Utilizing experienced neonatal medical directors and neonatal nurses that actively practice in Texas, TETAF provides NICU survey services for Level I, II, III and IV Texas hospitals.
Once the request for survey application form is received, the TETAF NICU survey coordinator will contact the requesting hospital regarding potential survey dates.
Utilizing experienced stroke coordinators, TETAF has an outstanding team of credentialed stroke surveyors trained to provide survey and consultative services for hospitals seeking Stroke Support Facility (Level III) designation.
Partnering with the Texas Department of State Health Services, TETAF staff provides technical assistance in program development as well as coordination of survey services to ensure a successful Stroke Support Facility (Level III) designation process.
Utilizing experienced trauma medical directors and trauma program managers, TETAF has an outstanding team of credentialed trauma surveyors trained to provide survey services for Level III and Level IV Texas hospitals.
Partnering with the Texas Department of State Health Services, TETAF staff provides technical assistance resources in trauma program development as well as coordination of survey services to ensure a successful designation process.
All hospitals must submit the appropriate level application to DSHS at least 12 months prior to the current designation expiration date. At the same time, the hospital should go to www.tetaf.org and click on the “Services” tab to complete a Trauma Survey Request form. Use the “Request a Trauma Survey or Consultation” button to access the form. On the form, use the radio buttons to indicate type of survey and designation level. Please note, as of June 1, 2016, the state is no longer required to approve a hospital to schedule a survey; surveys should be requested at the same time the DSHS application is submitted. Tip: Submit the state application and complete the TETAF trauma survey request form 12 months prior to the designation expiration date.
As soon as the application is submitted to DSHS, submit a Trauma Survey Request form via the TETAF website, services page. Requesting the survey at the same time the state application is submitted will provide the lead time necessary to schedule your survey and coordinate the completion of TETAF’s Pre-Survey Questionnaire (PSQ). Before you request a date or time frame with TETAF, please share this information with your hospital and trauma leadership teams to ensure there are no schedule conflicts. Trauma and hospital leadership not attending the survey may result in a potential deficiency. As soon as the survey date is confirmed with TETAF, send a meeting request that will put the survey on each attendee’s calendar, and convey that they are expected to meet their commitment to the trauma/stroke program by participating in the survey. Once the date is set with TETAF, rescheduling can create multiple coordination challenges and could result in requested dates not being available. Tip: Document communication and approval of the survey date with administration, physicians and other leadership team members. Emphasize the critical importance of each person’s participation.
The Survey Coordinator for TETAF will notify you when the Trauma Survey Request is received. The request will be placed in the queue for scheduling. TETAF will make every effort to provide the hospital with a survey date within 45 to 60 days of the receipt of the request. Within the form, there is an opportunity to record your preferred dates. TETAF will make every effort to meet those requests. However, TETAF requests flexibility as dates must also be coordinated with the availability of credentialed surveyors.Tip: Give as broad a range as possible to help meet your requested time frame.
Yes, to the degree possible. TETAF will work with you to avoid any date that may result in lack of participation, such as holidays. The hospital has the right to refuse or accept the dates TETAF offers. It is critical to the success of the survey to ensure that all supporting leadership and staff are available. Do not hesitate to request alternate dates if there is a potential conflict. Note that for Sunday-Monday surveys, Sunday evening medical record review is required. Please pay careful attention to dates when finalizing the survey schedule.Tip: Be sure to include both the day of the week as well as the date in your communication to hospital personnel.
The medical record review is a critical component of the survey and is typically held the evening before the opening conference. The program manager, medical director, registrar and any staff knowledgeable in the navigation of the medical record system must be available during the medical record review. This is a quiet working session. The number of people included in the session should be limited to only those necessary to complete the reviews. Conversations in the review room are distracting and should be avoided.Tip: Schedule the medical record review in a quiet location and alert those who may be needed to be available during the record review period.
State rules define specific requirements to ensure that surveyors are fair and objective. Assigned surveyors will be employed by facilities at least 100 miles from the hospital being surveyed, the surveyor’s facility will not be in the same RAC as the hospital being surveyed and a surveyor will not have conducted the survey in the immediate prior survey cycle.
TETAF screens for additional potential conflicts that may result in a bias for the assigned surveyor. These potential conflicts may include:
1. A relative is in a leadership position in the hospital or on the program staff.
2. There is a current or prior relationship such as employment, training, partners from the same provider, etc.
3. Previous survey services or other consultative services have been provided to the hospital.
4. The hospital has a tertiary facility relationship with the place of employment of the surveyor.
If the hospital believes a potential conflict exists, the program manager should notify the TETAF Survey Coordinator as soon as possible. All efforts will be made to ensure the survey team provides the hospital with a fair, consistent evaluation in compliance with appropriate state rules.
