consultants | 8.4 (70.) | A pharmacist with adequate critical care and burn experience is available on a 24-hour basis. | 1 |
| Section 08: Burn Team Members & Consultants | 8.5P | A pediatric pharmacist with adequate critical care and burn experience is available on a 24-hour basis. | 2 |
| Section 08: Burn Team Members & Consultants | 8.6 (71.) | Respiratory therapists are available for the assessment and management of patients on the burn service on a continuous basis. | 1 |
| Section 08: Burn Team Members & Consultants | 8.7 (73.) | A psychologist or psychiatrist is available to the burn service on an as needed basis. | 1 |
| Section 08: Burn Team Members & Consultants | 8.8P (72.) | A child life/recreational therapist is available for children cared for in the program. | 2 |
| Section 08: Burn Team Members & Consultants | 8.9 (106) | Burn team members are provided with a minimum of one regional, national or international burn-related continuing education opportunity annually OR demonstrate annual participation in internal educational process specific to burn care. | 1 |
| Section 08: Burn Team Members & Consultants | 8.10 (107) | A burn center orientation and ongoing continuing education program documents staff competencies specific to age appropriate care and treatment of burn patients, including critical care, wound care, and rehabilitation. | 1 |
| Section 09: Quality Improvement | 9.1 (102) | The burn center develops ongoing quality improvement projects to create a culture of safety and promote value-based programs. | 1 |
| Section 09: Quality Improvement | 9.2P | The pediatric burn center develops ongoing quality improvement projects to create a culture of safety and promote value-based programs. | 2 |
| Section 09: Quality Improvement | 9.3 (94.) | Sufficient QI documentation is available to verify problems, identify opportunities for improvement, resolve the problem and provide loop-closure. | 1 |
| Section 09: Quality Improvement | 9.4 (35.) | The burn center director is responsible for direction and active participation in the burn center Quality & Process Improvement Programs. | 1 |
| Section 09: Quality Improvement | 9.5 (92.) | The burn center director is responsible for the risk adjusted quality improvement program. | 1 |
| Section 09: Quality Improvement | 9.6 (93.) | A multidisciplinary burn center committee participates in the quality improvement program, meets at least quarterly and is integrated into the hospital QI structure. | 1 |
| Section 09: Quality Improvement | 9.7 (97.) | All life-threatening complications and deaths are discussed in a forum that includes specialist peers outside the core burn team, and are classified in a systemic fashion, so as to identify opportunities for improvement | 1 |
| Section 09: Quality Improvement | 9.8 (95.) | The morbidity and mortality conferences are held at least monthly. | 1 |
| Section 09: Quality Improvement | 9.9 (96.) | The morbidity and mortality conferences include specialist peer staff members other than those practicing in the burn center. | 1 |
| Section 09: Quality Improvement | 9.10 (98.) | The morbidity and mortality conferences include documentation of loop closure. | 1 |
| Section 09: Quality Improvement | 9.11 (99.) | Clinical team members involved in the direct care of the burn patients participate in at least 50% of the morbidity and mortality conferences. | 1 |
| Section 09: Quality Improvement | 9.12 (100) | Sentinel events are discussed in a timely manner at multi-disciplinary intensive reviews during which time a non-involved peer leads a discussion with all involved parties and areas for improvement and loop closure are identified. | 1 |
| Section 09: Quality Improvement | 9.13 (101) | The burn program conducts audits of their benchmarked outcomes data (using available resources such as NBR, UHC, NHSN, or CMS) at least quarterly. | 1 |
| Section 09: Quality Improvement | 9.14 (103) | The burn center has policies for infection control with regular monitoring for hospital-acquired infections, multi-drug resistant organisms and compliance. | 1 |
| Section 09: Quality Improvement | 9.15 (104) | The burn center participates in the ABA’s National Burn Repository or other equivalent data collection/analysis tool and submits data every year. | 1 |
