Day #1 – On Site Review

1:00–5:00 pm

Review Participants Review & Discussion
1. Chart Review Site reviewers Review charts, hospital/burn center quality improvement programs, policies, procedures, manuals
2. Review Deaths and/or Find Complications Site reviewers, burn center director and burn center key staff View documentation of the discussions, in a conference that provided open, candid, critical review of the problems, problem-solving, action items and loop closure
3. Performance Improvement Process Site reviewers, burn center director and burn center key staff Evaluation of performance improvement
Day #1 – Review Dinner

6:00–8:30 pm

The working review dinner is an important feature of the site review process, held at the end of Day #1.

Invited Guests− usually include 8-10 attendees (attendance maximum of 15):

  • Attendings caring for patients in the burn center
  • Nurse Manager(s)
  • Administrator, directly responsible for the burn center, outreach, prevention
  • Other key staff (i.e., Directors of Therapy and Rehabilitation, etc.) as appropriate
  • Anyone else involved in completing the pre-review questionnaire (PRQ) that may provide additional information

Format

  • arrange a quiet, private room
  • ensure that all are introduced, seated and served first
  • allow the site reviewers to conduct the meeting during dinner

9-10:00 pm: If necessary, the site review team meets briefly to discuss findings and prepare for Day #2.

Day #2 – On Site Review

7:00 am–12:00 pm

Review Participants Review & Discussion
1. Introductory Breakfast
(90 minutes)		 Site reviewers, burn team, hospital CEO, chief of Surgery, other key administrators and chief officers (pediatrics, surgery, ER, etc..), representatives of therapy, pharmacy, nursing, social work, nutrition, chaplain support, emergency medical personnel, liaisons, others important to the burn center mission Review of the past 3 years, staff express concerns regarding the burn center, opportunity to exchange ideas and receive feedback from the Site Reviewers.
2. Clinical Rounds Site reviewers, burn team that participates on rounds Attend rounds and in- depth discussion of selected patient charts
3. Burn Center Tour
(if requested)		 Site reviewers, burn team Review of recent changes in the facilities
4. Site Reviewer Meeting
30 minutes		 Site reviewers, burn center director Meeting and deliberation
5. Executive Session
closed		 Site reviewers Closed session for Site Reviewers to discuss findings.
6. Exit Interview
open		 Site reviewers, burn team, key administrators Brief summary of the site reviewer findings and recommendations are presented.