Contact with surveyors prior to the survey is prohibited until after the survey agenda is received by the hospital. This practice ensures there is no bias prior to the survey. Contact information for the surveyor(s) is provided with the agenda. Tip: Notify TETAF immediately if you believe a potential conflict-of- interest exists with an assigned surveyor.
TETAF provides the hospital with a Survey Agenda to describe and define the site survey process and it includes a list of medical record categories that will be reviewed. The agenda is delivered by email to the hospital no less than two weeks prior to the survey date.
Agendas are specific to the level of designation, and all hospitals within each level will receive the same agenda. This practice provides consistency in the survey process throughout Texas. The agenda will define expected participation, the timeline and the medical record review requirements.
The opening conference, led by the surveyor(s), is an opportunity to demonstrate hospital leadership’s commitment to the program under evaluation and to demonstrate the hospital-wide commitment to managing the care of these patients. Scenario methodology will frequently be used by the surveyors to offer departmental leadership an opportunity to describe each department’s role in managing the care of the patient. (Staff members are interviewed during the facility walk-through). Additionally, the state application will be reviewed for clarifications and questions. If the hospital is seeking its initial designation, a 10 to 15 minute PowerPoint presentation may be allowed at the discretion/approval of the surveyor. However, the time to complete the entire survey process rarely includes enough time for the hospital to make a lengthy presentation.Tip: Review the agenda for the survey and make sure participants are aware of the survey activities and their locations.
The surveyors will complete a facility walk-through, check equipment and conduct staff interviews following the opening conference. All departments should be prepared to answer questions and discuss their role in the management of the patient. The surveyors will validate equipment availability, knowledge of policies and procedure, written program guideline accessibility, feedback processes, required education and staff competencies and engagement.Tip: Be sure all departments are aware of the survey date and their role in the survey process. A reminder a couple of days before the survey can address any last-minute questions. In advance of the survey, it is a good idea to walk through all of the departments providing patient care and management within your program. Ask questions and ensure all team members are familiar with their roles and responsibilities to patients.
Each surveyor is required to randomly choose medical records for review from a log or hard copies of the records based on specific review requirements, including required review volume, patient injury types, pediatric considerations and death reviews. The program manager is not allowed to choose records for the surveyor. All records from the date range provided in the agenda are considered for review; however, the surveyor may also choose records from any time since the previous survey.
All medical records are reviewed for standard of care, hospital and guideline compliancy, compliancy with state rules including the essential criteria, standards and filters as well as patient outcomes. All quality improvement for each record reviewed will be evaluated for identification of opportunities, review team, intervention to improve identified opportunities, loop closure and reporting of all quality issues through committee and up to hospital leadership and governance as indicated. Through this process, the surveyors will evaluate the Process Improvement Plan and ensure the hospital is following all state requirements and internal hospital policies. This review is a critical part of the hospital survey. Tip: Be sure all medical records subject to potential review have been completed and are readily available. Ensure all documents supporting quality improvements for each record are organized and can be readily retrieved for the surveyor upon request. Although peer review committees’ minutes need not be in the review room, they must be made available to the surveyors if requested.
After the walk-through is completed, the surveyor(s) will go into a closed session to prepare for the exit conference. This closed session is typically 30 to 45 minutes. The exit conference will occur immediately following the closed session.
The exit conference has two phases. The Regulatory Phase is a discussion of identified potential deficiencies. The survey team is restricted to identifying the potential deficiencies.
If the hospital approves, there is an opportunity for a Consultative Phase, which will specifically discuss strengths, opportunities for improvement and recommendations for addressing identified potential deficiencies. During this phase, it is recommended that the program manager take notes, which will facilitate the development of a Corrective Action Plan, if needed.Tip: In advance, discuss if a Consultative Phase is desired and make sure that participants allot enough time for participation.
The survey reportwill be submitted to the hospital within 30 days of the site survey. The hospital will receive a program Survey Report and Consultation Report. Ten medical record reviews per surveyor will also be provided. The hospital must forward the Survey Report and the medical records to DSHS along with the request for designation or re-designation. The hospital should also include a Corrective Action Plan addressing any potential deficiencies. Copies of revised policies, education certificates or any other documents to support the correction of potential deficiencies may be included. The hospital should keep copies of all documents submitted to DSHS.
Once received, DSHS will review the report and the Corrective Action Plan to determine recommendations to the Commissioner of Health for designation consideration. The state may take two to three months for the review and final determination regarding designation/re-designation.Tip: Program managers should look for the survey report toward the end of the 30-day post-survey period. Prepare and submit the survey packet to DSHS as soon as possible. Do not submit the Consultative Report to DSHS. This document is intended for hospital internal use only and provides a road map to program development for the next three-year cycle.