24 – 25 January 2013 ADMINISTRATIVE REPORT€¦ · TCC presentation (slides will be provided morning of meeting) Page: 69 DOAA Report and discussion worksheet Page: 70 & 77 IRS

Jim Pettyjohn - [email protected] - 706.398.0842

4th ANNUAL STRATEGIC PLANNING WORKSHOP AND RETREAT

24 – 25 January 2013

ADMINISTRATIVE REPORT

Workshop Agenda Page: 2 Pilot Project Evaluation Report and slides Page: 4

TCC presentation (slides will be provided morning of meeting) Page: 69 DOAA Report and discussion worksheet Page: 70 & 77 IRS Form 1023 and relevant questions Page: 121 Day Two: November 2012 meeting minutes draft Page: 153 CY 2013 proposed meeting schedule Page: 167 FY 2013 mid-year expenditure report Page: 168 CY 2011 Readiness cost report and documents Page: 176

Region V Trauma Advisory Committee Update Page: 183 Northwest Georgia EMS Region I Trauma System Plan (proposed) Page: 186 & 242 Mitchell County ambulance disposition request documents Page: 254 & 277 Trauma Medical Directors subcommittee notes (November 2012) Page: 279 GCTE meeting minutes (September 2012) Page: 284 EMS Subcommittee meeting minutes (draft 03 January 2012) Page: 290 Data Subcommittee meeting notes (December 2012 & January 2013) Page: 310 GTRI presentation (slides will be provide morning of meeting) Page: 322

* Commission action anticipated

4th ANNUAL STRATEGIC PLANNING WORKSHOP AND RETREAT 24 – 25 January 2013

Stuenkel Conference Center

Floyd Medical Center 304 Turner McCall Boulevard

Rome, Georgia 30165

Day One: Thursday, 24 January 2013 Closed Session: 9:00 am to 11:00 am Performance review Commission members & executive director 11:00 to 11:30 am Lunch break: Everyone is invited. Open Session: 11:30 am to 11:45 am Opening comments and agenda review Dr. Dennis Ashley & Jim Pettyjohn 11:45 noon to 1:00 pm* Pilot Project Evaluation Report review Carol Pierce 1:00 pm to 2:00 pm Georgia Trauma Communications Center

report and discussion John Cannady 2:00 pm to 2:15 pm Break 2:15 pm to 4:00 pm DOAA Special Examination report

discussion and possible implications on strategic planning Dr. Dennis Ashley with Carol Pierce facilitator

4:00 pm to 5:00 pm* Georgia Trauma Foundation Q&A Laura Wartner, attorney Smith, Gambrell & Russell, LLP 5:00 pm Adjourn for day

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* Commission action anticipated

Day Two: Friday, 25 January 2013 8:00 am to 8:30 am * Commission business:

• November 2012 minutes approval • CY 2013 meeting schedule approval • AFY 2013 Expenditure Review • FY 2014 budget development process

discussion Jim Pettyjohn & Judy Geiger 8:30 am to 9:30 am CY 2011 Readiness Cost Assessment report

& Trauma System Performance Tool update Greg Bishop 9:30 am to 10:00 am RTAC reports (RTAC V, VI & IX) RTAC representatives 10:00 am to 10:15 am Break 10:15 am to 11:00 am* Northwest Georgia – Region I EMS

Regional Trauma System Plan presentation David Foster 11:00 am to 12:00 noon Lunch Break: Everyone is invited. 12:00 noon to 12:30 pm* Mitchell County Ambulance Disposition

Request Jerry Permenter, Mitchell County Administrator (via telephone connection)

12:30 pm to 1:30 pm Commission Subcommittees reports:

• Trauma Medical Directors (TMD) • GCTE • EMS Subcommittee • Data Subcommittee

1:30 pm to 2:30 pm Georgia Tech Research Institute GTRI

Presentation: “Annual EMS Resource Assessment AND Need for and benefit from healthcare capacities and emergency response systems integration” Ann Carpenter and Tim Boone

2:30 pm to 3:00 pm DPH OEMST Report Dr. Pat O’Neal 3:00 pm to 4 :00 pm Law Report, New Business and Adjourn

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Georgia Trauma System

Regionaliza8on Pilot Project Evalua8on

December 2012

Pilot Project Evalua8on •  Qualita8ve evalua8on conducted July-‐ October 2012 •  18 interviews conducted and included: OEMS&T staff

EMS Regional Council Chairs RTAC Chairs and RTAC V Coordinator Level I Trauma Coordinators/Managers OEMS&T Regional Coordinators GAEMS Chairman GTC staff

•  DraR summary of the interview informa8on sent to the interviewees from that region

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Evalua8on Criteria

•  Goal Met: all three regions accomplished the goal

•  Goal Substan8ally Met: two regions accomplished the goal

•  Goal Par8ally Met: one region accomplished the goal

•  Goal Not Met: none of the three regions accomplished the goal.

Goal 1) Introduce trauma system regionaliza8on as a possible construct for Georgia Trauma System development. •  Evalua8on criteria: ac8ons taken to introduce the pilot project and the framework to stakeholders and to develop an RTAC

•  Result: Goal was met

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Goal 1 Support

•  Small, credible steering commiZee or pilot project leaders to guide the introduc8on of regionaliza8on

•  Individual face-‐to-‐face mee8ngs held with regional stakeholders

•  LeZer sent to stakeholders describing vision •  Mee8ngs held to begin RTAC plan development

Goal 2) Test the Framework as a planning guide for a regional Council to develop a Plan. Evalua8on criteria: development of a regional trauma plan including the core elements iden8fied in the framework (Part One and Part Two). Result: Substan8ally met (Part One) Par8ally Met (Part Two)

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Goal 2 Support

•  Reg. V and VI each submiZed a regional trauma plan and Reg. X submiZed a business plan

•  The framework was a useful tool for regional trauma plan development

•  Trauma plans included descrip8ons of the required components and organiza8ons (part one)

•  Trauma plans describe the TCC but does not include specific protocols related to TCC communica8ons

Goal 3: Opera8onalize the Trauma Communica8ons Center (TCC) as the interoperable statewide communica8on component of the System. a) developed as statewide communica8on b) ac8vely used in each pilot region Evalua8on criteria: based on two perspec8ves, statewide and regional Result: a) met b) par8ally met

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Goal 3 Support

•  TCC in place as the GTS statewide communica8on component

•  TCC concept introduced in all three pilot regions

•  TCC is ac8vely used in Reg. V •  Inability to use cell phones and limited two-‐way radio communica8on has impacted TCC use

•  Many EMS Services already know where to tke pa8ents and did not see the need to call TCC

Goal 4) Iden8fy and involve regional trauma system stakeholders Evalua8on criterion: the inclusion of regional trauma system stakeholders in planning for regional trauma plan development Result: Goal was met

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Goal 4 Support

•  Mul8disciplinary par8cipants aZended mee8ngs

•  Strong working rela8onships among disciplines cri8cal to success

•  Wished for more physician par8cipa8on and agencies with a preven8on focus and rehab

•  Regional planning mee8ngs rotated to different loca8ons to promote access and decrease turf issues

Overarching Goals

•  Goal 5) Revise the Framework as a regional planning guide pursuant to the results of the pilot evalua8on.

•  Goal 6) Iden8fy specific steps to expand the GTS statewide by way of introducing regional trauma system planning statewide and by extending the coverage area of the TCC

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Goal 5: Proposed Framework Revisions

•  Iden8fy HRSA BIS assessment as an important resource to help with plan development

•  Crea8on of RTAC subcommiZees useful for trauma plan development

•  Reference na8onal research about preventable death rates when tx occurs in a trauma center

•  Include injury preven8on as a key component of the trauma system

Goal 5: Proposed Framework Revisions

•  Include implementa8on strategies that worked for the pilot project

•  Emphasize guidelines not protocols •  RTACs-‐CommiZee or Council •  Include list of resources useful for plan development

•  Strengthen informa8on about GTC and OEMS&T roles and responsibili8es related to trauma system development

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Goal 6: Recommended Next Steps

1.  Stakeholders want to understand the result of the pilot project including what works well and what needs to be changed before expansion occurs.

2.  Consider expansion in a region with mul8ple Level 1 Trauma Centers and in a region with no trauma centers to gather informa8on about regional trauma plan implementa8on.

3. Ongoing dialogue and clarifica8on needed to strengthen partnership between GTC and OEMS&T-‐ roles and responsibili8es of each related to trauma system development need to be more clearly described in the framework. 4.Con8nue to adapt TCC opera8ons to accommodate regional trauma planning including ability for TCC to recommend non-‐designated hospitals; use of addi8onal communica8on mechanisms for communica8on between EMS Services and TCC.

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5.  Discuss and develop agreed upon collec8on processes to measure pa8ent transport 8me to defini8ve care for all regions. Determine whether future funding will be available for ongoing RTAC support.

6.  Determine whether future funding will be

available for ongoing RTAC support.

Final Thought

Interviewees ar8culated a common Trauma System goal: get the right person to the right place at the right 8me by the right means.

The best trauma system possible in Georgia requires ongoing informa8on sharing and

discussion.

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Georgia Trauma System Regionalization

Pilot Project Evaluation

December 2012

Prepared by

Public Health Consultants, LLC

for the

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Georgia Trauma System Regionalization


I. Executive Summary……………………………………………………………….1

II. Overview and Context…………………………………………………………….2 III. Evaluation Methodology………………………………………………………….5 IV. Evaluation Results………………………………………………………………...8

V. References………………………………………………………………………..17

Appendices: A. Interview Results by Region

a. Region V……………………………………………………………..19 b. Region VI…………………………………………………………….29 c. Region IX…………………………………………………………….38 d. Statewide Stakeholders………………………………………………45

B. Interviewee Names…………………………………………………………..51

C. Interview Questions………………………………………………………….52

D. Glossary……………………………………………………………………...53

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I. Executive Summary In 2007, the Georgia Legislature through Senate Bill 60 established the Georgia Trauma Care Network Commission, also known as the Georgia Trauma Commission (GTC). The GTC has the responsibility to establish, maintain and administer a trauma center network and to coordinate the best use of existing trauma facilities in Georgia. 1 Following a Georgia trauma system review by the American College of Surgeons’ Trauma System Consultation Program in January 2009, the GTC identified the need for both a comprehensive state trauma system plan and for a statewide trauma communications system. In 2009, the GTC developed the "Regional Trauma System Planning Framework" and a plan to test that framework through a pilot project ("Pilot Project for Georgia Trauma System Regionalization, White Paper"). The pilot project tested the framework as a regional trauma plan development guide and was the opportunity for the GTC to operationalize the Statewide Trauma Communications Center. In 2011, the pilot project was funded and was implemented in three of the state's 10 EMS regions (Regions V, VI and IX). This report provides a qualitative evaluation of the pilot project For Georgia Trauma System Regionalization. The evaluation is based on interviews with trauma system stakeholders in each of the three pilot project regions. Interviewees were asked a set of questions intended to assess how well the pilot project had achieved each of the six identified goals specifically within their respective EMS Region. Each region is unique and has different assets, stakeholders and providers. This qualitative assessment evaluates how these unique regions implemented the pilot project. This evaluation addresses to what extent the regions accomplished the pilot project goals. The evaluation found that the pilot project has succeeded in introducing the framework as a planning tool for regional trauma plan development. The framework has been utilized as a guide to develop regional trauma plans. It was flexible and accommodated various regional needs, as the needs of each region are different. The GTC developed and operationalized the Trauma Communications Center as a statewide communications component. This evaluation of the pilot project found that utilization of the TCC varies by regions. RTAC and TCC staff are working to address communication needs and technology challenges between the TCC and EMS Services and hospitals.

The pilot project brought together multidisciplinary stakeholders in each region. This evaluation found that these discussions were successful in the development of a trauma plan and a Regional Trauma Advisory Committee (RTAC). Pilot region stakeholders consistently described the positive value of developing a plan for their region with input from a variety of perspectives including trauma centers, non-designated hospitals, physicians, EMS, Public Health and the public.

Interviewees recognized and articulated a common Trauma System goal: get the right person to the right place at the right time by the right means. The best trauma system possible in Georgia requires ongoing information sharing and discussion.

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II. Overview and Context

Each year in the United States, approximately two million people are hospitalized for treatment of a traumatic injury2. Even though there have been many safety measures in effect including seatbelts and airbags among others, injury remains the third leading cause of death overall and the leading cause of death up to 44 years of age.3 The years of potential life lost because of injury outweighs the loss from cancer, heart disease and stroke combined.4 The National Study on the Costs and Outcomes of Trauma (NSCOT) showed that the risk of death is 25% lower when care is provided in a Level I trauma center than when it is provided in a nontrauma center hospital.5 Similarly, a retrospective cohort study of 11,398 severely injured adult patients who survived to hospital admission in Ontario, Canada, indicated that mortality was significantly higher in patients initially under-triaged to nontrauma centers.6 However, not all injured patients can be quickly nor should be transported to a Level I trauma center. Other hospitals, lower-level designated trauma centers and committed community hospital emergency departments (ED) can effectively meet the needs of patients with less severe injuries and may be more readily accessed. Transporting all injured patients to Level I centers—regardless of injury severity—limits the availability of Level I trauma center capabilities for those patients who really need the level of care provided at those facilities. 7 Population-based research assessing the effectiveness of trauma systems concluded that there was approximately a 15-20% reduction in death among seriously injured trauma patients due to the implementation of a trauma system.8

The Georgia Trauma Commission (GTC) has the responsibility to establish, maintain and administer a trauma center network and to coordinate the best use of existing trauma facilities in Georgia. The GTC is to coordinate its activities with the Department of Public Health including data collection to evaluate the provision of trauma services and to determine the best practice and methods to improve trauma care services.9 Working to identify regional needs is not a new concept in Georgia. The formation of Regional Emergency Medical Service Advisory Councils (EMS Regional Councils) is included in the Department of Public Health, Office of Emergency Medical Services and Trauma Rules and Regulations established in the 1980’s.10 There are 159 counties in Georgia, which are divided into ten EMS regions. Each region has an EMS Regional Council. Some Councils have developed Trauma Committees. For example, the Region III EMS Regional Council has one of the most long-standing Trauma Care Committees.11 Currently (December 2012) in Georgia, there are six Level I Trauma Centers (five adult and one pediatric); nine Level II (eight adult and one pediatric); two Level III; five Level IV; and two designated burn trauma centers. Three of the five adult Level I centers are designated “with pediatric commitment.” See Figure 1. Following a trauma system review by the American College of Surgeons Trauma System Consultation Program in January 2009, the GTC identified the need for both a comprehensive state trauma system plan and for a statewide trauma communications system. A “Regional Trauma System Planning Framework” was developed and approved by the GTC in October 2009.12 The framework defines and describes the Georgia trauma system and provides a planning guide to develop trauma system plans in each EMS Region. In 2009, the “Pilot Project for Georgia Trauma System Regionalization White Paper” was approved by the GTC.13 The purpose of the pilot project was to test the framework as a regional trauma plan development guide and to operationalize the Georgia Trauma Communications Center.

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Figure 1: Designated Trauma Centers by EMS Region in Georgia as of June 2012

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The GTC funded the pilot project via administrative support grants to the Level I trauma centers in EMS Regions V, VI and IX. The white paper identified six pilot project goals. Goals 1 through 4 directly relate to the implementation of the pilot project. Goals 5 and 6 are overarching project goals that relate to the future development of regional trauma plans utilizing the framework. The purpose of this qualitative evaluation is to assess the degree of accomplishment of pilot project goals 1 through 4 and to provide information related to goals 5 and 6. The pilot project goals are:

Goal 1) Introduce trauma system regionalization as a possible construct for Georgia Trauma System development;

Goal 2) Test the Framework as a planning guide for a regional Council to develop a plan;

Goal 3) Operationalize the Georgia Trauma Communications Center (TCC) as the interoperable statewide communication component of the System; and

Goal 4) Identify and involve regional trauma system stakeholders including physicians, EMS, designated Trauma Centers, non-designated participating hospitals, hospital personnel, local governments and the public in system planning.

The Overarching Goals are:

Goal 5) Revise the Framework as a regional planning guide pursuant to the results of the pilot evaluation, and

Goal 6) Identify specific steps to expand the Georgia Trauma System statewide by introducing regional trauma system planning statewide and by extending the coverage area of the Trauma Communications Center.

Regional Trauma System Planning Framework

• Defines and describes the Georgia trauma system as comprised of integrated systems and plans with a centralized and statewide trauma communications center as the common component of a state trauma system.

• Identifies regional trauma system components to improve a region’s transport to care: pre-hospital, hospital, and communications with ongoing system assessment and improvement, as needed

• Establishes an RTAC in each Region to develop and maintain the Regional Trauma System Plan and to monitor system compliance and improvement activities

• Describes the development of a regional trauma plan including decisions about how regional trauma system components work together to get the right patient, to the right care, at the right time

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III. Evaluation Methodology

To evaluate the pilot project, key stakeholders were identified by critical positions in the three EMS regions. Several statewide system stakeholders were included as interviewees because of their knowledge relevant to the evaluation of the project goals. Individual telephone interviews were conducted between July and October 2012. A total of eighteen (18) people were interviewed. Interviewees included: GTC and OEMS&T staff, EMS Regional Council Chairs, Regional Trauma Advisory Committee/Council (RTAC) Chairs, Level I Trauma Coordinators/Managers from EMS Regions V, VI and IX, RTAC staff, OEMS&T Regional Coordinators, Georgia Association of Emergency Medical Services (GAEMS) Chairman and the TCC Manager.

This qualitative evaluation utilizes interview information representing the views, opinions and ideas of the interviewed stakeholders related to the six pilot project goals. The evaluation includes information from the regional trauma plans and the regional trauma business plan. EMS Regions V and VI each provided its regional trauma plan.15, 16 Region IX provided a regional trauma business plan.17 Based on this information, the evaluation assesses the degree of accomplishment of pilot project goals 1 through 4. Goals 5 and 6 are overarching goals that relate to the future development of regional trauma plans utilizing the framework. Evaluation criteria were established to score the accomplishment of goals 1-4. Evaluation criteria are not provided for overarching goals 5 and 6 as these goals relate to future changes to the framework revision and statewide regional trauma system development. The report provides the next steps to be considered and discussed among trauma system stakeholders. The evaluation criteria are as follow:

Goal Met: all three regions accomplished the goal Goal Substantially Met: two regions accomplished the goal Goal Partially Met: one region accomplished the goal Goal Not Met: none of the three regions accomplished the goal.

For the evaluation, the pilot project goals were interpreted to include:

Goal 1) Introduce trauma system regionalization as a possible construct for Georgia Trauma System development.

The evaluation criteria are stakeholder actions taken within the region to introduce the pilot project and the framework to stakeholders and actions taken to develop an RTAC.

Goal 2) Test the Framework as a planning guide for a regional Council to develop a Plan.

The evaluation criterion is the development of a regional trauma plan including the core elements identified in the framework. These core elements are:

Part One: Components and Organization

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Part Two: Regional Trauma System Function and Pre-Hospital Component.

Note: Part Three: Regional Plan Revision Process was not included since these plans have not been in place for two years.

Goal 3) Operationalize the Georgia Trauma Communications Center (TCC) as the interoperable statewide communication component of the System.

The evaluation was conducted based on two perspectives, statewide and from the regions participating in the pilot project. The evaluation criteria are:

Goal 3A) The GTC developed the TCC as the statewide communication component of the Georgia Trauma System.

Goal 3B) The TCC is actively in use in each pilot project region measured by its utilization for patient transport and destination recommendations.


The evaluation criterion is the inclusion of regional trauma system stakeholders in planning for regional trauma plan development.

Overarching Goals 5 and 6:

Goal 5) Revise the Framework as a regional planning guide pursuant to the results of the pilot evaluation.

Goal 6) Identify specific steps to expand the Georgia Trauma System statewide by way of introducing regional trauma system planning statewide and by extending the coverage area of the Trauma Communications Center.

The report provides information collected during stakeholder interviews related to goals 5 and 6. This information should be discussed among trauma system stakeholders to:

- make framework revisions; - strengthen the implementation of regional trauma system planning; and - be taken into consideration prior to regional trauma system planning expansion statewide. Of importance to note, the framework describes the development of a Regional Trauma Advisory “Council” that reports directly to OEMS&T; however, two of the three regions in the pilot have created a Regional Trauma Advisory Committee that reports to the EMS Regional Council. The term RTAC will be used in this report to describe both organizational structures. See Glossary for additional terms. At the start of this evaluation, Region V and VI regional trauma plans had been in place (from the date of GTC approval) for ten months and eight months respectively. Region IX’s business plan had been in place (from the date of GTC approval) for five months while Region IX’s regional trauma plan continues to be developed but has not been submitted to the GTC for approval. During the July-October 2012 evaluation

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period, the pilot project continued which resulted in new information during the evaluation period. To the degree possible, new information has been included in this report. Once the interviews were completed, the draft summary of the interview information for each region was sent to the interviewees from that region. All interviewees were given an opportunity to provide feedback; comments were received from seven interviewees. Their additional information was incorporated into Appendix A.

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IV. Evaluation Results

Based on the interviews conducted, pilot project goals were evaluated per established criteria. Information used to determine the result for each goal and the related region is noted. Additional interview details from each region are included in Appendix A. Hyperlinks to the regional trauma plans for Regions V and VI and the regional business plan for Region IX are available in V. References.

Goal 1) Introduce trauma system regionalization as a possible construct for Georgia Trauma System

development.

The evaluation criteria are stakeholder actions taken within the region to introduce the pilot project and the framework to stakeholders and actions taken to develop an RTAC.

Result: Goal was met.

Result Support:

• The development of a small, credible steering committee or pilot project leaders to guide the introduction of regionalization was important. (relevant to all three regions)

• Pilot project leaders scheduled individual face-to-face meetings with regional stakeholders such as hospitals, EMS Services and physicians to promote a shared understanding about the RTAC vision. In some regions, pilot project leaders traveled to meet regional stakeholders in their communities. (relevant to all three regions)

• Pilot project leaders mailed letters to all stakeholders in the region including hospitals (trauma centers and non trauma centers) and EMS Services to describe the intended vision of a regional trauma plan: get the right patient to the right hospital at the right time. (relevant to Region V and VI)

• Hired a knowledgeable and experienced RTAC Plan Coordinator with GTC-grant project funding. The Coordinator was essential to project success because of their knowledge and relationships with hospitals and EMS Services in the region. (relevant to Region V)

• Scenarios were used at the face-to-face meeting to illustrate the value of a regional plan. (relevant to Region V)

• Conducted multiple stakeholder meetings to discuss and begin RTAC plan development. Meetings were well attended. (relevant to all three regions)

• Included hospitals and EMS Services adjacent to the region but not geographically within the region in stakeholder meetings. (relevant to Region V and IX)

• As part of training, project leaders made visits to some EMS Services to talk about the regional plan and answer questions. (relevant to Region V)

Observations/Information About Differences Among Regions: • The pilot project leadership varied among the three regions but all included Trauma Coordinators

and Trauma Surgeons from Level I Trauma Centers.

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• Region IV and V developed Regional Trauma Advisory Committees and Regional IX established a Regional Trauma Advisory Council. The Regional Trauma Advisory Committees report to their respective EMS Council; the Regional Trauma Advisory Council reports to the GTC and OEMS&T.

• The EMS community has concern that the Region IX RTAC is not a Committee of the EMS Council.

• According to the Attorney General’s opinion,14 RTACs are considered review organizations and are afforded peer review protection and their work is non discoverable.

Goal 2) Test the Framework as a planning guide for a regional council to develop a plan.

The evaluation criterion is the development of a regional trauma plan including the core elements identified in the framework. These core elements are:

Part One: Components and Organization

Part Two: Regional Trauma System Function and Pre-Hospital Component.

Note: Part Three: Regional Plan Revision Process was not included since Plans have not been in place for two years.

Result: Substantially Met (Part One)

Partially Met (Part Two)

Table 1: Framework Core Elements Identified in the Regional Trauma Plans

Regional Trauma Plan

Region V Region VI Region IX

Evaluation Criteria Based on Framework

Part One: Components and Organizations Pre-Hospital X X 0 -Inclusion of TSEC criteria to determine entry

into the trauma system - EMS education regarding plan including protocol for interaction with the TCC

Hospital X X 0 - Resource Availability Display information -Non designated hospital inclusion

Communications X X 0 -Info. regarding status of pre-hospital capability, trauma center and non-designated participating hospital resource availability through TCC and RAD

Data-Driven Performance Improvement

X X 0 PI Utilizes: -EMS run data -Trauma Registry data maintained at each TC -TCC data -Each hospital conducts internal performance improvement

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Injury Prevention and

Outreach

X X 0 -Describe approach and goals for injury prevention.

Regional Trauma Advisory Council/

Committee

X X X -Describes responsibilities and reporting relationship -Multidisciplinary RTAC membership

Part Two: Regional Trauma System Function Trauma System Entry Criteria

X X O Inclusion of Primary Triage based on TSEC, CDC Field Triage Decision Scheme

Communication Protocols

O O O Describes the basic information EMS provides to TCC and the role of the TCC Note: Communication information is included in part one but specific protocols are not described.

Systems Operation

X O O -Secondary Triage to determine Trauma Center destination

Regional Trauma System

Compliance

X X O -Oversight of system compliance, participation and effectiveness. -Reports provided regarding effectiveness and improvement needed to EMS Council and/or OEMS&T (depending on RTAC structure)

Part Three: Regional Trauma System Revision Process Regular Review and Revision, as

needed

NA NA NA Review recommended every 2 years

Result Support:

• Regional trauma plans as described in the framework were submitted and approved by the GTC in September 2011 (Region VI) and November 2011 (Region V). A business plan was approved by the GTC for Region IX in March 2012.

• Regional trauma plans from Regions V and VI have all the required components for part one of the framework.

• Regional trauma plans from Regions V and VI have most of the required components for part two; however, both plans do not include TCC communications protocols. Region VI does not include Pre-Hospital Destination Guidelines. Guidelines are currently being developed.

• The framework was a useful tool for RTAC and regional trauma plan development. (relevant to all three regions)

• All three regions worked closely to share experiences on RTAC and regional trauma plan development. (relevant to all three regions)

• Establishing the RTAC and developing a regional trauma plan is very time and level-of-effort intensive. (relevant to all three regions)

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• Misunderstanding occurred among some stakeholders who believed the regional trauma plans would direct or mandate EMS service transport to a specific location for treatment. (relevant to all three regions)

Observations/Information About Differences Among Regions:

• Project leaders surveyed EMS Services to determine what services had a trauma patient triage protocol/policy in place and who incorporated CDC criteria into their protocols/policies. (relevant to Region V)

• The adaptation and inclusion of CDC Field Triage Decision Scheme Pre-Hospital Destination Guidelines and the Hospital Guidelines for the Inter-facility Transfer of Trauma System Patients were important for “buy-in” to the regional trauma plan. (relevant to Region V)

• The framework includes the importance of injury prevention and outreach; however, it is not specifically detailed in part one, Components and Organization section of the framework. However, the regional plans in Regions V and VI describe injury prevention and outreach in their plans.

Goal 3): Operationalize the Trauma Communications Center (TCC) as the interoperable statewide communication component of the System. The evaluation was conducted based on two perspectives, statewide and from the regions participating in them. The evaluation criteria are:

Goal 3A) The GTC developed the TCC as the statewide communication component of the Georgia Trauma System.

Goal 3B) The TCC is actively in use in each pilot project Region measured by its utilization for patient transport and destination recommendations. Result:

Goal 3A) Goal Met. The GTC developed the TCC as the statewide communication component of the Georgia Trauma System. Goal 3B) Goal Partially Met. Based on the data below, the TCC is actively in use in Region V, not actively used in Region VI and not implemented yet in Region IX.

Result Support:

• The TCC is actively utilized in Region V and the majority of counties in the Region have used the TCC. See Table 2.

• The TCC is in use in Region VI; however, it is used on a limited basis because of the inability of the largest EMS Service to contact the TCC. This EMS Service does not allow EMS personnel to use cell phones and there is limited two-way radio communication between EMS and the TCC. Cell phone or radio use is needed to communicate to the TCC. See Table 2.

• All three regions introduced the concept of the Trauma Communications Center to trauma system

stakeholders at individual and/or group face-to-face meetings. (relevant to all three regions)

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• Regional trauma plans describe the TCC, but protocols for TCC use are not included in regional trauma plans. (relevant to Region V and VI)

• Many interviewees expressed that the majority of EMS Services already knew where they needed to

take patients for care and did not see the need to call the TCC.

• Positive interactions between the RTACs and TCC Manager have resulted in improvements in hospital, EMS and TCC communication. Examples include: upcoming planned testing for use of the Resource Availability Display (RAD) by EMS Services and the use of TCC by EMS dispatchers for those without cell phones.

• A total of 616 calls were made to the TCC between January 2012 and October 2012. One-third of

the calls were made while en route to the hospital. EMS Services made another third of the calls when the patient was already at the hospital. While this communication pattern does not represent the intended process for EMS communications with the TCC, it represents a positive pattern of using the TCC as a part of trauma patients’ dispositions. See Table 3.

Observations/Information About Differences Among Regions:

• The number of patient calls going through the TCC with recommendations made and accepted are modest. See Table 4 and 5.

• Current TCC protocols do not allow a transport recommendation to a non-designated or community hospital for patients that meet Trauma Systems Entry Criteria unless regional guidelines indicate transfer to a non-designated or community hospital is acceptable. Region V trauma plan, Pre-Hospital Destination Guidelines includes specific provisions for transport in accordance with local medical direction and/or agency protocols for patients having pelvic fractures without significant mechanism of injury.

Table 2 Total patients by EMS Region that came through the TCC who met Trauma System Entry Criteria

(TSEC) Criteria and/or did not meet TSEC Criteria January 1, 2012 through June 30, 2012

Region 1 0 Region 2 0 Region 3 1 Region 4 72 Region 5 452 Region 6 72 Region 7 4 Region 8 4 Region 9 9

Region 10 2 Total 616

Table 3 Patient Location Upon Call to TCC

January 1, 2012 through June 30, 2012

Total patients on scene. 104

Total patients en route to hospital. 267

Total patients when EMS is en route to scene 22

Total patients already at hospital 213

Total patients from inter-facility transfers 10

Total number of calls based on location 616

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• Concerns have been expressed by hospitals about Resource Availability Display (RAD) relationship to HIPAA and EMTALA agreements. The Attorney General is currently addressing this issue. (relevant to Region IX)

Goal 4) Identify and involve regional trauma system stakeholders including physicians, EMS, designated Trauma Centers non-designated participating hospitals, hospital personnel, local governments and the public in system planning.

The evaluation criterion is the inclusion of regional trauma system stakeholders in planning for regional trauma plan development.

Result: Goal was met.

Result Support:

• Multidisciplinary participants attended meetings to discuss regional trauma plan development. Overall multidisciplinary representation was excellent; however, Regions expressed the desire for more physician participation including ED physicians, EMS Medical Directors, and agencies with a prevention focus and rehabilitation services. (relevant to all three regions)

Table 4 Number of patients who went through the TCC and met TSEC criteria; recommendation was

given/accepted, went to a designated trauma center January 1, 2012 through June 30, 2012

ALL Inter-facility transfers

En route to scene On Scene

En route to Hospital

Level 1 31 Level 1 2 Level 1 1 Level 1 19 Level 1 9

Level 2 0 Level 2 0 Level 2 0 Level 2 0 Level 2 0 Level 3 1 Level 3 0 Level 3 0 Level 3 0 Level 3 1 Level 4 0 Level 4 0 Level 4 0 Level 4 0 Level 4 0 Total 32 Total 2 Total 1 Total 19 Total 10

Table 5 Number of patients who went through the TCC and met TSEC criteria; recommendation was

given/accepted, went to a designated trauma center July 1, 2012 through September 30, 2012

ALL Inter-facility transfers

En route to scene On Scene

En route to Hospital

Level 1 12 Level 1 0 Level 1 0 Level 1 2 Level 1 10 Level 2 0 Level 2 0 Level 2 0 Level 2 0 Level 2 0 Level 3 0 Level 3 0 Level 3 0 Level 3 0 Level 3 0 Level 4 0 Level 4 0 Level 4 0 Level 4 0 Level 4 0 Total 12 Total 0 Total 0 Total 2 Total 10

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• The benefits of having multidisciplinary participants working together were valuable toward trauma

system development. (relevant to all three regions)

• The majority of the stakeholders including physicians, EMS, designated Trauma Centers non-designated participating hospitals, hospital personnel, local governments and the public participated in RTAC meetings and RTAC Subcommittees. (relevant to Region V and VI)

• Interviewees in Region V and VI related multidisciplinary representation on the EMS Regional Council promotes confidence and communication between the Council and the RTAC; strong working relationships among disciplines are critical and an important contributor to success.

Observations/Information About Differences Among Regions: • Regional planning meetings were rotated to different regional locations to promote accessibility and

minimize turf issues. (relevant to Region V)

• Diverse stakeholders were engaged to assure a variety of perspectives in trauma plan development. (relevant to Region V and VI)

• Smaller rural EMS providers did not attend stakeholder meeting perhaps because they are not 911

providers and/or they may have mutual aid agreements in place. (relevant to Region IX)

Overarching Goals 5 and 6


Based on the interviews, framework revisions have been suggested which may be helpful to regions utilizing the framework for trauma plan development.

Suggested Framework revisions are:

• Identification of the HRSA Model Trauma System Planning and Evaluation Trauma System Self-Assessment Tool: Benchmarks, Indicator, and Scoring (BIS) as an important resource to use and the first step for plan development. Regions used the BIS to evaluate the existing resources and to identify existing trauma system gaps. BIS assessment can inform the development of the Subcommittees/Task Forces for regional trauma plan development.

• Creation of RTAC Subcommittees to help develop the regional trauma plan and to monitor effectiveness and identify improvements needed as plan is implemented. For RTACs that are a Committee which reports to the EMS Council, review how RTAC Subcommittees and EMS Council Committees can work together or combine work since goals and members may be similar.

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• Referencing and inclusion of the national research which demonstrates a reduction in preventable death rates when treatment occurs in a designated trauma center and inclusion of the research demonstrating a risk reduction of seriously injured trauma patients due to the implementation of a trauma system which includes providing care through regionalized trauma system infrastructure.

