OAR 333-200-0245: Trauma Survey and Survey Team

(1) The Authority shall conduct an on-site survey using a survey team composed of persons selected by the Authority. (2) Notwithstanding section (1) of this rule, the Authority, in its discretion may conduct a survey without visiting the hospital in person and instead conduct the survey using alternative survey methods including but not limited to electronic and telecommunication technologies such as video communication, teleconference, landline and wireless communications for: (a) Any renewal of an existing categorization as a Level I,II, III or IV trauma hospital; or (b) Any application evaluation, review, re-survey or other process which requires a survey during a Governor-declared emergency, disease outbreak, disaster or other event that impacts local governments, the private sector or the public. (3) No person may serve as a member of the survey team that has any actual or potential personal, organizational or financial conflict of interest in the hospital under consideration. (4) The Authority shall provide the proposed list of survey team members to the applicant prior to conducting a survey. An applicant wishing to contest a member of the survey team shall provide written notice to the Authority within 10 calendar days of receiving the proposed list. The written notice must identify concerns and provide information that demonstrates a clear and convincing basis for the concern. (5) The quality of each hospital’s compliance with the standards set forth in Exhibit 4 shall be evaluated during a survey. Members of the survey team shall: (a) Evaluate medical records, staff rosters and schedules, minutes from quality improvement committee meetings, and other documents relevant to trauma care; (b) Evaluate equipment and premises; (c) Conduct informal interviews with hospital personnel; and (d) Report the findings and interpretations of the survey to the Authority. (6) During a survey, administrative staff, faculty, medical staff, employees and representatives are prohibited from having any contact with any survey team member, except as directed by the Authority. A violation of this provision may be grounds for immediate termination of the survey. (7) The Authority may review, inspect, evaluate, and audit patient trauma discharge summaries, trauma patient care logs, trauma patient care records, trauma quality improvement committee minutes and other documents relevant to trauma care of any hospital at any time to verify compliance with trauma system standards as set forth in these rules. The confidentiality of such records shall be maintained by the Authority in accordance with state law. (8) Information gathered during a survey by the survey team including oral and written reports and deliberations shall be confidential in accordance with ORS 431A.090. (9) A written report of the survey findings will be provided to the applicant only within 60 days of completing the survey and shall be confidential in accordance with ORS 431A.090. [ED. NOTE: To view attachments referenced in rule text, click here to view rule.]