| Section 09: Quality Improvement | 9.16 (105) | The burn center database includes all patients who are admitted to the burn center hospital for burn care. | 1 |
| Section 09: Quality Improvement | 9.17P | Evidence of at least one on-going QI metric in pediatric specific rehabilitation issues (i.e., garment compliance, splint compliance, rates of contracture, success with release, etc.) | 2 |
| Section 10: Pre-Hospital Care | 10.1 (17.) | The burn center has written guidelines for the triage, treatment, and transfer of burned patients from other facilities. | 1 |
| Section 10: Pre-Hospital Care | 10.2 (32.) | The burn center director is responsible for the coordination with regional EMS authorities regarding triage and transport of burn patients. | 1 |
| Section 10: Pre-Hospital Care | 10.3 (18.) | The burn center maintains access to an EMS system for the transport of patients with burns from referral sources within the service area. | 1 |
| Section 10: Pre-Hospital Care | 10.4 (19.) | The burn center offers input into the quality improvement of pre-hospital care of burn patients. | 1 |
| Section 11: Emergency Department | 11.1 (20.) | Written protocols developed with input from the burn center guide the care of burn patients in the emergency department. | 1 |
| Section 11: Emergency Department | 11.2 | Emergency department is available 24/7. | 2 |
| Section 11: Emergency Department | 11.3P | Emergency physicians are board certified or eligible for certification by an appropriate emergency medicine board according to current requirements in pediatric emergency medicine. | 2 |
| Section 11: Emergency Department | 11.4P | Evidence of collaborative clinical practice and educational activities between the burn program and the emergency services. | 2 |
| Section 11: Emergency Department | 11.5P | Emergency service representative serves as a liaison to the burn quality care program. | 2 |
| Section 12: Intensive Care Unit (ICU) | 12.1 (14.) | Burn centers caring for critically ill patients must demonstrate facilities, protocols and personnel specific to the care of critically ill patients. | 1 |
| Section 12: Intensive Care Unit (ICU) | 12.2P | The burn program works collaboratively with the pediatric critical care providers, although all significant therapeutic decisions involving burn patients are approved by the burn program, and the burn program is made aware of all significant clinical changes. | 2 |
| Section 12: Intensive Care Unit (ICU) | 12.3P | A PICU representative serves as a liaison to the burn quality improvement program. | 2 |
| Section 12: Intensive Care Unit (ICU) | 12.4P | There are protocols for burn specific care in collaboration with the PICU. | 2 |
| Section 12: Intensive Care Unit (ICU) | 12.5P | PICU works in concert with the Burn Center Director to develop protocols for intensive care. | 2 |
| Section 13: Operative Services (Including Anesthesiology): | 13.1 (8) | The burn center has timely access to operating rooms. | 1 |
| Section 13: Operative Services (Including Anesthesiology): | 13.2 (9) | A dedicated OR team with burn experience is available for the burn operating theatre. | 2 |
| Section 13: Operative Services (Including Anesthesiology): | 13.3 (51.) | A dedicated anesthesia team with burn experience is available for the burn operating theatre. | 2 |
| Section 13: Operative Services (Including Anesthesiology): | 13.4P | For centers admitting patients under 2 years of age and requiring surgery, an anesthesiologist with certification in pediatric anesthesiology is available 24/7. | 2 |
| Section 13: Operative Services (Including Anesthesiology): | 13.5P | A pediatric anesthesiology representative serves as a liaison to burn quality improvement program. | 2 |
| Section 14: Rehabilitation | 14.1 (89.) | Physiatrist consultation is available. | 2 |
| Section 14: Rehabilitation | 14.2 (90.) | The burn center coordinates with local and/or regional rehabilitation centers for inpatient rehabilitation. | 1 |
| Section 14: Rehabilitation | 14.3 (91.) | The burn center coordinates with local and/or regional outpatient facilities for ongoing outpatient therapy needs of patients needing rehabilitation after discharge. | 1 |
| Section 15: Ambulatory Care | 15.1 (74.) | The burn center has appropriate outpatient facilities, including adequate facilities for wound care. | 1 |