• Prevention of unnecessary injuries and deaths due to trauma is one of the major goals of the trauma

system. The framework needs to include Injury Prevention as a component in part one, components and organization and part two, regional trauma system function. Injury prevention programs specific to the region based on regional injury data and trends need to be included in the Plan.

• Provision of additional details in the framework Appendix F. Regional Trauma Plan Development

Process to include implementation strategies that worked for the pilot project (e.g. introduction letters, face-to-face meetings).

• Emphasis on the development of guidelines not protocols. Protocols are developed by local EMS Medical Directors in accordance with guidance from OEMS&T. The regional trauma plans will include agreed upon guidelines for their region; however, EMS Service protocols must be followed.

• The framework describes the development of a Regional Trauma Advisory Council that reports

directly to OEMS&T; however, two of the three regions in the pilot have created a Regional Trauma Advisory Committee that reports to the EMS Regional Council. This infrastructure variable should be addressed in the framework revision.

• Inclusion of a list of resources useful for regional trauma plan development. Examples include:

Minnesota Trauma System Performance Improvement Plan, Birmingham (AL) Regional Emergency Medical Services System Regional Trauma Plan, the New Mexico Trauma Strategic Action Plan and ACS Essential Criteria for Levels of Design.

• Strengthening information in the framework about the roles and responsibilities of the GTC and OEMS&T by specifically articulating how the organizations work together to improve trauma care in the region.

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Goal 6) Identify specific steps to expand the Georgia Trauma System statewide by way of introducing regional trauma system planning statewide and by extending the coverage area of the Trauma Communications Center.

The information below should be discussed among trauma system stakeholders to strengthen the introduction and implementation of regional trauma system planning statewide.

Suggested next steps (not in priority order) are:

1. Stakeholders want to understand the result of the pilot project including what works well and what needs to be changed before expansion occurs.

2. Consider expansion in a region with multiple Level 1 Trauma Centers and in a region with no

trauma centers to gather information about regional trauma plan implementation. 3. TC and OEMS&T Leadership have emphasized that their organizations have the same goal: to get

the right person to the right place at the right time; however, ongoing dialogue and clarification is needed to continue to strengthen the partnership between GTC and OEMS&T and to implement improvements as needed. The roles and responsibilities of each related to trauma system development need to be more clearly described in the framework.

4. Continue to adapt TCC operations to accommodate regional trauma planning. Discuss the ability for TCC to recommend non-designated hospitals to provide care. Explore additional communication mechanisms for communication between EMS Services and TCC to overcome EMS Service inability to use cell phones and limitations of two-way radio communication. (e.g. computer display)

5. There are multiple sources of trauma and EMS data held by different key organizations (GTC, OEMS&T, GHA). There is a need to discuss and develop agreed upon collection processes to measure patient transport time to definitive care for all regions. Utilize and integrate information from the TCC, EMS Reports, GHA Hospital Discharge Set, Trauma Registry and 911 Providers.

6. Determine whether future funding will be available for ongoing RTAC support.

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V. References

1. O.C.G.A. § 31-11-100 (2009) et seq. &. Georgia Office of Emergency Medical Services and Trauma Rules and Regulations, Sections 290-5-30-01 and 290-5-30-.03. 2. CDC. WISQARS: Nonfatal injury Reports. Available at http://webappa.cdc.gov/sasweb/ncipc/nfirates2001.html.

3. Hoyert DL, Kochanek KD, Murphy SL. Deaths: Final Data for 1997. National Vital Stat Rep 1999;47:1–104.

4. CDC. WISQARS: .Leading Causes of Death Reports. Available at http://webappa.cdc.gov/sasweb/ncipc/leadcaus10.html. Accessed May 12, 2010.

5. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of trauma center care on mortality. N Engl J Med. 2006;354: 366 –378.

6. Haas B, Gomez D, Zagorski B, Stukel TA, Rubenfeld GD, Nathens AB. Survival of the fittest: the hidden cost of undertriage of major trauma. J Am Coll Surg 2010;211:804–11.

7. Morbidity and Mortality Weekly Review (MMWR) Guidelines for Field Triage of Injured Patients Recommendations of the National Expert Panel on Field Triage, 2011, Recommendations and Reports January 13, 2012 / 61(RR01);1-20. 8. Mullins RJ, et al. Population-based Research Assessing the Effectiveness of Trauma Systems. J Trauma. 1999; 47:S59-S66. 9. O.C.G.A. § 31-11-100 (2009) et seq. &. Georgia Office of Emergency Medical Services and Trauma Rules and Regulations, Sections 290-5-30-01 and 290-5-30-.03. 10. O.C.G.A. § 31-11-100 (2009) et seq. &. Georgia Office of Emergency Medical Services and Trauma Rules and Regulations, Sections 290-5-30-01 and 290-5-30-.03. 11. Pilot Project Evaluation for Georgia Trauma System Regionalization, Key Informant Interviews, July-October 2012. 12. Georgia Trauma System, Regional Trauma System Planning Framework, October 2009. http://www.georgiatraumacommission.org/uploads/Approved_Framework_15_October_2009.pdf 13. Pilot Project for Georgia Trauma System Regionalization, White Paper, October 2009. http://georgiatraumacommission.org/uploads/Approved_Whitepaper_15_October_20091.pdf

14. According to a 1988 AG opinion, EMS Trauma Advisory Councils would be considered "review organizations" as defined in O.C.G.A. 17 section 31-7-131(2) and (3), and are covered by the immunity and confidentiality provisions of O.C.G.A. Sections 31-7-132 and 31-7-133. See RTAC VI Meeting Notes, August 2012. 15. Region V Trauma Plan, January 2011. http://georgiatraumacommission.org/trauma-system-development/rtac/rtac-v

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http://webappa.cdc.gov/sasweb/ncipc/nfirates2001.html

http://webappa.cdc.gov/sasweb/ncipc/leadcaus10.html

http://www.georgiatraumacommission.org/uploads/Approved_Framework_15_October_2009.pdf

http://georgiatraumacommission.org/uploads/Approved_Whitepaper_15_October_20091.pdf

http://georgiatraumacommission.org/trauma-system-development/rtac/rtac-v

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16. Region VI Trauma Plan, July 2011. http://georgiatraumacommission.org/trauma-system-development/rtac/rtac-v

17. Region IX Business Plan, October 2011. http://georgiatraumacommission.org/uploads/Regional_Trauma_Plan_Region_IX_Rv_3_142.pdf

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http://georgiatraumacommission.org/trauma-system-development/rtac/rtac-v

http://georgiatraumacommission.org/uploads/Regional_Trauma_Plan_Region_IX_Rv_3_142.pdf

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Appendix A

Region V

Interview Results

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Region V


Successes:

The Trauma Regionalization Pilot and RTAC Action Plan were first presented to Regional EMS Advisory Council in January 2011. The RTAC Steering Committee, consisting of the Regional EMS Advisory Council Chair, the Regional EMS Program Director, the Trauma Services Manager, and a Trauma Surgeon, along with the RTAC Coordinator worked to familiarize stakeholders with regionalization concepts as set forth in the Regional Trauma System Planning Framework and White Paper. Members of the RTAC Steering Committee and the RTAC Coordinator met with key stakeholders individually and discussed the RTAC vision with an emphasis on getting patients the care they need. • The project leaders sent a letter and information packet to key all stakeholders in the region, EMS

Services and hospitals (trauma centers and non trauma centers), to describe the idea of a regional plan and the intended goal of the plan: get the right person to the right place at the right time.

• The Steering Committee followed up the letter with face-to-face meetings with hospital and EMS Directors. During the meetings, the Steering Committee answered questions regarding the pilot and solicited stakeholder participation in regional trauma planning. The committee used scenarios to illustrate the potential of a regional plan (e.g. a paramedic from a rural county might not know what is happening in a particular trauma facility).

The project hired a knowledgeable and experienced person with trauma experience as project coordinator with project funding. • The Coordinator was essential to project success. The Coordinator’s knowledge and relationships with

hospitals and EMS Services in the region was very beneficial. The Coordinator hired as a .25 FTE.

EMS and hospital representatives from four counties located outside the Region attended initial RTAC meetings. They were included due to their proximity to the Region and patterns of transport to MCCG. • Of those invited from outside the Region, Crisp Regional Medical Center and Upson Regional Medical

Center have both EMS and hospital representatives that actively participate in the Region V RTAC and communicate with the TCC.

• Representatives from Emanuel Medical Center and Meadows Regional Medical Center participated in the Region V Trauma Plan Development and remain active participants in sister RTACs.

The majority of stakeholders in Region V believe that having RTAC as a committee of the EMS Council has worked and creates buy-in from the EMS community.

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The Region V RTAC was structured to operate in accordance with the current Region 5 EMS Advisory Council Bylaws. The RTAC is a subcommittee of the Regional EMS Advisory Council and is therefore governed by the Region V EMS Advisory Council Bylaws. • Current EMS Council by-laws require the RTAC Chair to be a member of the EMS Advisory Council

and to be appointed by the Regional Advisory Council Chair. • The Region V EMS Advisory Council Chair appoints RTAC members. • Appointed RTAC members are able to send proxies if they are unable to attend. • As a part of regional training, project leaders made visits to many EMS Services in the region to talk

about the regional plan and answer questions. • The Coordinator visited many EMS Services to clarify understanding about the regional trauma plan,

answer questions and dispel any misinformation.

Challenges:

Structural issues regarding RTAC needed to be figured out with the EMS Council.

• The appointed RTAC Chair was less able to participate in RTAC than anticipated due to other responsibilities.

• Initially, there was some uncertainty regarding whether or not the RTAC Vice Chair needed to be an EMS Council member. Regional V Plan states, “the Vice-chair is not required to be a member of the Region V EMS Council.”

• RTAC did not have a meeting quorum for a few meetings and the use of proxies had not yet been determined. Note: At the last RTAC meeting, there was a quorum and proxy votes were allowed.

There is a desire for broad multidisciplinary RTAC membership, which will provide a range of viewpoints. Currently, RTAC membership is more heavily weighted toward EMS representation.

• Fewer hospital representatives and physicians have attended than is optimal.

The RTAC plan represents a new way of doing things and the shift has been difficult for some entities.

• One difficulty was overcoming early concerns by the EMS community that the TCC was going to “tell EMS services” where to take patients.

• Once the regional trauma plan was approved by the Regional EMS Council and the RTAC appointed, the RTAC implemented a training initiative to operationalize the components of the plan and the use of the TCC.

• The RTAC coordinator worked closely with the TCC Manager to develop training materials appropriate for EMS and hospital providers.

• Four joint EMS and hospital train-the-trainer sessions were held by the RTAC coordinator throughout the region. Fifty-six individuals attended train-the-trainer sessions.

• The Train-the-Trainer sessions and the subsequent provider training served to clarify understanding about the regional trauma plan, answer questions, and dispel any misinformation.

• Region V RTAC participants currently average 53.5 calls a month. TCC calls have originated from 20 of the 25 counties participating in the Region V Plan.

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• Room for improvement does still exist. For instance, in September, EMS providers called 55 patients into the TCC. However, MCCG Trauma Registry data indicates that 13 prehospital patients meeting TSEC criteria were not called into the TCC.

• January - September 2012, Region V RTAC participants made 84% of all TCC calls. (439 of 545 TCC calls.) Of those, prehospital providers or their designees initiated 97%.

• Currently, all designated and non-designated participating hospitals within Region V are considered active plan participants.

Noteworthy Quotes:

" The initial introduction through a face-to-face meeting was key - you can’t just send out a memo.” “The buy-in from the EMS community is important.”

“Everybody knew there needed to be a link or a way to incorporate everybody and bring everyone to the table.”

“…no one had a big issue with the larger concept of the pilot. “

" I think the idea is great if we can make it work for the state of Georgia…but it requires people to be open-minded. “

“Could not have done the project without the position funded by grant money. The Coordinator was essential to project success.”

“Yes, a regional plan can be a tool to help improve care…we have the right stakeholders at the table to improve care.”

“It is difficult to support regionalization and the TCC with the hope it is going to work.”

“This pilot is about all of the stakeholders, would like things to be more in sync across disciplines.”


Successes:

The framework provided a good outline of what needed to be included in the plan.

The EMS Council and GTC submitted and approved the regional trauma plan.

• The regional trauma plan makes any issues about transport more transparent and allows for discussion. The RTAC has information to better understand the reasons for the final destination of patients.

• The regional plan includes 23 EMS Agencies (all 911 zone providers). Twenty agencies are 911 zone providers within Region 5. Three others were included due to their proximity to the Region and MCCG.

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The HRSA Model Trauma System Planning and Evaluation Trauma System Self-Assessment Tool: Benchmarks, Indicator, and Scoring (BIS) was used to evaluate the existing resources available in the region and to provide a broader perspective about trauma system needs.

The adaptation and inclusion of the CDC Field Triage Decision Scheme in the Region V Pre-Hospital Destination Guidelines and the Hospital Guidelines for the Inter-facility Transfer of Trauma System Patients was important for multidisciplinary “buy-in” to the regional trauma plan. • During the trauma plan development meetings, the EMS Subcommittee worked on Pre-Hospital

Destination Guidelines and the Hospital Subcommittee worked on the Hospital Guidelines for the Inter-facility Transfer of Trauma System Patients.

• Stakeholders felt it important that these two operational guidelines documents should be responsive to local variations in resources. For instance, though the CDC Guidelines for the Field Triage of Trauma Patients recommend that patients meeting mechanism of injury (MOI) criteria be transported to a Trauma Center, several non-designated participants indicated that they had sufficient resources to manage patients meeting only MOI criteria. They also maintained that having pre-hospital patients meeting only MOI criteria bypass their facilities would potentially tax their local EMS resources.

• The Region 5 Pre-Hospital Destination Guidelines included specific provisions for transport in

accordance with local medical direction and/or agency protocols for patients having pelvic fractures without significant mechanism of injury (MOI) and not meeting physiologic criteria for patients meeting MOI criteria but not meeting physiologic and/or anatomic criteria.

• Stakeholders share the understanding that the operational components of the regional trauma plan do

not include protocols, that only guidelines are included. Participating EMS Services and hospitals were encouraged to incorporate parts of the Region V Pre-Hospital Destination Guidelines and the Hospital Guidelines for the Inter-facility Transfer of Trauma System Patients into their protocols and SOP’s.

• The surveyed EMS services determined which services had a trauma patient triage protocol/policy in place and who incorporated CDC criteria into their protocols/policies. Fifty-four percent of EMS ground services indicated they did have a trauma patient triage protocol/policy in place. Forty-one percent indicated that they incorporated the CDC criteria into their protocols/policies.

• The surveyed hospitals determined who had a trauma patient transfer protocol/policy in place. Forty-

two percent indicated that they had a trauma patient transfer policy in place.

• Project leaders utilized existing EMS Services and OEMS&T protocols, which include the CDC criteria, to aid in the development of operational components of the regional trauma plan.

• The two guideline documents, Pre-Hospital Destination and Inter-facility Transfer of Trauma System

Patients were developed to meet the needs of all EMS services and hospitals in the region (those near or far to a trauma center).

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Project leaders worked closely with other pilot regions so as to not “reinvent the wheel” on RTAC development. • Pilot project leaders communicated frequently with pilot participants in Regions VI. Initial stakeholder

meetings were structured in a similar fashion. • The Region VI Trauma Plan served as an early template for Region V trauma plan. Early plan drafts

were modified to be Region V specific and then subsequently modified based on stakeholder input. • Goals and objectives were from Reg. VI Trauma Plan.

Noteworthy Quotes:

“We had to come up with a document that was palatable for everyone.... we addressed those issues in regional plans."

"We made allowances for local medical directors and hospitals to work together and evaluate local resources.”

"When we were educating EMS providers, they began to understand that not all trauma patients need to go to a Level 1 center. Before this pilot, few services had destination protocols…they may have been doing it right but it was not on paper. The medics had been taught in school about CDC criteria but didn't have the supporting documents to back them in their decision making."

“A written plan, guidance and protocols give the medics more support for the decisions they make. Written plans can separate the medics from the in politics that goes on in the regions. Information from the TCC provides the ability to track the information.”

Goal 3) Operationalize the Trauma Communications Center as the interoperable statewide communication component of the System.

Successes:

The majority of counties in the region have used the TCC.

• Of the 23 counties in the region, only 5 counties have not used the TCC...each of these counties is remote and covered by an individual service.

• Train-the-trainer sessions and subsequent provider training were implemented soon after the approval of the regional trauma plan. The RTAC Coordinator, TCC Manager, and TCC Operations Specialists worked together to train EMS and hospital participants on the operational components of the plan.

• Project leaders developed a standard EMS reporting format (PAMCo) was developed and field providers were trained on why, when, and how to call the TCC.

Improvements have been made in the interface between EMS services and the TCC.

• TCC Manager has attended all RTAC meetings, has been receptive to feedback and has provided follow-up and information.

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• The TCC Manager and RTAC Coordinator have worked together to provide feedback and data from the TCC to the RTAC and the Regional EMS Advisory Council. The manager and coordinator provide reports detailing the month-by-month TCC call totals; the distribution of TCC calls by location and agency, and the destination of TCC patients at each meeting. They make additional reports available on request.

• The communication interface between EMS services and TCC has improved to make sure the message the medics are trying to relay is reflected in the data and in the information the hospital is receiving.

• EMS and TCC staff have a better understanding of their roles as a result of more time and experience with the TCC.

RTAC Coordinator provided a laminated document with the CDC trauma triage criteria, standard EMS-TCC reporting format (PAMCo), and TCC contact information to all participating EMS services and hospitals. Coordinator distributed over 200 identification badge laminates containing TCC and the trauma triage scheme throughout the region.

Challenges:

For some services, the ability to communicate with the TCC is limited.

• There are some services that do not have cell phones which are needed to communicate with the TCC. Two-way radios can be used by some but have a limited mileage capability.

• Some services are calling the TCC after the patient has been transported.

Some EMS Services do not utilize the TCC and haven’t “bought in” to the advantage of using it.

• There are some medics who do not communicate with the TCC to find out where to go because they know where they are transporting the patient.

• Instances still occur in which patients are being initially transported to a trauma center even though they could have been well served in another facility. On the other hand, some hospitals are receiving patients that probably should have been initially transported to a trauma center.

• Project leaders need to get all the 911 centers on board…so they know what the TCC is and what they can do.

RTAC needs more data to check what is working or not about the use of TCC in the transport of patients.

• RTAC and TCC needs to make sure that the message that the medics are relaying is reflected in the data and in the information the hospital is receiving.

• More time and use of the TCC will result in more data to be able to discuss with RTAC and stakeholders.

• More information is needed from the field providers calling the TCC to find out what is working and not working.

• RTAC would like to determine if the utilization of the TCC to facilitate the interfacility transfer of patients has resulted in a reduction in time to definitive care.

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Concerns about the lack of health experience of some of the TCC dispatchers.

• TCC dispatchers did not all have EMS or health backgrounds which would have been helpful in communication with medics. Note: Now TCC dispatchers are going to EMT school or are being hired with a health background.

• The interpretation of medical terms and “jargon” is difficult without medical training.

Noteworthy Quotes: “Initially medics were giving too long of a report and people on the phone were not as familiar with medical terms as they needed to be…it is working better now.”

“ TCC staff have been very proactive and available.”

“The services that have utilized the TCC have only good things to say…wish I would have used the TCC when there was a burn patient…some of us are not in a habit of using.”

“Think the TCC Advisory Board will be helpful to provide guidance.”

“The TCC has been as successful as we could have been at this point…thought it “TCC” would have been more gradual. Would like to see more interfacility transfers occur.”

“A lot of paramedics are following the plan, ‘they have broken the code’. Now that it is written down, they should feel more protected because it is written in the plan. Some folks said, why do we need a TCC, we know where to go...but now there is a system to protect them.”

"I think we need to see it in action a little longer to see the impact in the region. I think people are still learning about it and still figuring it out. They are consistently getting better but they need more call time and experience before the TCC can be evaluated.” “The medics knew where they were going before the TCC was developed.….in this region there is only one Level 1 Trauma Center and not many other options.”

“There is not a free flow of information of how the TCC has been used.”


Successes: • Every county within Region V had representation during the initial stakeholder’s meetings and Trauma

Plan development.

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• The development of regional trauma plan and associated documents responded to stakeholder input. Project leaders worked with RTAC stakeholders to identify strengths of existing practices within the region and, when appropriate, incorporated the information collected into the regional trauma plan.

• Project leaders conducted three initial meetings in July, August and Sept. 2011. Meetings were well attended. There was a great turn out and positive feedback about the meetings.

• Project leaders rotated RTAC meetings to different locations to promote accessibility and attendance. • In the selection of RTAC members, a wide array of viewpoints was desirable for a balanced

perspective. • RTAC meets quarterly. Members represent a multidisciplinary group of people committed to making

the plan work.

Challenges:

• The project leaders wanted more physicians to participate. A few attended the initial meeting, but after that there was attrition in attendance from trauma and ER physicians and EMS Medical Directors.

• The project leaders wanted more stakeholders with a focus on accident/injury prevention from the beginning.

Noteworthy Quotes:

“We asked them to participate in the pilot as a way to work in the region together on challenges and have a way to communicate issues happening in the field with hospitals and visa versa ".

“We wanted everyone to be players in the system and to participate whether they were hospital-based EMS or county-based EMS, designated facility or non-designated facility."

“We had every EMS service and every hospital at the same shared table for the first time I can remember in my history." "We wanted to work through challenges together and needed everyone’s input to develop the region’s plan.

“Needed more EMS Medical Director participation because they sign off on the EMS Protocols.” Goal 5) Revise the Framework as a regional planning guide pursuant to the results of the pilot evaluation. • Developing the regional trauma plan could have been made easier by including a clearer outline for

plan development in the framework. Talking with other regions was useful to learn from them and their plan outlines.

• The framework could be more informative and useful if key reference documents were included to help standardize plans. Examples include the trauma plan template and templates for operational components of the plan.

• The framework does not provide enough clarification about the roles of GTC and OEMS&T staff.

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Goal 6) Identify specific steps to expand the Georgia Trauma system statewide by the way of

introducing regional trauma system planning statewide and by extending the coverage area of the

Trauma Communications Center.

OEMS&T and GTC Leadership have emphasized that OEMS&T and GTC have the same goal: get the right person to the right place at the right time; however, for some it has been difficult supporting regionalization work because this is work that OEMS&T used to be funded to do. For some with a long-standing history of EMS work, this change is difficult and role clarification is needed. Some stakeholders expressed concern about the focus on trauma since it is a small percent of the overall work of EMS.

• Ongoing dialogue and clarification will continue to strengthen the partnership between GTC and OEMS&T and to implement improvements as needed.

• GTC needs to provide additional information in the framework to clarify roles and responsibilities including how the work of different roles contributes to the overall goal of strengthening the Georgia Trauma System.

Stakeholders want to discuss the pilot project including what works well and what needs changed prior to expansion to the rest of the state.

Diligent work overcame early concerns by EMS community that the TCC was going to “tell EMS services” where to take patients. The TCC made some accommodations, which have promoted TCC use.

• Project leaders will continue to gather input from EMS Services to identify areas of improvement in trauma communication.

• Stakeholders will discuss and consider less expensive methods for trauma communication, which would provide better access to all medics including a mechanism to virtually display data that would be accessible to all. (e.g. web-based system).

Some stakeholders wish for a better way to integrate trauma data and work systemically to see impact.

• There is a need to discuss and develop an agreed-upon process to utilize the data to measure patient transport time to definitive care.

Noteworthy Quotes:

“ OEMS&T has authority and responsibility to get things done but doesn’t have the ability to get everything done with less and less funding every year. There are disparities in funding between OEMS&T and GTC. This has to be fixed to get the buy-in from other regions. ” “Looking at the Framework and the pilot, I don’t know what my role is.”

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Region VI

Interview Results

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Region VI

Goal 1: Introduce trauma system regionalization as a possible construct for Georgia Trauma System development.

Successes:

The development of a small, credible steering committee was important. The committee met with key stakeholders to lay the groundwork for regional trauma plan development success.

• At the onset of the pilot project, a small steering committee was developed and served as “champions” for the project. Steering committee members represented different disciplines (e.g. EMS, hospital) with credibility in their field. The steering committee included: EMS Council Chair and GTC member, Trauma Coordinator, OEMS&T Regional Coordinator and Georgia Association of Emergency Medical Services Chairman.

• All EMS Council members were provided a copy of the GTS Regional Trauma System Planning Framework, Oct. 2009, and Pilot Project for Georgia Trauma System Regionalization White Paper, October 2009.

• Project leaders sent letters to all the hospitals, EMS providers, local government agencies etc… in the region introducing the concepts of trauma system regionalization and inviting them to the Forum. The letter included the date, time and location for the first forum.

• Face-to-face meetings occurred with hospital administration, ED Directors and medical leadership to discuss regionalization concepts, provide information and to “dispel rumors” related to the project.

Formation of the RTAC as a committee of the EMS Council worked for the Region and the system stakeholders.

• Based on an opinion from the Attorney General’s Office, RTACs are considered review organizations and are afforded peer review protection and their work is non discoverable. RTAC members are health professionals serving and reviewing data to improve the quality of care rendered and to reduce morbidity and mortality due to trauma.

• EMS Council membership includes EMS, physicians, hospitals, and community organizations (e.g. Red Cross) resulting in views from different perspectives although the majority of members are from EMS. While there can be “turf” issues between EMS and hospitals--strong, good working, non-territorial relationships strongly prevail and contribute to the success of the RTAC.

• Organizing the RTAC as a Committee of the EMS Council promotes alignment and the potential to “speak with one voice.” This model fits with other health care charges in the region. For example, the Injury Prevention Committee is a committee of the EMS Council and had been independent.

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Funding for RTAC formation was important.

• Funding helps to pay for staff time and “raise awareness” for this work. It is an “easier sell” when a request is made when there is money available for this work. Funding was used to provide lunches during meetings and training--participants were very appreciative.

Challenges:

• Project leaders as concerns that the plan might not really impact change especially if there is not funding that follows the plan. Funding is needed to “return value” to the facilities and help with equipment, staffing or sharing resources such as on-call physicians.

Noteworthy Quotes:

“I was pleased with the openness of the discussion….didn’t hearing people say ‘we are going to do it our way’. All opinions were listened to with an open mind….people listened with the idea of meeting people’s needs. Process was very positive.”

“I don’t see a downside to the RTAC. Twenty years ago we set up all these designated centers….but it comes down to funding. The computer in the ED would not be there if the GTC had not funded it. Just knowing how care was rendered, improving communication –these are the important things to get done.”

“It [the RTAC] is formalizing what many of the regions have done in the past. In the past, [we] called each other up if we had a problem. Now we have the opportunity to serve on a committee and develop a joint plan. The RTAC formalized relationships.”

“EMS Council has been very open to assure that RTAC has the broadest membership possible, if they touch trauma they should be on the RTAC and appointments have been made.”

“It is formalizing what many of the regions have done in the past. The pieces for success are there; we’ve been there we can do this.”

Goal 2: Test the Framework as a planning guide for a regional Council to develop a Plan.

Successes:

The framework was a useful guide for plan development.

• Some parts of the framework were used directly in our trauma plan such as in the hospital section. • Definitions of terms were useful to establish shared understanding and were distributed in initial

meetings. • All stakeholders received the framework and pilot project description prior to face-to-face visits. • RTAC identified injury prevention resources in the region and goals and gaps and developed a plan

to address the gaps.

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Collaboration with other Pilot Regions was important and very useful.

• Talking with and learning from other pilot RTACs was very helpful especially so one didn’t need to “reinvent the wheel”.

The RTAC developed the regional trauma plan and the EMS Council approved the plan. The Georgia Trauma Commission accepted the plan.

• Regional trauma plan includes a Performance Improvement Matrix (and relates to the ACS Committee on Trauma and Performance Improvement and Patient Safety) in plan to identify how success will be measured.

• Regional trauma plan does not include Pre-hospital Guidelines at this time. As more data becomes available through the TCC, then Pre-Hospital Guidelines may be added. The lack of EMS participation in the TCC limits the available data.

• The Resource Subcommittee has identified local resources in the Region by surveying hospitals. The Resource Subcommittee discussed including non-designated hospitals. All hospitals agreed except two non-designated hospitals.

• RTAC decided not to include Interfacility Transfer Guidelines in the regional trauma plan at this time. Currently, physician-to-physician discussion occurs about transfers. The Subcommittee may decide to include Interfacility Transfer Guidelines in the future and may need to include repatriation language. Right now ACS does not require these Interfacility Transfer Guidelines to be in writing.

Face-to-face meetings and pre-assigned multi-disciplinary Task Forces worked to develop the plan by getting input and buy-in from a broad range of people.

• Project leaders invited system stakeholders to attend three Forums designed to develop the Regional Plan. Participants RSVP’d about attending and received a Task Force assignment ahead of time to assure broad multidisciplinary representation. Task Forces included: Development, Administrative, Pre-Hospital, Hospital, Performance Improvement and Injury Prevention and Outreach.

The HRSA Model Trauma System Planning and Evaluation Trauma System Self-Assessment Tool: Benchmarks, Indicator, and Scoring (BIS) provided valuable baseline information.

• The RTAC used the BIS to evaluate the existing resources available in the Region. This model is useful since it is based on the public health model, assurance, assessment and policy development.

• At the first of three Forum meetings, each Task Force completed their section of the BIS assessment tool. Stakeholders reached consensus regarding Region VI’s specific benchmark scores after completing a review of all scores. At the second Forum meeting, each Task Force presented their plan and identified performance indicators. At the third Forum, further agreement and alignment occurred on the plan. Meetings were held in “neutral” locations. The Forums provided the opportunity for input and involvement in plan development.

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RTAC and Subcommittee structure has evolved to include integrated committees between the EMS Council and RTAC, which are working on established goals.

• The structure combined EMS Council and RTAC Education Committees since many Council members were attending both Committees--it was efficient and made sense to combine the committees. Many of council members are members of the RTAC.

• The RTAC initially started with a TCC Subcommittee with each of the EMS services participating. Its initial responsibility was training. Now the TCC Subcommittee is merged with the Guidelines Subcommittee.

• The Resource Subcommittee is looking at data to identify where injuries are occurring. Based on the analysis, injury prevention education is needed for 16-18-year-olds on distracted driving. The Subcommittee is working on a presentation that will be distributed to EMS to use in their communities. The Trauma Coordinator and EMS Regional Director worked together to provide training to all EMS services in the region. The EMS Director sent out the notice and required services to attend the training. An overview of the training system, what is an RTAC, field triage including mock scenarios and CDC Field Triage criteria comprised the training.

• RTAC is focused on the process of care to make sure patients receive the treatment that results in the best outcome for the patient.

Challenges:

RTAC needs to continue to gather data to establish measurable goals.

• Establishing measurable goals was a challenge, but as the plan is implemented it may be easier to evaluate and modify as needed.

The RTAC did not include guidelines in the plan because they did not have data to inform the best decisions.

• RTAC would like the ability to transfer to non-designated hospitals if that is the most appropriate care for the patient. During the Resource Committee discussion there was limited attendance and all hospitals agreed except one.

Noteworthy Quotes:

“The Framework provided a good foundation. It would have been difficult to not have it as a guide and I wouldn’t have wanted to start from scratch.”

“The Commission has brought the structure and resources to bring together a multidisciplinary team and have an RTAC materialize.” “RTAC provides a focus to do an assessment and develop a plan based on the assessment.”

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Goal 3: Operationalize the Trauma Communications Center as the interoperable statewide

communication component of the System.

Successes:

• TCC Manager has done a good job of being available and attending regional meetings. He has listened to the need for changes and has made them when possible (e.g. Burke County made changes so they could be patched in when radio communication wouldn’t work).

• TCC operators are friendly and helpful. • The Manager sent the TCC report every month for review by Guidelines Subcommittee.

Challenges:

The ability for the EMS in the field to communicate with the TCC is limited.

• TCC cannot recommend a non-designated hospital if the patient does not meet TSEC criteria. This is a problem since the ambulance may be closest to a non-designated hospital that can provide definitive treatment.

• The ability for EMS services in the field to communicate to the TCC is limited because of the inability for cell phones use in ambulances and/or the ambulances are not within a range to use radio communication. Many ambulances do not have cell phones (often because of budget or limited cell coverage) and/or the service policy does not allow medics to use cell phones. The largest EMS 911 provider in the region does not allow cell phone use.

• Sometimes the TCC tracking number does not follow the patient. • Georgia patterned their communication system after Alabama’s system. Stakeholders expressed

concern that Alabama and Georgia have differences that impact the use of a communication system. Alabama introduced their central communication system at the same time they introduced trauma centers whereas trauma centers in Georgia have been established and around a long time.

• Some EMS services are communicating with the TCC retrospectively once they have arrived at their destination; however, that is not the intended use.

Noteworthy Quotes:

“Georgia is celebrating a 30 year history of trauma centers…there is a deeply entrenched way of doing things, not sure if changes can be made.”

“When I first came on, I went to ER and looked at availability “the jelly beans” it takes some time to get used to but the advantage is that the patient goes to appropriate level of care. It takes time and training. To adopt something new there will be resistance.”

“If medics can’t use cell phones, they can’t communicate with the TCC.”

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Goal 4) Identify and involve regional trauma system stakeholders including physicians, EMS, designated Trauma Centers non-designated participating hospitals, hospital personnel, local governments and the public in system planning.

Successes:

Fifteen member RTAC established and subcommittees continue to meet.

• RTAC meets quarterly. Members represent a multidisciplinary group of people committed to making the plan work. The group includes a community representative. Each of the Subcommittees are chaired by an RTAC member. Overall, meeting attendance has been good although some members have had to miss meetings. Subcommittees are active and will present information about goals met and not met at Oct. meeting, then update the RTAC plan.

Reference material was provided and included:

• Region VI Results from the Benchmarks, Indicators and Scoring BIS Self-Assessment completed in 2011. This assessment is from the Department of Health and Human Services, Health Resources and Service Administration (HRSA), Model Trauma System Planning and Evaluation, Benchmarks, Indicators and Scoring (BIS) developed in 2006.

