TETAF Survey Process FAQs
How far in advance should the hospital submit its state application for designation?
All hospitals must submit the appropriate level application to the Texas Department of State Health Services (DSHS) at least 12 months prior to the current designation expiration date.
What is the process to schedule a survey?
As soon as the application is submitted to the Texas Department of State Health Services (DSHS), submit a Trauma Survey Request form found on the TETAF Services webpage.
How soon will TETAF schedule the survey once the Trauma Survey Request has been submitted?
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 receiving the request.
Will TETAF accommodate the hospital's request for specific dates?
TETAF will accommodate within the requested four week range.
Why is my medical record review scheduled for a Sunday evening?
The surveyors request a Sunday start date to reduce the amount of time away from their hospitals and their patients.
What is included on the Survey Agenda?
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 included in the calendar attachment to the hospital no less than two weeks prior to the survey date.
An example of a Survey Agenda can be viewed here.
What happens during the hospital walk-through?
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 roles in the management of the patient.
What occurs during the medical record review?
Surveyors will randomly choose records of a variety of categories to complete a comprehensive record review and quality improvement documentation for each record. The surveyors are determining standards of care, scope of practice, and internal hospital policy compliance.
What happens in the exit conference?
Surveyors will review findings including potential deficiencies. Additionally, a consultation will be offered to provide recommendations to add potential improvement opportunities.
How is the survey report submitted and who is responsible?
TETAF will submit the survey report and medical record report reviews within 30 days. Anticipate an email from the TETAF survey coordinator. The hospital will then be responsible for submitting their reports and medical record reviews and any other documentation, such as an action plan, to the Texas Department of State Health Services (DSHS).
How far back does a hospital need to maintain its trauma/stroke documents?
Trauma designations are for three years. Record keeping for trauma should be a rolling three years from the previous survey. The record history must be available for review if requested by the surveyor.
For many years, we prepared the trauma charts for survey by pulling 10 charts per category for the surveyors to choose from those charts. We see there is now a change in the process that requires a 12-month trauma log be provided to the surveyors on survey day. Do we send this log in advance so the surveyors can choose and we can prepare the records in advance?
No, the surveyors will review the trauma log on site and randomly select the records at that time. You will then access the records and pull the QI for each record. There will be no advance notice of which records the surveyors will review. This process will ensure a random selection of records to review.
What information should be included in the trauma log to ensure the surveyors select the best records to evaluate patient care and quality assurance process?
The log should include the MR number, age, the date of admission, mode of arrival, the mechanism of injury, final diagnosis, final outcome, and a column identifying the survey categories including deaths, transfers out, admissions, ED-OR, ICU admissions, pediatric admissions, burns, spinal cord, and liver/spleen injuries.
What if my chart elements and PI documentation are in several places and systems? How would I access, print, and prepare each selected record onsite in a timely manner?
We encourage the program manager and system navigator to display the information electronically whenever possible. Surveyors will know to allow transition time among different systems. The program manager should receive the agenda with enough time to prepare the log, have a practice session, and troubleshoot accessing data.
Will delays in trauma transfers affect a designation?
No. Delays in trauma transfers will not affect a designation. However, the standard to transfer out trauma patients is less than two hours. When reviewing records, any fallouts greater than two hours (major or severe only) should be identified as an opportunity to examine the cause. Identifying the opportunity and implementing a plan of action will be validated during the survey process.
Are satellite ER facilities also required to be trauma designated? If so, does each location have its own survey and fee?
Satellite ER facilities cannot be trauma designated. Only hospitals can be trauma designated.
Previously the trauma agenda gave a date range for charts that ended 90-days prior to the survey date. When should the 12-month trauma log begin and end?
The date range for the medical record selection will remain the same for purposes of planning. However, if the program manager chooses to share more recent records that have completed loop closure, those records may be included. Additionally, if a surveyor identifies a trend and would like to review any records within the excluded 3 month time frame or older records, the surveyor may review any trauma records within the full last 3 year cycle since the prior survey.
My hospital has two free-standing emergency rooms. I know we enter trauma patients to our trauma registry if they are transferred to the main ED. Are these trauma patients considered “transfer in” patients on our trauma registry?
Yes, they need to be included in the registry and use the standing ED’s address so you can track and define the transfers quality of care.
Jorie Klein, MSN, MHA, BSN, RN