A Guide to Preparing Leadership for an ACS Verification Survey
Preparing hospital leadership for an American College of Surgeons (ACS) Verification Survey is a bit like preparing royalty for an unexpected castle inspection: the structure should already be sound, but everyone still scrambles to make sure the drawbridge is oiled and the dragons are fed. Fortunately, the ACS Verification, Review, and Consultation (VRC) Program provides a structured—and far less medieval—framework for achieving excellence in trauma care (American College of Surgeons, n.d.). The goal is not perfection; it is reliable systems, transparent performance improvement, and leaders who know their responsibilities as well as they know their morning coffee orders.
1. Set the Stage: Leadership Engagement and Commitment
The ACS makes one thing abundantly clear: trauma center excellence starts at the top. Leadership commitment is a foundational requirement across trauma center standards and verification criteria (American College of Surgeons, n.d.). Executives and program leaders should understand that an ACS survey is not a ceremonial event—it is an objective evaluation of institutional capability, readiness, resources, protocols, and performance improvement mechanisms.
Leadership must champion trauma program resourcing, foster interdisciplinary alignment, and maintain an accurate understanding of standards such as trauma staffing, registry requirements, and PI expectations (Fojut, 2022). The ACS expects trauma program leaders to not only support but actively participate in the preparation, review, and continuous improvement process.
2. Know the Standards: Because “I Didn’t Know” Is Not an Excuse
The Resources for Optimal Care of the Injured Patient (2022 Standards) are the backbone of ACS verification (American College of Surgeons, n.d.). Leaders need a high‑level but accurate grasp of these requirements—think of it as being fluent in trauma‑center‑ese without needing to recite every standard verbatim.
Newer expectations, such as increased staffing requirements for trauma registrars and dedicated performance improvement coordinators, reinforce the importance of robust human resources and high‑quality data (Fojut, 2022). Leadership should be able to articulate how the organization meets these requirements and where improvement efforts are ongoing.
3. Data: The Lifeblood of Verification
In the realm of ACS surveys, trauma registry data is the equivalent of an organization’s vital signs. Updated 2022 and 2025 revisions emphasize registry staffing, education, data validation, and timely case abstraction (Radeker, 2025). Leaders should be prepared to discuss registry infrastructure, technology, staffing FTEs per case volume, and mechanisms for improving accuracy and timeliness.
Quality data is not optional—it is the metric system of trauma verification. And nothing causes more collective leadership sweating than inconsistencies between what the team thinks is happening and what the data actually says.
4. Performance Improvement: Show Your Work
Performance Improvement and Patient Safety (PIPS) programs remain a major focus of ACS review. The ACS expects centers to have clear PI methodologies, documented case reviews, loop closure, specialist response documentation, and timely system analysis.
Recent updates—even the relaxed ICU clinician coverage requirements—have tightened expectations for timely bedside response and documentation (Fojut, 2025). Leaders should be ready to describe not just the existence of PI processes but their effectiveness, tracking mechanisms, and cross‑departmental communication strategies.
5. Practice Makes Prepared: Simulation and Leadership Walkthroughs
Before the survey team arrives, leadership should participate in structured walkthroughs, mock interviews, and “tabletop” simulations. These exercises help ensure consistent messaging and uncover gaps before the ACS team does.
Leadership should be able to confidently explain:
Program achievements
Challenges and mitigation strategies
Resource allocation decisions
Plans for meeting future standards
In other words, leaders should sound both competent and caffeinated.
6. Culture Counts
The survey team looks beyond binders and dashboards; they evaluate organizational culture—engagement, transparency, communication, and real‑world performance improvement. Leadership sets this tone.
A culture of accountability and teamwork cannot be invented the week before the survey. But it can be demonstrated convincingly when leadership is aligned, knowledgeable, and genuinely supportive of the trauma team.
Conclusion
Preparing leadership for an ACS Verification Survey requires a blend of strategic preparation, data mastery, thoughtful communication, and institutional humility. The ACS framework is rigorous by design, but it also serves as a roadmap to higher‑quality trauma care. With prepared leadership at the helm, the verification process becomes less of a stress test and more of an opportunity to proudly showcase the organization’s commitment to the injured patient.
References
American College of Surgeons. (n.d.). Trauma Verification, Review, and Consultation Program. https://www.facs.org/quality-programs/trauma/quality/verification-review-and-consultation-program/
Fojut, R. (2022). 9 new expectations in the 2022 ACS trauma center standards. Trauma System News. https://trauma-news.com/2022/01/9-new-expectations-in-the-2022-acs-trauma-center-standards/
Fojut, R. (2025). ACS relaxes requirements in 4 trauma center standards. Trauma System News. https://trauma-news.com/2025/07/acs-relaxes-requirements-in-4-trauma-center-standards/
Radeker, T. (2025). Assessing readiness to meet ACS trauma registry standards. Optimal Healthcare Advisors. https://oha-llc.com/assessing-readiness-to-meet-acs-trauma-registry-standards/