• RTAC By-Laws • RTAC Meeting Minutes • CDC Field Triage Criteria • American College of Surgeons Essential Criteria for Levels of Trauma Center Designation • Georgia Office of EMS/Trauma, Department of Human Resources, Division of Public Health

Hospital Resources Checklist For Trauma Center Designation, Re-designation or Upgrade.

A broad range of participants participated in the RTAC meetings.

• The Forums needed mental health and rehabilitation services representatives present. This was a recognized early on so subsequent meetings included participant representing these areas.

• Ensuring everyone has a voice and is involved in plan development is key. It is particularly important to engage those who are reluctant to participate or who think system planning is not necessary. Getting their input and addressing their concerns was important.

• EMS, Fire, and representatives from across the industry attended and had the opportunity to express concerns.

Challenges:

Establishing the RTAC is very time intensive.

• Some expressed the desire to have more ED physicians at the meetings. They can be a challenging group to get to attend because of their shift work.

• Public Health partners are important and needed to be included earlier.

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There was a short time frame for RTAC and plan development.

• RTAC and plan was developed in 5 months. A more reasonable timeframe is one year.

Noteworthy Quotes:

“ RTAC is helping to formalize relationships across boundaries and bringing different people together. No down side, not costing us anything…if it helps benefit the delivery of EMS and trauma care in region, the only side is up.”

“Need to take the time needed to set up the RTAC. A shaky foundation will lead to collapse of the system and this needs to be kept in mind each step of the way.” “The goal is to save lives….that is what people have to remember. This is not just another committee or another meeting, it is about the survivability. It is important to have people in the region that have a passion for this work.”

Goal 5) Revise the Framework as a regional planning guide pursuant to the results of the pilot

evaluation.

The framework is not an implementation manual.

• The framework needs information about the development and the implementation of the RTAC with details about how to set up the RTAC.

GTC should expand the framework to include additional information needed for plan development.

• Additions to the framework include: BIS assessment, ACS Essential Criteria for Levels of Design, US Dept. of Health and Human Services Trauma Program Design Policy.

• Information about the lead agency included in the framework is unclear to some and relates to the lack of role clarity.

Goal 6) Identify specific steps to expand the Georgia Trauma system statewide by the way of introducing regional trauma system planning statewide and by extending the coverage area of the Trauma Communications Center.

The GTC and OEMS&T each have specific responsibilities. The GTC has the responsibility to administer and fund the trauma system network; and OEMS&T has regulatory responsibilities. The organizations are interdependent and need each other to accomplish shared goals. For some staff, there is role confusion and uncertainty about who has the responsibility for EMS system development, which includes trauma. • Ongoing dialogue and clarification need to occur to strengthen the partnership between GTC and

OEMS&T and to implement improvements as needed.

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• GTC needs to provide additional information in the framework to clarify roles and responsibilities including how the work of different participant roles contributes to the overall goal of strengthening the Georgia Trauma System.

Different key organizations including GTC, OEMS&T and GHA have trauma and EMS data.

• There is a need to discuss and develop an agreed-upon process to utilize the data to measure patient transport time to definitive care.

Consider using alternative methods for EMS communication with the TCC. Stakeholders need to discuss the use of a web-based system.

Noteworthy Quotes:

“In the past, OEMS&T staff worked with Trauma Coordinators to look at data and was involved in addressing trauma needs. Now there are less OEMS&T staff and budget resulting in less ability to be involved.” “Regionalization is not a new concept.”

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Region IX

Interview Results

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Region IX


Accomplishments:

Project leaders had individual meetings with hospital CEOs, COOs and ED physicians in the region. Meetings were a positive introduction to the RTAC.

• The Director of Trauma Services and Trauma Chief from the Level 1 Trauma Center met with individual hospital CEOs, COOs and ED physicians. The agenda focused on the research about getting trauma patients into care, the role of trauma centers, the TCC and the plan to create an RTAC. The vision for creating an RTAC was received positively.

• Individual meetings occurred with all but two hospitals in the region that do not send patients to the Level 1 Trauma Center. These hospitals sent their patients to the closest trauma centers, which are over the border (into Jacksonville and Macon).

Project leaders organized and implemented a meeting to bring stakeholders together which was the “launching point” for plan development.

• Approximately seventy people representing hospital CEO’s and COO’s, ED Clinical Directors, EMS and GTC attended a face-to-face meeting to discuss trauma regionalization. The goals of the meeting were to introduce regionalization, to complete the BIS assessment and to gain participant perspective’s about regionalization.

Collaboration with other Pilot Regions was important.

• Participants learned from other pilot regions by talking with them so not to "reinvent the wheel". • Communication with other regions helped to create understanding of similarities and differences

among the regions.

Trauma regionalization was included as part of the Memorial University Medical Center business plan.

Some members in the region supported the formation of the RTAC as an independent council but not all.

• Project leaders conducted research to identify other state’s models for regionalization that had been successful. Reg. IX used the experiences in Texas, Michigan and Duke University (North Carolina) as their model.

• The framework describes the “regional trauma system” operating according to the Regional Trauma Advisory Council. Council formation requires dual reporting to OEMS&T and GTC, which is the structure desired and supported by the research conducted of working models in other states.

• Pilot project leaders did not believe “they had heard a good reason a hospital should report to the EMS Council.” Pilot project leaders wanted to have the same reporting relationship as the EMS Council.

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• Concern was expressed that there are not many hospital or physician representatives on the EMS Council.

• Trauma Coordinator provides RTAC updates to the EMS Council on behalf of RTAC Chair.

Challenges:

Formation of the RTAC as an independent council worked for some system members in the Region but was not supported by all.

• Project leaders wrote letter to the EMS Council requesting their endorsement for RTAC formation as an independent council. A motion was made at the EMS Council regarding the formation of the RTAC but was deferred.

More participation is needed on RTAC Subcommittees.

• More members are needed on Injury Prevention and Performance Improvement Subcommittees. • Few EMS Council members are active on the RTAC Prehospital Subcommittee. • Time required for travel to attend Subcommittee meetings can affect meeting attendance. • More consistent representation on Subcommittees is needed.

Noteworthy Quotes:

"The meeting was a healthy mix of people working with trauma."

“Regional Trauma Advisory Council is the umbrella that defines trauma care in our region.”

“The initial meeting was an opportunity to get all the players in the same room and have a dialogue.”

“The Pilot has been a very positive experience for the trauma center and those who have participated in the meetings.”

“It was very beneficial to meet with hospitals in the region. I wish I would have done that 15 years ago.” “There is an opportunity to look at data transparently to identify improvements that can be made.”


Successes:

The framework provided a useful roadmap for plan development. The RTAC developed the regional trauma business plan. The Georgia Trauma Commission accepted the plan. The RTAC is currently developing the regional trauma plan.

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Completion of the BIS assessment provided valuable information for plan development and provided the basis for committee development.

• The Trauma Director and a Trauma Chief completed the BIS assessment separately prior to the stakeholder meeting. At the face-to-face stakeholder meeting, participants completed the BIS assessment. The Trauma Director and a Trauma Chief and the participants compared and discussed ratings for each section of the assessment to identify a shared ranking. This process resulted in a baseline. Participants appreciated the Trauma Chief sharing his perspective on the assessment.

The RTAC created subcommittees to further develop plan objectives and tactics.

• Member interest was the basis for subcommittee development. The role of the subcommittees was to develop objectives and tactics to address the gaps identified in the BIS and the resulting improvements made. Subcommittees included: Performance Improvement, Pre-hospital, Injury Prevention, Education and Medical Oversight. There are an average of seven to eight people on the committees. The Performance Improvement Subcommittee has been the most active and has used conference calls to conduct its business.

• Medical Oversight and Prehospital Subcommittees are currently in the process of developing transportation and pre-hospital protocols. A Pre-hospital Ad Hoc Subcommittee is developing methods and plans to introduce the TCC to the hospitals and EMS in the region.

Challenges: Lack of familiarity with the framework.

• Not all interviewed stakeholders were familiar with the framework.

More people in the region need to know about the RTAC and its vision.

Not all people may participate in the RTAC, yet if it is an agreed upon, approach funding needs to be tied to their participation in the plan.

Noteworthy Quotes:

“The Framework is the foundation for building the plan.”

“Developing a plan is a tremendous amount of work and requires a lot of commitment.”

“If you want to get the data, it needs to be tied to funding. For example, in Alabama every 911 provider has to use the call center. If you don’t get funding…..that will get your attention. ”

“The BIS validated what we knew and that we had room for improvement...we scored low.”

Goal 3) Operationalize the Trauma Communications Center as the interoperable statewide


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Successes:

• At initial stakeholder meeting, participants discussed that there are hospitals that could take care of lower acuity patients and the process at would be described in the Pre-hospital Guidelines to be developed by the Pre-hospital Subcommittee.

• Belief that the TCC will be helpful to outlying counties for EMS to identify the most appropriate hospital which to transport the patient and that the TCC could be useful if a hospital is on diversion.

• The regional trauma plan will include the hospital’s role, which needs to be understood before hospitals sign the agreement to receive equipment. The Pre-hospital Subcommittee is facilitating this.

• There is good collaboration between the Chatham County EMS Council and the RTAC. Chatham County gave a presentation to the Prehospital Subcommittee to help develop Prehospital Guidelines for the plan.

• TCC use in the region cannot be operationalized without first developing the Transportation and Pre-hospital Guidelines.

Challenges:

• The EMS community has expressed concern since the RTAC is not formally part of the EMS Council.

TCC is not yet being used.

• Paramedics know that Savannah is the Region’s Level I trauma center. They already know where to transport.

• A comprehensive effort to get TCC information out to EMS and hospitals has not occurred yet until the Transportation and Pre-hospital Guidelines are developed.

Noteworthy Quotes: “Local medics don’t know how the TCC can be beneficial to them.”

"….it is a matter [of] how we will get all these rural EMS services to utilize the TCC. This is a new way and a change from how they have been doing things." “If you want to get data from EMS it needs to be tied to funding. That’s how it is done in other states. That will get your attention.”


Successes:

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• At the initial face-to-face meeting there was representation from hospital administration and EMS although more physicians present would have been preferable/optimal and of the ones who attended, some had to leave early. The physicians who attended were described as ”enthusiastic”.

• One hundred percent of the 911 zone providers attended the initial face-to-face meeting. • Trauma system stakeholders continue to be invited to participate in the RTAC to expand

representation at the meetings.

Challenges:

• Of the 18 hospitals in the region, not all had representatives at the face-to-face meeting. • Smaller rural EMS providers had limited attendance because they are not 911 providers and have

mutual aid agreements in place. • The EMS Regional Director was new to his position and attended the first RTAC formation

meeting; however, due to job demands and less staff, the Director was not able to attend subsequent RTAC meetings.

Noteworthy Quotes: “We need to get more participation from EMS and nursing. They all need to be at the table so we can establish better communication to work together.” “EMS is the foundation for trauma in Georgia and they have been there since the beginning; however, we’ve got to get beyond EMS and include a broad group of people thinking about trauma including rehabilitation and more.” “We developed communication links with people in the region that had not been there before.” “EMS has the ability to override the recommendations of RTAC and TCC and take the patient where they want to go.” “We want to get the patient the right care at the right time. Let’s look at outcomes.”

Goal 5) Revise the Framework as a regional planning guide pursuant to the results of the pilot

evaluation.

GTC should consider including additional information needed for plan development in the framework.

• Include research about other state’s models for regionalization that have been successful.

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Goal 6) Identify specific steps to expand the Georgia Trauma system statewide by way of introducing regional trauma system planning statewide and by extending the coverage area of the Trauma Communications Center.

• Hospitals expressed concerns about Resource Availability Display (RAD) relationships to HIPAA and EMTALA agreements. The Attorney General is addressing this issue.

• Participation in the regional trauma plan should be required and tied to funding.

• Stakeholders need to make a stronger statement about the importance of the TCC and how it can benefit EMS services and the trauma system. Stakeholders should consider having a forum for EMS to discuss the TCC and show them how the system can work.

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Statewide Stakeholder

Interview Results

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Statewide Stakeholders:


Strengths:

• Some EMS regions have strong acting regional programs for trauma. In 1999, OEMS&T staff attended EMS Regional Council meetings and discussed the idea of developing Trauma Committees as a part of the EMS Council. Regions III, V, and VI developed Trauma Committees. The Region III Trauma Committee was developed especially because the region had two major pediatric trauma centers. The Committee talked about the importance of having pediatric patients transported to those centers.

• RTACs provide an opportunity for dialogue among system stakeholders. • Regions reached across their regional boundaries to include hospitals that transferred patients to

them. Including hospitals outside the region is a good idea and worth replicating. • There is no downside to the creation of a plan; a detailed plan can provide useful structure to the

region. • Trauma is a small percent of the calls that EMS run; however, if trauma systems are strengthened,

the overall system will be improved, too.

Challenges:

• Benefits of the pilot might have been greater if EMS Regions were selected that did not already have a strong regional trauma program in existence or have any trauma centers.

• Regions were formed for administrative purposes not for patient care or clinical regions. Counties may transfer to different regions for definitive care. Regional boundaries can be misleading.

• A decline in OEMS&T funding has caused a decrease in staff. Staff has been involved in trauma system development and training but now there is only one staff person, an EMS Regional Director in each region with multiple responsibilities.

• There can be inconsistency in standards in different regions. • It seemed there was a “rush factor” to get everyone involved. It is important to allow enough time

for development of plans and to build relationships. In some states, regional plans took 10-15 years to be developed.

• Organizations have multiple stakeholders and if only one or two are represented, all the viewpoints may not be heard.

• Medical Directors set medical and community standards. RTAC and EMS Councils make recommendations to OEMS&T. RTACs and EMS Councils don’t set standards in the region. There are not ten independent sets of standards. They offer guidelines and recommendations which the local medical director may or may not adopt.

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Noteworthy Quotes:

“The RTAC work being done would have been done by state staff in the past, but none of the regions have a training person any more. They only have an EMS Regional Director.”

“Each region is going to move at a different pace; you can’t force feed the timeframe.”

“It is not like a hospital versus EMS versus physicians. The BIS assessment helps ground everyone in reality and put everyone on the same page.”


Strengths:

• The framework is comprehensive and was well organized. Many stakeholders could “relate” to the document including the EMS community.

• OEMS&T believes that regional work is best performed as a committee of the EMS Regional Council so resources are not divided and data collection is not duplicated.

• Region III RTAC, developed under the Region EMS Council, has been in place a long time and is working. Their Trauma Council is bigger than their EMS Council. They have good working relationships and committee structure in place.

• There should be consistent performance measures for trauma utilized by the EMS Council and RTAC.

• EMS Councils are not addressing the important issue of injury prevention. This can be addressed by RTACs especially when data is reviewed to identify specific interventions.

Challenges:

• There is potential for confusion with EMS providers when they cross regional boundaries and different guidelines are included each region’s plans.

• There is already a process in place for local EMS medical directors to develop transportation protocols. Interviewees were not sure if an RTAC provides help with the development of a transportation protocol.

Other:

• There is overlap in the systems of care among trauma between STEMI and stroke. Many people may experience a multiple system trauma.

• Having RTACs as a Committee of the EMS Council provides a structure to make recommendations to the EMS Regional Council. EMS Regional Councils are recognized in state statute and code.

Noteworthy Quotes:

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“Strengthen trauma and the overall system will be strengthened.”

Goal 3) Operationalize the Trauma Communication Center as the interoperable statewide


Strengths:

• The TCC corrected factual reporting errors, which occurred in the early phase of implementation. • Some believe there is a better solution than the TCC because in most cases the trauma center

accepts the patient being transported. • The TCC does help when a medic has trouble finding a receiving hospital and can be most useful to

rural EMS providers. • TCC staff has done a wonderful job communicating with “uninviting audiences” and maintaining

open communication with all stakeholders.

Challenges:

• Currently, the amount of time from onset of trauma to arrival for definitive care is not completely known. This timeframe is an important system indicator but is challenging to measure because there are not a large number of cases. Is the intended outcome of TCC to improve response time?

• Some believe that many TCC calls occur after the transport occurs. • Some expressed uncertainty about the difference being made by the TCC. • Many EMS providers do not allow personal cell phone use in ambulances or have cell phone

capability. Many EMS services rely on radio communication. The TCC has limited radio capability.

• When the TCC was first implemented, the TCC wanted to access trauma registry and EMS data. The data was not shared because it is HIPPA-protected information. Stakeholders would like to see the TCC system working and beneficial before data is shared.

Noteworthy Quotes:

“In the beginning of the project, communication got off track….TCC proposed telling the EMS community where to take patients but the medics know their primary transport patterns.”

“Reflecting on the TCC and moving forward, there are early adopters, but we need to continue the discussion and promotion with others.”

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Strengths: • Including counties who are not formally a part of the region to participate in discussions and plan

development is a good idea and worthy of replication.

Challenges: • Initially a wide variety of stakeholders were included in the RTAC discussions but some have

stopped attending and full participation is important. • More fire and police needed to be involved in plan development.

Noteworthy Quotes:

“Smaller hospitals, EMS services and public health were at the table to help develop plans.”

“It is very powerful to get the non-designated hospitals, physician representation, EMS all in the same room is very powerful.”

“People were hungry in their region to address trauma. Regions needed resources to do the planning.”


Strengths:

• Regional stakeholders have local knowledge about what organizational structure to develop a regional trauma plan may work best in their region. Stakeholders have different perspectives on the approach to take.

• Completing the BIS assessment provided valuable information about the resources in the region and helped to identify partners to include in plan development. Reference to BIS needs to be included in the framework.

Challenges:

• The framework uses the term Regional Trauma Advisory Council. There was not a clear understanding of the difference in the meaning of the terms “council” and “committee”.

• It may be challenging if different organization structures are used in the regions as opposed to one consistent way to organizationally approach regional trauma system development.

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Goal 6) Identify specific steps to expand the Georgia Trauma system statewide by way of introducing regional trauma system planning statewide and by extending the coverage area of the Trauma Communication Center.

• The biggest opportunity for improvement is in a region where there are no Trauma Centers. • The pilot project is too early in its implementation to fully know the impact. • Some expressed concern that the TCC was expanded statewide but many EMS services don’t know

about it.

Noteworthy Quotes:

“Let’s build on what has been learned in the three pilot regions so others don’t need to start from scratch.”

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Appendix B. People Interviewed for Report

Region V Debra Kitchens, Trauma Services Manager Medical Center of Central Georgia, Level One Trauma Center

Kristal Claxton Smith, RTAC Coordinator

Lee Oliver, EMS Region Council Chair

Chris Hobbs, RTAC Chair

Russ McGee, EMS Regional Director

Region VI Regina Medeiros DNP, RN, Trauma Program Coordinator (Medical College of Georgia) MCG Health, Inc, Level 1 Trauma Center

Ernie Doss, EMS Council Chair

Ralph Randall, RTAC Vice-Chair

Lawanna Mercer-Cobb, EMS Regional Director

Courtney Terwilliger, Chairman, Georgia Association of EMS

Region IX Elaine Frantz RN, BSN, MA, Vice President, Physicians' Services

Memorial Health University, Level 1 Trauma Center

Tim Genest, EMS Council Chair

Gage Ochsner, M.D., RTAC Chair

Robert Shad, EMS Regional Director

Statewide Dennis Ashley M.D., GTC Chair

Linda Cole, R.N., M.B.A., GTC Commission Member

Courtney Terwilliger, Chairman, Georgia Association of EMS

Renee Morgan, State Trauma Systems Manager

Keith Wages, Office of EMS Director

John Cannady, TCC Manager

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Appendix C. Interview Questions

Pilot Project for Georgia Trauma System Regionalization


August 2012

In 2010, a pilot project in three regions was funded to test the development of a regional trauma system structure based on the Regional Trauma System Planning Framework developed October 2009. The purpose of this evaluation is to understand how the pilot project goals were addressed; to identify overall benefits provided by the framework; and to make potential recommendations to adjust the framework. The six pilot project goals are:

• Introduce trauma system regionalization as a possible construct for Georgia Trauma System development;

• Test the framework as a planning guide for a regional Council to develop a Plan; • Operationalize the Trauma Communication Center as the interoperable statewide communication

component of the System; • Identify and involve regional trauma system stakeholders including physicians, EMS, designated

Trauma Centers, non-designated participating hospitals, hospital personnel, local governments and the public in system planning;

• Revise the framework as a regional planning guide pursuant to the results of the pilot evaluation; and,

• Identify specific steps to expand the Georgia Trauma system statewide by introducing regional trauma system planning statewide and by extending the coverage area of the Trauma Communication Center.

Interview Questions 1) Describe your experience with the pilot project. 2) What worked about introducing a regional structure for trauma system development? What didn’t

work? 3) How well has it worked to have a broad group of stakeholders in system planning? Have all the

representatives been at the table? If not, who is missing? 4) What was your experience using the framework as a guide to regional system plan development? How

much was it used? 5) In your development of the plan, did you use other planning resources to meet your regional planning

needs? If so what? 6) Understanding that the Trauma Communication Center became operational in January 2012, how has it

been used as a resource for EMS services in your region? What needs to be improved? 7) What are the benefits of having a Regional Trauma Advisory Committee/Council in your Region?

What is the downside? 8) What advice would you give other EMS Regions as they proceed to develop RTACs? 9) What else needs to be said that is an important part of this pilot process?

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Appendix D. Glossary of Georgia Trauma System Definitions

Benchmarks, Indicators and Scoring assessment (“BIS”) Health Resources and Services Administration (HRSA), an agency of the U.S. Dept. of Health and Human Services, developed the Model Trauma System Planning and Evaluation Benchmarks, Indicators and Scoring (BIS) assessment. Developed in 2006, this self-assessment tool is used to quantify a trauma system’s development.

EMS Region One of ten established geographic programmatic regions of the State of Georgia Office of Emergency Medical Services and Trauma within Georgia Department of Community Health.

EMS Regional Council One of ten established geographic programmatic regions of the State of Georgia Office of Emergency Medical Services and Trauma within Georgia Department of Community Health.

Non-designated participating hospital An acute care Georgia licensed hospital with an emergency services department and varying specialty physician coverage and service line capabilities to treat, stabilize and admit low acuity trauma patients. These hospitals have signed a letter of commitment indicating Trauma System participation.

Non-participating hospital A Georgia licensed hospital that has not signed a letter of commitment with the Georgia Trauma Commission indicating System participation and is not a designated Trauma Center.

Performance improvement A data-driven, documented, methodical and reviewable process for identifying and achieving component-specific, regional, or state-level system improvements.

Regional Trauma Advisory Committee –(“RTAC”) A body endorsed by the Georgia Trauma Commission within a trauma service area to develop, implement, and oversee a Regional Trauma System Plan.

Regional Trauma Advisory Council A body endorsed by the Georgia Trauma Commission within a trauma service area to develop, implement, and oversee a Regional Trauma System Plan.

RTAC Leadership Identified multidisciplinary people who guide and organize the development and implementation of the regional trauma plan.

Regional stakeholders A multidisciplinary group of people who represent the trauma system continuum from injury prevention through rehabilitation.

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Regional trauma system Assets, capabilities, stakeholders and providers of a given trauma service area, organized to improve the area’s ability to identify and then transport Trauma System patients to an appropriate hospital for definitive care within an optimal time.

Regional Trauma System Plan (“Plan”) A document developed by a Regional Trauma Advisory Council/Committee that specifies and formalizes the relationships between the various regional trauma system components.

Regional Trauma System Planning Framework (“framework”) A document put forth by the Georgia Trauma Commission to be used as a planning guide for regional trauma system plan development. The framework sets forth components and functions necessary for operation of a regional trauma system.

Resource Availability Display (RAD) A computer system screen, which indicates the system-open status for Trauma Centers and resource service line availability for each participating hospital in the Georgia Trauma System. RAD terminals are limited to participating hospitals and the Trauma Communications Center.

Subcommittees The structure used by Regional Trauma Advisory Committees to develop the regional trauma plan.

Trauma Center A Georgia licensed hospital designated by the State Office of EMS and Trauma as a Level I, II, III, or IV trauma facility. State designation standards are extrapolated from the American College of Surgeon’s Committee on Trauma, Trauma Center Verification Standards. Trauma System Entry Criteria Primary triage criteria.

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Placeholder for TCC Slides

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Summary DOAA Report Review Process

Finding #1 Service Delivery While data to measure improvement in service delivery and response times is limited, an increase in the number of trauma centers and in the percent of trauma patients going to trauma centers indicates improvement.

Recommendations

Responses Current Plans

1. GTC and OEMST should

collaborate to develop a performance improvement program that utilizes data to evaluate service delivery in the state’s trauma system. The performance measures should consider statewide and regional performance.

2. The Commission should utilize currently available data sets to obtain quantitative information showing the changes in system outcomes. Since OEMST is most familiar with its trauma registry and GEMSIS data, the Commission should request reports from OEMST showing statewide and

Commission Response: “We are in agreement with the findings and recommendations.” Regarding performance measurement, the Commission noted that “Georgia is one of only two states (Michigan) with statewide TQIP participation...Beginning in FY 2014, the Commission, working in collaboration with the trauma centers and the Georgia Chapter of the American College of Surgeons Committee on Trauma, will look to utilize performance information, determined by TQIP data, to advance our performance based payment program. Georgia’s incorporation of TQIP statewide and linkage of readiness payments to a performance based payment program is viewed nationally as best practice.”

OEMST Response: Regarding data quality, OEMST stated that its “staff recognizes the importance of the EMS data set and has been working tirelessly on improving the quality of the GEMSIS system,” especially since a 2007 rule change required all EMS providers to report data. “Currently Staff is assessing the use of the GEMSIS data to provide data analysis and link GEMSIS data with trauma data.”

1. Establish a Trauma System Evaluation Committee to identify and monitor system wide performance measures.

2. Review existing trauma data to include individual case analysis of patient transfer time to definitive care and recommend system-‐wide performance measures and identify baseline.

3. Compare data on patients treated in a trauma center and patients not treated in a trauma center based on Injury Severity Score (ISS).

4. Communicate with RTAC leadership to assure alignment between regional quality requirements and the system wide performance measures identified.

5. Begin individual case analysis of pt. transfers trauma center from another hospital and location of the scene of the injury. These cases will be used to illustrate key points about time to definitive care, communication protocols etc.

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historic trends related to trauma system performance.

In regard to providing data to the Commission, OEMST stated, “Data published through OEMST is vetted through the state process and must be validated. The Commission does not have a process for validation and publication approval through DPH. No request by the Commission for reports from the trauma registry has been denied.” It stated that it attempted to educate the Commission on data availability but that the Commission “chose to request the entire database instead of focusing on benchmarking.” It added that “Certain information available to OEMST has not been shared with the Commission because of its proprietary nature. Members of the Commission are also competing entities within the health care system. For this reason, OEMST does not share information that could give Commission members an unfair advantage over their competitors.”

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Finding #2: Service Delivery The Commission’s actions to improve trauma care are closely aligned with criteria set by the American College of Surgeons and other states; however, further improvements are needed.

Recommendations

Responses Current Plans

1. The General Assembly should consider revising state law to clearly define a lead agency for trauma care in Georgia. The lead agency should have the authority and responsibility to ensure compliance with rules and regulations and evaluate performance in a confidential manner.

2. In the absence of a state law change, the Commission and OEMST should continue with plans to clarify each entity’s roles and responsibilities, specifically noting any areas of uncertainty (e.g., overlap or gaps in responsibility). The entities should then negotiate their roles in those particular areas.

3. The Commission and OEMST should continue to utilize ACS recommendations and best

Commission Response: “We are in agreement with the findings and recommendations.” In addition, the Commission provided statements on two areas covered by the finding.

Concerning financing, the Commission stated that it “supports restoration of adequate OEMST funding to provide basic EMS regulatory services in Georgia.”

In regard to operations, the Commission stated that “During the time period addressed in the report, only two regions out of ten were participating in the [TCC] pilot project. Those two regions were chosen for the pilot project, in part, for the limited number of trauma centers contained within the two regions. In the majority of instances within the two chosen regions, medics should know the most appropriate destination for their trauma patient. This parameter provided the best environment to test the functionality of the TCC and its systems. For this purpose, the Commission believes the use of the TCC within the pilot regions has been successful. Going forward, the TCC will work to incorporate the use of available technologies in order to provide a more virtual access to the TCC to healthcare providers for effective trauma system patient disposition.” The Commission also noted that “The draft report emphasized the number of destination

1. Receive opinion from the Attorney General on a legal review of delineated roles in the statutes and codes.

2. Through collaborative process, analyze current trauma system roles and responsibilities of all Georgia agencies (e.g. trauma center designation, funding, registry).

3. Develop rules and regulations based on the analysis completed (under Objective #1).

4. Identify potential operational efficiencies, role conflicts, and opportunities for integration and collaboration among all agencies involved in trauma system development (including reporting efficiencies).

5. Present efficiency recommendations to the GTC that assures essential trauma tasks are addressed and effective collaboration and coordination among trauma system agencies occurs.

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practice states to guide trauma system activities.

recommendations made but did not acknowledge any of the other times the TCC has been of service to EMS providers. These services include: patching calls to the receiving facilities, relaying hospital service line availability, and identification of closest non-‐designated [hospitals] for non-‐trauma system patients.”

OEMST Response: “OEMST is identified as the agency for designation of trauma centers in rules and regulations. This rule has been in place since the late 1970s. Regulatory activities preceded the establishment of the Commission.”

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Finding #3: Number of Trauma Centers

While the number of designated trauma centers has increased since 2007, there are still areas of the state in which injured patients must be transported long distances to receive definitive care at a Level I or II trauma center.

Recommendations

Response Current Plans

1. The Commission and OEMST should determine the number and level of designated trauma centers needed in Georgia based on geographic location, population density, and hospitals’ capabilities.

2. If additional trauma centers are designated and additional funding is unavailable, the Commission should ensure that its funding programs continue to strengthen the system by investing in trauma centers that are having the greatest impact on the system.

Commission Response: “We are in agreement with the findings and recommendations.”

OEMS&T Response: No response provided.

1. Develop strategy to expand the number of designated trauma centers to strategic areas of state.

2. Develop statewide plan based on accepted strategy.

3. Present the Georgia trauma center regulatory process to the GTC. This will include designation standards and timelines for redesignation reviews and ongoing standard adherence, designation site survey process (team makeup and survey instruments) and DPH follow-‐up procedures for standards deficiencies identified during review.

4. Provide a summary report at each GTC meeting on Trauma Center designations and re-‐designations that maintains confidentiality and updates the GTC on trauma centers’ status and statewide gaps.

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Finding #4: Uncompensated Care

The Commission has mitigated approximately 24% of uncompensated care costs incurred by trauma centers and 65% incurred by participating EMS providers.

Recommendations


No recommendations made.

GTC Response: No response provided.

OEMS&T Response: No response provided.

1. Identify the steps needed to form a Georgia Trauma Foundation.

2. Identify potential stakeholders to participate in the Foundation (e.g. Tea Party, Auto Insurance companies, Blue Cross/Blue Shield Foundation, Safe Kids of Georgia and auto manufacturers).

3. Enhance trauma system development through application for federal funding.

4. Conduct a “post-‐mortem” review of the work done for the 2010 referendum.

5. Determine “adequate trauma system funding.”

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Finding #5: Ambulance Replacement Grants

The extent to which the Commission’s ambulance replacement grant program benefits trauma patients is unclear.

Recommendations


1. The Commission should evaluate the ambulance replacement program’s impact on trauma patients using defined metrics to determine whether it is the best use of EMS distribution funds.


1. Identify the number of EMS providers currently providing required report data (e.g. review EMS trip reports and other system reports).

2. Provide education to EMS providers about the value and the use of the data they provide her system reports).

3. Establish EMS data compliance

thresholds for services to receive funding from GTC.

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270 Washington Street, SW, Suite 1-156 Atlanta, Georgia 30334 Phone: (404)657-5220 www.audits.ga.gov

Why we did this review This review of the Georgia Trauma Care Network Commission (the Commission) was conducted at the request of the House Appropriations Committee. We were asked to measure the degree of success the Commission has attained in reaching their original goals, which include:

(1) Increasing the number of Level I, II, and III trauma centers; (2) Improving service delivery and response times; (3) Mitigating uncompensated care through the distribution of formula funds; and (4) Addressing the need for and benefit from providing ambulance purchases.

About the Commission The Georgia Trauma Care Network Commission was established in 2007 following recommendations from a 2006 Joint Comprehensive State Trauma Services Committee. The Commission’s main duties are to distribute funds to trauma centers and EMS providers to compensate for costs of readiness and uncompensated care related to trauma. The Commission is also responsible for establishing a trauma center network to ensure injured patients are cared for at best available facility.

The Commission currently receives approximately $15 million each year from fines related to Georgia’s super speeder law. Approximately 88% of its funding is distributed to trauma centers, physicians, and EMS providers.

Georgia Department of Audits and AccountsPerformance Audit Division

Greg S. Griffin, State AuditorLeslie McGuire, Director

Georgia Trauma Care Network Commission

Requested information on trauma system

What we found Georgia’s trauma system has made observable progress since the Georgia Trauma Care Network Commission (the Commission) was formed in 2007. Most notably, the number of designated trauma centers has increased, and a slightly higher percentage of trauma patients are being admitted to these facilities. However, further work is needed to ensure continued improvement.

In 2006, designated trauma centers were at risk of dropping out of the system, primarily due to financial constraints related to costs for uncompensated care and additional resources required to maintain designation. The Commission’s initial funding to trauma centers and emergency medical service (EMS) providers stabilized the system and re-engaged stakeholders to move forward on recommendations from national experts. Since 2007, no trauma centers have dropped out of the system.

The number of designated trauma centers has increased from 15 in 2007 to 21 in 2012. Two Level II trauma centers were added, which increases the number of hospitals able to provide definitive care to even the most seriously injured patients. The addition of one Level III and three Level IV trauma centers ensures these rural hospitals are trained to quickly identify and transfer patients needing a higher level of care.

In addition, the percent of trauma patients admitted to trauma centers has increased from 49% in calendar year 2007 to 52% in calendar year 2011. In some regions, the improvement was related to the designation of trauma centers, while in others it appears EMS providers have begun transporting their patients to designated trauma centers rather than community hospitals.

