pre site visit definition

Pre-Bid Meetings and Site Visits

• Jorge A. Lynch T.

Pre-bid meetings are usually held, if previously mentioned in the solicitation documents , during the bid / proposal preparation period. Their purpose is to clarify any concerns bidders may have with the solicitation documents , scope of work and other details of the requirement. These meetings are formal and the results are made available in writing to all prospective bidders that registered interest in the requirement, be it through requesting, buying or downloading the solicitation documents from an official website. Prospective bidders are permitted to request clarifications by a date and time stipulated in the solicitation documents .

It is most beneficial to hold pre-bid meetings prior to formally responding to the request for clarifications, that way the responses to the request for clarifications can be sent along with the results of the pre-bid meeting , including a copy of the minutes of the pre-bid meeting .

Although prospective bidders should be encouraged to get as much information as possible (including visiting the site) on a specific or upcoming requirement of a procuring entity , formal site visits are usually planned and carried out for works procurement and more complex goods requirements southafrica-ed.com .

When a site visit is planned, the details of the date and time must be stated in the solicitation documents . And the site visit should take place before (but not too far in advance of) the pre-bid meeting . The results are also formally sent to all prospective bidders that expressed interest in the requirement, by way of minutes of the site visit and pre-bid meeting , including consolidated responses to request for clarifications, also from prospective bidders.

The pre-bid meeting is usually open to all interested prospective bidders; however, in cases where pre-qualification or short-listing is carried out, only pre-qualified or short-listed bidders are invited to attend the pre-bid meeting .

Site visits, as mentioned above, can and should preferable be held prior to the pre-bid meeting . The reason for this preference is because after the site visit, bidders may have additional queries and these can be addressed at the pre-bid meeting and formally sent (with the minutes) to all prospective bidders that expressed interest in the requirement, or those that were short-listed through a pre-qualification exercise or restricted bidding process. The time and venue of these meetings are addressed in the solicitation documents , and attendance is usually not obligatory.

During the site visit the prospective bidders survey the site and ask questions to clarify any doubts or information provided in the solicitation documents . Sometimes, as a result of the site visit/ pre-bid meeting there might be a need to extend the bid / proposal submission date by way of Addendum to the solicitation documents to give bidders sufficient time to address any changes made to the solicitation documents as a result of the site visit and/or pre-bid meeting .

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Related posts:, pre-bid and pre-proposal meetings: similarities and differences, effectiveness and efficiency in public procurement: key pillars for optimal resource management, pre-bid meetings: what, why, who, when, where, how, 8 causes of delays in the public procurement process and how to avoid them, importance of using checklists in public procurement, 4 thoughts on “pre-bid meetings and site visits”.

can the site visit be in different times/ i belive no to keep all bidders expose to same info and not to miss any thing

what do you think

I agree with you Salem. In theory, the site visit could be at different time, and we should permit potential bidders to visit the site during the bid submission period. But, for practical purposes, it should be conducted in an organized manner and whatever is discussed must be put in writing and formally sent to all bidders that registered interest in the procurement.

What do you think?

I am interested in finding out how many days, before a scheduled pre-bid meeting (or bid document release date) should the legal notice be advertised in the paper?

Ideally, you want to give prospective bidders sufficient time to get familiar with the content of the bidding documents so they can prepare their questions and seek clarification either before or during the pre-bid meeting. At least 5 days after publication of the procurement notice is sufficient. Ten days is even better for more complex procurements.

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Conducting a Meaningful Site Visit

A site visit can be one of the most important tools you use, as a grantmaker, in determining your ultimate funding decisions. For example, an in-person look at a potential grantee’s activities can complement a grantee’s written proposal and give you a clearer picture of their request. In fact, site visits can be one of the most interesting parts of the grantmaking process.

What makes a site visit meaningful? Careful preparation, mutually understood goals, a willingness to see the event as part of an ongoing relationship. So how can you be a "good guest" while conducting a structured, but not stifling, site visit? Here grantmakers offer some helpful advice for:

"It's not surprising to feel a little nervous about site visits. One way to orient yourself is to put yourself in the shoes of the applicant and imagine how you'd like to be treated. Often, puzzles about what to say or how to say it will become immediately clear."

— A grantmaker recalling a first experience with site visits

Managing Your Role

Since the business of making grants primarily involves establishing a relationship between the grantor and the grantee, grantmakers often conduct site visits precisely to develop firsthand relationships with leaders and organizations in the communities and fields on which they focus. As such, a site visit can serve as an open-ended interview that allows you to ask pressing questions you may have and let potential grantees discuss the things they love to do. Talking at length and in depth with applicants about their work, and making certain they understand the fundamental purposes of your grant-making program, can also sometimes lead to exciting new ideas.

It can be a mistake, though, to think of a site visit as a discrete, one-time-only event. Site visits and one-to-one conversations are more likely to be continuing activities — at least with organizations directly involved in your program areas. Consequently, you may decide to make your first site visit to some organizations before you circulate a request for proposals, as a get-acquainted step, or as an element of your overall reconnaissance. Later, another visit may be part of your consideration of the group’s proposal. If you decide to award a grant, there are likely to be other visits — within reason — down the road, either to monitor the grant or maintain good relations.

Bear in mind that few organizations turn down a funder’s request for a meeting. They may be in the midst of their busiest season, rushing to prepare a proposal for another funder, or simply overwhelmed with work — they’ll probably still set aside two hours for you. As valuable as site visits can be, therefore, it’s important to make sure you’re not imposing on the organization’s time or distracting its staff. Remember: the organization is not likely to tell you — at least at first — that your request for a meeting comes at a bad time. You need to be alert and sensitive, and hope that at some point the group feels free to be more candid with you about its schedule.

Before You Visit

If the site visit is a first contact, do some homework. If you have not yet received a proposal from the organization, visit its Web site, if one exists, or research its area of work. This preparation allows you to use the time you spend with potential grantees efficiently, to ask pertinent, informed questions, and to understand what they’re trying to accomplish.

Even if the contact isn’t a new one, prepare yourself and the grantee before the visit. Be thoughtful and clear. For example, you might explain that you want to learn more about a particular aspect of the organization’s work. In any case, let them know how much time you have, and whether there are particular people or activities you would like to see.

Formulate some preliminary questions — but be careful of coming up with a long list. Narrow it down to the three most important ones, so as not to overwhelm your host. Notify the potential grantee of your questions ahead of time. You might also suggest that the organization send you an agenda of its own for the visit.

If possible, schedule site visits at times when you can observe some type of program activity. It helps to experience the work of the potential grantee firsthand.

While it can be helpful to conduct your visit with other staff from your foundation — the added perspective may be valuable — remember that having too many additional people can make it hard to have an informative, relaxed conversation.

Be aware that a site visit is a very important event to potential grantees. They will quite likely put a lot of energy into planning it and will hope to have your full attention. Difficulties in scheduling can create a misleading impression, as one grantmaker learned: "I remember a time when one of our team had to leave after half an hour. It wasn’t disrespectful; it was just someone juggling a tough working schedule. But it seemed as though perhaps we weren’t really that interested."

During the Visit

Begin by reminding people of the reason for your visit and about your role. You may have explained these points already, but nonprofits often play host to visitors, and may not remember what you told them. Be sure they understand that you’re there not only as an interested individual, but as your organization’s representative.

Since everyone's time is scarce, you may want to focus on what you most need to know to make a good grant, and on matters that call for the prospective grantee's impressions, interpretations, and personal reflection. In other words, the site visit is not usually the best time to bring up small, detailed matters that may require the applicant to do research or analysis. It is an opportunity to get to know the organization in a more personal way than is possible on paper

As the Visit Concludes

Don't forget to use the visit as an opportunity to expand your knowledge of the broader community or field. Ask applicants for suggestions about other organizations or activities that you should be looking at, or other people you should get to know.

Leave room for excitement: surprisingly good things can happen during a site visit. "I remember one visit," notes an experienced grantmaker, "when, after about an hour-and-a-half of talk and examination of the premises, the prospective grantee deferred going to another meeting so he could fill us in on his ideas for several different possible grants. It was a lively discussion, and I think curtailing it would have curtailed the making of the grant. You have to leave room for excitement."

And a final note. If the first one or two visits start off stiffly, don't worry. It takes more than an hour or two, and often more than a single visit, to establish the kind of trusting, open relationship in which a real exchange of ideas — the "excitement" — can take place.

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Learning from Site Visits (Funding Community Organizing) Managing Expectations: Site Visits (Saying Yes / Saying No)

Takeaways are critical, bite-sized resources either excerpted from our guides or written by Candid Learning for Funders using the guide's research data or themes post-publication. Attribution is given if the takeaway is a quotation.

This takeaway was derived from Building Community Inside and Out .

