Day #1 – On Site Review

1:00–5:00 pm

ReviewParticipantsReview & Discussion
1.Chart ReviewSite reviewersReview charts, hospital/burn center quality improvement programs, policies, procedures, manuals
2.Review Deaths and/or Find ComplicationsSite reviewers, burn center director and burn center key staffView 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 ProcessSite reviewers, burn center director and burn center key staffEvaluation 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


  • 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

ReviewParticipantsReview & 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 missionReview 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 RoundsSite reviewers, burn team that participates on roundsAttend rounds and in- depth discussion of selected patient charts
3.Burn Center Tour
(if requested)
Site reviewers, burn teamReview of recent changes in the facilities
4.Site Reviewer Meeting
30 minutes
Site reviewers, burn center directorMeeting and deliberation
5.Executive Session
Site reviewersClosed session for Site Reviewers to discuss findings.
6.Exit Interview
Site reviewers, burn team, key administratorsBrief summary of the site reviewer findings and recommendations are presented.