Special Examination Report No. 12-23 December 2012

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Though the number of trauma centers has increased, there has been little change in the percent of Georgians within 25 miles of definitive care at a Level I or II trauma center. There are still areas of the state—particularly in South Georgia—where residents are more than 50 miles away from a trauma center. There is currently no strategic plan for the desired number and type of trauma centers and where they should be located, though the Commission intends to have criteria in place by June 2013.

Work to further develop the trauma system is likely hampered by the lack of a defined lead agency in Georgia statute. Currently, two entities—the Commission and the state Office of EMS and Trauma (OEMST) within the Department of Public Health—have responsibilities related to the trauma system1; however, as noted by national experts, there is no clear delineation of authority and powers. For example, though the Commission is responsible for studying trauma care services and OEMST houses useful data on trauma center and EMS activities, we noted that the entities have not collaborated to develop a performance improvement plan for the state’s trauma system. The Commission plans to have a performance measurement program in place by June 2014.

Without performance measures and historic data, the Commission has been unable to quantitatively demonstrate the impact of its initiatives. For example, the Commission’s ambulance replacement grant program was designed to help rural EMS providers replace old, high-mileage vehicles and thus increase the likelihood that they would travel further to transport trauma patients to a designated trauma center. However, the Commission has not confirmed that recipients have changed their transport decisions now that they have a more reliable vehicle. Our analysis of hospital discharge data shows that it is unlikely the grants have increased the likelihood that recipients will transport to a trauma center.

Since fiscal year 2009, the Commission has distributed $96.7 million to trauma centers, EMS providers, and physicians, primarily for readiness and uncompensated care. Commission funding has mitigated approximately 24% and 65% of estimated uncompensated care costs incurred by trauma centers and participating EMS providers, respectively.

What we recommend To assure continued enhancement of the state trauma system, the General Assembly should consider revising state law to clearly define a lead agency, which would have the authority and responsibility to ensure compliance with rules and regulations and evaluate performance. In the absence of such a change, the Commission and OEMST should collaborate to define each entity’s roles and responsibilities, strategically determine the desired number and locations of designated trauma centers, and develop a performance improvement plan that utilizes currently available datasets.

The Commission should also ensure that its funding programs to trauma centers and EMS providers continue to strengthen the system by investing in areas that will have the greatest impact on trauma patient care.

1 The Commission’s statutory duties are generally related to distributing funds, investing in a trauma transportation system, and establishing a trauma center network to direct patients to the best care. OEMST is statutorily responsible for regulating EMS providers and designating trauma centers.

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Georgia Trauma Care Network Commission i

Table of Contents Purpose of the Special Examination 1

Background 1

Georgia Trauma Care Network Commission 1

Definition of Trauma 2

Components of a Trauma System 2

Trauma Center Activity Data 7

Financial Information 7

Requested Information 11

While data to measure improvement in service delivery and response times is

limited, an increase in the number of trauma centers and in the percent of

trauma patients going to trauma centers indicates improvement. 11

The Commission’s actions to improve trauma care are closely aligned with

criteria set by the American College of Surgeons and other states; however,

further improvements are needed. 17

While the number of designated trauma centers has increased since 2007,

there are still areas of the state in which injured patients must be transported

long distances to receive definitive care at a Level I or II trauma center. 21

The Commission has mitigated approximately 24% of uncompensated care

costs incurred by trauma centers and 65% incurred by participating EMS

providers. 26

The extent to which the Commission’s ambulance replacement grant program

benefits trauma patients is unclear. 29

Appendices 34

Appendix A: Objectives, Scope, and Methodology 34

Appendix B: Georgia Trauma System Entry Criteria 36

Appendix C: Critical American College of Surgeons Recommendations and

Current Status 37

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Georgia Trauma Care Network Commission ii

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Purpose of the Special Examination This review of the Georgia Trauma Care Network Commission (the Commission) was conducted at the request of the House Appropriations Committee. Specifically, we were asked to measure the degree of success the Commission has attained in reaching their original goals, which include:

1. Increasing the number of Level I, II, and III trauma centers;

2. Improving service delivery and response times;

3. Mitigating uncompensated care through the distribution of formula funds; and

4. Addressing the need for and benefit from providing ambulance purchases.

A description of the objectives, scope, and methodology used in this review is included in Appendix A. A draft of the report was provided to the Commission and the Department of Public Health for their review, and pertinent responses were incorporated into the report.

Background

Georgia Trauma Care Network Commission The Georgia Trauma Care Network Commission (the Commission) was established in 2007 following recommendations from a 2006 Joint Comprehensive State Trauma Services Study Committee. The Committee found that Georgia did not have a statewide, inclusive trauma system. As a result, Georgia’s trauma-related death rate was 20% above the national average, costing approximately 700 lives per year. The Committee also found that readiness and uncompensated care costs were the major obstacles trauma centers, physicians, and emergency medical service (EMS) providers faced in meeting the state’s trauma needs.

According to O.C.G.A. §31-11-102, the Commission’s main duties include:

Distributing funds for costs related to trauma care readiness. Readiness costs are for additional resources required to maintain a hospital’s status as a designated trauma center. The added resources may include 24-hour staffing, ground and air transportation, physician and nurse training, and trauma specific equipment.

Distributing funds for costs related to uncompensated care services. Uncompensated care costs are incurred when trauma centers, physicians, or EMS personnel serve a patient who has no medical insurance, is not eligible for medical assistance coverage, has no third party coverage, and has not paid despite documented attempts to collect payment.

Investing in a trauma transportation system, particularly in areas in which current options to transport trauma patients are limited.

Establishing, maintaining, and administering a trauma center network to coordinate the best use of existing trauma facilities and to direct patients to the best available facility for treatment.

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The Commission’s duties also include funding partial start-up costs for hospitals entering the trauma system and assisting in data collection to evaluate the provision of trauma care services.

The Commission is composed of nine members appointed by the Governor, the Lieutenant Governor, and the Speaker of the House. The Governor’s appointees must include an emergency trauma care physician, a representative of a designated trauma center, and a representative of a state 9-1-1 licensed EMS provider. The Commission also employs five full-time staff members.

The Commission is attached to the Department of Public Health (DPH) for administrative purposes only.2 DPH also houses the Office of Emergency Medical Services and Trauma (OEMST), which designates trauma centers and licenses EMS providers and personnel. OEMST created the EMS regions that have served as the regional and local infrastructure of the EMS system and are the basis for the Commission’s stakeholder groups, trauma plan development and trauma system assessments (see Exhibit 1 for a map of the regions). Each EMS region has a director who inspects ambulances, investigates complaints, and reports to OEMST.

Definition of Trauma A trauma patient is an injured person who requires timely diagnosis and treatment to diminish or eliminate the risk of death or permanent disability. Traumatic injuries include multiple fractures, paralysis, punctured lungs, stab wounds, and brain injuries. Trauma is the leading cause of death among children and adults below the age of 45. It is the fourth leading cause of death for all ages. In Georgia, an estimated 30,000 patients with traumatic injuries are admitted to hospitals each year. The most common causes of traumatic injuries are motor vehicle crashes and falls.

Components of a Trauma System Studies have shown that the preventable death rate among trauma patients can decrease by 10-30% if they are served within an established trauma system. The Health Resources and Services Administration defines a trauma system as a pre-planned, comprehensive, and coordinated statewide and local injury response network that includes all facilities with the capability to care for the injured. In particular, a trauma system helps ensure a trauma patient receives care within the “golden hour,” or the first 60 minutes after the occurrence of major injury.

According to national experts, the main components of a well-designed trauma system include: injury prevention, access to care through contact devices (such as 9-1-1 dispatch); pre-hospital care (provided by EMS); acute care (provided by designated trauma centers); and rehabilitative care. This report focuses on the two components on which the Commission has directed its funding: pre-hospital and acute care, described on page 4.

2 In fiscal years 2009 and 2010, the Commission was administratively attached to the Departments of Human Resources and Community Health, respectively. The Commission did not employ administrative staff and largely relied upon staff from the agencies in the performance of its duties.

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Exhibit 1 Georgia has 21 Designated Trauma Centers in 8 of 10 EMS regions

Newton

Appling

Atkinson

Bacon

Baker

Baldwin

Banks

Barrow

Bartow

Ben Hill

Berrien

Bibb

Bleckley

Brantley

Brooks

Bryan

Bulloch

Burke

Butts

Calhoun

Camden

Candler

Carroll

Catoosa

Charlton

Chatham

Chattahoochee

Chattooga

Cherokee

Clarke

Clay

Clayton

Clinch

Cobb

Coffee

Colquitt

Columbia

Cook

Coweta

Crawford

Dade

Dawson

Decatur

Dekalb

DodgeDooly

Dougherty

Douglas

Early

Echols

Effingham

Elbert

Emanuel

Evans

Fannin

Fayette

FloydForsyth

Franklin

Fulton

Gilmer

Glascock

Glynn

Gordon

Grady

Greene

Gwinnett

Habersham

Hall

Hancock

Haralson

Harris

Hart

Heard

Henry

Houston

Irwin

Jackson

Jasper

Jeff Davis

Jefferson

Jenkins

Johnson

Jones

Lamar

Lanier

Laurens

LeeLiberty

Lincoln

Long

Lowndes

Lumpkin

McDuffie

McIntosh

Macon

Madison

Marion

Meriwether

MillerMitchell

Monroe

Mon

tgom

ery

Morgan

Murray

Muscogee

Oconee OglethorpePaulding

Peach

Pickens

Pierce

Pike

Polk

Pulaski

Putnam

Quitman

Rabun

Randolph

Richmond

Rock

dale

Schley

Screven

Seminole

Spalding

Stephens

Stewart

Sumter

Talbot

Taliaferro

Tattnall

Taylor

Telfair

Terrell

Thomas

Tift

Toombs

Towns

Treutlen

Troup

Turner

Twiggs

Union

Upson

Walker

Walton

Ware

Warren

Washington

Wayne

WebsterWheeler

White

Whitfield

Wilcox

Wilkes

Wilkinson

Worth

Crisp

1 2

3

4

10

98

7

6

5

1

23

4

5

6

7

8

99

10

11 1213

14

15

16

17

18

21

20

1922

23

Burn Centers:22 Grady Burn Center23 Joseph M. Still Burn Center

*Adult trauma center with pediatric commitment ** Pediatric Center

Source: Georgia Trauma Network Commission

Level I Trauma Centers:1 Atlanta Medical Center2 Grady Memorial Hospital3 Children’s Healthcare of Atlanta at Egleston**4 Medical Center of Central Georgia*5 Georgia Health Sciences Medical Center*6 Memorial Health University Medical Center*

Level II Trauma Centers:7 Hamilton Medical Center8 Floyd Medical Center9 Gwinnett Medical Center10 North Fulton Regional Hospital 11 Wellstar Kennestone12 Children’s Healthcare of Atlanta at Scottish Rite**

Level II (Cont.):13 Athens Regional Medical Center 14 Medical Center - Columbus15 John D. Archbold Memorial Hospital

Level III Trauma Centers:16 Clearview Regional Medical Center17 Taylor Regional Hospital

Level IV Trauma Centers:18 Wills Memorial Hospital19 Morgan Memorial Hospital20 Lower Oconee Memorial Hospital21 Emanuel Medical Center

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Pre-Hospital Care (Emergency Medical Services)

Emergency Medical Services (EMS) describes the continuum of activities that begin with rapid response to an initial call for help and conclude when the patient is admitted to the hospital. EMS services are typically provided by local government agencies, fire departments, hospitals, or private for-profit or non-profit entities. EMS providers may be licensed for ambulance, air transport, first responder, or neonatal transport services. Currently, 240 EMS providers are licensed for ambulance transport in Georgia, operating 1,900 vehicles and employing approximately 19,000 medics. There are also five air ambulance services with 13 helicopters. EMS providers receive an estimated one million calls for service per year, though OEMST staff estimated approximately 3% (30,000) of the calls are trauma related. The majority of trauma care patients are transported to definitive care by EMS personnel.

As shown on Exhibit 1, the state is divided into 10 EMS regions. The state is further divided into 170 9-1-1 zones (typically one per county, though some metro counties have two or three); each 9-1-1 zone is assigned to a specific EMS provider. An EMS provider may serve more than one 9-1-1 zone.

According to national experts at the American College of Surgeons (ACS), the successful management of a patient first requires that EMS correctly identify the severity of injuries to triage the patient to the appropriate facility. Destination protocols should be clearly defined and understood by all pre-hospital personnel. In March 2011, the Commission adopted criteria developed by the federal Centers for Disease Control and Prevention as the triage criteria for entrance into the Georgia trauma system (see Appendix B). This decision scheme considers the patient’s vital signs and level of consciousness, the type of injuries, the cause of injury, and special considerations such as age or pregnancy. Patients best served by the highest level trauma centers (I and II) include those who are unconscious, have low blood pressure and/or low breathing, or sustained injuries such as penetrating injuries, pelvic fractures, or skull fractures.

Acute Care (Designated Trauma Centers)

Studies have shown that a trauma patient’s preventable death rate is lower when treated at a designated trauma center, a hospital distinguished by the immediate availability of specialized personnel, equipment, and services to treat the most severe and critical injuries. Trauma centers are different from general hospital emergency departments because they provide, on a 24-hour per day, 7-day per week basis, teams of specialists able to handle the most severe injuries within the golden hour. In Georgia, trauma centers are designated as Level I, II, III, or IV based on the extent to which they meet criteria set forth by ACS, described below and on Exhibit 2 (see page 6).

Level I trauma centers offer the greatest level of comprehensive trauma care from prevention through rehabilitation. They are also responsible for trauma education, research, and system planning. Level I trauma centers are typically attached to a medical school.

Level II trauma centers provide the same level of clinical care as Level I trauma centers but do not focus on research, education, or system planning.

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Level III trauma centers provide trauma assessment, resuscitation, emergency surgery, and stabilization but will usually transfer patients requiring more extensive care.

Level IV trauma centers provide advanced life support in rural areas where no higher-level facility is available. Patients are then transported to a Level I or II trauma center.

OEMST also uses ACS criteria to designate the following specialty trauma centers:

Pediatric trauma centers specialize in treating injured children. They must have the same resources as the level counterpart in adult trauma centers in addition to pediatric requirements.

Burn centers are recognized as destinations for the transport of trauma burn patients in Georgia.

There are 21 designated trauma centers (two are pediatric trauma centers) and two burn centers in Georgia. As shown on Exhibit 1 on page 3, eight of the 10 EMS regions have at least one designated trauma center within their borders (the exceptions are Regions 2 and 4).

Non-Designated Hospitals

According to ACS, in an inclusive trauma system, non-designated hospitals’ emergency departments may be appropriate destinations for patients with minor injuries such as isolated fractures or minor concussions to ensure Level I and II trauma centers remain available to care for the more seriously injured patients. Trauma patients may also be transported to non-designated hospitals based on the transporting EMS medic’s discretion and patient preference.

In addition to the 21 designated trauma centers, there are 120 non-designated hospitals with emergency rooms in 110 counties in Georgia. Thirty-one of these hospitals are designated by the Office of Rural Health as Critical Access Hospitals, rural hospitals with less than 25 beds that have 24/7 emergency care services. Twenty-six non-designated hospitals have more than 200 beds.

Process for Becoming a Designated Trauma Center

In Georgia, trauma center designation is voluntary. Hospitals seeking to become designated trauma centers first notify their Regional EMS Council and OEMST of their intent. They must appoint a trauma medical director and a trauma coordinator and implement a trauma registry program (see page 7) for at least six months. After OEMST has reviewed data from the registry, the hospital completes a pre-review questionnaire to document how it meets the ACS criteria for the designation it is pursuing.

OEMST reviews the questionnaire and required documentation and then sends a site review team to visit the facility. The site review team then submits a recommendation regarding designation to OEMST and then to the DPH Medical Director. The length of time to become designated varies by hospital, depending on the level of commitment of administrative and medical staff and the time it takes to develop and document the processes and infrastructure required by ACS.

Trauma centers are inspected every three years to maintain their designation. They must also submit quarterly reports and data to the trauma registry. Trauma centers may request to upgrade their designation level (from II to I, for example); this process is similar to the initial designation.

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Exhibit 2 OEMST Utilizes ACS Criteria to Designate Trauma Centers in Georgia

Level IV Level ILevel IILevel III

Employ a trauma program, trauma team, and a trauma coordinator

Employ a trauma service, a trauma program medical director, and a trauma multi-disciplinary committee

Institutional Organization

Hospital Departments/Divisions/Sections (available 24 hours per day)

Clinical CapabilitiesGeneral Surgery, Anesthesia, Emergency Medicine immediately available 24 hours per day Radiology and Orthopedic and Plastic Surgery promptly available 24 hours per day

Hand, Neurologic, OB/GYN, Opthalamic, Oral/Maxillofacial, and Thoracic Surgery promptly available 24 hours per day

Published on-call schedule

Cardiac and Microvascular/Replant Surgery promptly available 24 hours per day

Facilities/Resources/Capabilities

Must admit 1,200 trauma patients per year; at least 240 trauma patients (or 35 per surgeon) must have an ISS > 15; operating room immediately available 24 hours per day; surgical intensive care unit staff

Emergency department with basic resuscitation equipment and communication with EMS vehicles; operating room with personnel available 24 hours per day and X-ray capability; recovery room with resuscitation equipment; clinical laboratory services available 24 hours per day; transfer agreements to rehabilitative services

Additional resuscitation and X-ray equipment and personnel requirements in emergency department, operating room, and recovery room; staffed and equipped intensive care unit, radiological and respiratory therapy services available 24 hours per day; physical therapy and social services

Equipment related to head injuries in emergency department, operating suite, recovery room, and intensive care unit; additional radiological and rehabilitative services

Performance ImprovementPerformance improvement programs; participation in state trauma registry; audit of all trauma deaths; medical nursing audit

Participation in multidisciplinary trauma conference, review pre-hospital trauma care

Review times/reasons for trauma related bypass and transfers, performance improvement personnel dedicated to care of injured patients

Continuing Education/OutreachGeneral Surgery Residency Program; provide/participate in ATLS courses

Provide programs for staff & community physicians, nurses, allied health personnel, and pre-hospital personnel

Prevention

Injury control studies; collaboration with other institutions; monitoring the progress/effect of prevention programs

Designated prevention coordinator; outreach activities; information resources for the public; collaboration with existing national and state programs

Trauma registry improvement activities

Research committee; educational presentations; scientific publications

Research

Note: The requirements listed here are inclusive.Source: OEMST Hospital Resources Checklist, adapted from ACS Resources for Optimal Care of the Injured Patient

General Surgery, Orthopedic Surgery, Emergency Medicine, Anesthesia

Neurologic Surgery

Clinical Qualifications

General/trauma surgeon and emergency medicine staff with ATLS course completion

Board certified general/trauma surgeon; emergency medicine staff and orthopedic surgeon who attend trauma committee meetings

Board certified emergency medicine staff, neurosurgeon, and orthopedic surgeon who meet continuing education requirements

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Trauma Center Activity Data Designated trauma centers are required to collect and submit trauma patient data to the Georgia Trauma Registry.3 Non-designated hospitals may also voluntarily contribute to the trauma registry. As shown on Exhibit 3 below, designated trauma centers have served approximately 64,000 trauma patients in the past five calendar years.4 Level I and II trauma centers have cared for nearly all of the trauma patients reported to the registry.

Exhibit 3 Increasing Number of Trauma Patients Served in Designated Trauma Centers Since 2007

Trauma Center Level(1) 2007 2008 2009 2010 2011 Total

Level I 5,966 6,621 6,283 6,264 9,206 34,340 Level II 5,570 5,843 6,231 6,192 4,778 28,614 Level III 0 0 136 163 228 675 Level IV 104 86 18 109 49 218 Trauma Center Total 11,640 12,550 12,668 12,728 14,261 63,847 (1)A trauma center’s level is based on its designation at the end of the calendar year. For example, since Athens Regional was designated as a Level II in December 2009, its 2009 registry patients are admissions to a Level II trauma center. Source: Georgia Trauma Registry

Financial Information In fiscal year 2008, the Commission received an initial appropriation of nearly $60 million to be distributed to trauma centers and EMS providers in fiscal year 2009. Commission funding is now tied to revenue collected from “super speeders.”5 Since 2008, funding for the Commission has decreased by 77% to $15.5 million in fiscal year 2013.

As discussed above, one of the Commission’s primary responsibilities is to distribute funds to trauma centers, physicians, and EMS providers. In fiscal year 2009, nearly all of the Commission’s initial appropriation was distributed to these entities (see Exhibit 4 on the next page). Over time, the percent available for distribution has decreased to approximately 88% of total funds in fiscal year 2013, mainly due to new trauma system initiatives such as the Trauma Communications Center (TCC) and regionalization.

3 The Georgia Trauma Registry includes patient demographics, injury information, pre-hospital information, hospital procedures and diagnoses, outcomes, financial information, and quality assurance data. 4 Criteria for inclusion in the trauma registry is as follows: any patient admitted for an injury who was admitted for at least 48 hours or was transferred to or from another facility, died or was dead on arrival, was admitted to the ICU, or had unscheduled readmissions associated with the trauma within 72 hours of discharge from the first visit. Excluded from this group are patients admitted for late effects of injury, blisters, contusions, abrasions, insect bites, or foreign bodies, as well as patients over 65 years of age with isolated hip fractures resulting from a same-level fall. 5 “Super speeders” are convicted of driving 85 miles per hour or more on any road or highway and 75 miles per hour or more on any two-lane road or highway. In addition to local fines and penalties imposed, super speeders must pay a $200 fee, which is deposited into the general fund to be used to fund a trauma care system in Georgia.

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Exhibit 4 Approximately 90% of Commission Funding Distributed to Stakeholders (Fiscal Years 2009-2012)

Readiness Payments $23,851,385 40% $6,696,610 38% $1,583,469 15% $4,355,542 27% $36,487,006 36% $3,634,632 24%

Uncompensated Care Payments

23,851,385 40% 6,043,406 35% 2,262,103 22% 5,444,433 34% 37,601,327 37% 5,192,331 34%

Capital Grants (Level I & II Trauma Centers)

4,148,602 7% 0 0% 0 0% 0 0% 4,148,602 4% 0 0%

Level IV Trauma Center Stipend(1) 200,000 0% 54,000 0% 0 0% 0 0% 254,000 0% 0 0%

Performance Based Payments

0 0% 760,380 4% 678,629 7% 1,077,692 7% 2,516,701 2% 1,557,699 10%

New Trauma Start-up Grants

0 0% 0 0% 1,000,000 10% 0 0% 1,000,000 1% 0 0%

Trauma Registry 0 0% 0 0% 0 0% 583,301 4% 583,301 1% 565,804 4%

Total Trauma Center/ Physician Allocation $52,051,372 88% $13,554,396 78% $5,524,201 53% $11,460,968 72% $82,590,937 80% $10,950,466 71%

Vehicle Replacement Grant $4,000,000 7% $1,392,242 8% $1,385,258 13% $1,228,318 8% $8,005,818 8% $721,740 5%

Uncompensated Care Payments

1,479,945 3% 1,000,000 6% 284,988 3% 748,028 5% 3,512,961 3% 733,125 5%

GPS & Automatic Vehicle Locator System

996,452 2% 0 0% 72,842 1% 0 0% 1,069,294 1% 360,250 2%

Training 0 0% 338,445 2% 453,763 4% 333,264 2% 1,125,472 1% 281,060 2%

Trauma Related Equipment 0 0% 338,445 2% 338,444 3% 409,096 3% 1,085,985 1% 496,489 3%

Administrative 0 0% 0 0% 4,127 0% 1,464 0% 5,591 0% 3,500 0%

Total EMS Allocation $6,476,397 11% $3,069,132 18% $2,539,422 24% $2,720,170 17% $14,805,121 14% $2,596,164 17%

Total Distribution to Trauma Centers, Physicians, & EMS

$58,527,769 99% $16,623,528 95% $8,063,623 78% $14,181,138 89% $97,396,058 95% $13,546,630 88%

Admin/ Operations $375,000 1% $192,173 1% $286,871 3% $384,974 2% $1,239,018 1% $440,175 3%

OEMST Allocation 0(2) 0% 189,400(2) 1% 264,321 3% 489,715 3% 943,436 1% 463,773 3%

Trauma Communications Center

0 0% 0 0% 1,113,847 11% 495,447 3% 1,609,294 2% 574,469 4%

New Projects/System Support

0 0% 459,833 3% 655,355 6% 377,525 2% 1,492,713 1% 434,050 3%

Total Funding for Other Trauma Care Initiatives & Administrative Expenses

$375,000 1% $841,406 5% $2,320,394 22% $1,747,661 11% $5,284,461 5% $1,912,467 12%

Total Commission Expenditures $58,902,769 $17,464,934 $10,384,017 $15,928,799 $102,680,519 $15,459,097

(1) For the first tw o years of the Commission's funding, Level IV trauma centers received a stipend, w hile higher level trauma centers recieved funding based on readiness anduncompensated care formulas. Beginning in f iscal year 2011, Level IV trauma centers received readiness and uncompensated care funding.(2) According O.C.G.A. §31-11-102, OEMST receives 3% of the Commission's funding each year. According to Commission staff, in f iscal year 2009 OEMST received a portionof the $375,000 allocated for administration and operations. In fiscal year 2010, DCH allocated $655,500 of the Commission's funding to OEMST. OEMST utilized $189,400 forthree staff positions and returned the remaining $466,100 to the general fund. Beginning in fiscal year 2011, the Commission transferred the funds as part of a memorandum ofunderstanding w ith OEMST.Source: PeopleSoft Financials; Commission budget documents

Other Trauma Care Initiatives & Administrative Expenses

FY09 FY10 FY11 FY12 Total FY13(Budgeted)(FY09-FY12)

Distribution to Trauma Centers, Physicians, & EMSTrauma Center/Physician Allocation

EMS Allocation

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Designated trauma centers have received approximately 85% ($83 million) of the $97 million available for distribution from fiscal year 2009 to fiscal year 2012, primarily to mitigate costs associated with readiness and uncompensated care, which are funded by formulas described below. Trauma centers are required to give 25% of their readiness and uncompensated care funding to physicians who provided trauma care.

Readiness Funding: Readiness costs are incurred for additional resources required to maintain a trauma center’s designation. Trauma centers have received $36.5 million in readiness payments, which are awarded based on the trauma center’s designation level. Readiness costs were initially determined through a survey of the Level I and II trauma centers, the results of which were then adjusted according to national trauma center norms. In fiscal year 2012, Level II trauma centers received 60% of Level I trauma center awards, and Level III and IV received 10% and 5%, respectively. The Commission will begin awarding burn centers 50% of Level I readiness costs in fiscal year 2013.

Uncompensated Care Funding: The Commission has awarded trauma centers approximately $37.6 million to cover uncompensated care costs over the past four years. The Commission calculates uncompensated care costs by injury severity score6 using cost norms developed by the National Foundation for Trauma Care. These cost norms are applied to the number of trauma patients served based on audited survey results from the designated trauma centers.7 Each trauma center receives a percent of the Commission’s fund that corresponds to its percent of all trauma centers’ claims.

The Commission also devoted $4.1 million for capital equipment grants to Level I and II trauma centers in fiscal year 2009 and $1 million in start-up grants to new trauma centers in fiscal year 2011. Finally, approximately $2.5 million has been provided to trauma centers for meeting certain performance standards since fiscal year 2010.

EMS agencies have received 14% ($14.1 million) of funds available for distribution since fiscal year 2009. Approximately 57% ($8 million) of the EMS allocation has been awarded as competitive grants for rural EMS providers seeking to replace an older, high mileage ambulance. Approximately 25% ($3.5 million) has covered uncompensated care costs, which are awarded as a grant to any EMS provider who submits a claim. The Commission has also funded trauma-related equipment purchases ($748,000) and various EMS trainings ($790,000). Finally, the Commission has collaborated with the Georgia Tech Research Institute and the Georgia Emergency Management Agency to develop and implement the Automatic Vehicle Location System, which has placed GPS devices in 685 vehicles across the state ($1.1 million).

6 An Injury Severity Score (ISS) provides an overall score for patients with multiple injuries. ISS range from 0 to 75 based on severity. To calculate uncompensated care cost norms, the National Foundation for Trauma Care grouped patients by ISS of 0-8, 9-15, 16-24, and over 24. 7 Trauma centers report the number of patients served three years prior to the grant year. For example, uncompensated care distributions for fiscal year 2013 are based on claims from services rendered in calendar year 2010.

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Approximately 5% of the Commission’s total funding from fiscal year 2009 to 2012 has been spent on other trauma care initiatives. In fiscal year 2011, the Commission began funding the TCC, a call center that coordinates EMS transports and hospital transfers based on the patient’s injury and trauma centers’ availability. The Commission has also distributed grants to EMS regions to develop stakeholder groups. Finally, in accordance with O.C.G.A. §31-11-102, the Commission allocates 3% of its total annual funding to OEMST for the administration of an adequate system for monitoring state-wide trauma care, recruitment of trauma care service providers into the network as needed, and for research as needed to continue to operate and improve the system.

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Requested Information

Service Delivery

While data to measure improvement in service delivery and response times is limited, an increase in the number of trauma centers and in the percent of trauma patients going to trauma centers indicates improvement.

A comprehensive assessment of trauma system improvement since the Commission’s creation is hindered by the unavailability of historical performance data maintained by the Commission or OEMST. Despite this limitation, we were able to note performance in two areas that indicate improvement in the state’s trauma system. Since 2007, the number of designated trauma centers has increased, as well as the percentage of trauma victims admitted to designated trauma centers.

In addition to these measures of improvement, the Commission is taking action to address recommendations to improve the trauma system made by the American College of Surgeons. These activities are discussed in the finding on page 15.

Performance Measurement

The Commission has not created performance measures or used data to evaluate whether service delivery along the continuum of trauma care has improved over the past five years. According to ACS, system-wide evaluation should include access to care, availability of services, quality of services rendered, and financial impact.

The Commission has tied a portion of its trauma centers’ readiness funding to performance since 2010; however, these measures have been limited to participation in Commission initiatives and meeting data submission deadlines. Commission members and staff recognize the importance of measuring patient and system outcomes, and, according to the Commission’s strategic plan, a program will be in place by June 2014. Already, Level I and II trauma centers have begun participating in ACS’s national Total Quality Improvement Program (TQIP), which benchmarks them against other participating trauma centers on outcome areas such as mortality and morbidity. The Commission intends to tie a portion of these trauma centers’ funding to TQIP data, specifically reviewing care outcomes, standard of care adherence, and overall performance.

OEMST collects two datasets that could be used in assessing the trauma system: (1) Georgia EMS Information Systems (GEMSIS), which documents information from EMS medics’ patient care reports and includes information such as time of notification, time to scene, and time of arrival to the hospital; and (2) the state trauma registry, which includes data such as injury type, length of stay, and final disposition of trauma patients served by trauma centers.

According to OEMST staff, GEMSIS data was not sufficient for the audit team to create a baseline of performance prior to the Commission’s formation, though calendar year 2012 data will be complete enough to analyze response times. In addition, the datasets are limited in their usefulness in assessing the system as a whole. For example, it is not possible to link GEMSIS with trauma registry data to track a patient through the entire continuum of care. Finally, since trauma patients

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may be treated at non-designated hospitals, trauma registry patients are only a subset of the entire patient population. While information on all trauma patients is available through the Georgia Hospital Association (GHA), information such as injury severity or time to find an available specialist is not captured.

OEMST has denied the Commission’s requests for access to the trauma registry and GEMSIS, citing a need to maintain individual hospitals’ and EMS providers’ confidentiality and a lack of data analysis expertise within the Commission. As a result, the Commission has begun to create its own dataset in an attempt to link patients across the continuum of care. When an EMS provider calls the Commission’s Trauma Communications Center8 (TCC) the operator collects information such as a description of the patient’s injuries, whether the patient’s injuries warrant transport to a trauma center, and the patient’s status upon arrival at the hospital. However, based on the number of EMS calls to the TCC over the past nine months (approximately two per day), this dataset is not likely to be complete enough to use for performance measurement.

Despite these limitations, the datasets provide useful information in assessing certain aspects of the trauma system’s performance. As shown in Exhibit 5 below, the datasets contain a number of potential metrics that could be used to assess the system. OEMST staff indicated they would run reports showing these data elements on a statewide and regional level.

Exhibit 5 Data Currently Available to Measure Trauma System Performance

Measure Data Source Pre-Hospital Care

Time between notification and arrival to patient GEMSIS

Time between scene and hospital GEMSIS

Percent of trauma patients transferred from another facility to a higher level of care

Trauma Registry, GHA Hospital Discharge Data

Number and percent of trauma patients treated at designated trauma centers

Trauma Registry, GHA Hospital Discharge Data

Percent of EMS providers submitting patient reports to the state GEMSIS

Acute Care

Patient disposition by injury severity Trauma Registry

Length of stay by injury severity Trauma Registry Time in emergency department Trauma Registry Start time of essential hospital procedures Trauma Registry

Time on diversion by specialty TCC Hospital Resource Availability Display

Sources: ACS, Georgia Trauma Registry data dictionary, stakeholder interviews

8 The TCC was established to coordinate EMS transports and hospital transfers based on the trauma centers’ availability. All trauma centers—and participating non-designated hospitals—update a Resource Availability Display, which shows TCC operators their availability in specialties trauma patients typically need (orthopedics, neurology, etc.). When EMS calls the TCC, the operator will recommend a hospital based on the specialties available.

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Number of Trauma Centers

The Commission has cited the increase in the number of trauma centers as evidence of an improved trauma system. The number of trauma centers has increased from 15 at the end of fiscal year 2007 to 21 at the end of fiscal year 2012, with two Level II trauma centers, one Level III, and three Level IV trauma centers entering the system.

According to trauma stakeholders we interviewed, the increased number of trauma centers improves service delivery because it means more hospitals are being held to a standard level of care for trauma patients. While non-designated hospitals may have the clinical capabilities to handle a trauma patient’s injuries, emergency room staff at trauma centers are required to have specific processes in place to quickly triage a trauma patient to definitive care (either by transferring to a higher level trauma center or admitting them to the hospital). Finally, designated trauma centers are required to have a performance improvement program in place to identify and correct any issues in providing optimal patient care.

ACS states that large, resource-rich trauma centers are central to an ideal trauma system because they can provide immediate medical care for significant numbers of injured patients at any time. The designation of Athens Regional and Wellstar Kennestone as Level II trauma centers means that two additional hospitals are held accountable to providing definitive care to trauma patients in their catchment area.

