TETAF Survey Process Frequently Asked Questions

TETAF Trauma Survey Process FAQs

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.

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.

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.

TETAF will accommodate within the requested four week range. 

The surveyors request a Sunday start date to reduce the amount of time away from their hospitals and their patients. 

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

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.

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. 

Surveyors will review findings including potential deficiencies. Additionally, a consultation will be offered to provide recommendations to add potential improvement opportunities. 

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)

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. 

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. 

Satellite ER facilities cannot be trauma designated. Only hospitals can be trauma designated.