| Section 15: Ambulatory Care | 15.2 (75.) | The outpatient facility must be able to provide for appropriate pain management during wound care. | 2 |
| Section 15: Ambulatory Care | 15.3 (80.) | The burn center provides appropriate multi-disciplinary follow-up. | 1 |
| Section 15: Ambulatory Care | 15.4 (76.) | For continuity of care, staffing of the outpatient area should be by multi-disciplinary experienced burn team members, approved by the burn center director and nurse leader. | 2 |
| Section 15: Ambulatory Care | 15.5 (86.) | The burn center provides access to outpatient social service, pharmacist and dietary consultations, as needed. | 2 |
| Section 15: Ambulatory Care | 15.6 (77.) | A representative of the outpatient staff participates in weekly multi-disciplinary burn conferences and the burn center QI program. | 1 |
| Section 16: Community Reintegration | 16.1 (79.) | The burn center provides coordinated transition of care to the outpatient status. | 1 |
| Section 16: Community Reintegration | 16.2 (78.) | The burn center follows >75% of all patients who transition to the outpatient setting. | 1 |
| Section 16: Community Reintegration | 16.3 (83.) | A burn therapist is available in the outpatient clinic to provide services, including follow up, as needed. | 1 |
| Section 16: Community Reintegration | 16.4 (81.) | The burn center provides brief psychological screening/intervention. | 1 |
| Section 16: Community Reintegration | 16.5P (82.) | The burn center provides evaluation of patient developmental status (for children). | 2 |
| Section 16: Community Reintegration | 16.6 (84.) | The burn center provides timely access to reconstructive surgery. | 2 |
| Section 16: Community Reintegration | 16.7 (85.) | The burn center facilitates access to peer-to peer and burn survivor resources for patient and family support. Provides access to peer support (such as but not exclusively a Phoenix Society SOAR program). | 1 |
| Section 16: Community Reintegration | 16.8 (87.) | The burn center provides access to vocational counseling. | 2 |
| Section 16: Community Reintegration | 16.9 P | Burn center has established relationship with one of the many camps and demonstrated active attempts at recruitment for children to attend. | 2 |
| Section 17: Prevention & Outreach | 17.1 (111) | Burn program is involved in local, regional, national, or international prevention outreach efforts. | 1 |
| Section 17: Prevention & Outreach | 17.2 (108) | The burn program regularly participates in regional education related to burn care. | 1 |
| Section 17: Prevention & Outreach | 17.3 (110) | The burn center participates regularly in community burn outreach programs. | 2 |
| Section 18: Advocacy & Research | 18.1 (112) | Burn Center multi-disciplinary staff, under the leadership of the burn center director, work locally, regionally, or nationally to advocate for burn related health care issues. | 2 |
| Section 18: Advocacy & Research | 18.2 (113) | The burn center multi-disciplinary staff is involved in research (including basic science, clinical, industry-sponsored, QI, multi-center) and presents posters or oral presentations at hospital based, regional national or international meetings. | 2 |
| Section 19: Disaster Planning | 19.1 (21.) | The burn center interfaces with regional trauma centers to coordinate care of patients with multiple injuries and to develop regional educational programs, disaster planning and advocacy efforts. | 2 |
| Section 19: Disaster Planning | 19.2 (22.) | The burn center has a written Mass Casualty Disaster Plan for the triage and treatment of those patients burned in a mass casualty incident occurring within its service area. | 1 |
| Section 19: Disaster Planning | 19.3 (23.) | The Mass Casualty Disaster Plan is reviewed and updated as needed and on an annual basis by EMS representatives and the burn center director. | 2 |
| Section 19: Disaster Planning | 19.4 (24.) | There are current (within the past 3 years) written memoranda of understanding with other burn centers regarding secondary triage. | 1 |
| Section 19: Disaster Planning | 19.5 (25.) | The burn center must maintain accurate and up to date contact information for burn surgeons and managers on the ABA website. | 2 |
The burn center must document active participation in at least one of the Advocacy (18.1) or Research (18.2) activities.