In addition, the designation of the Level III and IV trauma centers helps ensure that trauma patients in rural areas can be identified, stabilized, and transferred quickly. Emergency room staffs in these hospitals have been trained to recognize when a patient needs a higher level of care than they can provide. As a result, rural trauma patients’ time to definitive care is reduced. Level III and IV trauma centers can also treat trauma patients with minor injuries, ensuring higher level trauma centers are free to care for the most severely injured.

A more detailed discussion on the number of trauma centers can be found on page 21.

Georgia Hospital Discharge Data Analysis

Another metric of improved service delivery is whether a larger percentage of trauma patients is being cared for at designated trauma centers. We found that in the past five calendar years the percent of Georgia trauma patients treated at trauma centers has increased by three percentage points (from 49% in 2007 to 52% in 2011), though improvements in some regions were more significant. In addition, patients with multiple traumatic injuries are more likely to be admitted to a trauma center than those with single injuries.

We obtained from the Georgia Hospital Association (GHA) 2007-2011 hospital discharge data, which shows every patient who was admitted to a Georgia hospital.9 To identify our trauma patient population, we utilized criteria set by ACS, as well as methodology utilized by OEMST for a similar study. Based on information such as injury type, cause of injury, and length of stay, we identified trauma patients whose

9 Our review does not include patients who were treated at the emergency department and were either released or died without being admitted to the hospital. According to the Commission consultant and OEMST’s epidemiologist, the patients who were released would not fit criteria for severely injured patients, and those who died would have minimal effects on the results.

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injuries were serious enough to warrant treatment at a designated trauma center.10 We reviewed this methodology with Commission members, a consultant frequently utilized by the Commission, and the epidemiologists at OEMST, who found it to be a valid method of identifying the most serious trauma patients.

It should be noted that the Commission has hired a consultant to utilize 2011 GHA data to conduct a similar study. The consultant will use an algorithm to assign each patient an injury severity score to more precisely define the trauma patient population that should be served by trauma centers. The Commission expects a report at the end of fiscal year 2013.

Exhibit 6 Statewide Percent of Georgia Trauma Patients Admitted to Trauma Centers Has Increased Three Percentage Points Since 2007

10 A more detailed description of our methodology can be found in Appendix A.

Note: This analysis does not account for trauma transports to Erlanger (Level I in Chattanooga, TN) and Shands Jacksonville (Level I in Jacksonville, FL), which are utilized by EMS providers in Regions 1 and 9, respectively. Including the transports to these hospitals would result in a higher percentage of trauma patients from these regions going to trauma centers.Source: GHA Hospital Admissions Data

10%

20%

30%

40%

50%

60%

70%

80%

2007 2008 2009 2010 2011

% o

f Tra

uma

Patie

nts

Adm

itted

to T

raum

a C

ente

rs

Region 1 Region 2 Region 3 Region 4

Region 5 Region 6 Region 7 Region 8

Region 9 Region 10 Statewide

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As shown on Exhibit 6 on the previous page, the percent of Georgia trauma patients admitted to trauma centers has increased from 49% in calendar year 2007 to 52% in calendar year 2011. The percent of trauma patients going to trauma centers has increased in seven of the 10 EMS regions. It appears that improvement in some regions is related to the designation of trauma centers, while in others EMS behavior is likely to have changed. These reasons were present in the two regions with the greatest improvement, as noted below:

Region 8: Even though no new trauma centers have been designated in Region 8, the percent of trauma patients admitted to trauma centers has increased from 19% in 2007 to 45% in 2011. It appears that EMS providers have begun taking trauma patients to Archbold Memorial (the Level II trauma center in Region 8) rather than the non-designated hospitals. Commission staff also speculated that increased availability of air transport in Region 8 may have affected medics’ transport decisions.

Region 10: The largest improvement in the percent of Region 10 trauma patients going to trauma centers occurred between 2009 (34%) and 2010 (67%). Athens Regional became a designated trauma center in December 2009. It appears that EMS providers were already taking patients to Athens Regional, and its designation increased the percentage.

Further improvements will likely occur in 2012 because Wellstar Kennestone (Region 3) became a Level II trauma center in November 2011. Wellstar Kennestone is one of the largest hospitals in the state, and it was already serving trauma patients from Cobb County and the surrounding area before its designation.

Exhibit 7 Patient Admissions to a Trauma Center Based on Number of Injuries Have Not Changed Significantly Since 2007

Note: This analysis does not consider severity of the injuries, only the number.Source: GHA Hospital Admissions Data

0%

10%

20%

30%

40%

50%

60%

70%

80%

2007 2008 2009 2010 2011

% A

dmitt

ed to

a T

raum

a C

ente

r

Isolated Injuries Two Injuries Three or More Injuries

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According to ACS, patients with minor injuries may be treated at non-designated hospitals, while those with more severe injuries should be transported to a trauma center. As shown on Exhibit 7, our review found that EMS transports are likely consistent with this criteria.11 Approximately 44% of trauma patients with an isolated injury have been admitted to a trauma center over the past five years, compared to 68% of trauma patients with three or more injuries.12 It does not appear that statewide EMS behavior has changed significantly since 2007; the most severely injured patients have always been more likely to be treated at trauma centers. In addition, the percent of patients with multiple injuries treated at trauma centers increased two percentage points (68% in 2007 to 70% in 2011). However, if more Level II facilities became designated, further improvements would likely be observed.

RECOMMENDATIONS

1. The Commission and OEMST should collaborate to develop a performance improvement program that utilizes data to evaluate service delivery in the state’s trauma system. The performance measures should consider statewide and regional performance.

2. The Commission should utilize currently available data sets to obtain quantitative information showing the changes in system outcomes. Since OEMST is most familiar with its trauma registry and GEMSIS data, the Commission should request reports from OEMST showing statewide and historic trends related to trauma system performance.

Commission Response: “We are in agreement with the findings and recommendations.” Regarding performance measurement, the Commission noted that “Georgia is one of only two states (Michigan) with statewide TQIP participation…Beginning in FY 2014, the Commission, working in collaboration with the trauma centers and the Georgia Chapter of the American College of Surgeons Committee on Trauma, will look to utilize performance information, determined by TQIP data, to advance our performance based payment program. Georgia’s incorporation of TQIP statewide and linkage of readiness payments to a performance based payment program is viewed nationally as best practice.”

OEMST Response: Regarding data quality, OEMST stated that its “staff recognizes the importance of the EMS data set and has been working tirelessly on improving the quality of the GEMSIS system,” especially since a 2007 rule change required all EMS providers to report data. “Currently Staff is assessing the use of the GEMSIS data to provide data analysis and link GEMSIS data with trauma data.”

In regard to providing data to the Commission, OEMST stated, “Data published through OEMST is vetted through the state process and must be validated. The Commission does not have a process for validation and publication approval through DPH. No request by the Commission for reports from the trauma registry has been denied.” It stated that it attempted to educate the Commission on data

11 GHA data does not show who transported the patient to the hospital (ground ambulance, helicopter, or civilian transport). However, the majority of trauma patients are transported to the hospital by ground ambulance. 12 It should be noted that this analysis does not consider the severity of the injuries, only the number. ACS recommends that a patient with an isolated head injury, for example, should be treated at a trauma center, whereas care at a non-designated hospital may be sufficient for someone with two closed fractures.

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availability but that the Commission “chose to request the entire database instead of focusing on benchmarking.” It added that “Certain information available to OEMST has not been shared with the Commission because of its proprietary nature. Members of the Commission are also competing entities within the health care system. For this reason, OEMST does not share information that could give Commission members an unfair advantage over their competitors.”

The Commission’s actions to improve trauma care are closely aligned with criteria set by the American College of Surgeons and other states; however, further improvements are needed.

In 2009, the Commission and OEMST requested a consultation by the American College of Surgeons (ACS), widely viewed as the authority on what is required for an optimal trauma system. The Commission has partially addressed many of the ACS recommendations within its authority; however, significant work remains to fully address the recommendations. Much of this work is included in the Commission’s 2012-2015 strategic plan.

The ACS report noted that Georgia’s trauma system had limited central state authority to set standards; little uniformity in trauma triage and destination protocols; limited resources to support infrastructure; and limited analysis of trauma registry data for performance. The report included dozens of recommendations to improve Georgia’s trauma system, but 20 were labeled as the most critical for the Georgia trauma system’s short and long-term success. We condensed these 20 recommendations into five areas: structure, financing, system development, operations, and performance measurement. ACS’s recommendations – and the Commission’s actions – are described below. Information on the current status of all 20 recommendations can be found in Appendix C.

We also interviewed several states about their trauma operations, including states contiguous to Georgia and best practice states identified by trauma stakeholders.13 Information about these states is included in the discussion below.

Structure

Georgia statute does not define a single lead agency for the trauma system. According to ACS, there must be a statutorily assigned lead agency that has the legal authority to enhance and improve trauma care. The agency should create rules and regulations, define policies for stakeholders to work together, and evaluate performance. In our interviews of the contiguous and best practice states, we found that eight of the nine states had a defined structure in which the state office was the lead agency and was advised by a committee of trauma experts. Louisiana assigned an appointed commission as its lead agency.

Staff at the Commission and OEMST agree that the Commission’s statutory responsibilities are related to funding and system development and OEMST’s responsibilities are related to EMS regulation and trauma center designation.

13 The audit team interviewed Alabama, Arkansas, Florida, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Texas.

Georgia statute does not currently define a lead

agency for the enhancement and

improvement of the trauma system.

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However, ACS noted that without a lead agency defined in statute, there was no clear delineation of authority and powers between the Commission and OEMST. As such, it is unclear which entity is responsible for or authorized to ensure all trauma stakeholders are working together to effectively implement the system. For example:

ACS interpreted that O.C.G.A. §31-11-102(8) provided the Commission with the authority to promulgate rules and regulations for the statewide trauma transportation network only. The Commission does not have the same authority for other aspects of the trauma system. (It does have limited ability to influence the system through grants.)

While statute gives OEMST the authority to regulate EMS providers, it does not include responsibility for ensuring adherence to trauma system policies and procedures that may be adopted or endorsed by the Commission.

The Commission is statutorily responsible for studying the provision of trauma care services in Georgia to develop best practices and propose changes to improve the system. However, data to evaluate the trauma system is housed at OEMST.

The Commission is responsible for system development, but OEMST has the authority to recruit and designate trauma centers irrespective of selection factors that may be preferred by the Commission.

Unclear responsibilities have likely contributed to a relationship between OEMST and the Commission that is not always effectively collaborative. During the course of the review, we noted that the Commission and OEMST could not agree on which entity should analyze the datasets necessary for performance benchmarking (GEMSIS and the trauma registry) and that no meaningful effort to resolve this impasse was apparent. Commission staff also appeared unaware of the details of OEMST’s trauma system-related activities, such as the status of potential trauma center designation and even the occurrence of the follow-up to the ACS report.

The Commission and OEMST have acknowledged the importance of a working relationship. A memorandum of understanding between the two entities includes deliverables expected from OEMST in accordance with the funding received from the Commission. In addition, the two entities intend to collaborate on various initiatives moving forward.

Financing

In its recommendations, ACS noted the importance of identifying a sustainable and protected source of revenue to fund the administrative, personnel, and infrastructure costs of the system and its lead agency. ACS noted that all components of a trauma system (injury prevention, pre-hospital care, acute care, and rehabilitation) need sufficient funding to assure maximum service delivery.

Effective January 1, 2010, Commission funding became tied to fines related to Georgia’s super speeder law, which brings in approximately $15 million per year14.

14 In fiscal year 2012, super speeder fines amounted to $16.5 million; approximately 73% ($11.9 million) had been collected as of June 30, 2012.

Georgia’s trauma system currently receives

approximately $15 million per year from super

speeder fines.

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Also in 2010, a referendum expected to generate $80 million for the trauma system through vehicle registration fees did not pass. The Commission plans create a Georgia Trauma Foundation to raise money for the system by June 2013 and launch a campaign for permanent, additional funding in the future.

In addition, the budget for OEMST has decreased each year. OEMST staff reported losing approximately half of their regional officers; only one person now oversees each EMS region.

Trauma system funding in other states we interviewed varies. For example, in states such as Alabama, Louisiana, and North Carolina, state appropriations fund administrative costs only. In other states such as Florida and Mississippi, funding was available through fines and fees. Florida receives approximately $32 million per year from fines related to traffic violations. Mississippi receives approximately $24 million per year through an increase in fines related to moving violations, license plate renewal fees, and motorcycle, boat, and ATV point-of-sale fees. This revenue enables these states to distribute funds to trauma system stakeholders.

System Development

As recommended by ACS, the Commission has begun to re-engage a broad range of trauma stakeholders across the state. This broad constituency works to inform and educate others about the trauma system, implement trauma prevention programs, and assist in trauma system evaluation and research to ensure the right patient is sent to the right hospital at the right time. According to ACS criteria, involved stakeholders should include trauma center medical directors, nurse coordinators, EMS personnel, injury prevention advocates, and others.

Stakeholders are primarily involved in the trauma system through the Regional Trauma Advisory Councils (RTACs) in each EMS region.15 Three RTACs have been created and include stakeholders representing trauma centers and hospitals, EMS providers, physicians, nurses, and the public. Five regions will receive $50,000 RTAC startup grants in fiscal year 2013. The Commission intends to have RTACs in all regions by June 2014.

In addition, the Commission has three subcommittees that consist of trauma center medical directors, trauma coordinators and registrars, and EMS providers representing each EMS region.

Operations

The Commission has not yet developed a statewide trauma plan to facilitate the continuum of trauma care in Georgia, as recommended by ACS. The Commission has developed a framework for RTACs to use in developing regional trauma plans, which will then be compiled into a state trauma plan.

The framework follows ACS recommendations for identifying the role of stakeholders (EMS, trauma centers, and participating non-designated hospitals) and presents a general overview of system operations. EMS providers, for example, should have knowledge of the Georgia Trauma System Entry Criteria (see Appendix

15 Most RTACs will be committees of the region’s EMS Council. As such, the RTACs will report to both the Commission and OEMST.

The Commission has re-engaged a broad range

of trauma system stakeholders.

No state trauma plan exists; however, the

Commission has worked to improve pre-hospital and hospital operations.

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B) and the protocol for using the Commission’s TCC. Trauma centers and participating hospitals should regularly update their availability of trauma-related specialties on the Commission’s Resource Availability Display, utilized by TCC operators making recommendations to medics transporting trauma patients.

The Commission cites the TCC as a major initiative in improving trauma system operations. However, to date it appears to be of limited usefulness to EMS providers. The TCC received 524 calls from January to September 3016, approximately two calls per day. Approximately 10% of the calls resulted in an accepted recommendation; EMS did not request a recommendation in 87% of the calls. The TCC can also be used by hospitals looking to transfer a patient to a trauma center. During the period reviewed, it received 18 hospital calls and had two with a recommendation given and accepted. The majority of EMS providers and trauma center representatives we interviewed did not intend to utilize the TCC on a daily basis because EMS medics and hospital staff were already aware of where they needed to take patients. The Commission intends to reevaluate the TCC based on the results of the pilot.

Performance Improvement

As discussed in the previous finding, the Commission has not developed a performance improvement plan for the state trauma system. According to ACS, evaluation of system-wide effectiveness would include outcomes of population-based injury prevention programs, access to care, availability of services, quality of services provided in pre-hospital and acute care phases, and financial impact or cost. Neither the Commission nor OEMST has utilized available data to measure whether operations and outcomes have improved over the past five years.

The performance improvement programs in other states we interviewed varied. Three states do not have a formal performance program, while other states regularly monitor data points related to pre-hospital and acute care. For example, Florida monitors the percent of trauma patients served within the golden hour, the state’s mortality rate, the rate of readmissions to the intensive care unit, and the number of hours that more than one trauma center was on diversion. Louisiana also measures the percent of patients who were transported to the appropriate facility within an hour, as well as the number and percent of hospitals and EMS providers that participate in the system.

According to the Commission’s strategic plan, the Commission plans to establish system performance metrics by June 2014. Additionally, Level I and II trauma centers are participating in ACS’s Total Quality Improvement Program (TQIP), which helps measure quality of care against other participating trauma centers. The Commission intends to connect performance funding to the trauma centers’ performance in TQIP.

RECOMMENDATION

1. The General Assembly should consider revising state law to clearly define a lead agency for trauma care in Georgia. The lead agency should have the authority and responsibility to ensure compliance with rules and regulations and evaluate performance in a confidential manner.

16 The TCC was a pilot program in Regions 5 and 6 from January to July and then went statewide in July. During the pilot program the TCC received approximately 67 calls per month (2.2 calls per day). After July, the average number of calls per month has increased to 71, or 2.4 calls per day.

The Commission has not developed a performance

improvement plan or utilized data to measure

improvements in operations or outcomes.

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2. In the absence of a state law change, the Commission and OEMST should continue with plans to clarify each entity’s roles and responsibilities, specifically noting any areas of uncertainty (e.g., overlap or gaps in responsibility). The entities should then negotiate their roles in those particular areas.

3. The Commission and OEMST should continue to utilize ACS recommendations and best practice states to guide trauma system activities.

Commission Response: “We are in agreement with the findings and recommendations.” In addition, the Commission provided statements on two areas covered by the finding.

Concerning financing, the Commission stated that it “supports restoration of adequate OEMST funding to provide basic EMS regulatory services in Georgia.”

In regard to operations, the Commission stated that “During the time period addressed in the report, only two regions out of ten were participating in the [TCC] pilot project. Those two regions were chosen for the pilot project, in part, for the limited number of trauma centers contained within the two regions. In the majority of instances within the two chosen regions, medics should know the most appropriate destination for their trauma patient. This parameter provided the best environment to test the functionality of the TCC and its systems. For this purpose, the Commission believes the use of the TCC within the pilot regions has been successful. Going forward, the TCC will work to incorporate the use of available technologies in order to provide a more virtual access to the TCC to healthcare providers for effective trauma system patient disposition.” The Commission also noted that “The draft report emphasized the number of destination recommendations made but did not acknowledge any of the other times the TCC has been of service to EMS providers. These services include: patching calls to the receiving facilities, relaying hospital service line availability, and identification of closest non-designated [hospitals] for non-trauma system patients.”

OEMST Response: “OEMST is identified as the agency for designation of trauma centers in rules and regulations. This rule has been in place since the late 1970s. Regulatory activities preceded the establishment of the Commission.”


While the number of designated trauma centers has increased since 2007, there are still areas of the state in which injured patients must be transported long distances to receive definitive care at a Level I or II trauma center.

Since the Commission’s creation in 200717, the number of trauma centers has increased from 15 to 21. Two of the six hospitals became Level II trauma centers, thus increasing the number of trauma centers able to provide definitive care to even the most serious trauma patients. However, the geographic distribution of Level I and II trauma centers has improved only slightly. As a result, there are still areas of the

17 It should be noted that while Commission members and staff may work to recruit prospective hospitals to become trauma centers, the final decision about designation is made at DPH.

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state—particularly in South Georgia—where residents are more than 50 miles away from definitive care at a Georgia trauma center.

Neither the Commission nor OEMST has developed a strategic plan for the desired number and type of trauma centers or where they should be located, though staff from both entities indicated a general idea of which areas of the state lacked definitive care through a Level I or II trauma center. According to the Commission’s strategic plan, criteria for the number of trauma centers will be developed by June 2013, and all Georgians will be within one hour of a Level I, II, or III trauma center by June 2015. The Commission will utilize GHA hospital discharge data to identify the non-designated hospitals that are serving large numbers of severely injured patients and work to recruit those hospitals into the system.


Prior to the Commission’s formation, designated trauma centers were at risk of dropping out of the system, mainly due to the financial constraints. The Commission’s initial $52 million distribution helped stabilize the trauma centers, and no trauma center has lost its designation since 2007. Beginning in fiscal year 2010, OEMST began adding more trauma centers to the system.

As shown in Exhibit 8 below, the number of trauma centers has increased from 15 at the end of fiscal year 2007 to 21 at the end of fiscal year 2012. In fiscal year 2010, Athens Regional became a Level II trauma center, and Clearview Regional upgraded from a Level IV to a Level III. In fiscal year 2011, Taylor Regional became a Level III trauma center, and Atlanta Medical Center upgraded from a Level II to a Level I. Finally, in fiscal year 2012, Wellstar Kennestone became a Level II trauma center, Emanuel Medical and Wills Memorial became Level IV trauma centers, and Children’s Healthcare of Atlanta-Egleston upgraded from a Level II to a Level I.

Exhibit 8 Six Trauma Centers Have Been Added Since Fiscal Year 2007

Trauma Center 2007 2008 2009 2010 2011 2012 Change

Since 2007

Level I 4 4 4 4 5 6 +2 Level II 9 9 9 10 9 9 0 Level III 0 0 0 1 2 2 +2 Level IV 2 2 2 1 2 4 +2

TOTAL 15 15 15 16 18 21 +6 Source: OEMST

As noted on page 5, the process of becoming a trauma center is extensive, particularly for those seeking Level I or II designation. Oftentimes, hospitals must obtain commitments from administrative and medical staff, hire additional staff such as trauma coordinators and registrars, and train emergency department personnel on how to triage and care for a trauma patient. For all facilities, the process takes at least six months to fulfill OEMST’s requirement of submitting data to the trauma registry. Staff at one recently designated trauma center estimated the process took approximately two years.

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Commission staff indicated that two large hospitals intend to become Level II trauma centers in the coming year, though at the time of this report OEMST has not received any applications. In addition, a number of smaller hospitals have expressed interest in becoming Level III trauma centers.

Geographic Distribution of Trauma Centers

In order to assess the geographic distribution of trauma centers, we determined the number of Georgians living within 25 miles and 50 miles of the state’s Level I and II trauma centers, since they offer the highest level of care to even the most severe trauma patients. Though this methodology does not take into account travel time, which would vary in urban and rural areas, or identify areas that may have higher levels of trauma due to their proximity to heavily traveled roads, it is one useful metric to identify gaps in the system.

Exhibit 9 Approximately 66% of Georgians Reside within 25 Miles of Georgia’s Level I and II Trauma Centers

86%

51%

90%

17%54% 72% 78% 15%

34% 90%0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

4,000,000

1 2 3 4 5 6 7 8 9 10

Popu

latio

n

Region

Within 25 miles Outside 25 miles

(1)This chart shows residents within 25 miles of a designated trauma center in Georgia. An additional 6% of Region 1 residents are within 25 miles of Erlanger Hospital, a Level I trauma center in Chattanooga, TN, which increases Region 1's percent to 92%. No other out-of-state trauma centers are within 25 miles of Georgia residents.Source: MapPoint analysis, United States Census

Total Population: 9,462,929Within 25 miles: 6,285,476 (66%)

(1)

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As shown in Exhibit 9, 66% of Georgians reside within 25 miles and 90% reside within 50 miles of a Level I or II trauma center (see map in Exhibit 10 on the page 23). The percent of residents covered by a 25-mile radius from a Level I or II trauma center ranges from 15% in Region 8 to 90% in Regions 3 and 10. Of particular note:

Region 3: The eight counties in Region 3 (metro Atlanta) account for nearly 40% of the state’s population. Approximately 90% of residents are within 25 miles of a Level I or II trauma center and 100% are within 50 miles. In addition, EMS providers from Region 3 indicated the distribution of trauma centers enables most patients to be transported to definitive care within the golden hour.

Regions 8 and 9: Only 26% of Georgians in these regions live within 25 miles of a Level I or II trauma center, and about half are within 50 miles. In addition, there are no Level III or IV trauma centers in these regions to offer stabilization and transfer services. Region 9 EMS providers we interviewed stated they often transport trauma patients to the Level I trauma center in Jacksonville, FL (Shands Jacksonville). Approximately 7% of Region 9’s residents are within 50 miles of this trauma center, which increases the percent of Region 9 residents within 50 miles from 54% to 61%.

Though two Level II trauma centers have been added to the system since 2007, the percent of Georgians statewide within 25 miles of a Level I or II trauma center has increased only slightly from 63% in 2007 to 66% in 2012. This is mainly due to the geographic location of the trauma centers added.

With the addition of Athens Regional, the percent of Region 10 residents within 25 miles increased from 34% in 2007 to 90% in 2012. While Wellstar Kennestone’s designation did not increase the percentage of Georgians within 25 miles of a trauma center, the travel time to a trauma center for residents in the north metro Atlanta area decreased by at least 30 minutes.18

It should be noted that large, non-designated hospitals may have the clinical capabilities to provide adequate care to patients in areas that are far from a trauma center. For example, Exhibit 10 includes six hospitals that are similar in size to some Level II trauma centers19 and, in at least some cases, serve a significant number of trauma patients due to their distance from designated trauma centers (as previously noted, two large hospitals intend to obtain Level II designation).

The option of having a Level I or II trauma center does not exist in all areas of the state. As shown in Exhibit 10, in large parts of Regions 5 and 9, there is no large non-designated hospital within a reasonable distance, but these areas do include other hospitals that provide emergency care 24 hours a day. While these smaller hospitals are unlikely to obtain a Level I or II designation, some may be able to provide the services required of a Level III or IV trauma center. ACS notes that Level III and IV trauma centers are crucial in rural areas.

18 In normal traffic conditions, it takes approximately 30 minutes to drive the 21 miles from Wellstar Kennestone in Marietta to Grady Memorial Hospital (Level I) in Atlanta and 30 minutes to drive the 18 miles from Wellstar Kennestone to North Fulton Regional Hospital (Level II) in Roswell. 19 This is based on the number of beds. Trauma center designation, however, is based on the availability of specialties such as orthopedics, neurology, etc.

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In addition, as previously noted, EMS providers from Regions 1 and 9 indicated that they often transport trauma patients to Erlanger Medical Center (Level I trauma center in Chattanooga, TN) and Shands Jacksonville (Level I trauma center in Jacksonville, FL), respectively. Finally, EMS providers in counties far from a designated trauma center indicated they utilize air transportation when the patient’s condition warrants faster transport times.

Exhibit 10 A Large Portion of South Georgia is More Than 50 miles From a Level I or II Trauma Center

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RECOMMENDATION

1. The Commission and OEMST should determine the number and level of designated trauma centers needed in Georgia based on geographic location, population density, and hospitals’ capabilities.

2. If additional trauma centers are designated and additional funding is unavailable, the Commission should ensure that its funding programs continue to strengthen the system by investing in trauma centers that are having the greatest impact on the system.


Uncompensated Care

The Commission has mitigated approximately 24% of uncompensated care costs incurred by trauma centers and 65% incurred by participating EMS providers.

The Commission has distributed approximately $43.4 million to designated trauma centers to mitigate approximately 24% of their $183 million in uncompensated care costs for serving trauma patients over the past five years. EMS providers have received approximately $3.4 million from the Commission, which has covered approximately 65% of the $5.3 million in claims reported.

Trauma Centers

The Commission funds trauma centers’ uncompensated care costs based on patient volume and patient treatment cost norms developed by the National Foundation for Trauma Care. Trauma centers report the number of eligible trauma patients served three calendar years prior to the reporting year20, categorized by severity. The Commission then calculates uncompensated care costs using the cost norms (e.g., the cost of treating a patient with an injury severity score of 4, for example, costs $5,267 at a community hospital compared to nearly $20,000 for a patient with an injury severity score of 24). Trauma centers’ total uncompensated care costs are added together for a total statewide cost. Trauma centers are given a percent of the funding available equal to their percent of the statewide total claims. Trauma centers must give 25% of their uncompensated care funding to individual physicians who provide trauma services to patients at the trauma center.21

Since fiscal year 2009, designated trauma centers reported providing uncompensated care services to 13,300 trauma patients, totaling approximately $183.2 million. On average, trauma centers reported about $36.6 million in uncompensated care each year, though over the past two fiscal years the average has been approximately $28 million. Commission staff stated this decrease likely resulted from a more refined

20 For example, uncompensated care distributions for fiscal year 2013 are based on claims from services rendered in calendar year 2010. These numbers are audited by a consultant for the Commission. 21 Eligible physicians include emergency physicians, trauma surgeons, burn surgeons, neurosurgeons, radiologists, orthopedists/hand surgeons, plastics/maxillofacial surgeons and anesthesiologists who are identified in the trauma center’s trauma registry and burn repository.

Uncompensated Care: Care to a trauma patient

who has no medical insurance, is not eligible for medical assistance coverage, has no third

party coverage, and has not paid after

documented attempts by the service provider to

collect payment.

(OCGA §31-11-100)

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definition of applicable patients, as well as the Commission’s audits of trauma centers’ reported numbers.

Most (84%) of the uncompensated care costs are incurred by the Level I trauma centers. In particular, Grady Memorial Hospital’s (Level I in Atlanta) uncompensated care claims constituted 41% of the total claims of the past five fiscal years; the next highest, Memorial Health (Level I in Savannah), comprised 14%.

As shown on Exhibit 11 below, the Commission’s uncompensated care funding was nearly $24 million in fiscal year 2009; it has dropped to $5.2 million in fiscal year 2013. As a result, the percent of trauma centers’ uncompensated care costs mitigated by Commission funding decreased from 61% in fiscal year 2009 to 18% in fiscal year 2013. Trauma center staff we interviewed indicated that while the funding is helpful, it is not enough to make a significant impact in their operations.

Exhibit 11 Commission Funding has Mitigated Approximately 20% of Trauma Centers’ Uncompensated Care Costs in Last Two Fiscal Years

61%

13%6%

20% 18% $-

$10,000,000

$20,000,000

$30,000,000

$40,000,000

$50,000,000

$60,000,000

2009 2010 2011 2012 2013(Budgeted)

Funded by Commission Unfunded

Source: Commission documents

Total Claims (FY09-FY13): $183 millionTotal Funding: $43 million (24%)

Number of Recipients 13 13 14 15

15

EMS

While all designated trauma centers receive some level of uncompensated care funding (if they have applicable patients), EMS providers receive reimbursement through a grant application process. Eligible trauma patients must have been transported to a designated trauma center in Georgia (as confirmed by inclusion on

107


the trauma center’s trauma registry). Cost is calculated using a $400 base pay plus a mileage reimbursement rate of $6.85 per mile for urban counties and $10.28 for rural counties.22 Providers are then paid a percent of total available funds equal to their share of the total calculated costs.

As shown on Exhibit 12 below, funding for EMS uncompensated care has decreased from $1.4 million in fiscal year 2009 to $748,000 in fiscal year 2012. The percent of claims funded has varied, ranging from 100% in 2009 to 30% in 2011.

Exhibit 12 Commission Funding Since 2009 has Mitigated Approximately 65% of EMS Providers’ Uncompensated Care Costs

100%

51%

30%

75%

$-

$500,000

$1,000,000

$1,500,000

$2,000,000

2009 2010 2011 2012 2013(Budgeted)

Funded by Commission Unfunded

Number of Recipients 40 44 36 40

Total Claims (FY09-FY12): $5.3 millionTotal Funding: $3.4 million (65%)Number of Participants: 75

(1) EMS providers had not submitted grant applications for the fiscal year 2013 funding at the time of our review. Therefore, we could not calculate the number of recipients or percent of claims funded.Source: Commission documents

(1)

The program has largely benefited urban providers, with approximately 60% ($2.1 million) going to 13 EMS providers in Region 3 (metro Atlanta). The second highest region—Region 5—received 14% ($465,000).

While the Commission staff initially estimated that 155 providers transport trauma patients to designated trauma centers and would thus qualify for an uncompensated care grant, approximately 50% (75) providers have participated thus far. Some EMS providers we interviewed indicated that the number of eligible patients was not high enough to warrant taking the steps necessary to demonstrate that attempts were made to collect payment.

22 The ratio for rural mileage is based on Medicare payment formula.

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Ambulance Replacement Grants

The extent to which the Commission’s ambulance replacement grant program benefits trauma patients is unclear.

Over the past four years, the Commission has awarded 76 EMS providers 111 grants to replace old, high mileage ambulances. According to Commission members, the program was expected to increase the likelihood that EMS providers would transport trauma patients to trauma centers. While the Commission has not determined whether the grants have impacted EMS transport decisions, our analyses indicate that the grants have had little effect on EMS transport decisions.

According to O.C.G.A. §31-11-102 (7) and (8), the Commission is responsible for supporting trauma transportation. It is expected to compensate members of EMS providers for readiness and should appropriate money for investment in a system specifically for trauma transportation…to provide transport to trauma victims where current options are limited. As shown on Exhibit 4 on page 8, the Commission has distributed $14.1 million to EMS providers for ambulance grants, uncompensated care reimbursements, training, and equipment grants.

The $8 million in ambulance replacement grants comprises approximately 57% of the EMS funding over the past four years. The program targets rural EMS providers by favoring those that operate in counties located a greater distance from a trauma center that have a low number of hospital beds in their county and low population density (the uncompensated care program was designed to benefit urban EMS providers due to the volume of patients). Each grant amounts to approximately $72,000 per vehicle. As shown in Exhibit 13 below, grant recipients continue to meet the Commission’s initial criteria. In particular, the average age and mileage of vehicles replaced has not diminished significantly over the past four years, indicating the continuing presence of old/high mileage ambulances. See Exhibit 14 on the next page for a map of the counties in which grant recipients operate.