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Estimating, Quoting, Budgeting and Managing Art-based Projects

Identifying the Purpose of a site visit for a project. Part 1 of 3

The requester of the site visit should provide the site visit’s essential information in writing. The information should include all contact information for the site visit as well as a description and piece count of the object or objects.

Conducting a site visit with only the immediate or short-term goals in mind can lead to a failed project. An example of a short-term goal would be a request to measure an object for a crate. Providing measurements for the crate might satisfy the specific request but without considering the other aspects of the object’s environment or the primary project goals, the project may be undermined or fail.

It does not help to measure an object for a 40 x 40” wide crate if the door the crate needs to be moved through is 36” wide.

Understanding the long-term goals of the project will help you focus the information in your report and include all aspects that could affect a successful result.

If you are serious about your role as a Project Manager, then you are more than a note taker. You are a problem solver. Your job is to analyze complex situations and offer solutions. The site visit is the first step in recognizing the problems and issues hidden within a project, and solving them. Your solutions are presented in your site visit report and quote.

Review the site visit request before responding to the requester. The request itself may answer many of your questions. Identifying the purpose of the site visit beyond the specific request then requires asking the requester questions. These are also questions to keep in mind during the site visit and while you are developing your plan.

• Where is it going?
• Is its destination local, national or international?
• Is the destination an exhibition or storage location?
• Is the site visit for packing, crating, transportation or installation?
• If crating is required, is it a one-way or two-way shipment?
• What is the objects size?
• What is its weight?
• What is it condition?
• If it’s a 2D artwork is it framed?
• If it’s a 3D artwork, and if there is a base, is the base included in the site visit quote?
• Is there an existing condition report to review?
• Will the object require special equipment or rigging to pack and move?
• When does it need to be at the receiving location?
• How is it traveling?
• Is it coming back?
• When is it coming back?
• Who is accepting it at the other end?
• What are the conditions at the receiving end?
• Is there a loading dock at the release or receiving end?
• Who is paying for this?
• Who is the primary contact on site?
• Is the contact the client, the client’s representative or an agent?
• What is their contact information?

The client is the person that manages the collection end of the site visit and that you will have direct contact with on the project. They could be external as with a vendor contacting a museum representative or internal such as a Registrar technician contacting a Collections Manager within the same institution.

There will be other questions to ask as you become more familiar with the request. You should first review the request to see if the information you require has already been provided by the requester. If you do require answers you should ask for the information in an email so that you have a hard copy of the conversation to reference.

You also want to have a clear understanding of the requester’s perception of the site visits goal and what the project associated with the site visit intends to accomplish. This will prepare you for any possible misunderstandings that may have occurred between the requester and the client. You also want a clear understanding of what information has already been gathered and what questions have been asked of the client, so you don’t bother the client with redundant questions.  Having to answer the same question multiple times is annoying, no one likes having to go through this and it is a poor way to start your relationship with the client.

Specifically, it subtly says to the client that you are unfamiliar with, unprepared for or insensitive to their artwork or their role in the project and this leads to distrust especially concerning the handling of their valuable objects. Your contact, the client, should be considered one of the many stakeholders in this project, someone with a vested interest in the outcome of the project, and they should be treated as such.

Your goal in preparing for the site visit is to make a good impression and instill trust and confidence in you, your company or department, and your ability to manage this project. The client’s confidence and trust in you begins with the first impressions created during first contact and confirmed during the site visit.

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Clinical site qualification visits best practices.

Medha Datar

• March 12, 2023

Clinical site qualification visits are an essential step in ensuring that clinical trial sites are qualified to conduct a study. These visits allow sponsors and contract research organizations (CROs) to assess the suitability of potential sites and verify that they meet the study requirements.

Here are some best practices for conducting clinical site qualification visits:

• Prepare in advance

Preparation is critical to the success of a site qualification visit. Before the visit, review the study protocol, site-specific documents, and any other relevant study materials to understand the site’s capabilities and needs. This will help you prepare a list of questions and requirements that need to be addressed during the visit.

• Establish clear objectives

It is essential to establish clear objectives for the visit and communicate them to the site staff. Make sure they understand the purpose of the visit and what is expected of them. Clear communication will ensure that the visit runs smoothly and that the site staff is fully engaged in the process.

• Conduct a pre-visit assessment: 

Conduct a pre-visit assessment to gather information about the site’s history, experience, infrastructure, and staffing. This will help you identify any potential issues that need to be addressed during the visit.

• Plan the visit itinerary

It is crucial to plan the itinerary of the visit to ensure that all necessary areas are covered. Schedule time to meet with key staff members, review documentation and tour the site facilities. A well-planned itinerary will help ensure that the visit is efficient and that all relevant areas are evaluated.

• Conduct an opening meeting

Conduct an opening meeting to introduce the site staff to the study team and clarify the objectives of the visit. This meeting should include a review of the study protocol, site-specific documents, and any relevant study materials. The meeting is an opportunity to establish rapport with the site staff and to build a positive working relationship.

• Review documentation

Review the site’s regulatory and institutional review board (IRB) documentation to ensure that it is up to date and in compliance with local regulations. This includes reviewing the informed consent forms, investigator brochures, and other relevant documents. The review will help ensure that the site is qualified to conduct the study and that all regulatory requirements have been met.

• Assess facilities and equipment

Evaluate the site’s facilities and equipment to ensure that they meet the study requirements. This includes reviewing the storage, security, and access control measures in place for investigational products and study documents. The assessment will help ensure that the site is equipped to handle the study materials and that they are being stored and secured appropriately.

• Assess site personnel

Assess the qualifications and experience of the site personnel, including the principal investigator, sub-investigators, research coordinators, and study nurses. Verify that they have received appropriate training and are familiar with the study procedures. The assessment will help ensure that the site staff is qualified to conduct the study and that they have the necessary experience to manage the study requirements.

• Evaluate data management procedures

Evaluate the site’s data management procedures, including the use of electronic data capture (EDC) systems, source documentation, and quality control measures. The evaluation will help ensure that the site is equipped to manage the study data and that the data is being collected and managed accurately and securely.

• Conduct a closeout meeting

Conduct a closeout meeting to summarize the findings of the visit and provide feedback to the site staff. Clarify any deficiencies and outline the steps that need to be taken to address them. The meeting is an opportunity to ensure that the site staff understands the findings and to establish a plan of action to address any deficiencies.

Follow up with the site staff after the visit to ensure that any deficiencies have been addressed and that the site is ready to proceed with the study. Continue to monitor the site throughout the study to ensure that it is meeting the study requirements. Ongoing communication with the site staff is critical to the success of the study.

In conclusion, site qualification visits are an essential

By following these best practices, sponsors and CROs can conduct effective and efficient clinical site qualification visits that ensure the quality of the study data and the safety of the study participants.

Cloudbyz Unified Clinical Trial Management (CTMS) is a comprehensive, integrated solution to streamline clinical trial operations. Built on the Salesforce cloud platform, our CTMS provides real-time visibility and analytics across study planning, budgeting, start-up, study management, and close-out. Cloudbyz CTMS can help you achieve greater efficiency, compliance, and quality in your clinical operations with features like automated workflows, centralized data management, and seamless collaboration. Contact us today to learn how Cloudbyz CTMS can help your organization optimize its clinical trial management processes.

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• The role of the site revie...

The role of the site reviewer: Ensuring patient-centered standards for optimal patient outcomes

This article focuses on requirements for the site reviewer role, characteristics shared by productive reviewers, and real-world examples of process improvements tied to reviewer assessment.

Tony Peregrin

July 21, 2020

HIGHLIGHTS Identifies how accreditation standards enhance quality of care Describes the qualities of effective site reviewers Provides examples of process improvements developed from reviewer feedback Summarizes the College’s initiative to align ACS Quality Programs to enhance client experience

Editor’s note: Because of the coronavirus disease 2019 (COVID-19) pandemic, the American College of Surgeons (ACS) Quality Programs are exploring innovative virtual options for the traditional in-person site visit. Each ACS Quality Program suspended on-site visits during the pandemic and has developed a proposed plan and agenda for conducting these reviews in the future. Pilot sites for alternative approaches are being identified this summer. The ACS will provide updates on these programs as they become available.

Each of the ACS quality improvement (QI) accreditation and verification programs is a singular entity tasked with the responsibility of verifying compliance with the standards established for that particular specialty. All of the programs feature the same general structure: application, pre-review questionnaire (PRQ), site visit, assessment, and facility report.

At present, 388 surgeons serve as site reviewers for the following ACS accreditation and verification programs, collectively known as the ACS Quality Programs: the Accredited Education Institutes, the Children’s Surgery Verification (CSV) Quality Improvement Program, the Commission on Cancer (CoC), the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), the National Accreditation Program for Breast Centers (NAPBC), the National Accreditation Program for Rectal Cancer (NAPRC), and Trauma Verification and Review Committee (VRC) (see Figure 1, page 20). Program standards criteria range from 20 to 200 standards or more depending on the specialty (CSV and Trauma have the highest number of standards because of the complex nature of those specialties).

