Who Should Attend the Reviewer Interviews during ACS Verifications?
A guide for trauma programs that want zero surprises—and zero preventable findings.
When the American College of Surgeons (ACS) Verification, Review, and Consultation (VRC) team arrives (in-person or virtually), the reviewer interviews are your program’s moment to show how the orchestra plays together, not just how well the soloists perform. Think of the agenda as a quality “grand rounds”: reviewers triangulate what’s in your PRQ, your medical records, and your Performance Improvement and Patient Safety (PIPS) outcomes with the people who actually do the work (ACS, 2026).
Below is a pragmatic roster—organized by interview purpose—of who belongs in the room (or on the Zoom), and why. It’s based on the current Resources for Optimal Care of the Injured Patient (2022 Standards) and the ACS VRC process guidance (ACS, 2025).
1) Program Governance & Institutional Commitment
Bring:
Hospital senior leadership (e.g., CMO/COO/VP Nursing) who can speak to board-level support, resources, and strategic alignment. ACS standards begin with institutional commitment for staffing, equipment, and adherence to verification requirements (ACS, 2025).
Trauma Medical Director (TMD) and Trauma Program Manager (TPM)—the dyad that owns the clinical and operational execution of the standards. The formal agenda even calls out a TMD/TPM meeting; they’ll also anchor most content-heavy interviews (ACS, 2026).
Why it matters: Verification validates the structure supporting care (Donabedian’s triad of structure-process-outcome), and reviewers look for visible leadership commitment that translates into day-to-day readiness and improvement (Cryer, Fildes, & Nathens, 2012).
2) PIPS (Performance Improvement & Patient Safety) and Data Systems
Bring:
PIPS Committee leaders (often TMD plus PI nurse/coordinator, quality leaders) who can demonstrate case reviews, action plans, and loop closure (ACS, 2025).
Trauma Registrar/CSTR and Data quality lead—to speak to registry completeness, definitions, reporting periods vs. verification cycle, and TQIP participation (ACS, 2022; ACS, 2026).
Why it matters: The VRC team correlates chart findings with PIPS activity; robust PI and sound data are linked to better outcomes and collaborative performance at scale (ACS, 2026; Mlaver et al., 2025).
3) Clinical Services Coverage & Call Structure
Bring service chiefs or designees who can speak to resources, coverage, and protocols—aligned to your center’s level and patient mix:
Emergency Medicine leadership (ED medical director and nursing leadership) (ACS, 2014).
Neurosurgery (for TBI pathways and call) (ACS, 2024).
Orthopaedic surgery (fracture management, pelvic ring injury pathways) (ACS, 2014).
Anesthesia/Airway/OR leadership (rapid access, MTP support) (ACS, 2014).
Critical Care/ICU leadership (ACS, 2014).
Radiology (CT access, turnaround, interventional radiology availability) (ACS, 2014).
Rehabilitation (early mobilization, access plans) (ACS, 2014).
Blood bank/transfusion medicine (MTP effectiveness, TEG/ROTEM if used) (ACS, 2014).
Pediatrics (if mixed center or PTC)—Pediatric surgery, EM, ICU leaders per scope (ACS, 2014).
Why it matters: ACS standards specify personnel and service resources; reviewers test real-world availability, response times, and protocol adherence—not just policy binders (ACS, 2026).
4) Injury Prevention & Community Outreach
Bring:
Injury Prevention Coordinator (that’s your cue!) and prevention team to show evidence-based initiatives, measurable outcomes, and alignment with community needs and trauma epidemiology (ACS, 2025).
Why it matters: Injury prevention is a core standard—programs demonstrate a system-level approach beyond the ED door (ACS, 2026).
5) Prehospital & System Integration
Bring:
EMS liaison/prehospital medical director (or system representative) to discuss triage criteria, destination protocols, feedback loops, and joint training (ACS, 2025).
Why it matters: Verification checks how well “right patient, right place, right time” is operationalized across the regional trauma system; mature systems consistently reduce mortality (Alharbi et al., 2021).
6) Nursing & Operational Logistics
Bring:
ED/ICU/OR nursing leadership and Bed management/transfer center—to demonstrate staffing plans, onboarding/education, throughput, and interfacility transfers (ACS, 2025).
IT/EMR navigators/site visit logistics coordinator, especially for virtual visits (chart navigation, screen-sharing, room links). Reviewers appreciate smooth tech; ACS prep materials explicitly flag IT readiness (McMahon, 2020).
Why it matters: Efficient logistics make chart audits and hospital tours credible; reviewers can focus on substance, not scavenger hunts (ACS, 2026).
7) Finance/Business Intelligence (Optional—but wise)
Bring:
Finance/BI partner who can speak to resource investment, access to care, and sustainability—useful if reviewers probe how commitment translates into budget lines and staffing models (ACS, 2025).
Putting It Together: A Sample Invite Matrix
Kickoff/Introductions: Senior leadership, TMD, TPM, core trauma team (ACS, 2026).
Chart Audit & PIPS: TMD, PI nurse/coordinator, registrar, relevant service chiefs as cases require (ACS, 2026).