Exhibit 13 2009-2012 Grant Applicants Continue to Meet Commission Criteria for Need

Grant Criteria 2009 2010 2011 2012 Average Vehicle Age 10.2 10.9 11.3 10.2 10.5

Vehicle Mileage 197,717 203,424 227,709 191,642 200,685

Distance from a Trauma Center 65.2 78.9 68.5 83.7 71.8

Population Density 48.7 51.5 45.0 55.4 50.1

Number of Acute Care Beds 31.8 37.9 27.0 39.2 34.1

Source: Commission Documents

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Exhibit 14 2009-2012 Ambulance Grant Recipients Operate in Rural Counties Across the State

Newton

Appling

Atkinson

Bacon

Baker

Baldwin

Banks

Barrow

Bartow

Ben Hill

Berrien

Bibb

Bleckley

Brantley

Brooks

Bryan

Bulloch

Burke

Butts

Calhoun

Camden

Candler

Carroll

Catoosa

Charlton

Chatham

Chattahoochee

Chattooga

Cherokee

Clarke

Clay

Clayton

Clinch

Cobb

Coffee

Colquitt

Columbia

Cook

Coweta

Crawford

Dade

Dawson

Decatur

Dekalb

DodgeDooly

Dougherty

Douglas

Early

Echols

Effingham

Elbert

Emanuel

Evans

Fannin

Fayette

FloydForsyth

Franklin

Fulton

Gilmer

Glascock

Glynn

Gordon

Grady

Greene

Gwinnett

Habersham

Hall

Hancock

Haralson

Harris

Hart

Heard

Henry

Houston

Irwin

Jackson

Jasper

Jeff Davis

Jefferson

Jenkins

Johnson

Jones

Lamar

Lanier

Laurens

LeeLiberty

Lincoln

Long

Lowndes

Lumpkin

McDuffie

McIntosh

Macon

Madison

Marion

Meriwether

MillerMitchell

Monroe

Mon

tgom

ery

Morgan

Murray

Muscogee

Oconee OglethorpePaulding

Peach

Pickens

Pierce

Pike

Polk

Pulaski

Putnam

Quitman

Rabun

Randolph

Richmond

Rock

dale

Schley

Screven

Seminole

Spalding

Stephens

Stewart

Sumter

Talbot

Taliaferro

Tattnall

Taylor

Telfair

Terrell

Thomas

Tift

Toombs

Towns

Treutlen

Troup

Turner

Twiggs

Union

Upson

Walker

Walton

Ware

Warren

Washington

Wayne

WebsterWheeler

White

Whitfield

Wilcox

Wilkes

Wilkinson

Worth

Crisp

1 2

3

4

10

98

7

6

5

2

7

8

99

10

11 1213

14

15

16

17

18

21

20

22

23

4

5

6

1 3

19

Burn Centers:22 Grady Burn Center23 Joseph M. Still Burn Center

*Adult trauma center with pediatric commitment ** Pediatric centerSource: Commission, OEMST documents

Level II (Cont.):13 Athens Regional Medical Center 14 Medical Center - Columbus15 John D. Archbold Memorial Hospital

Level III Trauma Centers:16 Clearview Regional Medical Center17 Taylor Regional Hospital

Level IV Trauma Centers:18 Wills Memorial Hospital19 Morgan Memorial Hospital20 Lower Oconee Memorial Hospital21 Emmanuel Medical Center

Level I Trauma Centers:1 Atlanta Medical Center2 Grady Memorial Hospital3 Children’s Healthcare of Atlanta at Egleston**4 Medical Center of Central Georgia*5 Georgia Health Sciences Medical Center*6 Memorial Health University Medical Center*

Level II Trauma Centers:7 Hamilton Medical Center8 Floyd Medical Center9 Gwinnett Medical Center10 North Fulton Regional Hospital 11 Wellstar Kennestone12 Children’s Healthcare of Atlanta at Scottish Rite**

No grant

1 grant ($72,000)

2 grants ($144,000)

3 grants ($218,000)

4 grants ($291,000)

The Commission believed that EMS medics who had to travel long distances to transport patients to a trauma center were less likely to make the trip if they had an older, high mileage ambulance. However, the Commission has not confirmed that grant recipients have changed their transport decisions because they now have a

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more reliable vehicle. Rather, the Commission’s studies and surveys have confirmed that recipients are located in counties far from a trauma center, that older, high mileage vehicles have been replaced, and that the new vehicle has improved the dependability of the EMS fleet and reduced time related to unscheduled repairs.

Based on our analysis of GHA hospital discharge data, it appears that the grants did not increase the likelihood of a transport to a trauma center. We compared the GHA hospital discharge data of trauma patients from counties that received an ambulance replacement grant in fiscal years 2009 and/or 2010 with those from counties that did not receive a grant.23 As shown in Exhibit 15 below, the percent of trauma patients admitted to trauma centers increased by two to three percentage points from 2008 to 2011, regardless of whether the EMS provider serving the patient’s county of residence received a grant in 2009 and/or 2010.

Exhibit 15 2009-2010 Ambulance Grants Do Not Appear to Affect Trauma Patient Transports

23 The GHA data does not specify the location of the patient’s injury or the entity that transported the trauma patient, only the county where the patient resides. The audit team cannot conclude that all patients from a county were injured in that county and were also transported by the EMS provider serving the 911 zone in that county.

Ave

rage

Num

ber o

f Tra

uma

Patie

nts

(1)

(1) These numbers indicate the county in which the patient resides, which may or may not be the county in which the patient was injured. In addition, GHA data does not indicate who transported the patient to the hospital (911 EMS provider, air ambulance, or civilian transport).Source: GHA Hospital Admissions Data

0

20

40

60

80

100

120

140

160

2008 2011

33% 35%

Counties that Received a Grant in 2009/2010

2008 2011

55%57%

Counties that did not Receive a Grant

2008 2011

51% 52%

Statewide Average

Admitted to a designated trauma center Admitted to a non-designated hospital

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Potential Alternatives for Fulfilling O.C.G.A. §31-11-102 (Based on interviews with trauma stakeholders)

Air Transport: While air transport cannot be relied upon 24/7 due to weather limitations, it is a valuable resource in areas far from a trauma center. Helicopters can generally transport patients to definitive care faster than ground ambulances. Though it is considerably more expensive, the Commission could consider ways to invest in air transport as a component of the trauma transportation system, particularly in areas without designated trauma centers.

Trauma-Related Training: A number of EMS providers we interviewed indicated more training should be made available to EMS in rural areas, as well as first responders. In addition, all EMS providers could benefit from education about the CDC trauma triage criteria and transport decision scheme, trauma centers’ and community hospitals’ capabilities, and system participation. The Commission could work with OEMST and Georgia EMS Association to require EMS providers and medics to take a trauma-related course to maintain their licensure.

Trauma-Related Equipment: In a recent Commission-sponsored survey of EMS providers who had received a vehicle grant, the most commonly requested funding was trauma equipment.

Consolidation of EMS Providers in Small Counties: According to EMS stakeholders, small rural counties could improve their operations – and thus improve service delivery to their patients – through consolidation. This spreads out administrative costs and increases the number of vehicles and medics able to respond to a call. Montgomery and Toombs counties, as well as Wilcox and Crisp counties, utilize this structure, and, according to the EMS providers, the arrangement has benefited patients in these counties. The Commission could help subsidize pilot programs for counties that would benefit from a more regionalized EMS program.

At the regional level, it appears the grant may have impacted EMS providers in Region 5.24 Trauma patients from counties that received a grant in 2009 and/or 2010 were 16% more likely to be admitted to a trauma center, compared to 5% in counties that did not receive a grant. However, the difference in improvement was not as significant elsewhere in the state, and, in some regions, improvement was less pronounced in counties that received grants compared to those that did not.

Exhibit 15 also shows that that it is unlikely that EMS providers in the counties that have received a grant transport a large number of trauma patients. On average, 165 trauma patients admitted from 2008-2011 resided in a county that received a grant, less than half the statewide average of 381. As such, the return on investment in those counties is not likely to be significant.

Our interviews with EMS stakeholders support these findings, with EMS providers citing additional factors related to their transport decisions. EMS providers in small rural counties stated they may not go to a trauma center because there is no backup crew to cover the county for the duration of the transport. Additionally, EMS providers operating in remote counties indicated that when a trauma patient’s injuries are severe enough to warrant care at a trauma center, the EMS provider calls for air transport.

Prior to the Commission’s funding, both public and private EMS providers replaced their vehicles as a standard operating expense. However, EMS providers indicated that due to financial constraints they would not have been able to get a new vehicle without the Commission’s funding. Some EMS providers stated that the grant enabled them to use their own funds to purchase additional equipment.

24 Region 5 is the only region to have implemented its regional trauma plan, which may have also impacted EMS providers’ transport decisions.

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No other state we interviewed has EMS funding streams devoted solely to ambulance replacement grants, or even uncompensated care. Rather, states that fund EMS distribute general block grants that can pay for a variety of items. For example, Mississippi distributes approximately $4 million to EMS in grants based on county size, which can be used for medic salaries, training, commodities such as gas, equipment, capital investments such as ambulances, or an escrow account. In Arkansas, 15% of the total trauma budget goes to EMS providers based on the level of basic or advanced life saving training and population; grants must be used toward trauma system enhancement.

RECOMMENDATION

1. The Commission should evaluate the ambulance replacement program’s impact on trauma patients using defined metrics to determine whether it is the best use of EMS distribution funds.


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Appendix A: Objectives, Scope, and Methodology

Objectives

This report examines the Georgia Trauma Care Network Commission (the Commission) at the request of the House Appropriations Committee. Specifically, the Committee asked us to measure the degree of success the Commission has attained in reaching their original goals, which include:

1. Increasing the number of Level I, II, and III trauma centers;

2. Improving service delivery and response times;

3. Mitigating uncompensated care through the distribution of formula funds; and

4. Addressing the need for and benefit from providing ambulance purchases.

Scope

This audit generally covered activity related to the Commission that occurred from its inception in 2007 to 2012. Information used in this report was obtained by reviewing relevant laws, rules, and regulations, interviewing Commission members and staff, interviewing staff at the state Office of EMS and Trauma (OEMST), and reviewing Commission and OEMST documents.

We reviewed calendar years 2007-2011 hospital discharge data collected by the Georgia Hospital Association (GHA), which includes information such as patient demographics, injury type and cause, and whether the facility was a designated trauma center. We assessed the controls over data used for this examination and determined that the data used were sufficiently reliable for our analyses.

We interviewed representatives from seven designated trauma centers, one burn center, and two non-designated hospitals.25 Our sample was based on location, designation level, and duration of designation. We conducted site visits of one trauma center in each designation level, as well as one non-designated hospital. We also interviewed 14 EMS providers based on their location, urban vs. rural, size of operation, and participation in Commission initiatives and grant programs.

Finally, we interviewed representatives of state trauma programs in the contiguous states, as well as best practice states mentioned in discussions with Commission and OEMST staff.26

Methodology

To determine the extent to which the number of Level I, II, and III trauma centers has increased, we reviewed documentation from OEMST showing the dates of designation for each of the current trauma centers. We also assessed whether the geographic distribution of trauma centers had increased the percent of Georgia residents living within 25 and 50 miles of a designated trauma center. We utilized the most recent census tract population data from the United States Census. 25 We interviewed representatives from Grady Memorial Hospital, Georgia Health Sciences University, Floyd Medical Center, Wellstar Kennestone, Archbold Memorial, Taylor Regional Hospital, Morgan Memorial, Grady Burn Center, Phoebe Putney Memorial Hospital, and Northeast Georgia Medical Center. We conducted site visits at Grady, Kennestone, Taylor, Morgan, and Northeast Georgia. 26 The audit team interviewed Alabama, Arkansas, Florida, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Texas.

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To obtain information on service delivery and response times, we attempted to utilize OEMST’s trauma registry and EMS data; however, the data was insufficient to develop a baseline of performance prior to the Commission’s formation. We also reviewed critical recommendations made by the American College of Surgeons during a 2009 evaluation of Georgia’s trauma system and assessed current status based on document reviews and interviews with Commission and OEMST staff.

We reviewed calendar year 2007-2011 GHA hospital discharge data to determine whether a larger percentage of trauma patients are being cared for at designated trauma centers. We utilized criteria set by ACS, as well as methodology utilized by OEMST for a similar study, to identify our trauma patient population. We selected all patients whose primary reason for admission was an injury. We limited our population to patients who were admitted to the hospital for more than 48 hours, patients who were transferred to or from another hospital, and patients who died. We excluded patients whose primary injuries were likely treatable at non-designated hospitals or specialty centers, including sprains and strains, dislocations, burns, closed fractures, and pelvic or femoral fractures that resulted from a same-level fall in patients over 65 years. We reviewed this methodology with Commission members, a consultant utilized by the Commission, and OEMST epidemiologists, who found it to be a valid method of identifying the most serious trauma patients.

To determine the extent to which the Commission has mitigated uncompensated care costs through the use of formula funds, we reviewed Commission documents showing the number of patients reported by trauma centers, the Commission’s cost calculations, and the amount of funding distributed. We also reviewed documents showing EMS claims and the amount of Commission funding.

To determine the extent to which the Commission has addressed the need for and benefit from providing ambulance purchases, we reviewed grant recipients’ applications and interviewed trauma stakeholders and other states representatives. We also used GHA data to compare the percent of trauma center admissions of trauma patients from counties who had received a vehicle replacement grant in 2009 and/or 2010, those that had not received a grant, and the statewide average.

This special examination was not conducted in accordance with generally accepted government auditing standards (GAGAS) given the timeframe in which the report was needed. However, it was conducted in accordance with Performance Audit Division policies and procedures for non-GAGAS engagements. These policies and procedures require that we plan and perform the engagement to obtain sufficient, appropriate evidence to provide a reasonable basis for the information reported and that data limitations be identified for the reader.

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Appendix B: Georgia Trauma System Entry Criteria

Source: Georgia Trauma Care Network Commission

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Appendix C: Critical American College of Surgeons Recommendations and Current Status

Recommendation Current Status

Structure

Recommend to the legislature to enact legislation that includes an assigned lead agency and the establishment of rules, regulations, policy, and procedures.

Not Implemented: Georgia law currently does not assign a lead agency to the trauma system.

Clearly define in statute, rule, or policy the relationship between OEMST and the Commission, along with reporting and accountability mechanisms.

Partially Implemented: The Commission and OEMST now have a memorandum of agreement tied to OEMST’s funding from the Commission. However, current statute does not clearly delineate the roles of each entity related to trauma. The Commission has requested an Attorney General opinion to clarify responsibilities.

Ensure that system leadership delineates the vision for Georgia’s trauma system, including the development and deployment of operational policy.

Partially Implemented: The Commission’s regionalization framework presents a vision for the state trauma system’s operations. The Commission plans to promulgate rules and regulations by June 2013, though enforcement authority is unclear.

Perform a strategic analysis to assess the optimal lead agency structure and position within Georgia’s state government.

Partially Implemented: OEMST hired an epidemiologist dedicated to the trauma registry in December 2010. The Commission and OEMST plan to identify additional key positions needed by June 2014.

Provide OEMST and regional EMS offices with adequate staff to efficiently manage and ensure EMS services and providers are appropriately educated, credentialed, licensed, certified, and monitored to ensure competent patient care.

Not Implemented: OEMST’s regional staff has been reduced by half since 2009. Currently there is only one person over each EMS region. Though the Commission now gives 3% of its total funding to OEMST, this has supplanted the decreased state appropriations.

Appoint a state EMS medical director who has medical oversight of the EMS system as that individual’s primary focus.

Fully Implemented: OEMST’s deputy medical director has had primary oversight over the EMS division for the past two years.

Financing

Identify a sustainable and protected revenue source for the essential administrative, personnel, and infrastructure costs for the trauma system’s lead agency.

Partially Implemented: A 2010 referendum to add $10 to annual vehicle registrations for trauma system development did not pass. Commission funding is now tied to super speeder revenue. The Commission intends to implement a campaign for adequate and permanent funding in the future.

Seek legislative changes to O.G.C.A. §31-11, Article 5 that continue the cost of readiness support to trauma centers and EMS and clarify that the lead agency funding allotments must be payable before other funds are distributed.

Fully Implemented: O.G.C.A. §31-11 continues readiness support to trauma centers and EMS. Though the law does not prioritize OEMST’s funding over distribution funds, Commission budget documents show this to be the practice.

System Development

Re-engage a broad range of stakeholders and empower them to provide input on system development.

Fully Implemented: Commission subcommittees and Regional Trauma Advisory Councils (RTACs) include stakeholder representatives, including physicians, designated trauma centers, non-designated hospitals, local governments, and the public.

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Appendix C (Continued)


Identify roles for all hospitals and stakeholders in an inclusive trauma system within the trauma system plan.

Fully Implemented: Roles for trauma centers, non-designated hospitals, and EMS providers are defined in the Commission’s regionalization framework, which serves as a model for each region’s trauma plan.

Establish multi-disciplinary regional trauma advisory committees centered around Level I or II trauma centers and their catchment areas.

Partially Implemented: RTACs are established in three of the 10 EMS regions. The Commission expects all RTACs to be established by June 2014.

Define roles, responsibilities, and accountabilities for all acute care facilities in an inclusive system related to trauma care.

Partially Implemented: Roles for trauma centers and participating non-designated hospitals are outlined in the Commission’s regionalization framework. The Commission is currently working to create letters of commitment for participating non-designated hospitals.

Operations

Develop a comprehensive trauma system plan to facilitate integration of all services through a collaborative process involving all stakeholders and community partners.

Partially Implemented: RTACs will create regional plans that will then form the state trauma plan. Currently, two regional plans have been developed.

Ensure each region has an established plan for back-up EMS coverage at the local level when the patient’s condition requires primary transport to a distant trauma center or specialty care facility.

Partially Implemented: Though EMS providers have been required to have mutual aid agreements, OEMST staff indicated these are not regularly reviewed. OEMST and Commission staff indicated this would be addressed in RTAC regional plans.

Establish uniform, clearly defined designation criteria, including critical and non-critical criteria deficiencies for each trauma center level, modeled on current ACS guidelines.

Partially Implemented: OEMST is currently developing a manual for potential trauma centers that will clearly identify critical and non-critical deficiencies for each trauma center level.

Establish state criteria for trauma center diversion with regional adoption of notification plans and time frames for diversion. Make diversion a reportable event tied to funding support and designation.

Partially Implemented: State criteria for diversion do not exist. However, trauma centers and participating hospitals operate a Resource Availability Display, which shows the availability of specialties related to trauma care. The Commission will monitor trauma centers’ RADs and will tie a portion of performance funding to their RAD updates in fiscal year 2014.

Focus disaster training and preparedness initiatives on programs that can be integrated into daily and routine use.

Fully Implemented: The Commission has partnered with the Georgia Emergency Management Agency’s Automatic Vehicle Locator System program, which enables EMS directors to know the location of all their vehicles on a daily basis and in the event of a disaster. The Commission has also helped fund First Responder Training. Finally, DPH’s Office of Emergency Preparedness has partnered with the Georgia Hospital Association to create a system for tracking patients and their possessions during a disaster event, which EMS medics can use on a daily basis.

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Appendix C (Continued)


Performance Measurement

Link allocation of cost of readiness funding to deliverables designed to support performance improvement in areas of system management, access to care, patient safety and outcomes, and the financial stability of the system and its components.

Partially Implemented: A portion of trauma centers’ readiness funding has been tied to performance measures since fiscal year 2010. The measures, however, are limited to outputs rather than outcomes or access to care. The Commission plans to tie future funding to more sophisticated measures.

Develop and implement a statewide and regional trauma system performance improvement plan.

Not Implemented: The Commission has not developed a performance improvement plan for the system. The Commission intends to establish performance metrics by June 2014.

Use existing trauma registry data to develop simple benchmarking reports.

Not Implemented: The trauma registry has been used to provide a descriptive picture of trauma in Georgia; however, it does not appear to have been used for benchmarking.

Source: Commission documents, stakeholder interviews

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The Performance Audit Division was established in 1971 to conduct in-depth reviews of state-funded programs.

Our reviews determine if programs are meeting goals and objectives; measure program results and effectiveness;

identify alternate methods to meet goals; evaluate efficiency of resource allocation; assess compliance with laws

and regulations; and provide credible management information to decision-makers. For more information, contact

us at (404)657-5220 or visit our website at www.audits.ga.gov.

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http://www.audits.ga.gov/

Georgia Trauma Foundation, Inc. Questions re Form 1023

1. Who will be the Directors and Officers of the Corporation? Please provide names and

addresses for each. Are any of the officers and/or directors of the Corporation related to each other through family or business relationship?

“Family relationships” include the individual’s spouse, ancestors, children, grandchildren, great grandchildren, siblings (whether by whole or half blood), and the spouses of children, grandchildren, great grandchildren, and siblings. “Business relationships” include employment and contractual relationships, and common ownership of a business where any officers, directors, or trustees, individually or together, possess more than a 35% ownership interest in common. “Ownership” means voting power in a corporation, profits interest in a partnership, or beneficial interest in a trust. If yes, we need to describe such relationship(s).

3. For each of the Corporation’s officers and directors, please provide their qualifications,

average hours worked, and duties. 4. Do any of the officers and/or directors receive compensation from any other

organizations, whether tax exempt or taxable, that are related to the Corporation through “Common Control”?

“Common Control” means that the Corporation and one or more other organizations have (1) a majority of their governing boards or officers appointed or elected by the same organization(s), or (2) a majority of the Corporation’s governing boards or officers consist of the same individuals. Common control also occurs when the Corporation and one or more commonly controlled organizations have a majority ownership interest in a corporation, partnership, or trust.

5. Will the Corporation have any leases, contracts, loans, or other agreements with any organization in which any of the officers or directors are also officers and/or directors, or in which any individual officer or director owns more than a 35% interest?

6. Please provide the Corporation’s estimated annual projected spending and the amount of

annual contributions (approx) for 3-4 years. Please see pages 9 and 10 of the attached Form 1023 for detailed information.

7. We need a description of the Corporation’s charitable purpose. If the purpose is to make

contributions to other charitable organizations, how will those organizations be chosen? Will application forms or grant proposals be required?

121

(Rev. October 2012)

Reminder: Do Not Include Social SecurityNumbers on Publicly Disclosed FormsBecause the IRS is required to disclose approved exemption applications and information returns, exempt organiztions shouldn’tinclude social security or bank account numbers on these forms. By law, with limited exceptions, the IRS has no authority to remove that information before making the forms publicly available. Documentssubject to disclosure include supporting documents �led with the form, and correspondence with the IRS about the �ling.

Cat. No. 52336F

Notice 1382

(Continued)

Notice 1382 (Rev. 10-2012)

Department of the Treasury Internal Revenue Service

Changes for Form 1023• Mailing address• Parts IX, X and XI

Changes for Form 1023, Application forRecognition of Exemption Under Section501(c)(3) of the Internal Revenue Code

Change of Mailing AddressThe mailing address shown on Form 1023 Checklist, page 28, the�rst address under the last checkbox; and in the Instructions for Form 1023, page 4 under Where to File, has been changed to:

Internal Revenue ServiceP.O. Box 12192Covington, KY 41012-0192

Changes for Parts IX and XChanges to Parts IX and X are necessary to comply with new regulations that eliminated the advance ruling process. Until Form 1023 is revised to re�ect this change, please follow the directions on this notice when completing Part IX and Part X ofForm 1023. For more information about the elimination of the advance ruling process, visit us at IRS.gov. In the top right “Search” box, type "Elimination of the Advance Ruling Process" (exactly as written) and select “Search.”

Part IX. Financial DataThe instructions at the top of Part IX on page 9 of Form 1023 are now as follows. For purposes of this schedule, years in existence refer to completed tax years.

1. If in existence less than 5 years, complete the statement foreach year in existence and provide projections of your likely revenues and expenses based on a reasonable and good faithestimate of your future �nances for a total of:

a. Three years of �nancial information if you have not completed one tax year, orb. Four years of �nancial information if you have completed one tax year.

IRS.gov

To �le using a private delivery service, mail to:

201 West Rivercenter Blvd.Attn: Extracting Stop 312Covington, KY 41011

122

Notice 1382 (Rev. 10-2012)

Part X. Public Charity StatusDo not complete line 6a on page 11 of Form 1023, and do not sign the form under the heading “Consent Fixing Period of Limitations Upon Assessment of Tax Under Section 4940 of the Internal Revenue Code.”

Only complete line 6b and line 7 on page 11 of Form 1023, if in existence 5 or more tax years.

Part XI. Increase in User FeesUser fee increases are effective for all applications post marked afterJanuary 3, 2010.

1. $400 for organizations whose gross receipts do not exceed $10,000 or less annually over a 4-year period.

2. $850 for organizations whose gross receipts exceed $10,000 annually over a 4-year period.

For the current user fee amounts, go to IRS.gov and in the “Search” box type “Where Is My Exemption Application,” click on the link for that page, and in the second paragraph click on “user fee.” Alternatively, you can do a search for “user fees” with the applicable year in the “Search” box in the top right. Finally, you can also call 1-877-829-5500.

Application for reinstatement and retroactive reinstatement. Afteryour organization’s tax-exempt status was automatically revoked forfailing to �le a return or notice for three consecutive years, yourorganization must apply to have its tax-exempt status reinstated. You must �le a Form 1023 if applying under section 501(c)(3) or Form 1024 if applying under a different Code section, pay theappropriate user fee, and write “Automatically Revoked” at the topof your application and the mailing envelope. If approved, the dateof reinstatement will be the date of the application. See Notice2011-44, 2011-25 I.R.B. 883, at http://www.irs.gov/irb/2011-25_IRB/ar10.html, for details.

Transitional relief scheduled to end December 31, 2012. Smaller organizations — de�ned as having annual gross receipts of$50,000 or less, in its most recently completed tax year — that have lost their tax-exempt status because of failure to file a required electronic notice (Form 990-N e-Postcard) may beeligible for transitional relief, including retroactive reinstatement and a reduced user fee of $100. See Notice 2011-43, 2011-25 I.R.B. 882, athttp://www.irs.gov/irb/2011-25_IRB/ar09.html, for details.

Changes for the Instructions for Form 1023 • Change to Part III. Required Provisions in Your Organizing

Documents• Clarification to Appendix A. Sample Conflict of Interest Policy

(Continued)IRS.gov

2. If in existence 5 or more years, complete the schedule for the most recent 5 tax years. You will need to provide a separate statement that includes information about the most recent 5 tax years because the data table in Part IX has not been updated to provide for a 5th year.

123

Notice 1382 (Rev. 10-2012)

Appendix A, Sample Conflict of Interest Policy, is only intended to provide an example of a con�ict of interest policy for organizations.The sample con�ict of interest policy does not prescribe anyspeci�c requirements. Therefore, organizations should use a con�ict of interest policy that best �ts their organization.

Appendix A. Sample Conflict of InterestPolicy

IRS.gov

Changes to Instructions for Form 1023,Application for Recognition of Exemption Under Section 501(c)(3) of the Internal Revenue Code (Rev. June 2006)Part III. Required Provisions in Your Organizing DocumentChanges are necessary to comply with Rev. Proc. 82-2, 1982-1 C.B. 367, to incorporate the state of New York as jurisdiction thatcomplies with the cy pres doctrine to keep a charitable testamentarytrust from failing the requirement for a dissolution clause under Regulation sections 1.501(c)(3)-1(b)(4), when the language of the trustinstrument demonstrates a general intent to bene�t charity. Therefore,the instructions on page 8, line 2c, after the third paragraph nowincludes the state of New York in the state listing as an authorizedstate. Since the state of New York allows testamentary charitabletrusts formed in that state and the language in the trustinstruments provides for a general intent to bene�t charity, you donot need a speci�c provision in your trust agreement or declarationof trust providing for the distribution of assets upon dissolution.

124

1I.R.S. SPECIFICATIONS TO BE REMOVED BEFORE PRINTING

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

TLS, have youtransmitted all Rtext files for thiscycle update?

Date

Action

Revised proofsrequested

Date Signature

O.K. to print

INSTRUCTIONS TO PRINTERSFORM 1023, PAGE 1 OF 28MARGINS; TOP 13mm (1/2"), CENTER SIDES. PRINTS: HEAD TO HEADPAPER: WHITE WRITING, SUB. 20. INK: BLACKFLAT SIZE: 216mm (8-1/2") x 279mm (11")PERFORATE: None

Application for Recognition of ExemptionUnder Section 501(c)(3) of the Internal Revenue Code

OMB No. 1545-0056Form 1023 Note: If exempt status is

approved, thisapplication will be openfor public inspection.

(Rev. June 2006)Department of the TreasuryInternal Revenue Service

Identification of Applicant

c/o Name (if applicable)2Full name of organization (exactly as it appears in your organizing document)1

For Paperwork Reduction Act Notice, see page 24 of the instructions.

Part I

Cat. No. 17133K Form 1023 (Rev. 6-2006)

Use the instructions to complete this application and for a definition of all bold items. For additional help, call IRS ExemptOrganizations Customer Account Services toll-free at 1-877-829-5500. Visit our website at www.irs.gov for forms andpublications. If the required information and documents are not submitted with payment of the appropriate user fee, theapplication may be returned to you.

Employer Identification Number (EIN)4Mailing address (Number and street) (see instructions)3

Month the annual accounting period ends (01 – 12)5City or town, state or country, and ZIP + 4

Room/Suite

Primary contact (officer, director, trustee, or authorized representative)6

Are you represented by an authorized representative, such as an attorney or accountant? If “Yes,”provide the authorized representative’s name, and the name and address of the authorizedrepresentative’s firm. Include a completed Form 2848, Power of Attorney and Declaration ofRepresentative, with your application if you would like us to communicate with your representative.

7

Was a person who is not one of your officers, directors, trustees, employees, or an authorizedrepresentative listed in line 7, paid, or promised payment, to help plan, manage, or advise you aboutthe structure or activities of your organization, or about your financial or tax matters? If “Yes,”provide the person’s name, the name and address of the person’s firm, the amounts paid orpromised to be paid, and describe that person’s role.

8

Organization’s website:9a

a Name: b Phone:

c Fax: (optional)

Yes No

Yes No

Certain organizations are not required to file an information return (Form 990 or Form 990-EZ). If youare granted tax-exemption, are you claiming to be excused from filing Form 990 or Form 990-EZ? If“Yes,” explain. See the instructions for a description of organizations not required to file Form 990 orForm 990-EZ.

Yes No

Date incorporated if a corporation, or formed, if other than a corporation. (MM/DD/YYYY)11

Were you formed under the laws of a foreign country?If “Yes,” state the country.

12 Yes No

/ /

10

Organization’s email: (optional)b

Attach additional sheets to this application if you need more space to answer fully. Put your name and EIN on each sheet andidentify each answer by Part and line number. Complete Parts I - XI of Form 1023 and submit only those Schedules (A throughH) that apply to you.

125




Organizational Structure

1

Part III

Form 1023 (Rev. 6-2006)

2

5

Are you a corporation? If “Yes,” attach a copy of your articles of incorporation showing certificationof filing with the appropriate state agency. Include copies of any amendments to your articles andbe sure they also show state filing certification.

Yes No

– Page 2Form 1023 (Rev. 6-2006) Name: EIN:

You must be a corporation (including a limited liability company), an unincorporated association, or a trust to be tax exempt.(See instructions.) DO NOT file this form unless you can check “Yes” on lines 1, 2, 3, or 4.

Are you a limited liability company (LLC)? If “Yes,” attach a copy of your articles of organization showingcertification of filing with the appropriate state agency. Also, if you adopted an operating agreement, attacha copy. Include copies of any amendments to your articles and be sure they show state filing certification.Refer to the instructions for circumstances when an LLC should not file its own exemption application.

Are you an unincorporated association? If “Yes,” attach a copy of your articles of association,constitution, or other similar organizing document that is dated and includes at least two signatures.Include signed and dated copies of any amendments.

Are you a trust? If “Yes,” attach a signed and dated copy of your trust agreement. Include signedand dated copies of any amendments.Have you been funded? If “No,” explain how you are formed without anything of value placed in trust.

Have you adopted bylaws? If “Yes,” attach a current copy showing date of adoption. If “No,” explainhow your officers, directors, or trustees are selected.

3

4a

b

Yes No

Yes No

Yes No

Yes NoYes No

Required Provisions in Your Organizing Document

1

Part IV

2a

Section 501(c)(3) requires that your organizing document state your exempt purpose(s), such as charitable,religious, educational, and/or scientific purposes. Check the box to confirm that your organizing documentmeets this requirement. Describe specifically where your organizing document meets this requirement, such asa reference to a particular article or section in your organizing document. Refer to the instructions for exemptpurpose language. Location of Purpose Clause (Page, Article, and Paragraph):

The following questions are designed to ensure that when you file this application, your organizing document contains the required provisionsto meet the organizational test under section 501(c)(3). Unless you can check the boxes in both lines 1 and 2, your organizing documentdoes not meet the organizational test. DO NOT file this application until you have amended your organizing document. Submit youroriginal and amended organizing documents (showing state filing certification if you are a corporation or an LLC) with your application.

Section 501(c)(3) requires that upon dissolution of your organization, your remaining assets must be used exclusivelyfor exempt purposes, such as charitable, religious, educational, and/or scientific purposes. Check the box on line 2a toconfirm that your organizing document meets this requirement by express provision for the distribution of assets upondissolution. If you rely on state law for your dissolution provision, do not check the box on line 2a and go to line 2c.

Compensation and Other Financial Arrangements With Your Officers, Directors, Trustees,Employees, and Independent ContractorsPart V

List the names, titles, and mailing addresses of all of your officers, directors, and trustees. For each person listed, state theirtotal annual compensation, or proposed compensation, for all services to the organization, whether as an officer, employee, orother position. Use actual figures, if available. Enter “none” if no compensation is or will be paid. If additional space is needed,attach a separate sheet. Refer to the instructions for information on what to include as compensation.

Name Title Mailing addressCompensation amount(annual actual or estimated)

1a

Part II

Using an attachment, describe your past, present, and planned activities in a narrative. If you believe that you have already provided some ofthis information in response to other parts of this application, you may summarize that information here and refer to the specific parts of theapplication for supporting details. You may also attach representative copies of newsletters, brochures, or similar documents for supportingdetails to this narrative. Remember that if this application is approved, it will be open for public inspection. Therefore, your narrativedescription of activities should be thorough and accurate. Refer to the instructions for information that must be included in your description.

Narrative Description of Your Activities

If you checked the box on line 2a, specify the location of your dissolution clause (Page, Article, and Paragraph).Do not complete line 2c if you checked box 2a.

2b

See the instructions for information about the operation of state law in your particular state. Check this box ifyou rely on operation of state law for your dissolution provision and indicate the state:

2c

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2a

Form 1023 (Rev. 6-2006)

Yes No


Compensation and Other Financial Arrangements With Your Officers, Directors, Trustees,Employees, and Independent Contractors (Continued)

Part V

List the names, titles, and mailing addresses of each of your five highest compensated employees who receive or willreceive compensation of more than $50,000 per year. Use the actual figure, if available. Refer to the instructions forinformation on what to include as compensation. Do not include officers, directors, or trustees listed in line 1a.


b

List the names, names of businesses, and mailing addresses of your five highest compensated independent contractorsthat receive or will receive compensation of more than $50,000 per year. Use the actual figure, if available. Refer to theinstructions for information on what to include as compensation.


c

The following “Yes” or “No” questions relate to past, present, or planned relationships, transactions, or agreements with your officers,directors, trustees, highest compensated employees, and highest compensated independent contractors listed in lines 1a, 1b, and 1c.