According to the Optimal Resources for Surgical Quality and Safety manual (also known as the Red Book), “In high reliability organizations (HROs), the focus is on development and implementation of effective systems, transparency, and teamwork. The intent is to bring process failures and systemic issues to light and to solve them in a nonpunitive way. Lessons learned from analysis of errors are shared as best practices in order to mitigate future errors.” 1

The Red Book also identifies specific concepts that reinforce the principles of high reliability, including standardization of best practices that reduce unwarranted variation and optimizes reproducible outcomes. 1 “When care is standardized, variation arises only because of differences in patient needs or resources,” according to the manual. “Standardization accentuates deviations from best practices, making them easier to spot than if every health care provider used a different approach to deliver care.” 1

Site reviewers, previously referred to as “surveyors,” are trained members of the health care team that assist facilities in identifying gaps in their adherence to standards, enabling HROs to continue to provide consistent, high-quality care to the surgical patient.

Accreditation standards enhance quality of care

The ACS Quality Programs collectively accredit and/or verify more than 3,000 hospitals. Studies examining the effectiveness of these programs suggest that the levels of care necessary to meet accreditation standards lead to improved quality of care.

For example, a study published in the Journal of Trauma examined the effect of preparing for and achieving ACS Level I trauma verification on patient outcomes and hospital performance. After evaluating 1,098 trauma patients admitted to a facility in 1994, and 1,658 patients admitted in 1998, the authors concluded, “Trauma system improvement as related to achieving ACS Level I verification appeared to have a positive impact on survival and patient care,” with a notable decrease in mortality for severely injured patients, a marked decrease in average length of stay, and an estimated cost savings for 1998 of more than $4,000 per patient. 2

Another study published in the Journal of the American College of Surgeons compared bariatric surgery outcomes in U.S. accredited versus nonaccredited centers based on a review of 13 studies that covered more than 1.5 million patients. Researchers found that “10 of the 13 studies identified a substantial benefit of Center of Excellence accreditation for risk-adjusted outcomes, and six of the eight studies reported a considerable reduction in mortality in patients operated on in Centers of Excellence.” 3

ACS CoC accreditation programs also have been linked to improved outcomes. A survey of the CoC and NAPBC program participants revealed more than 90 percent of respondents displayed a “high level of agreement that accreditation is regarded as important in improving oncologic outcomes through compliance with standards that include continuous quality improvement.” 4

Although the literature suggests that accreditation standards are linked to improved quality of care, the Red Book notes a “paucity of research that evaluates accreditation status and surgical quality” and states, “…further research to specifically address outcomes at accredited institutions will better illuminate the specific structural components of care that may be associated with improved outcomes.” 1

Requirements to serve as a reviewer

The minimum qualifications for the site reviewer role vary by program, but generally the requirements are organized into three main components: credentials/affiliations and skills and knowledge. 5-8 A site reviewer must be in active practice in a clinical, academic, or administrative role and employed or affiliated with the corresponding ACS-accredited program. As for the skills and knowledge component, reviewers should have an extensive and demonstrable knowledge of the current standards, significant knowledge of specialty registries where applicable, and strong verbal and written communication skills. 5-8 The site visit team typically includes one to five members, depending on the program and site request (the average is a three-person team), with one individual designated as the lead reviewer.

Dr. Margulies

“Certain requirements are in place that are unchangeable,” including that the reviewer is active in the specialty, according to Daniel Margulies, MD, FACS, professor of surgery, Cedars-Sinai Medical Center; chief section of trauma, emergency surgery and surgical intensive care, University of California-Los Angeles, David Geffen School of Medicine; and Chair, ACS VRC Program Committee. “An older surgeon who is no longer active will not be allowed to continue to do reviews. We actually remove them as reviewers within one year of retirement. In terms of the young reviewers, there’s a requirement that they have to have been a trauma director or director of a service like the surgical intensive care unit, and generally a very young, inexperienced person is not going to be in that role,” said Dr. Margulies, who became a VRC reviewer in October 2011.

Teresa LaMasters, MD, FACS, FASMBS, DABOM, medical director, bariatric surgery, UnityPoint Clinic Weight Loss Specialists, Des Moines, IA, and a reviewer for MBSAQIP since September 2014, noted that capable reviewers generally have been in practice seven to 15 years.

Dr. LaMasters

Someone who has been in practice for five to seven years and is invested in learning about quality could definitely be a good site reviewer, Dr. LaMasters added. “But a lot of surgeons early in their careers are focused on practice building. And some of them have not really learned the principles behind quality improvement. I think that seven-year mark is ideal because these physicians have some experience, they’re excited to learn, and they have some time to commit to doing this.”

Site reviewers must be willing to commit six to 12 hours per site visit, with an additional two to four hours for preparation and final review. Depending on the program, each reviewer should plan on participating in four to eight site visits a year as specified in the individual specialty site reviewer agreement.

Linda Farkas, MD, FACS, a site reviewer for NAPRC, and professor of surgery with University of Texas-Southwestern, Dallas, noted that time-related barriers are a significant challenge in recruiting new reviewers. “There are a lot of surgeons whose salaries are based on revenue, or they’re in a busy practice where they’re just not afforded the time to take off to be on a site visit,” explained Dr. Farkas. “In those instances, surgeons would have to use their vacation time, or the revenue’s going to be down. If we had more reviewers, especially if we could get more surveyors distributed across the country, then maybe the time commitment wouldn’t be so bad—so the reviewer in Florida doesn’t have to fly to Washington if we can have a reviewer who lives in Oregon.”

Site reviewers are compensated for their time and effort. The College provides an honorarium to each reviewer, which generally is used to cover the cost of travel expenses. Although the honorarium is a practical benefit, reviewers are motivated to take on this role for a variety of reasons—from an interest in refining the accreditation/verification process to learning best practices employed at other institutions.

“I had undergone a site review in a previous system, and that site review was really unsatisfying for me,” said Dr. LaMasters. “The previous system would isolate each member of the team in something like an interrogation room in an effort to identify problems rather than work with the whole team together to talk through processes and understand the reasoning behind the processes. When I came in as a site reviewer, I felt like that approach should be completely flipped on its head. The team should be kept together. The physician leadership should be there, and it should be an open, collaborative process for learning rather than an isolating process.”

Dr. Hopewood

Peter Hopewood, MD, FACS, a site reviewer for both the CoC and NAPBC, and a surgeon with Cape Cod Healthcare Cancer Programs, Falmouth, MA, said he became a reviewer to gain exposure to innovative quality improvement practices.

“I’m in Cape Cod, so I’m a little out of the mainstream,” Dr. Hopewood said. “I’m not in an academic hospital, I’m in a community hospital, and the initiatives (clinical trials, community outreach activities) that are happening in the academic teaching centers can take years to filter down into the community hospitals. However, as a reviewer, I’m visiting these centers and I’m observing cancer conferences as part of the site visit, and I’m talking to all the specialists. I learn a lot. So, it’s helping my practice and improving the care I give to my patients.”

Qualities of effective reviewers

Effective site reviewers share specific personality and leadership traits, including a collaborative approach to and an innate interest in quality improvement starting at the local level. For example, site reviewers often are involved in their hospital’s QI committee or are peer reviewers or case reviewers for a medical board or journal before taking on the site reviewer role.

Dr. Barnhart

“When selecting a reviewer, we look for someone who is actively doing this in their own center,” said Douglas C. Barnhart, MD, MSPH, FACS, FAAP, who started his role as a CSV reviewer in January 2017. Dr. Barnhart is a professor, division of pediatric surgery, University of Utah School of Medicine, and medical director for surgical patient safety and quality, Primary Children’s Hospital, Salt Lake City, UT. “Reviewers should know from their own experience which standards are hard and which ones are aspirational. Effective reviewers will recognize the struggles involved in solving some of these problems and will appreciate the work that’s been done, rather than focusing only on the gap. I always introduce the fact that I come from a center that’s been through the verification part, and that we appreciate all the work that they’ve gone through. Reviewers should also be actively practicing clinicians. Our foremost goal is improving patient care, and in order to do that, reviewers should have ongoing, direct experience in caring for patients.”

“As a site reviewer, you have to be patient and a little charismatic,” said Dr. Farkas. “Team members at the site may be a little nervous when you come in because you’re a surgeon and a site reviewer, and they may be program nurse coordinators, for example, and feel like their job is on the line with this survey.” She added, “The purpose of the survey is not to be punitive; it is to give hospitals feedback so that they can get over any impediments necessary for accreditation.”

According to Dr. LaMasters, “You have to be able to articulate the entire vision of the accreditation process and goals and spirit on the positive side, not just the negative side, and to do it in a way that I think really inspires them to want to continue to improve their quality, to see where they can go next, to not be complacent or content simply because they passed.”