Program Documents & Standards Alignment: TPM, registrar/data lead, injury prevention, EMS liaison, nursing leadership (ACS, 2022; ACS 2026).
Hospital Tour: TPM/logistics, nursing unit leads, radiology, blood bank, OR/ICU leadership (ACS, 2026).
TMD/TPM Closed Meeting: TMD and TPM only (per agenda) (ACS, 2026).
Exit Interview: Senior leadership, TMD/TPM, service chiefs as appropriate (ACS, 2026).
Pro tip: Build a single calendar with named agenda blocks, dedicated links, and clear attendee lists. This small project management step prevents the #1 virtual-visit failure mode: “Who’s supposed to be in this room, right now?” (McMahon, 2020).
The Evidence Case for Showing Up (and Showing Well)
Why curate attendance so carefully? Because robust verification correlates with measurable improvements in outcomes—both at individual centers and at statewide collaboratives tied to ACS verification requirements (Piontek et al., 2003; Mlaver et al., 2025).
Level I vs II differences in outcomes often narrow when core resources and processes are equivalent, underscoring that execution (people, protocols, PI) is king (Tariq et al., 2024).
Witty, Last-Mile Advice
Send principals, not proxies. If the neurosurgery fellow has all the details but the reviewer asks about coverage standards, you’ll want the chief and the fellow (ACS, 2014).
Match people to standards. Build your invite list by mapping each agenda block to the specific standards it evidences (e.g., Personnel & Services, PIPS, Education/Outreach) (ACS, 2025).
Practice the handoffs. Run a mock interview: PI → registrar → service chief → nursing—so reviewers experience your team’s seamless continuity of care (Radeker, 2024).
If you orchestrate the attendees with this intent, your reviewer interviews won’t just check boxes—they’ll tell your story: a program with committed leadership, reliable resources, and a culture of performance improvement that measurably benefits patients.
References (APA 7th ed.)
Alharbi, R. J., Shrestha, S., Lewis, V., & Miller, C. (2021). The effectiveness of trauma care systems at different stages of development in reducing mortality: A systematic review and meta-analysis. World Journal of Emergency Surgery, 16(1), Article 38. https://doi.org/10.1186/s13017-021-00381-0
American College of Surgeons. (2014). Resources for Optimal Care of the Injured Patient (2014)—chapters on clinical services and rehab. https://georgiatraumafoundation.org/wp-content/uploads/2015/04/resources-for-optimal-care.pdf
American College of Surgeons. (2022). Pre-Review Questionnaire for 2022 Standards (Dec 2022 revision). https://www.cotrauma.org/wp-content/uploads/2023/04/PRQ%20for%202022%20Standards_Updated%20for%20Dec%202022%20Revision.pdf
American College of Surgeons. (2026). The verification, review, and consultation process. https://www.facs.org/quality-programs/trauma/quality/verification-review-and-consultation-program/process/
American College of Surgeons. (2025). Resources for Optimal Care of the Injured Patient (2022 Standards) — July 2025 revision. https://www.facs.org/quality-programs/trauma/quality/verification-review-and-consultation-program/standards/
Cryer, H. G., Fildes, J., & Nathens, A. B. (2012). The American College of Surgeons Trauma Quality Improvement Program. Surgical Clinics of North America, 92(2), 441–454. https://doi.org/10.1016/j.suc.2012.01.003
McMahon, M. F. (2020). How to prepare for a virtual site visit (PTS webinar deck). Pediatric Trauma Society. https://pediatrictraumasociety.org/meeting/meet/multimedia/files/Maria_PTS-Meeting-Prepping-for-an-ACS-visit.pdf
Mlaver, E., Atkins, E. V., Medeiros, R. S., Sharma, J., Solomon, G., Galloway, L., Todd, S. R., Dunne, J. R., Ashley, D. W., & the Georgia Research Institute for Trauma Study Group. (2025). Impact of American College of Surgeons trauma verification on statewide collaborative outcomes. Journal of Trauma and Acute Care Surgery. https://doi.org/10.1097/TA.0000000000004505
Piontek, F. A., Coscia, R., Marselle, C. S., Korn, R. L., & Zarling, E. J. (2003). Impact of American College of Surgeons verification on trauma outcomes. Journal of Trauma, 54(6), 1041–1047. https://doi.org/10.1097/01.TA.0000061107.55798.31
Radeker, T. (2024). Gearing up for success – A new trauma program manager’s guide to mastering their first trauma survey. Optimal Healthcare Advisors. https://oha-llc.com/a-tpms-guide-to-mastering-their-first-trauma-site-survey/
Tariq, A., Chawla-Kondal, B., Smith, E., Dubina, E. D., Sheets, N. W., & Plurad, D. (2024). Impact of trauma verification level on management and outcomes of combined traumatic brain and solid organ injuries: An NTDB retrospective review. The American Surgeon. https://doi.org/10.1177/00031348241257472
Trauma Managers of California. (2024). Level II verification experience (site visit lessons). https://www.traumamanagersca.org/_docs/Level_II_Verification_Experience.pdf