Do you have a business relationship with any of your officers, directors, or trustees other thanthrough their position as an officer, director, or trustee? If “Yes,” identify the individuals and describethe business relationship with each of your officers, directors, or trustees.

Are any of your officers, directors, or trustees related to your highest compensated employees orhighest compensated independent contractors listed on lines 1b or 1c through family or businessrelationships? If “Yes,” identify the individuals and explain the relationship.

For each of your officers, directors, trustees, highest compensated employees, and highestcompensated independent contractors listed on lines 1a, 1b, or 1c, attach a list showing their name,qualifications, average hours worked, and duties.

Do any of your officers, directors, trustees, highest compensated employees, and highestcompensated independent contractors listed on lines 1a, 1b, or 1c receive compensation from anyother organizations, whether tax exempt or taxable, that are related to you through commoncontrol? If “Yes,” identify the individuals, explain the relationship between you and the otherorganization, and describe the compensation arrangement.

In establishing the compensation for your officers, directors, trustees, highest compensatedemployees, and highest compensated independent contractors listed on lines 1a, 1b, and 1c, thefollowing practices are recommended, although they are not required to obtain exemption. Answer“Yes” to all the practices you use.

Do you or will the individuals that approve compensation arrangements follow a conflict of interest policy?Do you or will you approve compensation arrangements in advance of paying compensation?Do you or will you document in writing the date and terms of approved compensation arrangements?

3a

4

Yes No

Yes No

Yes No

Yes NoYes NoYes No

b

b

b

c

c

a

Are any of your officers, directors, or trustees related to each other through family or businessrelationships? If “Yes,” identify the individuals and explain the relationship.

127




Form 1023 (Rev. 6-2006)

Yes No



Part V

Yes No

Yes No

Yes No

Yes No

Do you or will you approve compensation arrangements based on information about compensation paid bysimilarly situated taxable or tax-exempt organizations for similar services, current compensation surveyscompiled by independent firms, or actual written offers from similarly situated organizations? Refer to theinstructions for Part V, lines 1a, 1b, and 1c, for information on what to include as compensation.

Do you or will you record in writing both the information on which you relied to base your decisionand its source?If you answered “No” to any item on lines 4a through 4f, describe how you set compensation that isreasonable for your officers, directors, trustees, highest compensated employees, and highestcompensated independent contractors listed in Part V, lines 1a, 1b, and 1c.

Have you adopted a conflict of interest policy consistent with the sample conflict of interest policyin Appendix A to the instructions? If “Yes,” provide a copy of the policy and explain how the policyhas been adopted, such as by resolution of your governing board. If “No,” answer lines 5b and 5c.

What procedures will you follow to assure that persons who have a conflict of interest will not haveinfluence over you for setting their own compensation?

What procedures will you follow to assure that persons who have a conflict of interest will not haveinfluence over you regarding business deals with themselves?

Note: A conflict of interest policy is recommended though it is not required to obtain exemption.Hospitals, see Schedule C, Section I, line 14.

Do you or will you compensate any of your officers, directors, trustees, highest compensated employees,and highest compensated independent contractors listed in lines 1a, 1b, or 1c through non-fixedpayments, such as discretionary bonuses or revenue-based payments? If “Yes,” describe all non-fixedcompensation arrangements, including how the amounts are determined, who is eligible for sucharrangements, whether you place a limitation on total compensation, and how you determine or willdetermine that you pay no more than reasonable compensation for services. Refer to the instructions forPart V, lines 1a, 1b, and 1c, for information on what to include as compensation.

e

f

g

5a

b

c

6a

Do you or will you compensate any of your employees, other than your officers, directors, trustees,or your five highest compensated employees who receive or will receive compensation of more than$50,000 per year, through non-fixed payments, such as discretionary bonuses or revenue-basedpayments? If “Yes,” describe all non-fixed compensation arrangements, including how the amountsare or will be determined, who is or will be eligible for such arrangements, whether you place or willplace a limitation on total compensation, and how you determine or will determine that you pay nomore than reasonable compensation for services. Refer to the instructions for Part V, lines 1a, 1b,and 1c, for information on what to include as compensation.

Do you or will you purchase any goods, services, or assets from any of your officers, directors,trustees, highest compensated employees, or highest compensated independent contractors listed inlines 1a, 1b, or 1c? If “Yes,” describe any such purchase that you made or intend to make, fromwhom you make or will make such purchases, how the terms are or will be negotiated at arm’slength, and explain how you determine or will determine that you pay no more than fair marketvalue. Attach copies of any written contracts or other agreements relating to such purchases.

Do you or will you sell any goods, services, or assets to any of your officers, directors, trustees,highest compensated employees, or highest compensated independent contractors listed in lines 1a,1b, or 1c? If “Yes,” describe any such sales that you made or intend to make, to whom you make orwill make such sales, how the terms are or will be negotiated at arm’s length, and explain how youdetermine or will determine you are or will be paid at least fair market value. Attach copies of anywritten contracts or other agreements relating to such sales.

Yes No

Yes No

b

b

7a

Do you or will you record in writing the decision made by each individual who decided or voted oncompensation arrangements?

Yes Nod

Do you or will you have any leases, contracts, loans, or other agreements with your officers, directors,trustees, highest compensated employees, or highest compensated independent contractors listed inlines 1a, 1b, or 1c? If “Yes,” provide the information requested in lines 8b through 8f.

Describe any written or oral arrangements that you made or intend to make.Identify with whom you have or will have such arrangements.Explain how the terms are or will be negotiated at arm’s length.Explain how you determine you pay no more than fair market value or you are paid at least fair market value.Attach copies of any signed leases, contracts, loans, or other agreements relating to such arrangements.

Yes No

b

8a

cdef

Yes No9a Do you or will you have any leases, contracts, loans, or other agreements with any organization inwhich any of your officers, directors, or trustees are also officers, directors, or trustees, or in whichany individual officer, director, or trustee owns more than a 35% interest? If “Yes,” provide theinformation requested in lines 9b through 9f.

128




Form 1023 (Rev. 6-2006)



Part V

bcde

f

Describe any written or oral arrangements you made or intend to make.Identify with whom you have or will have such arrangements.Explain how the terms are or will be negotiated at arm’s length.Explain how you determine or will determine you pay no more than fair market value or that you arepaid at least fair market value.

Attach a copy of any signed leases, contracts, loans, or other agreements relating to such arrangements.

Your Members and Other Individuals and Organizations That Receive Benefits From YouPart VI

Yes NoIn carrying out your exempt purposes, do you provide goods, services, or funds to individuals? If“Yes,” describe each program that provides goods, services, or funds to individuals.

1a

The following “Yes” or “No” questions relate to goods, services, and funds you provide to individuals and organizations as partof your activities. Your answers should pertain to past, present, and planned activities. (See instructions.)

In carrying out your exempt purposes, do you provide goods, services, or funds to organizations? If“Yes,” describe each program that provides goods, services, or funds to organizations.

Do any of your programs limit the provision of goods, services, or funds to a specific individual orgroup of specific individuals? For example, answer “Yes,” if goods, services, or funds are providedonly for a particular individual, your members, individuals who work for a particular employer, orgraduates of a particular school. If “Yes,” explain the limitation and how recipients are selected foreach program.

Do any individuals who receive goods, services, or funds through your programs have a family orbusiness relationship with any officer, director, trustee, or with any of your highest compensatedemployees or highest compensated independent contractors listed in Part V, lines 1a, 1b, and 1c? If“Yes,” explain how these related individuals are eligible for goods, services, or funds.

Yes No

Yes No

Yes No

b

2

3

Your HistoryPart VII

Yes NoAre you a successor to another organization? Answer “Yes,” if you have taken or will take over theactivities of another organization; you took over 25% or more of the fair market value of the netassets of another organization; or you were established upon the conversion of an organization fromfor-profit to non-profit status. If “Yes,” complete Schedule G.

1

The following “Yes” or “No” questions relate to your history. (See instructions.)

Are you submitting this application more than 27 months after the end of the month in which youwere legally formed? If “Yes,” complete Schedule E.

Yes No2

Your Specific ActivitiesPart VIII

Yes NoDo you support or oppose candidates in political campaigns in any way? If “Yes,” explain.1

The following “Yes” or “No” questions relate to specific activities that you may conduct. Check the appropriate box. Youranswers should pertain to past, present, and planned activities. (See instructions.)

Do you attempt to influence legislation? If “Yes,” explain how you attempt to influence legislationand complete line 2b. If “No,” go to line 3a.

Yes No2a

Have you made or are you making an election to have your legislative activities measured byexpenditures by filing Form 5768? If “Yes,” attach a copy of the Form 5768 that was already filed orattach a completed Form 5768 that you are filing with this application. If “No,” describe whether yourattempts to influence legislation are a substantial part of your activities. Include the time and moneyspent on your attempts to influence legislation as compared to your total activities.

b Yes No

Do you or will you operate bingo or gaming activities? If “Yes,” describe who conducts them, andlist all revenue received or expected to be received and expenses paid or expected to be paid inoperating these activities. Revenue and expenses should be provided for the time periods specifiedin Part IX, Financial Data.

Do you or will you enter into contracts or other agreements with individuals or organizations toconduct bingo or gaming for you? If “Yes,” describe any written or oral arrangements that you madeor intend to make, identify with whom you have or will have such arrangements, explain how theterms are or will be negotiated at arm’s length, and explain how you determine or will determine youpay no more than fair market value or you will be paid at least fair market value. Attach copies orany written contracts or other agreements relating to such arrangements.

List the states and local jurisdictions, including Indian Reservations, in which you conduct or willconduct gaming or bingo.

3a

b

c

Yes No

Yes No

129




Form 1023 (Rev. 6-2006)


4a Do you or will you undertake fundraising? If “Yes,” check all the fundraising programs you do or willconduct. (See instructions.)

mail solicitationsemail solicitationspersonal solicitationsvehicle, boat, plane, or similar donationsfoundation grant solicitations

phone solicitationsaccept donations on your websitereceive donations from another organization’s websitegovernment grant solicitationsOther

Yes No

Attach a description of each fundraising program.

b

5

Do you or will you have written or oral contracts with any individuals or organizations to raise fundsfor you? If “Yes,” describe these activities. Include all revenue and expenses from these activitiesand state who conducts them. Revenue and expenses should be provided for the time periodsspecified in Part IX, Financial Data. Also, attach a copy of any contracts or agreements.

Yes No

Do you or will you engage in fundraising activities for other organizations? If “Yes,” describe thesearrangements. Include a description of the organizations for which you raise funds and attach copiesof all contracts or agreements.

List all states and local jurisdictions in which you conduct fundraising. For each state or localjurisdiction listed, specify whether you fundraise for your own organization, you fundraise for anotherorganization, or another organization fundraises for you.

Do you or will you maintain separate accounts for any contributor under which the contributor hasthe right to advise on the use or distribution of funds? Answer “Yes” if the donor may provide adviceon the types of investments, distributions from the types of investments, or the distribution from thedonor’s contribution account. If “Yes,” describe this program, including the type of advice that maybe provided and submit copies of any written materials provided to donors.

Are you affiliated with a governmental unit? If “Yes,” explain.

Do you or will you engage in economic development? If “Yes,” describe your program.Describe in full who benefits from your economic development activities and how the activitiespromote exempt purposes.

6ab

c

d

e

Yes No

Yes No

Yes No

Yes No

Do or will persons other than your employees or volunteers develop your facilities? If “Yes,” describeeach facility, the role of the developer, and any business or family relationship(s) between thedeveloper and your officers, directors, or trustees.

Do or will persons other than your employees or volunteers manage your activities or facilities? If“Yes,” describe each activity and facility, the role of the manager, and any business or familyrelationship(s) between the manager and your officers, directors, or trustees.

If there is a business or family relationship between any manager or developer and your officers,directors, or trustees, identify the individuals, explain the relationship, describe how contracts arenegotiated at arm’s length so that you pay no more than fair market value, and submit a copy of anycontracts or other agreements.

Do you or will you enter into joint ventures, including partnerships or limited liability companiestreated as partnerships, in which you share profits and losses with partners other than section501(c)(3) organizations? If “Yes,” describe the activities of these joint ventures in which youparticipate.

Are you applying for exemption as a childcare organization under section 501(k)? If “Yes,” answerlines 9b through 9d. If “No,” go to line 10.

Do you provide child care so that parents or caretakers of children you care for can be gainfullyemployed (see instructions)? If “No,” explain how you qualify as a childcare organization describedin section 501(k).

Of the children for whom you provide child care, are 85% or more of them cared for by you toenable their parents or caretakers to be gainfully employed (see instructions)? If “No,” explain howyou qualify as a childcare organization described in section 501(k).

Are your services available to the general public? If “No,” describe the specific group of people forwhom your activities are available. Also, see the instructions and explain how you qualify as achildcare organization described in section 501(k).

Do you or will you publish, own, or have rights in music, literature, tapes, artworks, choreography,scientific discoveries, or other intellectual property? If “Yes,” explain. Describe who owns or willown any copyrights, patents, or trademarks, whether fees are or will be charged, how the fees aredetermined, and how any items are or will be produced, distributed, and marketed.

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

7a

8

9a

10

b

b

c

c

d Yes No

Yes No

Your Specific Activities (Continued)Part VIII

130




Form 1023 (Rev. 6-2006)


Do you or will you operate in a foreign country or countries? If “Yes,” answer lines 12b through12d. If “No,” go to line 13a.Name the foreign countries and regions within the countries in which you operate.Describe your operations in each country and region in which you operate.Describe how your operations in each country and region further your exempt purposes.

Yes No12a

bcd

13a

bcde

Do you or will you make grants, loans, or other distributions to organization(s)? If “Yes,” answer lines13b through 13g. If “No,” go to line 14a.

Describe how your grants, loans, or other distributions to organizations further your exempt purposes.Do you have written contracts with each of these organizations? If “Yes,” attach a copy of each contract.Identify each recipient organization and any relationship between you and the recipient organization.Describe the records you keep with respect to the grants, loans, or other distributions you make.

Yes No

Yes No

Do you or will you accept contributions of: real property; conservation easements; closely heldsecurities; intellectual property such as patents, trademarks, and copyrights; works of music or art;licenses; royalties; automobiles, boats, planes, or other vehicles; or collectibles of any type? If “Yes,”describe each type of contribution, any conditions imposed by the donor on the contribution, andany agreements with the donor regarding the contribution.

Yes No11

f Describe your selection process, including whether you do any of the following:Yes NoDo you require an application form? If “Yes,” attach a copy of the form.

Do you require a grant proposal? If “Yes,” describe whether the grant proposal specifies yourresponsibilities and those of the grantee, obligates the grantee to use the grant funds only for thepurposes for which the grant was made, provides for periodic written reports concerning the useof grant funds, requires a final written report and an accounting of how grant funds were used,and acknowledges your authority to withhold and/or recover grant funds in case such funds are,or appear to be, misused.

Describe your procedures for oversight of distributions that assure you the resources are used tofurther your exempt purposes, including whether you require periodic and final reports on the use ofresources.

Do you or will you make grants, loans, or other distributions to foreign organizations? If “Yes,”answer lines 14b through 14f. If “No,” go to line 15.

Provide the name of each foreign organization, the country and regions within a country in whicheach foreign organization operates, and describe any relationship you have with each foreignorganization.

Does any foreign organization listed in line 14b accept contributions earmarked for a specific countryor specific organization? If “Yes,” list all earmarked organizations or countries.

Do your contributors know that you have ultimate authority to use contributions made to you at yourdiscretion for purposes consistent with your exempt purposes? If “Yes,” describe how you relay thisinformation to contributors.

Do you or will you make pre-grant inquiries about the recipient organization? If “Yes,” describe theseinquiries, including whether you inquire about the recipient’s financial status, its tax-exempt statusunder the Internal Revenue Code, its ability to accomplish the purpose for which the resources areprovided, and other relevant information.

Do you or will you use any additional procedures to ensure that your distributions to foreignorganizations are used in furtherance of your exempt purposes? If “Yes,” describe these procedures,including site visits by your employees or compliance checks by impartial experts, to verify that grantfunds are being used appropriately.

(ii)(i)

g

14a

b

c

d

e

f

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No


131




Form 1023 (Rev. 6-2006)


Do you or will you provide scholarships, fellowships, educational loans, or other educational grants toindividuals, including grants for travel, study, or other similar purposes? If “Yes,” completeSchedule H.

Note: Private foundations may use Schedule H to request advance approval of individual grantprocedures.

22 Yes No

Do you have a close connection with any organizations? If “Yes,” explain.

Are you applying for exemption as a cooperative hospital service organization under section501(e)? If “Yes,” explain.

Are you applying for exemption as a cooperative service organization of operating educationalorganizations under section 501(f)? If “Yes,” explain.Are you applying for exemption as a charitable risk pool under section 501(n)? If “Yes,” explain.

Is your main function to provide hospital or medical care? If “Yes,” complete Schedule C.

Do you or will you provide low-income housing or housing for the elderly or handicapped? If“Yes,” complete Schedule F.

15

16

17

18

Do you or will you operate a school? If “Yes,” complete Schedule B. Answer “Yes,” whether youoperate a school as your main function or as a secondary activity.

19

20

21

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No


132




Form 1023 (Rev. 6-2006)


Financial Data

24

For purposes of this schedule, years in existence refer to completed tax years. If in existence 4 or more years, complete theschedule for the most recent 4 tax years. If in existence more than 1 year but less than 4 years, complete the statements foreach year in existence and provide projections of your likely revenues and expenses based on a reasonable and good faithestimate of your future finances for a total of 3 years of financial information. If in existence less than 1 year, provide projectionsof your likely revenues and expenses for the current year and the 2 following years, based on a reasonable and good faithestimate of your future finances for a total of 3 years of financial information. (See instructions.)

1

234

5

6

7

8

9

1011

1213

14

15

16

17

1819202122

23

A. Statement of Revenues and ExpensesType of revenue or expense Current tax year 3 prior tax years or 2 succeeding tax years

(a) From

To

(e) Provide Total for(a) through (d)

(b) From

To

(c) From

To

(d) From

To

Rev

enue

sE

xpen

ses

Gifts, grants, andcontributions received (do notinclude unusual grants)

Membership fees receivedGross investment incomeNet unrelated businessincomeTaxes levied for your benefit

Value of services or facilitiesfurnished by a governmentalunit without charge (notincluding the value of servicesgenerally furnished to thepublic without charge)

Any revenue not otherwiselisted above or in lines 9–12below (attach an itemized list)

Total of lines 1 through 7

Gross receipts from admissions,merchandise sold or servicesperformed, or furnishing offacilities in any activity that isrelated to your exemptpurposes (attach itemized list)

Total of lines 8 and 9Net gain or loss on sale ofcapital assets (attachschedule and see instructions)

Unusual grantsTotal RevenueAdd lines 10 through 12Fundraising expenses

Contributions, gifts, grants,and similar amounts paid out(attach an itemized list)

Disbursements to or for thebenefit of members (attach anitemized list)

Compensation of officers,directors, and trusteesOther salaries and wagesInterest expenseOccupancy (rent, utilities, etc.)Depreciation and depletionProfessional fees

Any expense not otherwiseclassified, such as programservices (attach itemized list)

Total ExpensesAdd lines 14 through 23

Part IX

133




Form 1023 (Rev. 6-2006)


Financial Data (Continued)B. Balance Sheet (for your most recently completed tax year) Year End:

123456789

1011

1213141516

171819

1a

b

Assets (Whole dollars)

CashAccounts receivable, netInventoriesBonds and notes receivable (attach an itemized list)Corporate stocks (attach an itemized list)Loans receivable (attach an itemized list)Other investments (attach an itemized list)Depreciable and depletable assets (attach an itemized list)LandOther assets (attach an itemized list)

Total Assets (add lines 1 through 10)Liabilities

Accounts payableContributions, gifts, grants, etc. payableMortgages and notes payable (attach an itemized list)Other liabilities (attach an itemized list)

Total Liabilities (add lines 12 through 15)Fund Balances or Net Assets

Total fund balances or net assetsTotal Liabilities and Fund Balances or Net Assets (add lines 16 and 17)

Have there been any substantial changes in your assets or liabilities since the end of the periodshown above? If “Yes,” explain.

123456789

1011

1213141516

1718

Yes No

Public Charity StatusPart X is designed to classify you as an organization that is either a private foundation or a public charity. Public charity statusis a more favorable tax status than private foundation status. If you are a private foundation, Part X is designed to furtherdetermine whether you are a private operating foundation. (See instructions.)

Are you a private foundation? If “Yes,” go to line 1b. If “No,” go to line 5 and proceed as instructed.If you are unsure, see the instructions.

As a private foundation, section 508(e) requires special provisions in your organizing document inaddition to those that apply to all organizations described in section 501(c)(3). Check the box toconfirm that your organizing document meets this requirement, whether by express provision or byreliance on operation of state law. Attach a statement that describes specifically where yourorganizing document meets this requirement, such as a reference to a particular article or section inyour organizing document or by operation of state law. See the instructions, including Appendix B,for information about the special provisions that need to be contained in your organizing document.Go to line 2.

Are you a private operating foundation? To be a private operating foundation you must engagedirectly in the active conduct of charitable, religious, educational, and similar activities, as opposedto indirectly carrying out these activities by providing grants to individuals or other organizations. If“Yes,” go to line 3. If “No,” go to the signature section of Part XI.

Have you existed for one or more years? If “Yes,” attach financial information showing that you are a privateoperating foundation; go to the signature section of Part XI. If “No,” continue to line 4.

Have you attached either (1) an affidavit or opinion of counsel, (including a written affidavit or opinionfrom a certified public accountant or accounting firm with expertise regarding this tax law matter),that sets forth facts concerning your operations and support to demonstrate that you are likely tosatisfy the requirements to be classified as a private operating foundation; or (2) a statementdescribing your proposed operations as a private operating foundation?

2

3

4

Yes No

Yes No

Yes No

Yes No

Part X

Part IX

5

a

c

d

b

If you answered “No” to line 1a, indicate the type of public charity status you are requesting by checking one of the choices below.You may check only one box.

The organization is not a private foundation because it is:509(a)(1) and 170(b)(1)(A)(i)—a church or a convention or association of churches. Complete and attach Schedule A.509(a)(1) and 170(b)(1)(A)(ii)—a school. Complete and attach Schedule B.509(a)(1) and 170(b)(1)(A)(iii)—a hospital, a cooperative hospital service organization, or a medical researchorganization operated in conjunction with a hospital. Complete and attach Schedule C.

509(a)(3)—an organization supporting either one or more organizations described in line 5a through c, f, g, or hor a publicly supported section 501(c)(4), (5), or (6) organization. Complete and attach Schedule D.

134




Form 1023 (Rev. 6-2006)


Public Charity Status (Continued)

Yes No

ef

g

h

i

6

(i)

(ii)

7

509(a)(4)—an organization organized and operated exclusively for testing for public safety.509(a)(1) and 170(b)(1)(A)(iv)—an organization operated for the benefit of a college or university that is owned oroperated by a governmental unit.

509(a)(1) and 170(b)(1)(A)(vi)—an organization that receives a substantial part of its financial support in the formof contributions from publicly supported organizations, from a governmental unit, or from the general public.

509(a)(2)—an organization that normally receives not more than one-third of its financial support from grossinvestment income and receives more than one-third of its financial support from contributions, membershipfees, and gross receipts from activities related to its exempt functions (subject to certain exceptions).

A publicly supported organization, but unsure if it is described in 5g or 5h. The organization would like the IRS todecide the correct status.

If you checked box g, h, or i in question 5 above, you must request either an advance or a definitive ruling byselecting one of the boxes below. Refer to the instructions to determine which type of ruling you are eligible to receive.

Request for Advance Ruling: By checking this box and signing the consent, pursuant to section 6501(c)(4) ofthe Code you request an advance ruling and agree to extend the statute of limitations on the assessment ofexcise tax under section 4940 of the Code. The tax will apply only if you do not establish public support statusat the end of the 5-year advance ruling period. The assessment period will be extended for the 5 advance rulingyears to 8 years, 4 months, and 15 days beyond the end of the first year. You have the right to refuse or limitthe extension to a mutually agreed-upon period of time or issue(s). Publication 1035, Extending the TaxAssessment Period, provides a more detailed explanation of your rights and the consequences of the choicesyou make. You may obtain Publication 1035 free of charge from the IRS web site at www.irs.gov or by callingtoll-free 1-800-829-3676. Signing this consent will not deprive you of any appeal rights to which you wouldotherwise be entitled. If you decide not to extend the statute of limitations, you are not eligible for an advanceruling.

a

b Request for Definitive Ruling: Check this box if you have completed one tax year of at least 8 full months andyou are requesting a definitive ruling. To confirm your public support status, answer line 6b(i) if you checked boxg in line 5 above. Answer line 6b(ii) if you checked box h in line 5 above. If you checked box i in line 5 above,answer both lines 6b(i) and (ii).

(a)(b)

Enter 2% of line 8, column (e) on Part IX-A. Statement of Revenues and Expenses.Attach a list showing the name and amount contributed by each person, company, or organization whosegifts totaled more than the 2% amount. If the answer is “None,” check this box.

For each year amounts are included on lines 1, 2, and 9 of Part IX-A. Statement of Revenues andExpenses, attach a list showing the name of and amount received from each disqualified person. If theanswer is “None,” check this box.

For each year amounts are included on line 9 of Part IX-A. Statement of Revenues and Expenses, attacha list showing the name of and amount received from each payer, other than a disqualified person, whosepayments were more than the larger of (1) 1% of line 10, Part IX-A. Statement of Revenues andExpenses, or (2) $5,000. If the answer is “None,” check this box.

Did you receive any unusual grants during any of the years shown on Part IX-A. Statement ofRevenues and Expenses? If “Yes,” attach a list including the name of the contributor, the date andamount of the grant, a brief description of the grant, and explain why it is unusual.

(a)

(b)

(Date)(Signature of Officer, Director, Trustee, or otherauthorized official)

(Type or print title or authority of signer)

Part X

Consent Fixing Period of Limitations Upon Assessment of Tax Under Section 4940 of the Internal Revenue Code

For Organization

For IRS Use Only

(Date)

(Type or print name of signer)

IRS Director, Exempt Organizations

135




Form 1023 (Rev. 6-2006)


I declare under the penalties of perjury that I am authorized to sign this application on behalf of the above organization and that I have examined thisapplication, including the accompanying schedules and attachments, and to the best of my knowledge it is true, correct, and complete.

PleaseSignHere (Date)(Signature of Officer, Director, Trustee, or other

authorized official)

�

(Type or print title or authority of signer)

User Fee InformationPart XI

Have your annual gross receipts averaged or are they expected to average not more than $10,000?1

You must include a user fee payment with this application. It will not be processed without your paid user fee. If your averageannual gross receipts have exceeded or will exceed $10,000 annually over a 4-year period, you must submit payment of $750. Ifyour gross receipts have not exceeded or will not exceed $10,000 annually over a 4-year period, the required user fee paymentis $300. See instructions for Part XI, for a definition of gross receipts over a 4-year period. Your check or money order must bemade payable to the United States Treasury. User fees are subject to change. Check our website at www.irs.gov and type “UserFee” in the keyword box, or call Customer Account Services at 1-877-829-5500 for current information.

Check the box if you have enclosed the reduced user fee payment of $300 (Subject to change).2Check the box if you have enclosed the user fee payment of $750 (Subject to change).3

Yes NoIf “Yes,” check the box on line 2 and enclose a user fee payment of $300 (Subject to change—see above).If “No,” check the box on line 3 and enclose a user fee payment of $750 (Subject to change—see above).

(Type or print name of signer)

Reminder: Send the completed Form 1023 Checklist with your filled-in-application.

136




Form 1023 (Rev. 6-2006)


Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Schedule A. Churches1a

b

2a

c

3

4a

5a

6

7

8a

d

9

10

11a

12

13

14

15

16

17

Do you have a written creed, statement of faith, or summary of beliefs? If “Yes,” attach copies ofrelevant documents.

Do you have a form of worship? If “Yes,” describe your form of worship.

Do you have a formal code of doctrine and discipline? If “Yes,” describe your code of doctrine anddiscipline.

Do you have a distinct religious history? If “Yes,” describe your religious history.

Do you have a literature of your own? If “Yes,” describe your literature.

Describe the organization’s religious hierarchy or ecclesiastical government.

Do you have regularly scheduled religious services? If “Yes,” describe the nature of the services andprovide representative copies of relevant literature such as church bulletins.

What is the average attendance at your regularly scheduled religious services?

Do you have an established place of worship? If “Yes,” refer to the instructions for the informationrequired.

Do you own the property where you have an established place of worship?

Do you have an established congregation or other regular membership group? If “No,” refer to theinstructions.

How many members do you have?

Do you have a process by which an individual becomes a member? If “Yes,” describe the processand complete lines 8b–8d, below.

If you have members, do your members have voting rights, rights to participate in religious functions,or other rights? If “Yes,” describe the rights your members have.

May your members be associated with another denomination or church?

Are all of your members part of the same family?

Do you conduct baptisms, weddings, funerals, etc.?

Do you have a school for the religious instruction of the young?

Do you have a minister or religious leader? If “Yes,” describe this person’s role and explain whetherthe minister or religious leader was ordained, commissioned, or licensed after a prescribed course ofstudy.

Do you have schools for the preparation of your ordained ministers or religious leaders?

Is your minister or religious leader also one of your officers, directors, or trustees?

Do you ordain, commission, or license ministers or religious leaders? If “Yes,” describe therequirements for ordination, commission, or licensure.

Are you part of a group of churches with similar beliefs and structures? If “Yes,” explain. Include thename of the group of churches.

Do you issue church charters? If “Yes,” describe the requirements for issuing a charter.

Did you pay a fee for a church charter? If “Yes,” attach a copy of the charter.

Do you have other information you believe should be considered regarding your status as a church?If “Yes,” explain.

b

b

b

b

b

c

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

137




Form 1023 (Rev. 6-2006)


Yes No

Yes No

Schedule B. Schools, Colleges, and Universities

1a

b

2a

3

4

5

6

7

8

Do you normally have a regularly scheduled curriculum, a regular faculty of qualified teachers, aregularly enrolled student body, and facilities where your educational activities are regularly carriedon? If “No,” do not complete the remainder of Schedule B.

b

If you operate a school as an activity, complete Schedule BSection I Operational Information

Is the primary function of your school the presentation of formal instruction? If “Yes,” describe yourschool in terms of whether it is an elementary, secondary, college, technical, or other type of school.If “No,” do not complete the remainder of Schedule B.

Are you a public school because you are operated by a state or subdivision of a state? If “Yes,”explain how you are operated by a state or subdivision of a state. Do not complete the remainder ofSchedule B.

Are you a public school because you are operated wholly or predominantly from government fundsor property? If “Yes,” explain how you are operated wholly or predominantly from government fundsor property. Submit a copy of your funding agreement regarding government funding. Do notcomplete the remainder of Schedule B.

In what public school district, county, and state are you located?

Were you formed or substantially expanded at the time of public school desegregation in the aboveschool district or county?

Has a state or federal administrative agency or judicial body ever determined that you are raciallydiscriminatory? If “Yes,” explain.

Has your right to receive financial aid or assistance from a governmental agency ever been revokedor suspended? If “Yes,” explain.

Do you or will you contract with another organization to develop, build, market, or finance yourfacilities? If “Yes,” explain how that entity is selected, explain how the terms of any contracts orother agreements are negotiated at arm’s length, and explain how you determine that you will pay nomore than fair market value for services.

Note. Make sure your answer is consistent with the information provided in Part VIII, line 7a.

Do you or will you manage your activities or facilities through your own employees or volunteers? If“No,” attach a statement describing the activities that will be managed by others, the names of thepersons or organizations that manage or will manage your activities or facilities, and how thesemanagers were or will be selected. Also, submit copies of any contracts, proposed contracts, orother agreements regarding the provision of management services for your activities or facilities.Explain how the terms of any contracts or other agreements were or will be negotiated, and explainhow you determine you will pay no more than fair market value for services.

Note. Answer “Yes” if you manage or intend to manage your programs through your own employeesor by using volunteers. Answer “No” if you engage or intend to engage a separate organization orindependent contractor. Make sure your answer is consistent with the information provided in PartVIII, line 7b.

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Section II Establishment of Racially Nondiscriminatory PolicyInformation required by Revenue Procedure 75-50.

1

2

3

4

Have you adopted a racially nondiscriminatory policy as to students in your organizing document,bylaws, or by resolution of your governing body? If “Yes,” state where the policy can be found orsupply a copy of the policy. If “No,” you must adopt a nondiscriminatory policy as to studentsbefore submitting this application. See Publication 557.

Do your brochures, application forms, advertisements, and catalogues dealing with studentadmissions, programs, and scholarships contain a statement of your racially nondiscriminatorypolicy?

If “Yes,” attach a representative sample of each document.If “No,” by checking the box to the right you agree that all future printed materials, including websitecontent, will contain the required nondiscriminatory policy statement.

ba

Have you published a notice of your nondiscriminatory policy in a newspaper of general circulationthat serves all racial segments of the community? (See the instructions for specific requirements.) If“No,” explain.

Does or will the organization (or any department or division within it) discriminate in any way on thebasis of race with respect to admissions; use of facilities or exercise of student privileges; faculty oradministrative staff; or scholarship or loan programs? If “Yes,” for any of the above, explain fully.

Yes No

Yes No

Yes No

Yes No

�

138




Form 1023 (Rev. 6-2006)


Schedule B. Schools, Colleges, and Universities (Continued)5 Complete the table below to show the racial composition for the current academic year and projected for the next

academic year, of: (a) the student body, (b) the faculty, and (c) the administrative staff. Provide actual numbers rather thanpercentages for each racial category.

Yes No

If you are not operational, submit an estimate based on the best information available (such as the racial composition ofthe community served).

Racial Category (a) Student Body (b) Faculty (c) Administrative StaffCurrent Year Next Year

Total

Current Year Current YearNext Year Next Year

6 In the table below, provide the number and amount of loans and scholarships awarded to students enrolled by racialcategories.