“It’s just not about checking a box, indicating the hospital was compliant or not compliant, and that’s why it’s so critical for us, across all of our programs, that we pick the right people to do these site visits, be they surgeons, nurses, other physician specialists, or others,” said Teresa Fraker, MS, RN, Program Administrator, MBSAQIP. “Because that’s what our sites are paying for, more than data registries or anything else—the education, the consultation, the mentoring, and the sharing of best practices that our reviewers offer them.”

Preparing for a site visit

ACS accreditation/verification programs share some similar practices based on compliance with patient-centered standards. For example, each program has a manual that outlines the optimal resources for care of the patient served in each program. 9-11

Each program also employs varying business processes for verifying and accrediting participating facilities. For example, during the verification review process, a trauma center is assessed on criteria outlined in the ACS Trauma Programs’ standards manual, including volumes of severely injured patients, 24-hour availability of trauma surgeons and other specialists, surgical capabilities, and availability of specialized equipment. Based on the review, the trauma center is categorized as Level I, II, or III. 12

The site review process generally occurs in four phases: reviewer selection, pre-site visit preparation, site visit, and report generation.

A notable component of the pre-site verification process is the completion of a pre-review document. For most programs, such as trauma and CSV, this document is the PRQ. These questionnaires inform reviewers of the existing care capabilities of the hospital or center before the on-site review. 13

“These site visits aren’t intended to be a surprise inspection with some element for which people aren’t prepared,” said Dr. Barnhart. “For example, when we had our site visit here, I knew we had some areas of weakness, having read the criteria and having been on some of these site visits. I knew we had some problem areas that we were in the process of solving but had not completely solved. And in my introductory comments to our site visit, I said, ‘Look, I want to tell you about our place. I want to tell you about our strengths, and I want to show you two things that we’ve struggled with. I’m going to show you our audit data.’ That’s really what we’re looking for places to do. If you know your weaknesses, and you’re committed to performance improvement, you’ll solve your weaknesses,” Dr. Barnhart said.

“We’re not saying that you have to be perfect, but we are saying you should have a process in place to look at your mistakes, think critically about them, and work to make a sustainable change in your program that addresses problems more generally than just looking at outcomes,” added Dr. Margulies.

“I tell the team that throughout the day I’m going to look for things that they can do better, and that doesn’t mean that they’re not doing a great job. We all can learn to do things better,” said Dr. LaMasters. “I try to engage each person in the team around the standards and how they apply to this part of the site visit. It’s not just about the case that we’re auditing, it’s really about how you develop the team culture to get everybody behind a process improvement that came from this adverse event.”

Process improvements

Site reviewers identify patient care challenges across a spectrum of clinical topic areas and offer suggestions for improvements in administrative processes related to equipment needs, scheduling and job sharing, and time management.

“One program was able to arrange one-stop shopping for its patients so that they can get their CEA [carcinoembryonic antigen], their CAT [computerized axial tomography] scan, and their MRI [magnetic resonance imaging] in one day,” said Dr. Farkas, noting that such strengths are institution-specific and may be difficult to achieve at every site.

Dr. Margulies offered another example of a process improvement, one that a site reviewer to his institution sought to replicate at his center. “The use of whole blood is new in trauma. We developed a mobile refrigerator so that the blood that is sent out to trauma is kept at a specified temperature, rather than in a cooler where the blood warms up and is basically wasted if it is not used,” Dr. Margulies said.

Dr. Hopewood said a process improvement his institution is adopting—based on what he encountered as a site reviewer—involves decreasing emergency room (ER) visits and unexpected admission for chemotherapy patients. “Some programs preemptively call patients early in the morning to ascertain how they are feeling. Certain chemotherapy regimens result in potential diarrhea or neutropenia, and targeting those patient populations and leaving room for empty appointments later in the day can reduce visits to the ER, resulting in better quality of care,” Dr. Hopewood said.

Dr. LaMasters said process improvements often entail understanding why the standard was created and realizing the difference between “the letter of the law and the spirt of the law.”

“The letter of the law might state that you have to have equipment that is weight-based appropriate for our patients, but the spirit of the law means understanding that you can’t have only one chair in your waiting room that is appropriate for a person of size because often family members may also be of size,” explained Dr. LaMasters. “Understanding that the concept of this standard is to help the entire institution recognize and be sensitive to patients of size and to be prepared to care for those patients wherever they occur in the institution—even though I’m specifically reviewing the sites where bariatric surgery patients will go,” she said.

Aligning ACS Quality Programs

To unify ACS quality programs, the College launched a project in July 2017 to enhance both the site reviewer and the client experience. Although each program was originated with the similar aim of improving surgical care, the models to achieve that goal varied by specialty.

The ACS alignment team identified three goals to unify ACS Quality Programs, including the development of a shared information technology platform, similar site visit and performance reports, and a common standards framework and template, including both the formatting and branding of the standards manuals. This updated standards framework comprises nine standard domains:

• Institutional administrative commitment
• Program scope and governance
• Facilities and equipment resources
• Personnel and services resources
• Patient care: Expectations and protocols
• Data surveillance and systems
• Quality improvement
• Education: Professional and community outreach

In 2019, the MBSAQIP was the first program to translate its standards into the new framework, successfully meeting one of three goals the ACS established to unify these programs. Other programs migrating to the new standards format this year include:

• GSV: July 2019
• CoC: October 2019
• NAPRC: May 2020
• Trauma: 2021 (Q1)
• CSV: 2021 (Q1)
• NAPBC: late 2021

In March 2019, the ACS Quality Portal (QPort) was completed, successfully meeting another goal in the alignment process. The MBSAQIP was the first to migrate to QPort, and other quality programs will be migrating to the portal in the near future.

Alignment efforts are intended to provide consistent, high-quality experiences to all our hospitals participating in ACS Quality Programs. By providing a consistent framework for the standards manuals, portal, and reports for all ACS verification programs, the ACS aims to bring QI and leadership teams at participating hospitals together to work toward surgical quality within their institutions. The objective is to provide a road map of strengths and opportunities for improvement.

ACS Quality Programs in the future

With more than 105 years of experience in QI, the ACS continues to define the standards necessary to provide optimal patient care across all surgical specialties. The College’s ongoing commitment to this goal continues with the development of a new standards-based program—a verification program based on the Optimal Resources for Surgical Quality and Safety, with pilot visits occurring over the last year. 14,15

Site visits are an essential component of achieving quality in all phases of surgical care. Standardizing the College’s approach to verification and accreditation processes for both established and new Quality Programs will likely enhance the effectiveness of site reviews.

“Participation in accreditation programs does not guarantee high-quality care,” note the authors of the Red Book, “but it does demonstrate a commitment to such aims.” 1 The authors assert that “clearly defined roles and responsibilities, coupled with appropriate resources and support” can lead to improved patient outcomes, shorter lengths of stay, and a reduction in costs.

• Hoyt DB, Ko C (eds). Optimal Resources for Surgical Quality and Safety. Chicago, IL: American College of Surgeons; 2017.
• DiRusso S, Holly C, Kamath R, et al. Preparation and achievement of American College of Surgeons level I trauma verification raises hospital performance and improves patient outcome. J Trauma. 2001;51(2):294-299.
• Azagury D, Morton JM. Bariatric surgery outcomes in U.S. accredited vs non-accredited centers: A systematic review. J Am Coll Surg. 2016;223(3):469-477.
• Knutson AC, McNamara EJ, McKeller DP, Kaufman CS, Winchester DP. The role of the American College of Surgeons’ cancer program accreditation in influencing oncologic outcomes. J Surg Oncol. 2014;110(5):611-615.
• American College of Surgeons. Quality Programs. National Accreditation Program for Rectal Cancer. Become an NAPRC site reviewer. Available at: facs.org/quality-programs/cancer/naprc/site-reviewer . Accessed March 17, 2020.
• American College of Surgeons. Quality Programs. Commission on Cancer. Become a site visit reviewer. Available at: facs.org/quality-programs/cancer/coc/become-site-reviewer . Accessed March 17, 2020.
• American College of Surgeons. Quality Programs. National Accreditation Program for Breast Centers. Become a site reviewer. Available at: facs.org/quality-programs/napbc/become-reviewer . Accessed March 17, 2020.
• American College of Surgeons. Quality Programs. Verification, Review, and Consultation Program. VRC site reviewer criteria and application. Available at: facs.org/quality-programs/trauma/tqp/center-programs/vrc/reviewer . Accessed March 17, 2020.
• American College of Surgeons. Quality Programs. Verification, Review, and Consultation Program. The VRC consultation process. Available at: facs.org/quality-programs/trauma/tqp/center-programs/vrc/process . Accessed March 17, 2020.
• American College of Surgeons. Quality Programs. Children’s Surgery. Children’s Surgery Verification. Available at: facs.org/quality-programs/childrens-surgery/childrens-surgery-verification . Accessed March 17, 2020.
• American College of Surgeons. Quality Programs. Commission on Cancer. Apply for accreditation. Available at: facs.org/quality-programs/cancer/coc/apply . Accessed March 17, 2020.
• Bost SJ, Ball JN, Sanddal ND, et al. ACS COT leads study to develop comparative data on trauma care organization. Bull Am Coll Surg. 2020;105(4):43-48. Available at: bulletin.facs.org/2020/04/acs-cot-participates-in-study-to-develop-comparative-data-on-trauma-care-organization/ . Accessed June 19, 2020.
• American College of Surgeons. Quality Programs. Commission on Cancer. Site visit preparation. Pre-Review Questionnaire. Available at: facs.org/quality-programs/cancer/coc/accreditation/site-visit-prep . Accessed March 17, 2020.
• Hoyt DB. Executive Director’s annual report. Bull Am Coll Surg. 2019;104(12):37-53. Available at: bulletin.facs.org/2019/12/2019-executive-directors-annual-report/ . Accessed April 1, 2020.
• Puls MW, Hughes TG, Sarap MD, Caropreso PR, Nakayama DK, Welsh DJ. New ACS-led verification program aims to improve care for rural surgical patients. Bull Am Coll Surg. 2020;105(4):24-28.

