Trauma Program

Trauma Program 1. There shall be a written commitment on behalf of the entire facility to the organization of trauma care. The written commitment shall be in the form of a resolution at the time of application passed by an appropriate quorum of the members of the governing authority. Should the business organization be other than a corporation, a letter explaining such, together with a written commitment of the hospital’s chief executive officer, to the establishment of a trauma care program may be sufficient. The trauma program must be established and recognized by the medical staff and hospital administration. The trauma program must come under the direction of a board-certified general surgeon with special interest in trauma care. An identified hospital administrative leader must work closely with the trauma medical director to establish and maintain the components of the trauma program including appropriate financial support. The trauma program location in the organizational structure of the hospital must be such that it may interact effectively with at least equal authority with other departments providing patient care. The administrative structure must minimally include an administrator, medical director (TMD), trauma program manager (TPM), trauma registrar and appropriate support staff. Administrative support includes human resources, education activities, community outreach activities, and research. The trauma program must be multidisciplinary in nature and the performance improvement evaluation of this care must be extended to all the involved departments. 2. Compliance with the above will be evidenced by but not limited to: a. Governing authority and medical staff letter of commitment in the form of a resolution; b. Written policies and procedures and guidelines for the care of the trauma patient; c. Defined trauma team and written roles and responsibilities; d. Appointed Trauma Medical Director with a written job description; e. Appointed Trauma Program Manager with a written job description; f. A written Trauma Performance Improvement plan; and g. Documentation of representative attendance at statewide PI meetings.