TETAF Survey Process Frequently Asked Questions
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, 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.
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.
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.
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.
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.
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