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Handling Pre-Study Site Visits (PSSV) & Site Initiation Visits (SIV) in this Digital Era

Our lives are now incredibly straightforward and structured, thanks to technology. Additionally, this technology has been essential in advancing clinical trials. Clinical trials are being digitized to save time, boost productivity, and reduce paperwork.

In general discussion of Pre-Study Site Visits (PSSV) and Site Initiation Visits (SIV) in the clinical trial process,

A PSSV is a visit to the study site prior to the start of the trial, typically conducted by the sponsor or their representative. The main purposes of a PSSV are

A SIV is a visit to the study site at the start of the trial, typically conducted by the sponsor or their representative. The main purpose of a SIV is to ensure that the site is ready to begin enrolling patients and conducting the trial according to the protocol.

PSSV & SIV in Digital Transformation World:

Overall, technology can aid in making PSSV & SIV process more efficient, cost-effective and increase the success rate of clinical trials.

Technologies Enhancing PSSV:

• Virtual Visits: PSSV can be conducted remotely through virtual technology such as video conferencing, which can save time and costs associated with travel.
• Site qualification and management software: These tools can help to automate and standardize the process of identifying and qualifying potential study sites and managing the ongoing relationship with these sites.
• Cloud-based document management: This technology allows for easy access and sharing of important documents such as site agreements, protocols, and regulatory submissions, among the different stakeholders.
• Geographic Information System (GIS): GIS technology can help to identify and map potential study sites, and to analyze their suitability based on factors such as patient demographics, accessibility, and proximity to other healthcare facilities.

Technologies Enhancing SIV:

• Electronic Data Capture (EDC): Electronic data collection and management systems can streamline the data collection process during SIV, making it easier to analyze and report on the findings.
• Remote monitoring: Video conferencing, remote access to data, and other technologies can enable sponsors and monitors to track a study’s progress and ensure compliance without the need for on-site visits.
• Electronic informed consent: Electronic informed consent (eIC) software can facilitate the informed consent process by providing patients with interactive, multimedia information about the study and allowing them to sign the consent form electronically.
• Electronic case report forms (eCRF): eCRF allows for the electronic capture, validation, and reporting of study data, which can help to improve data quality and reduce errors.

Conclusion:

In summary, PSSV and SIV are critical stages in the clinical trial process for digital transformation in the healthcare industry, it is important to conduct them to ensure the quality and integrity of the trial data and are typically required by regulatory agencies. They play a crucial role in compliance with regulations and the protocol, and that the data collected is accurate and reliable, also they help ensure that the trial is conducted in a timely and efficient manner, and that the patients are protected and treated ethically.

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Pre-visit Planning Saves Time

• Practice Transformation

Learn about some pre-visit planning strategies that can make office visits more efficient, productive, and meaningful for both the health care team and patient.

Marie T. Brown, MD, discusses the benefits of pre-visit planning and shares strategies to help ensure that providers and patients are prepared to assess and address diabetes management during office visits.

Q: How do health care professionals, medical practices, and patients with diabetes benefit from pre-visit planning?

A: Pre-visit planning is a process where you plan for patients’ future appointments at the conclusion of the current visit, arrange for what should happen between this visit and the next visit, and huddle with your team prior to the patient’s next visit. With pre-visit planning, everyone is prepared to make the most meaningful use of everyone's time during the office visit.

When it comes to providing care for people with diabetes, you are often caring for someone with numerous comorbidities. Your patient may be cared for by several doctors and prescribed numerous medications. A key component of pre-visit planning is making sure that everything the patient and provider need to assess diabetes management is on-hand during the office visit. This requires the patient to have lab tests a week or so before the visit so that any changes in treatment, such as medication changes, occur face-to-face to ensure optimal communication.

In many clinics, the available A1C is from 3 months prior—too long ago to make any adjustments in a treatment plan. You order an A1C, receive the results the next day, and now you need to reach your patient to adjust therapy based on the most recent A1C results. Attempting to reach them by phone or email causes delay and needless inefficiencies. If only you had the needed results during the patient visit!

Q: During a patient visit, how can health care professionals and patients plan for the next visit?

A: It’s important to have a conversation with your patient about the next visit at the end of the current visit. For instance, if your patient is not reaching his or her goals for blood glucose, you might suggest scheduling office visits every month until things start to improve. If your patient is reaching his or her blood glucose goals, he or she may only need to be seen once or twice a year. The vast majority of patients who have diabetes are seen every 3 months. It’s important that the patient understands and agrees with the plan, too.

In addition to talking about the next visit with your patient, let your patient know which lab work needs to be done before the next visit and order the necessary pre-visit lab tests . These tests can be done at a laboratory closer to the patient's home or during another visit your patient may have scheduled at your office or center for another reason. If a second visit is too much of a burden, point-of-care testing would also provide the needed lab test results.

Some doctors use a pre-visit planning checklist. Once a year, the checklist may include annual tests or referrals such as a lipid test, albumin creatinine ratio, urine test, a referral for a diabetes educator, a referral to an ophthalmologist, and so on. For the checklist, you can use order sets in electronic health records (EHRs) or use paper checklists that are handed to your team.

Q: What planning is needed in the days or hours before a patient visit?

A: The team should sit together to plan what a pre-visit planning checklist should look like. The main goal of pre-visit planning is to deliver quality efficient patient care. If you’re just beginning to do this, the process should involve the entire team so that everyone on the team understands, “What’s in it for me?” We don’t want pre-visit planning to shift the burden from one team member to another. With pre-visit planning, patients will be more likely to be seen on time, which is a much more pleasant experience for everyone. If everyone on the team understands that one of the goals of pre-visit planning is to make sure that the office stays on schedule, then the receptionist knows that they are going to have more pleasant patients in the waiting room. The team members, such as the medical assistant or nurse, will also have more time to develop a relationship with the patient, and they’ll be able to get out on time with a feeling of a “job well-done.” Care gaps such as immunizations and cancer prevention are addressed prior to the office visit and orders entered or “pended” by the team. The front desk team members can help by printing lists of patients with care gaps so that the clinical team can address them during “downtime.” 

Usually, a day or two before the patient visit, a team member will look at the notes in the EHR to make sure lab test results are up-to-date and remind patients if they still need to get their blood drawn. This review helps identify gaps in care, such as needed immunizations, annual lab tests, preventive health screenings, or referrals to a diabetes educator or other health care professional. This is time well spent because a half hour one day can save two hours the next day.

The pre-clinic care team huddle is also part of pre-visit planning. At the start of the day, huddle with the whole team to look at the schedule and get an overview of what the day is going to look like. This is an opportunity for team members to share information that could affect the day. For instance, someone might need to take a phone call or need a longer lunch break to handle a personal matter. It's also important to look at all the patients scheduled for the day and identify, for example, who may need a larger room because they use a wheelchair or have family members accompanying them. This is an opportunity to find out who might require an interpreter. You might find that there is a patient on the list who is routinely, for many reasons, always late—maybe due to public transportation delays—and planning for that disruption is important so that you minimize the effect on the schedule.

The American Medical Association (AMA) STEPSforward ™ module on pre-visit planning , authored by Dr. Christine Sinsky, is a free resource that outlines 10 steps to pre-visit planning and offers tools including checklists as well as case studies. STEPSforward™ also offers a module on developing an efficient  team-based approach to managing diabetes .

Q: How can health care professionals engage patients in pre-visit planning? What technologies can help?

