In Person Site Visit Information

The State of Michigan verification process provides an objective, external review of institutional capabilities and performance. It is designed to assist hospitals in the evaluation and improvement of trauma care. The on-site review is conducted by healthcare professionals with expertise in trauma care and trauma program development. The review team assesses commitment, readiness, resources, policies, patient care, performance improvement, and other relevant criteria as outlined by the State of Michigan and American College of Surgeons.

Get Started! 

1. Hospitals seeking re-verification/designation
   • At least 90 days prior to the designation expiration, submit a Request for In-State Verification Site Review. 
2. Hospitals seeking inital verification/designation
   • If not previously completed, submit a Request for In-State Verification Site Review. If a request has already been submitted for your hospital, the State Trauma Designation Coordinator will contact you once it is time to begin scheduling the site visit. 
3. Submit the Pre-Review Questionnaire (PRQ) no later than 45 days prior to the scheduled site visit.
4. Submit the Application for Designation no later than 45 days prior to the scheduled site visit.
5. Prepare for the scheduled site visit by having all documents and medical records carefully organized and accessible to the reviewers. The PRQ will serve as a guide for the site review. However, the site reviewers may look beyond the requested documents and medical records if additional validation of compliance is needed. Before the site review is completed, the site reviewers will discuss their findings with the facility.
6. The site reviewer reports will go to the Designation Subcommittee who will make a recommendation on designation determination to the Michigan Department of Health and Human Services.
7. The Michigan Department of Health and Human Services makes the final designation determination. 

Relevant Documents and Resources:

• Michigan Criteria
• Regional Work Plans
• Example of a Trauma Flow Sheet - Courtesy of Minnesota's Trauma System
• NTDS Inclusion Criteria

Level III (Revised 8/6/18)

• Request for Verification In-State Level III
• Application for Designation, In-State Verified Level III Trauma Facility
• Pre-Review Questionnaire (PRQ) for Michigan Level III Trauma Facility
• Criteria Quick Reference Guide, Level III
• Alternate Pathway Criteria for Non-Board Certified Surgeons and Physicians

Level IV (Revised 8/6/18)

• Request for Verification In-State Level IV
• Application for Designation, In-State Verified Level IV Trauma Facility
• Pre-Review Questionnaire (PRQ) for Michigan Level IV Trauma Facility 
• Criteria Quick Reference Guide, Level IV

Site Visit Resources (Revised 8/6/18)
Resources to assist in-state facilities to prepare and organize for a site visit.

• Facility Designation Site Visit Guidelines
• Binder Organization Checklist, Level III
• Binder Organization Checklist, Level IV
• Facility Guidelines for On-Site Focused Review*

*Only applicable to facilities undergoing an on-site focused review.

Post Site Visit Resources

Designation Appeal Policy