Racial Category Number of Loans Amount of Loans Number of ScholarshipsCurrent Year Next Year

Total

Current Year Current YearNext Year Next YearAmount of ScholarshipsCurrent Year Next Year

7a Attach a list of your incorporators, founders, board members, and donors of land or buildings,whether individuals or organizations.

Do any of these individuals or organizations have an objective to maintain segregated public orprivate school education? If “Yes,” explain.

Will you maintain records according to the non-discrimination provisions contained in RevenueProcedure 75-50? If “No,” explain. (See instructions.)

8

b

Yes No

139




Form 1023 (Rev. 6-2006)


Schedule C. Hospitals and Medical Research OrganizationsCheck the box if you are a hospital. See the instructions for a definition of the term “hospital,” whichincludes an organization whose principal purpose or function is providing hospital or medical care.Complete Section I below.

Yes No

Check the box if you are a medical research organization operated in conjunction with a hospital. Seethe instructions for a definition of the term “medical research organization,” which refers to anorganization whose principal purpose or function is medical research and which is directly engaged in thecontinuous active conduct of medical research in conjunction with a hospital. Complete Section II.

7

8

b

Yes No

1a

Section IAre all the doctors in the community eligible for staff privileges? If “No,” give the reasons why andexplain how the medical staff is selected.

Hospitals

2a

b

c

3a

4a

5a

d

e

6a

9

Do you or will you provide medical services to all individuals in your community who can pay forthemselves or have private health insurance? If “No,” explain.

Do you or will you provide medical services to all individuals in your community who participate inMedicare? If “No,” explain.

Do you or will you provide medical services to all individuals in your community who participate inMedicaid? If “No,” explain.

Do you or will you require persons covered by Medicare or Medicaid to pay a deposit beforereceiving services? If “Yes,” explain.Does the same deposit requirement, if any, apply to all other patients? If “No,” explain.

Do you or will you maintain a full-time emergency room? If “No,” explain why you do not maintain afull-time emergency room. Also, describe any emergency services that you provide.

Do you have a policy on providing emergency services to persons without apparent means to pay? If“Yes,” provide a copy of the policy.

Do you have any arrangements with police, fire, and voluntary ambulance services for the delivery oradmission of emergency cases? If “Yes,” describe the arrangements, including whether they arewritten or oral agreements. If written, submit copies of all such agreements.

Do you provide for a portion of your services and facilities to be used for charity patients? If “Yes,”answer 5b through 5e.

Explain your policy regarding charity cases, including how you distinguish between charity care andbad debts. Submit a copy of your written policy.

Provide data on your past experience in admitting charity patients, including amounts you expend fortreating charity care patients and types of services you provide to charity care patients.

Describe any arrangements you have with federal, state, or local governments or governmentagencies for paying for the cost of treating charity care patients. Submit copies of any writtenagreements.

Do you provide services on a sliding fee schedule depending on financial ability to pay? If “Yes,”submit your sliding fee schedule.

Do you or will you carry on a formal program of medical training or medical research? If “Yes,”describe such programs, including the type of programs offered, the scope of such programs, andaffiliations with other hospitals or medical care providers with which you carry on the medical trainingor research programs.

Do you or will you carry on a formal program of community education? If “Yes,” describe suchprograms, including the type of programs offered, the scope of such programs, and affiliation withother hospitals or medical care providers with which you offer community education programs.

Do you or will you provide office space to physicians carrying on their own medical practices? If“Yes,” describe the criteria for who may use the space, explain the means used to determine thatyou are paid at least fair market value, and submit representative lease agreements.

Is your board of directors comprised of a majority of individuals who are representative of thecommunity you serve? Include a list of each board member’s name and business, financial, orprofessional relationship with the hospital. Also, identify each board member who is representative ofthe community and describe how that individual is a community representative.

Do you participate in any joint ventures? If “Yes,” state your ownership percentage in each jointventure, list your investment in each joint venture, describe the tax status of other participants ineach joint venture (including whether they are section 501(c)(3) organizations), describe the activitiesof each joint venture, describe how you exercise control over the activities of each joint venture, anddescribe how each joint venture furthers your exempt purposes. Also, submit copies of allagreements.Note. Make sure your answer is consistent with the information provided in Part VIII, line 8.

b

b

b

c

c

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

140




Form 1023 (Rev. 6-2006)


Schedule C. Hospitals and Medical Research Organizations (Continued)Section I Hospitals (Continued)10 Do you or will you manage your activities or facilities through your own employees or volunteers? If

“No,” attach a statement describing the activities that will be managed by others, the names of thepersons or organizations that manage or will manage your activities or facilities, and how thesemanagers were or will be selected. Also, submit copies of any contracts, proposed contracts, orother agreements regarding the provision of management services for your activities or facilities.Explain how the terms of any contracts or other agreements were or will be negotiated, and explainhow you determine you will pay no more than fair market value for services.Note. Answer “Yes” if you do manage or intend to manage your programs through your ownemployees or by using volunteers. Answer “No” if you engage or intend to engage a separateorganization or independent contractor. Make sure your answer is consistent with the informationprovided in Part VIII, line 7b.

Yes No

Do you or will you offer recruitment incentives to physicians? If “Yes,” describe your recruitmentincentives and attach copies of all written recruitment incentive policies.

Do you or will you lease equipment, assets, or office space from physicians who have a financial orprofessional relationship with you? If “Yes,” explain how you establish a fair market value for thelease.

Have you purchased medical practices, ambulatory surgery centers, or other business assets fromphysicians or other persons with whom you have a business relationship, aside from the purchase? If“Yes,” submit a copy of each purchase and sales contract and describe how you arrived at fairmarket value, including copies of appraisals.

Have you adopted a conflict of interest policy consistent with the sample health care organizationconflict of interest policy in Appendix A of the instructions? If “Yes,” submit a copy of the policy andexplain how the policy has been adopted, such as by resolution of your governing board. If “No,”explain how you will avoid any conflicts of interest in your business dealings.

11

12

13

14

Yes No

Yes No

Yes No

Yes No

Section II Medical Research Organizations1

2

3

Name the hospitals with which you have a relationship and describe the relationship. Attach copiesof written agreements with each hospital that demonstrate continuing relationships between you andthe hospital(s).

Attach a schedule describing your present and proposed activities for the direct conduct of medicalresearch; describe the nature of the activities, and the amount of money that has been or will bespent in carrying them out.

Attach a schedule of assets showing their fair market value and the portion of your assets directlydevoted to medical research.

141




Form 1023 (Rev. 6-2006)


Schedule D. Section 509(a)(3) Supporting OrganizationsSection I Identifying Information About the Supported Organization(s)

Yes No

Section II Relationship with Supported Organization(s)—Three Tests

1

2

3

State the names, addresses, and EINs of the supported organizations. If additional space is needed, attach a separatesheet.Name Address EIN

–

–

Are all supported organizations listed in line 1 public charities under section 509(a)(1) or (2)? If “Yes,”go to Section II. If “No,” go to line 3.

Do the supported organizations have tax-exempt status under section 501(c)(4), 501(c)(5), or501(c)(6)?

If “Yes,” for each 501(c)(4), (5), or (6) organization supported, provide the following financialinformation:

If “No,” attach a statement describing how each organization you support is a public charity undersection 509(a)(1) or (2).

Yes No

To be classified as a supporting organization, an organization must meet one of three relationship tests:Test 1: “Operated, supervised, or controlled by” one or more publicly supported organizations, orTest 2: “Supervised or controlled in connection with” one or more publicly supported organizations, orTest 3: “Operated in connection with” one or more publicly supported organizations.

1

2

3

Information to establish the “operated, supervised, or controlled by” relationship (Test 1)Is a majority of your governing board or officers elected or appointed by the supportedorganization(s)? If “Yes,” describe the process by which your governing board is appointed andelected; go to Section III. If “No,” continue to line 2.

Information to establish the “supervised or controlled in connection with” relationship (Test 2)Does a majority of your governing board consist of individuals who also serve on the governingboard of the supported organization(s)? If “Yes,” describe the process by which your governingboard is appointed and elected; go to Section III. If “No,” go to line 3.

Information to establish the “operated in connection with” responsiveness test (Test 3)Are you a trust from which the named supported organization(s) can enforce and compel anaccounting under state law? If “Yes,” explain whether you advised the supported organization(s) inwriting of these rights and provide a copy of the written communication documenting this; go toSection II, line 5. If “No,” go to line 4a.

Information to establish the alternative “operated in connection with” responsiveness test (Test 3)Do the officers, directors, trustees, or members of the supported organization(s) elect or appoint oneor more of your officers, directors, or trustees? If “Yes,” explain and provide documentation; go toline 4d, below. If “No,” go to line 4b.

Do one or more members of the governing body of the supported organization(s) also serve as yourofficers, directors, or trustees or hold other important offices with respect to you? If “Yes,” explainand provide documentation; go to line 4d, below. If “No,” go to line 4c.

Do your officers, directors, or trustees maintain a close and continuous working relationship with theofficers, directors, or trustees of the supported organization(s)? If “Yes,” explain and providedocumentation.

Do the supported organization(s) have a significant voice in your investment policies, in the makingand timing of grants, and in otherwise directing the use of your income or assets? If “Yes,” explainand provide documentation.

Describe and provide copies of written communications documenting how you made the supportedorganization(s) aware of your supporting activities.

4a

b

c

d

e

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

● Part IX-A. Statement of Revenues and Expenses, lines 1–13 and● Part X, lines 6b(ii)(a), 6b(ii)(b), and 7.

142




Form 1023 (Rev. 6-2006)


Schedule D. Section 509(a)(3) Supporting Organizations (Continued)Section II Relationship with Supported Organization(s)—Three Tests (Continued)

6a

bc

d

Yes No

Yes No

Yes No

5 Information to establish the “operated in connection with” integral part test (Test 3)Do you conduct activities that would otherwise be carried out by the supported organization(s)? If“Yes,” explain and go to Section III. If “No,” continue to line 6a.

Yes No

Information to establish the alternative “operated in connection with” integral part test (Test 3)Do you distribute at least 85% of your annual net income to the supported organization(s)? If “Yes,”go to line 6b. (See instructions.)

If “No,” state the percentage of your income that you distribute to each supported organization. Alsoexplain how you ensure that the supported organization(s) are attentive to your operations.

How much do you contribute annually to each supported organization? Attach a schedule.What is the total annual revenue of each supported organization? If you need additional space,attach a list.

Do you or the supported organization(s) earmark your funds for support of a particular program oractivity? If “Yes,” explain.

Does your organizing document specify the supported organization(s) by name? If “Yes,” state thearticle and paragraph number and go to Section III. If “No,” answer line 7b.Attach a statement describing whether there has been an historic and continuing relationshipbetween you and the supported organization(s).

7a

b

Section III Organizational Test1a If you met relationship Test 1 or Test 2 in Section II, your organizing document must specify the

supported organization(s) by name, or by naming a similar purpose or charitable class ofbeneficiaries. If your organizing document complies with this requirement, answer “Yes.” If yourorganizing document does not comply with this requirement, answer “No,” and see the instructions.

If you met relationship Test 3 in Section II, your organizing document must generally specify thesupported organization(s) by name. If your organizing document complies with this requirement,answer “Yes,” and go to Section IV. If your organizing document does not comply with thisrequirement, answer “No,” and see the instructions.

Yes No

Yes No

Section IV Disqualified Person Test

1a

You do not qualify as a supporting organization if you are controlled directly or indirectly by one or more disqualified persons(as defined in section 4946) other than foundation managers or one or more organizations that you support. Foundationmanagers who are also disqualified persons for another reason are disqualified persons with respect to you.

Do any persons who are disqualified persons with respect to you, (except individuals who aredisqualified persons only because they are foundation managers), appoint any of your foundationmanagers? If “Yes,” (1) describe the process by which disqualified persons appoint any of yourfoundation managers, (2) provide the names of these disqualified persons and the foundationmanagers they appoint, and (3) explain how control is vested over your operations (including assetsand activities) by persons other than disqualified persons.

Do any persons who have a family or business relationship with any disqualified persons withrespect to you, (except individuals who are disqualified persons only because they are foundationmanagers), appoint any of your foundation managers? If “Yes,” (1) describe the process by whichindividuals with a family or business relationship with disqualified persons appoint any of yourfoundation managers, (2) provide the names of these disqualified persons, the individuals with afamily or business relationship with disqualified persons, and the foundation managers appointed,and (3) explain how control is vested over your operations (including assets and activities) inindividuals other than disqualified persons.

Do any persons who are disqualified persons, (except individuals who are disqualified persons onlybecause they are foundation managers), have any influence regarding your operations, including yourassets or activities? If “Yes,” (1) provide the names of these disqualified persons, (2) explain howinfluence is exerted over your operations (including assets and activities), and (3) explain how controlis vested over your operations (including assets and activities) by individuals other than disqualifiedpersons.

Yes No

Yes No

Yes No

b

c

b

143




Form 1023 (Rev. 6-2006)


Schedule E. Organizations Not Filing Form 1023 Within 27 Months of Formation

2a

Schedule E is intended to determine whether you are eligible for tax exemption under section 501(c)(3) from the postmark dateof your application or from your date of incorporation or formation, whichever is earlier. If you are not eligible for tax exemptionunder section 501(c)(3) from your date of incorporation or formation, Schedule E is also intended to determine whether you areeligible for tax exemption under section 501(c)(4) for the period between your date of incorporation or formation and thepostmark date of your application.

Yes No

b

1 Are you a church, association of churches, or integrated auxiliary of a church? If “Yes,” completeSchedule A and stop here. Do not complete the remainder of Schedule E.

Are you a public charity with annual gross receipts that are normally $5,000 or less? If “Yes,” stophere. Answer “No” if you are a private foundation, regardless of your gross receipts.

If your gross receipts were normally more than $5,000, are you filing this application within 90 daysfrom the end of the tax year in which your gross receipts were normally more than $5,000? If “Yes,”stop here.

Were you included as a subordinate in a group exemption application or letter? If “No,” go to line 4.

If you were included as a subordinate in a group exemption letter, are you filing this applicationwithin 27 months from the date you were notified by the organization holding the group exemptionletter or the Internal Revenue Service that you cease to be covered by the group exemption letter? If“Yes,” stop here.

If you were included as a subordinate in a timely filed group exemption request that was denied, areyou filing this application within 27 months from the postmark date of the Internal Revenue Servicefinal adverse ruling letter? If “Yes,” stop here.

Were you created on or before October 9, 1969? If “Yes,” stop here. Do not complete the remainderof this schedule.

If you answered “No” to lines 1 through 4, we cannot recognize you as tax exempt from your date offormation unless you qualify for an extension of time to apply for exemption. Do you wish to requestan extension of time to apply to be recognized as exempt from the date you were formed? If “Yes,”attach a statement explaining why you did not file this application within the 27-month period. Do notanswer lines 6, 7, or 8. If “No,” go to line 6a.

If you answered “No” to line 5, you can only be exempt under section 501(c)(3) from the postmarkdate of this application. Therefore, do you want us to treat this application as a request for taxexemption from the postmark date? If “Yes,” you are eligible for an advance ruling. Complete Part X,line 6a. If “No,” you will be treated as a private foundation.

Note. Be sure your ruling eligibility agrees with your answer to Part X, line 6.Do you anticipate significant changes in your sources of support in the future? If “Yes,” completeline 7 below.

3a

b

c

4

5

6a

b

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

144




Form 1023 (Rev. 6-2006)


Schedule E. Organizations Not Filing Form 1023 Within 27 Months of Formation (Continued)7 Complete this item only if you answered “Yes” to line 6b. Include projected revenue for the first two full years following the

current tax year.

Type of Revenue Projected revenue for 2 years following current tax year

(a) FromTo

(b)FromTo

(c) Total

1

2

3

4

5

6

7

8

9

10

11

12

13

Gifts, grants, and contributions received (donot include unusual grants)

Membership fees received

Gross investment income

Net unrelated business income

Taxes levied for your benefit

Value of services or facilities furnished by agovernmental unit without charge (not includingthe value of services generally furnished to thepublic without charge)

Any revenue not otherwise listed above or inlines 9–12 below (attach an itemized list)

Total of lines 1 through 7

Gross receipts from admissions, merchandisesold, or services performed, or furnishing offacilities in any activity that is related to yourexempt purposes (attach itemized list)

Total of lines 8 and 9

Net gain or loss on sale of capital assets(attach an itemized list)

Unusual grants

Total revenue. Add lines 10 through 12

8 According to your answers, you are only eligible for tax exemption under section 501(c)(3) from thepostmark date of your application. However, you may be eligible for tax exemption under section501(c)(4) from your date of formation to the postmark date of the Form 1023. Tax exemption undersection 501(c)(4) allows exemption from federal income tax, but generally not deductibility ofcontributions under Code section 170. Check the box at right if you want us to treat this as arequest for exemption under 501(c)(4) from your date of formation to the postmark date.

Attach a completed Page 1 of Form 1024, Application for Recognition of Exemption Under Section501(a), to this application.

�

145




Form 1023 (Rev. 6-2006)


Schedule F. Homes for the Elderly or Handicapped and Low-Income HousingSection I General Information About Your Housing

Yes No

1

2

3

Yes No

Describe the type of housing you provide.

Provide copies of any application forms you use for admission.

Explain how the public is made aware of your facility.

4a Provide a description of each facility.What is the total number of residents each facility can accommodate?What is your current number of residents in each facility?Describe each facility in terms of whether residents rent or purchase housing from you.

Attach a sample copy of your residency or homeownership contract or agreement.

Do you participate in any joint ventures? If “Yes,” state your ownership percentage in each jointventure, list your investment in each joint venture, describe the tax status of other participants ineach joint venture (including whether they are section 501(c)(3) organizations), describe the activitiesof each joint venture, describe how you exercise control over the activities of each joint venture, anddescribe how each joint venture furthers your exempt purposes. Also, submit copies of all jointventure agreements.

Note. Make sure your answer is consistent with the information provided in Part VIII, line 8.

Do you or will you contract with another organization to develop, build, market, or finance yourhousing? If “Yes,” explain how that entity is selected, explain how the terms of any contract(s) arenegotiated at arm’s length, and explain how you determine you will pay no more than fair marketvalue for services.

Note. Make sure your answer is consistent with the information provided in Part VIII, line 7a.

Do you or will you manage your activities or facilities through your own employees or volunteers? If“No,” attach a statement describing the activities that will be managed by others, the names of thepersons or organizations that manage or will manage your activities or facilities, and how thesemanagers were or will be selected. Also, submit copies of any contracts, proposed contracts, orother agreements regarding the provision of management services for your activities or facilities.Explain how the terms of any contracts or other agreements were or will be negotiated, and explainhow you determine you will pay no more than fair market value for services.Note. Answer “Yes” if you do manage or intend to manage your programs through your ownemployees or by using volunteers. Answer “No” if you engage or intend to engage a separateorganization or independent contractor. Make sure your answer is consistent with the informationprovided in Part VIII, line 7b.

Do you participate in any government housing programs? If “Yes,” describe these programs.

Do you own the facility? If “No,” describe any enforceable rights you possess to purchase the facilityin the future; go to line 10c. If “Yes,” answer line 10b.

How did you acquire the facility? For example, did you develop it yourself, purchase a project, etc.Attach all contracts, transfer agreements, or other documents connected with the acquisition of thefacility.

Do you lease the facility or the land on which it is located? If “Yes,” describe the parties to thelease(s) and provide copies of all leases.

bcd

5

6

7

8

9

10a

b

c

Yes No

Yes No

Yes No

Yes No

146




Form 1023 (Rev. 6-2006)


Schedule F. Homes for the Elderly or Handicapped and Low-Income Housing (Continued)Section II Homes for the Elderly or Handicapped

Yes No1a

2a

3a

Do you provide housing for the elderly? If “Yes,” describe who qualifies for your housing in terms ofage, infirmity, or other criteria and explain how you select persons for your housing.

4

b

5

Do you provide housing for the handicapped? If “Yes,” describe who qualifies for your housing interms of disability, income levels, or other criteria and explain how you select persons for yourhousing.

Do you charge an entrance or founder’s fee? If “Yes,” describe what this charge covers, whether it isa one-time fee, how the fee is determined, whether it is payable in a lump sum or on an installmentbasis, whether it is refundable, and the circumstances, if any, under which it may be waived.

Do you charge periodic fees or maintenance charges? If “Yes,” describe what these charges coverand how they are determined.

Is your housing affordable to a significant segment of the elderly or handicapped persons in thecommunity? Identify your community. Also, if “Yes,” explain how you determine your housing isaffordable.

Yes No

Yes No

Yes No

Yes No

b

c

Do you have an established policy concerning residents who become unable to pay their regularcharges? If “Yes,” describe your established policy.

Do you have any arrangements with government welfare agencies or others to absorb all or part ofthe cost of maintaining residents who become unable to pay their regular charges? If “Yes,” describethese arrangements.

Do you have arrangements for the healthcare needs of your residents? If “Yes,” describe thesearrangements.

Are your facilities designed to meet the physical, emotional, recreational, social, religious, and/orother similar needs of the elderly or handicapped? If “Yes,” describe these design features.

b

Yes No

Yes No

Yes No

Yes No

Section III Low-Income Housing

Do you provide low-income housing? If “Yes,” describe who qualifies for your housing in terms ofincome levels or other criteria, and describe how you select persons for your housing.

In addition to rent or mortgage payments, do residents pay periodic fees or maintenance charges? If“Yes,” describe what these charges cover and how they are determined.

Is your housing affordable to low income residents? If “Yes,” describe how your housing is madeaffordable to low-income residents.

Note. Revenue Procedure 96-32, 1996-1 C.B. 717, provides guidelines for providing low-incomehousing that will be treated as charitable. (At least 75% of the units are occupied by low-incometenants or 40% are occupied by tenants earning not more than 120% of the very low-income levelsfor the area.)

Do you impose any restrictions to make sure that your housing remains affordable to low-incomeresidents? If “Yes,” describe these restrictions.

Do you provide social services to residents? If “Yes,” describe these services.

1

2

3a

b

4

Yes No

Yes No

Yes No

Yes No

Yes No

147




Form 1023 (Rev. 6-2006)


Schedule G. Successors to Other Organizations1a

2a

3

4

b

5

bc

Are you a successor to a for-profit organization? If “Yes,” explain the relationship with thepredecessor organization that resulted in your creation and complete line 1b.

Yes No

Explain why you took over the activities or assets of a for-profit organization or converted fromfor-profit to nonprofit status.

Are you a successor to an organization other than a for-profit organization? Answer “Yes” if you havetaken or will take over the activities of another organization; or you have taken or will take over 25%or more of the fair market value of the net assets of another organization. If “Yes,” explain therelationship with the other organzation that resulted in your creation.Provide the tax status of the predecessor organization.Did you or did an organization to which you are a successor previously apply for tax exemptionunder section 501(c)(3) or any other section of the Code? If “Yes,” explain how the application wasresolved.

Was your prior tax exemption or the tax exemption of an organization to which you are a successorrevoked or suspended? If “Yes,” explain. Include a description of the corrections you made tore-establish tax exemption.

Explain why you took over the activities or assets of another organization.

Provide the name, last address, and EIN of the predecessor organization and describe its activities.

d

e

Yes No

Yes No

Yes No

Name:Address:

EIN: –

List the owners, partners, principal stockholders, officers, and governing board members of the predecessor organization.Attach a separate sheet if additional space is needed.

Name Address Share/Interest (If a for-profit)

Do or will any of the persons listed in line 4, maintain a working relationship with you? If “Yes,”describe the relationship in detail and include copies of any agreements with any of these persons orwith any for-profit organizations in which these persons own more than a 35% interest.

Were any assets transferred, whether by gift or sale, from the predecessor organization to you?If “Yes,” provide a list of assets, indicate the value of each asset, explain how the value wasdetermined, and attach an appraisal, if available. For each asset listed, also explain if the transferwas by gift, sale, or combination thereof.

Were any restrictions placed on the use or sale of the assets? If “Yes,” explain the restrictions.

Provide a copy of the agreement(s) of sale or transfer.

Were any debts or liabilities transferred from the predecessor for-profit organization to you?If “Yes,” provide a list of the debts or liabilities that were transferred to you, indicating the amount ofeach, how the amount was determined, and the name of the person to whom the debt or liability isowed.

Will you lease or rent any property or equipment previously owned or used by the predecessorfor-profit organization, or from persons listed in line 4, or from for-profit organizations in which thesepersons own more than a 35% interest? If “Yes,” submit a copy of the lease or rental agreement(s).Indicate how the lease or rental value of the property or equipment was determined.

Will you lease or rent property or equipment to persons listed in line 4, or to for-profit organizationsin which these persons own more than a 35% interest? If “Yes,” attach a list of the property orequipment, provide a copy of the lease or rental agreement(s), and indicate how the lease or rentalvalue of the property or equipment was determined.

6a

b

c

7

8

9

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

148




Form 1023 (Rev. 6-2006)


Schedule H. Organizations Providing Scholarships, Fellowships, Educational Loans, or Other EducationalGrants to Individuals and Private Foundations Requesting Advance Approval of Individual Grant ProceduresSection I Names of individual recipients are not required to be listed in Schedule H.

Public charities and private foundations complete lines 1a through 7 of this section. See theinstructions to Part X if you are not sure whether you are a public charity or a privatefoundation.

1a

2

3

Describe the types of educational grants you provide to individuals, such as scholarships, fellowships, loans, etc.

4a

bcd

5

6

7 Yes No

Describe the purpose and amount of your scholarships, fellowships, and other educational grants and loans that youaward.

If you award educational loans, explain the terms of the loans (interest rate, length, forgiveness, etc.).Specify how your program is publicized.Provide copies of any solicitation or announcement materials.Provide a sample copy of the application used.

Do you maintain case histories showing recipients of your scholarships, fellowships, educationalloans, or other educational grants, including names, addresses, purposes of awards, amount of eachgrant, manner of selection, and relationship (if any) to officers, trustees, or donors of funds to you? If“No,” refer to the instructions.

Describe the specific criteria you use to determine who is eligible for your program. (For example, eligibility selectioncriteria could consist of graduating high school students from a particular high school who will attend college, writers ofscholarly works about American history, etc.)

Describe the specific criteria you use to select recipients. (For example, specific selection criteria could consist of prioracademic performance, financial need, etc.)

Describe how you determine the number of grants that will be made annually.Describe how you determine the amount of each of your grants.Describe any requirement or condition that you impose on recipients to obtain, maintain, or qualify for renewal of a grant.(For example, specific requirements or conditions could consist of attendance at a four-year college, maintaining a certaingrade point average, teaching in public school after graduation from college, etc.)

Describe your procedures for supervising the scholarships, fellowships, educational loans, or other educational grants.Describe whether you obtain reports and grade transcripts from recipients, or you pay grants directly to a school underan arrangement whereby the school will apply the grant funds only for enrolled students who are in good standing. Also,describe your procedures for taking action if the terms of the award are violated.

Who is on the selection committee for the awards made under your program, including names of current committeemembers, criteria for committee membership, and the method of replacing committee members?

Are relatives of members of the selection committee, or of your officers, directors, or substantialcontributors eligible for awards made under your program? If “Yes,” what measures are taken toensure unbiased selections?

Note. If you are a private foundation, you are not permitted to provide educational grants to disqualifiedpersons. Disqualified persons include your substantial contributors and foundation managers andcertain family members of disqualified persons.

b

cdef

Yes No

Section II Private foundations complete lines 1a through 4f of this section. Public charities do notcomplete this section.

1a

b

2

3

If we determine that you are a private foundation, do you want this application to beconsidered as a request for advance approval of grant making procedures?

For which section(s) do you wish to be considered?● 4945(g)(1)—Scholarship or fellowship grant to an individual for study at an educational institution● 4945(g)(3)—Other grants, including loans, to an individual for travel, study, or other similar

purposes, to enhance a particular skill of the grantee or to produce a specific product

Do you represent that you will (1) arrange to receive and review grantee reports annuallyand upon completion of the purpose for which the grant was awarded, (2) investigatediversions of funds from their intended purposes, and (3) take all reasonable andappropriate steps to recover diverted funds, ensure other grant funds held by a granteeare used for their intended purposes, and withhold further payments to grantees until youobtain grantees’ assurances that future diversions will not occur and that grantees willtake extraordinary precautions to prevent future diversions from occurring?

Do you represent that you will maintain all records relating to individual grants, includinginformation obtained to evaluate grantees, identify whether a grantee is a disqualifiedperson, establish the amount and purpose of each grant, and establish that youundertook the supervision and investigation of grants described in line 2?

No N/A

Yes No

Yes No

Yes

149




Form 1023 (Rev. 6-2006)


Schedule H. Organizations Providing Scholarships, Fellowships, Educational Loans, or Other EducationalGrants to Individuals and Private Foundations Requesting Advance Approval of Individual Grant Procedures(Continued)Section II Private foundations complete lines 1a through 4f of this section. Public charities do not

complete this section. (Continued)

4a

b

Do you or will you provide scholarships, fellowships, or educational loans to attend aneducational institution to employees of a particular employer?

Do you or will you award scholarships, fellowships, and educational loans to attend aneducational institution based on the status of an individual being an employee of aparticular employer? If “Yes,” complete lines 4b through 4f.

No N/A

Yes No

Yes

Will you comply with the seven conditions and either the percentage tests or facts andcircumstances test for scholarships, fellowships, and educational loans to attend aneducational institution as set forth in Revenue Procedures 76-47, 1976-2 C.B. 670, and80-39, 1980-2 C.B. 772, which apply to inducement, selection committee, eligibilityrequirements, objective basis of selection, employment, course of study, and otherobjectives? (See lines 4c, 4d, and 4e, regarding the percentage tests.)

Do you provide scholarships, fellowships, or educational loans to attend an educationalinstitution to children of employees of a particular employer?

If you provide scholarships, fellowships, or educational loans to attend an educationalinstitution to children of employees of a particular employer, will you award grants to 10%or fewer of the number of employees’ children who can be shown to be eligible for grants(whether or not they submitted an application) in that year, as provided by RevenueProcedures 76-47 and 80-39?

Note. Statistical or sampling techniques are not acceptable. See Revenue Procedure85-51, 1985-2 C.B. 717, for additional information.

If you provide scholarships, fellowships, or educational loans to attend an educationalinstitution to children of employees of a particular employer without regard to either the25% limitation described in line 4d, or the 10% limitation described in line 4e, will youaward grants based on facts and circumstances that demonstrate that the grants will notbe considered compensation for past, present, or future services or otherwise provide asignificant benefit to the particular employer? If “Yes,” describe the facts andcircumstances that you believe will demonstrate that the grants are neither compensatorynor a significant benefit to the particular employer. In your explanation, describe why youcannot satisfy either the 25% test described in line 4d or the 10% test described in line 4e.

If “Yes,” will you award grants to 10% or fewer of the eligible applicants who wereactually considered by the selection committee in selecting recipients of grants in thatyear as provided by Revenue Procedures 76-47 and 80-39?

If “Yes,” will you award grants to 25% or fewer of the eligible applicants who wereactually considered by the selection committee in selecting recipients of grants in thatyear as provided by Revenue Procedures 76-47 and 80-39? If “No,” go to line 4e.

If “Yes,” describe how you will determine who can be shown to be eligible for grantswithout submitting an application, such as by obtaining written statements or otherinformation about the expectations of employees’ children to attend an educationalinstitution. If “No,” go to line 4f.

c

d

e

f

No N/AYes

No N/AYes

NoYes

NoYes

Yes No

Yes No

150




Form 1023 Checklist(Revised June 2006)Application for Recognition of Exemption under Section 501(c)(3) of theInternal Revenue Code

Note. Retain a copy of the completed Form 1023 in your permanent records. Refer to the General Instructionsregarding Public Inspection of approved applications.

Check each box to finish your application (Form 1023). Send this completed Checklist with your filled-inapplication. If you have not answered all the items below, your application may be returned to you asincomplete.

Assemble the application and materials in this order:● Form 1023 Checklist● Form 2848, Power of Attorney and Declaration of Representative (if filing)● Form 8821, Tax Information Authorization (if filing)● Expedite request (if requesting)● Application (Form 1023 and Schedules A through H, as required)● Articles of organization● Amendments to articles of organization in chronological order● Bylaws or other rules of operation and amendments● Documentation of nondiscriminatory policy for schools, as required by Schedule B● Form 5768, Election/Revocation of Election by an Eligible Section 501(c)(3) Organization To Make

Expenditures To Influence Legislation (if filing)● All other attachments, including explanations, financial data, and printed materials or publications. Label

each page with name and EIN.

User fee payment placed in envelope on top of checklist. DO NOT STAPLE or otherwise attach your check ormoney order to your application. Instead, just place it in the envelope.

Employer Identification Number (EIN)

Schedules. Submit only those schedules that apply to you and check either “Yes” or “No” below.

Completed Parts I through XI of the application, including any requested information and any requiredSchedules A through H.

● You must provide specific details about your past, present, and planned activities.● Generalizations or failure to answer questions in the Form 1023 application will prevent us from recognizing

you as tax exempt.● Describe your purposes and proposed activities in specific easily understood terms.● Financial information should correspond with proposed activities.

Schedule A Yes No

Schedule B Yes No

Schedule C Yes No

Schedule D Yes No

Schedule E Yes No

Schedule F Yes No

Schedule G Yes No

Schedule H Yes No

151




An exact copy of your complete articles of organization (creating document). Absence of the proper purposeand dissolution clauses is the number one reason for delays in the issuance of determination letters.

Signature of an officer, director, trustee, or other official who is authorized to sign the application.

Your name on the application must be the same as your legal name as it appears in your articles oforganization.

Send completed Form 1023, user fee payment, and all other required information, to:

Internal Revenue ServiceP.O. Box 192Covington, KY 41012-0192

If you are using express mail or a delivery service, send Form 1023, user fee payment, and attachments to:

Internal Revenue Service201 West Rivercenter Blvd.Attn: Extracting Stop 312Covington, KY 41011

● Location of Purpose Clause from Part III, line 1 (Page, Article and Paragraph Number)● Location of Dissolution Clause from Part III, line 2b or 2c (Page, Article and Paragraph Number) or by

operation of state law

● Signature at Part XI of Form 1023.

152