A: Having patients take ownership of completing blood tests prior to the visit is important, because patients often prefer to discuss medication changes face-to-face. It also helps visits start and end on time, and helps patients achieve their goals more readily.

Organizations can use technology to develop automated reminders for patients. Patients can also use online patient portals to upload their blood glucose or blood pressure logs and review their medications before a visit. Sending educational materials also streamlines the visit.

Engaging patients in pre-visit planning continues in the waiting room. For example, before a patient visit, a receptionist may print out a list of the patient’s medications and ask the patient to review the list and provide feedback.

Asking patients to write down their priorities for the visit while they’re in the waiting room saves time, as well as ensures the patients’ needs are met. They may need a handicapped parking sticker or a referral to a podiatrist. The receptionist or medical assistant can begin addressing some of these issues while the provider can address issues that require higher decision-making skills, assess adherence, and build a trusting relationship with the patient.

Q: Are there specific examples of pre-visit planning strategies that have improved your visits with patients who have type 2 diabetes?

A: Absolutely. Many of my patients see the diabetes educator four times a year, usually a week before they see me. Recently, I saw a patient with newly diagnosed diabetes following their first visit with the diabetes educator, where they had learned how much sugar is in a 20-ounce bottle of soda. Just by cutting out soda intake, which was one soda a day, the patient began losing weight. She was excited!

At check-in, patients are handed a list of their medications and asked to circle those that need refills, cross out medications they are no longer taking, and add a question mark to medications they don’t think they need.

In our patient portal, patients can see their test results, and they know what their A1C is before I see them. So, they're prepared to hear a congratulatory message or have a conversation about adherence, diet, or the need to escalate therapy. They’re prepared to be part of the discussion about next steps and goals. Agreeing on the A1C goal and ensuring the patient understands and agrees with the goal is of paramount importance. The same is true for blood pressure goals. Often, providers assume that the patient understands the goals of therapy.

Q: Are there any other aspects of pre-visit planning that health care professionals should consider?

A: It’s important to start small so that you're successful. For instance, some organizations have done pre-visit planning for the last three or four patients of the day, since that is when the clinic is running late and staff is tired. Once the team sees that doing pre-visit planning for the last few patients of the day saved everybody time, usually one of the team members will say, “Why don’t we do this with all of our patients?” Some organizations start pre-visit planning for all patients and close all care gaps all at once. This takes planning and more resources (time for training, protected time to do the planning, and possibly more staff).

My advice is to choose a small group of patients to start with pre-visit planning. You could do this with patients over 70 years old, or just for patients with diabetes. See how successful it is, what you've learned from it, and if you're going to adopt it or adapt it.

Start with what the team values most and use the Plan-Do-Study-Act cycle : plan it; do it; study the effect; and adopt it, adapt it, or abandon it and try something else. Pre-visit planning will look different at every organization, depending on the organization's resources and the team’s level of interest.

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Applied techniques for putting pre-visit planning in clinical practice to empower patient-centered care in the pandemic era: a systematic review and framework suggestion

Marsa gholamzadeh.

1 Health Information Management Department, School of Allied Medical Sciences, Tehran University of Medical Sciences, 5th Floor, Fardanesh Alley, Qods Ave, Tehran, Iran

Hamidreza Abtahi

2 Pulmonary and Critical care Medicine Department, Thoracic Research Center, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran

Marjan Ghazisaeeidi

Associated data.

The study involves only a review of the literature without involving any data.

One of the main elements of patient-centered care is an enhancement of patient preparedness. Thus, pre-visit planning assessment tools was emerged to prepare and involve patients in their treatment process.

The main objective of this article was to review the applied tools and techniques for consideration of putting pre-visit planning into practice.

Web of Science, Scopus, IEEE, and PubMed databases were searched using keywords from January 2001 to November 2020. The review was completed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Then, qualitative analysis was done to suggest an appropriate framework by mapping the main concepts.

Out of 385 citations were retrieved in initial database searches, 49 studies from ten countries were included. Applied pre-visit techniques can be classified into eight categories. Our results showed that almost 81% of studies were related to procedures that were done between each visit, while 42% of articles were related to before visits. Accordingly, the main approach of included articles was patient preparedness. While 38 studies reported this approach is effective, three studies reported the effectiveness of such tools as moderate, only two articles believed it had a low effect on improving patient-centered care.

This survey summarized the characteristics of published studies on pre-visit planning in the proposed framework. This approach could enhance the quality of patient care alongside enhancement patient-provider communication. However, such an approach can also be helpful to control pandemic diseases by reducing unnecessary referrals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06456-7.

In the information-driven care era, although the ultimate goal of health systems is still improving the quality of patient care, the patient care model has shifted from personal responsibility to participatory medical decision-making [ 1 ]. Thus, the responsibility of the patient’s health is no longer solely with the physician. On the other hand, the role of the patient in promoting his health status cannot be denied [ 2 ]. Hence, the patient-centered care (PCC) model was introduced to show the participatory role of the patient and other health care providers in the process of treatment and patient care [ 3 – 6 ]. Since the PCC idea was introduced, various definitions and models have been proposed to distinguish the main elements of this model [ 5 , 7 – 12 ]. Up to now, the best model that has been able to explain the main components of such a care model is the model presented by the Picker Institute [ 13 ]. This model consists of eight parts that outline the factors affecting the achievement of an optimal patient-centered care model [ 5 , 12 , 14 ].

One of the main elements of the PCC approach is respect for patients’ value by preparation of patients for each visit [ 6 ]. Sometimes patients have to spend more time in the waiting room than in a physician’s office [ 15 , 16 ]. Also, in each appointment, especially in the first visit, more than 5 min should be devoted to determining who the patient is, what is his problems, which drugs she/he used, what is his/her medical history, and so on [ 17 ]. This process is so complex in patients who have a chronic condition or patients with multiple chronic conditions with multiple medications [ 18 , 19 ]. It can be useful to prevent the spread of the disease. Limited time for each visit and patient complexity might have a negative impact on the patient-physician relationship.

In this context, pre-visit planning and visit preparation concepts have been suggested by American Medical Association (AMA) as a solution to address these challenges. It can help physicians when the patient checks in for the first time, he is already behind [ 20 ]. This term (pre-visit planning) was introduced by Sinsky et al. in 2014 to collect and organize patient data before a patient visit [ 21 ].

The purpose of pre-visit planning is to help the patient and physician to save time and improve care by gathering and organizing information in a structured way. Therefore, a health care provider can pay more attention to interpretation, discussion, and response to a patient during the visit. This idea is not just to plan ahead before each visit. Dr. Sinsky explains that pre-visit planning could include a broader concept that could generally refer to preparing the patient for a face-to-face visit more effectively [ 21 ]. The pre-visit planning concept is described in Fig.  1 as a conceptual model.

The conceptual model of pre-visit planning

However, there are various methods to apply this new approach into practice, it usually includes scheduling future appointments and preparing patients before the visit [ 22 ]. These techniques are known as pre-visit assessment tools. The use of pre-visit assessment tools focuses on involving the patient and the physician through the patient care process [ 23 ]. As it is apparent in Fig. ​ Fig.1, 1 , it can occur at end of each visit, arranging for the next visit, programming for the next clinical and paraclinical testing, gathering the necessary information for the subsequent visits, and take steps regarding the handoff of patients [ 24 ].

With pre-visit planning, patients and physicians are prepared to make meaningful use of their time during each visit. Furthermore, patients could have an impressive role in clinical decision-making regarding their treatment process [ 25 ]. Hence, several studies have focused on the power of patient-centered care to improve patient care, but no studies have been published to examine the applying pre-visit planning techniques in the context of patient-centered care. The main objective of this study is to review the consideration of pre-visit planning used in patient-centered care. Throughout this paper, the term pre-visit planning will refer to any intervention, care program, patient-centered planning, or even educational plan that is considered to prepare the patient for a face-to-face visit or improve the patient-provider relationship. Specific aims of this survey are as follows: 1) representing an overview of applied methods regarding pre-visit planning with their characteristics in published studies, 2) to investigate the published studies on applying pre-visit planning regarding clinical aspects such as type of disease, 3) to determine the effectiveness of putting pre-visit planning into routine practice, 3) providing an overview of the sample size, approaches, and collected information concerning applied methods and techniques, 4) suggesting a framework in this context.

A systematic search of four databases (Web of Science, Scopus, IEEE, and PubMed) was conducted from January 2001 to November 2020 using keywords alongside Mesh terms. These databases were selected for their inclusion of qualitative studies and health research. The keywords used in the search strategy were drawn from preliminary searches according to our study goals. Those keywords were validated and additional keywords added by checking the terms used in articles identified in preliminary searches. Boolean search strategies were described in Additional file 1 : Table A-1. Since no result was found in the IEEE database, it was removed from source databases in Table A- 1 . This systematic review was completed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist to ensure the inclusion of relevant studies [ 26 ].

