Verification Process – Burn Centers

Below is the preferred site visit schedule.

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.

Day #1

• 1:00-4:00 PM – Chart review and performance improvement
• 4:00-5:00 PM –  Review of prevention, outreach, and research documentation
• 6:30-8:30 PM –  Executive session and PRQ review over dinner, with hospital and burn center leadership

Day #2

• 7:00-8:30 AM – Breakfast meeting with representatives of the entire burn team
• 8:30-10 AM – Patient rounds and tour
• 10-10:15 AM – Private meeting of surveyors with burn center director
• 10:15-11 AM – Private reviewer deliberation
• 11:00 AM – Exit interview

Role of Burn Center Director

• Burn Center must set up 90-minutes virtual breakout session with therapy and nursing. Breakouts must be scheduled either on the first day of the site visit, ideally in the morning before chart review begins, or in the week preceding the onsite visit. A 30-minute video conference should also be arranged for all 4 surveyors to debrief and collate their input after both breakout sessions have been completed.
• 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.

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. Deaths: 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. Transfers: 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. Complications: 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

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

Additional Case: 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, abacentraloffice@ameriburn.org, or 312-642-9260.

Please see the checklist of materials to have ready for your reviewers during their site review.