Trauma Program

Trauma Program 1. There must 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 surgeon with current or previous board certification in General Surgery. 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 placed so that it may interact effectively with at least equal authority with other departments providing patient care. An administrative structure must minimally include an administrator, medical director (TMD), trauma program manager (TPM), trauma registrar and the appropriate support staff. Administrative support includes human resources, educational activities and community outreach activities. The trauma program must be multidisciplinary in nature and the performance improvement evaluation of this care must extend 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 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;