Inclusion and exclusion criteria for study selection

Articles were included if they met the following criteria: 1) The focus of the study was on applying the pre-visit approach through the patient care process. 2) Population includes all of the patients with any type of disease, 3) This study covered all phases of the patient care process, 4) Published in recent 10 years and matched with the search query, 5) Limited to those published in the English language, 6) Only published articles and reviews in peer-reviewed journals were included, 7) All type of study designs, 8) Improve patient-centered care, 9) Studies that received an acceptable score in terms of quality based on the checklist. Articles excluded if they met the following criteria: 1) The title, abstract, or full text of the article did not relate to pre-visit planning, 2) Thesis, book chapters, letters to editors, short briefs, reports, technical reports, book reviews, review, or meta-analysis, 3) Non-English papers, 4) Publication that their full-text is not available.

Data screening phase

Based on our search strategy; articles were retrieved from databases. Additionally, related studies were added manually by a simple search in Google Scholar and reference checking. All of the citations were imported to EndNote software for better resource management. Then, duplicated articles were removed. In the first phase, all titles and abstracts of articles were examined based on our main objective to select relevant studies by one author (MG). A second reviewer (MGH) reviewed a sample of studies randomly. After that, the full texts of relevant studies were screened thoroughly by two reviewers (MG and MGH). If there was a disagreement between the authors in the selection of relevant studies, the final decision was made by HA. Lastly, some studies remained as eligible articles for qualitative analysis. The extraction forms were designed by researchers to manage and investigate the obtained information. To diminish bias, key subjects of articles summarized and entered into customized extraction forms based on specific classifications. Two authors (MG and MGH) independently extracted the study characteristics based on the classification. The information extracted by the researchers was re-examined to reach an agreement. The next reviewer (HA) assessed and verified the extracted information.

Critical quality appraisal

The methodological quality of the included articles was evaluated using the Qualitative research Critical Appraisal Program (CASP) tool by two authors. This instrument was used in systematic reviews frequently for qualitative synthesis [ 27 ]. It was employed for appraising the strengths and limitations of any qualitative research methodology. It was recommended for health-related researches and it is appropriate for novice researchers [ 28 ]. Critical appraisal was performed independently by two researchers.

To extract some necessary information, specific categories were considered to classify and analyze relevant articles. All of the articles were synthesized regarding general and specific domains. The general domain comprises the title, author, year of publication, journal name, type of study, the main objectives. Accordingly, the specific domain comprises applied pre-visit techniques, disease, clinic, sample size, country, outcome measures, effectiveness, and collected data. Analysis of the extracted information from eligible articles and framework suggestions were conducted based on these predefined categories.

In total, systematic literature searching of databases yielded 385 citations. Of which 99 articles were removed due to duplication. Next, one hundred and sixty-six papers were excluded after screening titles and abstracts. In the following, 72 papers were excluded after full-text reading. Finally, 49 papers are identified as an eligible article which met our inclusion criteria. The screening process for articles based on the PRISMA checklist is shown in Fig.  2 . All included papers had the minimum score (10 from 20) of quality assessment using the CASP tool. Only four papers were excluded based on quality appraisal assessment. Therefore, forty-nine articles were identified as eligible studies for qualitative analysis.

PRISMA workflow for summarizing the selection of papers process

General characteristics

All included studies are published in journals from 2001 to 2020. The trend of publishing articles in this field was following an upward trend. In terms of the type of study, studies were conducted in different designs. Most of which were clinical trial studies. The descriptive analysis regarding the type of study in the included articles is represented in Table  1 . In the following, the results of the review of studies by author, year of publication, the main objectives, the sample size, type of pre-visit planning, clinic, the effectiveness of the applied method, and outcome of using the pre-visit planning are summarized in Table  2 .

The frequency of different types of study

Summary of reviewed articles and evidence

Analysis of studies showed that the application of pre-visit planning is the most favorite of developed countries. Of them, the USA has the most contribution among other studies. After that Canada ranks second in the deployment plan is allocated to pre-visit intervention. The distribution of studies concerning the country is shown in Fig.  3 .

The distribution of studies based on their conducted countries worldwide

Different techniques for putting pre-visit into practice

The investigation showed that pre-visit can apply in different ways regarding timing, main approaches, and types. The analysis showed that different types of pre-visit techniques have been employed by authors to facilitate office visits and patient care. All of these plans can be categorized into eight different categories, utilizing an electronic pre-office checklist with 12 studies (24.5%) [ 25 , 29 – 35 , 48 , 58 , 59 , 68 ], educating patients and support them before each visit in form of online and offline source of information with 12 studies (24.5%) [ 23 , 36 – 42 , 60 – 62 , 66 , 74 ], applying an EHR-linked care program with different checklists and assessment tools with nine studies (18.4%) [ 22 , 43 , 44 , 49 , 63 , 67 , 70 , 71 , 73 ], using paper-based checklists with nine studies (18.4%) [ 45 , 46 , 50 – 52 , 64 , 65 , 69 , 72 ], preparing and assess patient with the pre-visit phone-based intervention with two studies (4.1%) [ 24 , 53 ], using self-triage or self-assessment tools with two studies (4.1%) [ 54 , 55 ], using automatic reminders and sheets with one article (2%) [ 56 ], and using pre-clinic consultation by other health care team member with one article (2%) to prepare the patient for each visit [ 57 ].

According to findings, the most favorite types of pre-visit model were related to using electronic pre-office visit checklists and supporting patients by providing them with the necessary information in the form of online and offline training. In three articles, this information was provided to patients in the form of educational websites [ 37 , 39 , 40 , 60 ], while in the other six articles, the information was provided to patients in the form of training sessions before the patient’s visit and referring to the clinic [ 23 , 36 , 38 , 41 , 42 , 61 , 62 , 66 ].

The next widely applied method was the EHR-linked care program that put pre-visit planning into practice. Ten articles used pre-visit solutions such as electronic checklists, automated reminders, decision-making tools, and reviewable forms that could be implemented by connecting to electronic medical records. In third place, there are paper-based checklists used for patient preparation with nine papers. These checklists included questions about demographic information, the main problems, medical history, general symptoms, illness history, hospitalizations, medications, family history of a specific illness, level of education, location, and questions about the patient’s lifestyle. Other solutions were used in a smaller number of articles. Regarding pre-visit counseling, only one article applied the consultation of clinical pharmacists before the office visit. This approach leads to providing the physician with better information after the initial completion of the medical record.

In terms of timing, pre-visit intervention could be conducted at a different time in the patient care process. Taken together, all of these possibilities could be categorized into four situations. It can be occurred before each visit, between visits, at the end of each visit on the current visit, and in a combination of the previous three models. Our results showed that almost 81% of studies were related to procedures that were done between each visit, while 42% of articles were related to procedures that were done before each visit. Only 10 % of studies were conducted at end of the current visit.

In terms of main approaches, the analysis of studies showed that all studies can be divided into three main categories based on the main approaches. These three approaches comprise, improving the current visit and preparing the patient for the next visit, perform some procedures for patient preparedness such as sending reminders or filling pre-visit checklists, and providing more inclusively insight about the patient for the physician before they come in for an office visit. The final analysis of the studies based on the main objectives and the timing is summarized in Table  3 . Out of 49 studies, the main approach forty-eight of articles were related to patient preparedness and enhance patient adherence to their treatment.

Results of study analysis based on main objectives and timing

Out of 49 studies, only one study did not report the sample size of their study. In total, the sample size ranged from 15 to 12,228 with a mean sample size of 1160.3877 (SD = ± 2613.799). In Fig.  4 , the distribution of studies based on sample size, year, and different techniques are represented.

Distribution of studies based on sample size, year, and different techniques

The effectiveness of pre-visit planning

Articles were also reviewed regarding the effectiveness of the applied methods. Out of 49 studies, the authors of 41 articles (83.67%) considered pre-visit planning to be effective in clinical practice. While six studies (12.24%) reported the effectiveness of these tools as moderate, only two articles (4.08%) believed that using this method had very little effect on improving patient-centered care. The effectiveness of studies concerning applied methods is shown in Fig.  5 .

Effectiveness of studies concerning applied methods

The effectiveness has been reported by researchers using various outcome measures in studies. These outcome measures reported in reviewed articles, along with their frequency and their effectiveness, are shown in Table  4 .

Outcome measures reported in these articles with their frequency and their effectiveness

Different diseases and the main reason for referral

Through this survey, the referred clinic and the main reasons for the referral were also examined in reviewed articles. In terms of the reason for referral and diseases, the most common reason for referral was related to chronic disease and general problems. The frequency of disease regarding applied methods and their effectiveness are represented in Fig.  6 . Regarding the type of clinic that was considered for implementing pre-visit planning, the highest frequency was related to primary care clinics. Next, surgical clinics had the largest number of pre-visit programs.

Frequency of disease regarding applied methods and their effectiveness

Information and collected data

To implement pre-visit planning, various types of data and information have been collected in studies. These collected data were very diverse. Hence, these different types of information can be divided into nine categories concerning their application. The different types of information regarding applied techniques are shown in Fig.  7 .

Distribution of different kinds of collected data regarding pre-visit techniques

Determining the main categories of applied techniques regarding medical informatics

Coding of all research studies and extracted themes using thematic analysis leads to discover the main sub-themes in terms of medical informatics. Therefore, all of the employed techniques can be divided into four categories, pre-assessment forms, educational resources, decision aid tools, and reminders as the main themes. The main themes and sub-themed are shown in Fig.  8 . Different aspects of such a model were shaped by mapping the main concepts obtained through this survey. The details of applied techniques in terms of the medical informatics view are described in Table ​ Table2 2 .

The main applied techniques through pre-visit planning in terms of medical informatics

Framework suggestion and IT-based solution

After a qualitative analysis of the results based on predetermined categories, the main ideas can be summarized in a proposed framework as an electronic-based advanced care program. Based on the results, this model is divided into four main parts in terms of time. This model is represented in Fig.  9 . In this model, the main focus is on the patient. The workflow is designed to improve the relationship between physician and patient in the simplest way. It is done by involving the patient in their care, which is one of the main purposes of using pre-visits in studies.

The overall model of pre-visit planning care

In this model, it is assumed that an electronic system is available to manage patient information. To implement a pre-visit-based program, a section is also considered for patient access to his care plan in the proposed model. Based on this model, the patient can pursue the main goals of pre-visit planning through suggested workflow, such as disease management, treatment adherence, receiving the necessary advice and training, and preparing for each visit. To increase the effectiveness of the devised model, it is suggested that the proposed system should have interacted with existing databases and electronic health systems.

Summary of findings

This survey summarized the characteristics of published studies on pre-visit planning and its application in various health domains. To our knowledge, this study represents the first overview of the existing evidence about the different pre-visit planning techniques in clinical practice. Forty-nine articles from ten countries were included in this survey. As mentioned in the results, these techniques can classify into eight categories. Among them, the most widely used methods are related to using electronic pre-office visit checklists and supporting patients by providing them with the necessary information in the form of online and offline educational resources.

Consistent with the present findings, our results showed that applying pre-visit techniques was not restricted to office visits [ 75 ]. So, pre-consultation planning can employ before each patient’s consultation, between the patient’s visits, and during the current visit to facilitate complicated patient care process.

One of the remarkable results of this study is that this approach has been used more in developed countries. It may be because it is easier to take a participatory approach to patient care in developed countries due to a high level of patient literacy.

Results in the context of other researches

Our results showed that most studies have been conducted with the main goal of preparing the patient by involving them in their treatment process. Patient preparedness had the most impact on the patient’s perceptions of his disease and overall patient satisfaction [ 76 ]. Similarly, Ringdal et al. [ 77 ] indicated through their survey that patients were satisfied with their active role as a partner on the healthcare team. Also, this is exactly in line with the main goal of the patient-centered care paradigm regarding the individualized approach to the patient’s treatment [ 78 – 80 ].

However, Geraghty et al. [ 81 ] showed through their study that there is a linear relationship between patient satisfaction and visit length. Unfortunately, long waits are common at outpatient clinics [ 82 ]. Hence, our results illustrated that using a pre-visit assessment tool such as a simple checklist or questionnaire is almost effective to maximize the available time during a consultation for making the best decisions by physicians. Also, it can provide better insight for physicians to better communicate with the patient by knowing the patient’s background during the consultation [ 22 , 33 , 35 , 47 , 54 , 60 , 64 , 67 , 69 , 70 , 83 – 88 ].

Analysis of results revealed that most studies considered the pre-visit assessment tool as an independent solution that was not connected to existing electronic systems. However, in some studies, a comprehensive care plan has been taken. A pre-visit planning program could be linked to a patient’s electronic medical record as used in some reviewed studies. This approach is similar to the motivational interviewing (MI) technique that is applied to improve patient-centeredness in other studies. Motivational interviewing is a technique to help patients address their chief problems and increase their understanding of their participatory role in the treatment process [ 89 ].

Implications for research and practice

Planned and targeted care is one of the main components of the patient-centered care model [ 79 ]. Hence, implementing pre-visit tools within an advanced planned care program might be more effective in moving towards effective patient-centered care. However, pre-visit planning care is a new approach, no framework or conceptual model was introduced according to this subject. Only a planned care model was introduced by the Health Research and Quality Agency as a comprehensive patient-centered medical home (PCMH) approach in which one of its main components is pre-visit planning [ 90 , 91 ]. Hence, our findings are summarized in a conceptual model regarding applying the pre-visit assessment tool in electronic-based planned patient care (Fig. ​ (Fig.9). 9 ). However, the EHR-linked pre-visit type was used only in the nine studies, the suggested model is not devised in a stand-alone model. Nowadays, with the advent of the digital age, applying integrative electronic systems and medical informatics-based solutions are inevitable [ 92 ].

One of the significant gaps that were mentioned in the studies is the unnecessary referrals of patients to outpatient offices [ 93 , 94 ]. These unnecessary visits in the event of pandemics can also lead to the spread of disease [ 95 , 96 ]. In such a framework, avoiding unnecessary referrals was considered to fight the pandemic. Such an approach can be useful to prevent the spread of the COVID-19 disease too.

Limitations

Since this study is the first attempt to review and analyze the published articles regarding pre-visit planning, it encounters some limitations. The results of some studies might be published in the form of reports, letters to the editor, or other types of study. Thus, we might not have considered them based on our exclusion criteria. The results showed that most studies point out pre-visit planning conducted by large institutions and reputable organizations; their data are absurdly confounded by the fact that better-funded institutions probably produce better outcomes. Also, some researchers might put pre-visit into practice but they did not publish their attempts in form of any research article or conference paper. It could cause publication bias. Thus, further researches for specific domains in clinical practices might be done in the future.

Using a systematic review approach leads to get a comprehensive overview of literature conducted in the use of various pre-visit approaches. Our results revealed that the direct outcome of planning a pre-visit care program was enhancing the quality of patient care alongside enhancement patient-provider communication. Improving the patient-physician relationship is a key factor in moving towards a patient-centered care paradigm. The qualitative and thematic analysis of the articles also showed that pre-visit planning has the greatest impact on the relationship between physician and patient. It can account for such a useful tool to move toward patient-centered care. However, such an approach can also be helpful to control pandemic diseases by reducing unnecessary referrals. Thus, the application of pre-visit tools can be considered as one of the key components of designing a patient-centered care system. In this survey, we tried to summarize our findings and our suggestions in a complete patient care framework based on pre-visit planning techniques.

Acknowledgments

We would also like to express our gratitude to Farideh Namazi for their support with us during this research.

Abbreviations

Authors’ contributions.

Conception idea of study: Marjan Ghazisaeeidi, Hamidreza Abtahi, Marsa Gholamzadeh; Acquisition of data: Marjan Ghazisaeeidi, Hamidreza Abtahi, Marsa Gholamzadeh. Analysis and/or interpretation of data: Marsa Gholamzadeh, Marjan Ghazisaeeidi. Drafting the manuscript: Marjan Ghazisaeeidi, Marsa Gholamzadeh. Revising the manuscript critically for important intellectual content: Marjan Ghazisaeeidi, Marsa Gholamzadeh, Hamidreza Abtahi. Approval of the version of the manuscript to be published: Marjan Ghazisaeeidi, Hamidreza Abtahi, Marsa Gholamzadeh. The author(s) read and approved the final manuscript.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Availability of data and materials

Declarations.

The study involves only a review of literature without involving humans and/or animals. The authors have no ethical conflicts to disclose.

Not applicable.

The authors declare that they have no conflicts of interest.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Marsa Gholamzadeh, Email: ri.ca.smut.izar@hedazmalohg-m .

Hamidreza Abtahi, Email: ri.ca.smut@ihatbarh .

Marjan Ghazisaeeidi, Email: ri.ca.smut@ramizahg .

FAC Number: 2024-05 Effective Date: 05/22/2024

36.523 Site visit.

The contracting officer shall insert a provision substantially the same as the provision at 52.236-27 , Site Visit ( Construction ), in solicitations which include the clauses at 52.236-2 , Differing Site Conditions, and 52.236-3 , Site Investigations and Conditions Affecting the Work. AlternateI may be used when an organized site visit will be conducted.

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pre-site visit

• Thread starter peaced-dreamer
• Start date Apr 14, 2013

peaced-dreamer

• Apr 14, 2013

What does "pre-site visit" mean ? The Committee will make a pre-site visit to each of the countries in order to evaluate...  

post mod (English Only / Latin)

Definition of 'previsit'

Previsit in british english.

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