Trauma Survey Services

Trauma is the original survey service line to TETAF and successfully serves as the guiding model for all TETAF survey service lines.

The TETAF Survey Operations team strategically selects a survey team with the expertise to meet your specific hospital needs. Our credentialed surveyors include experienced trauma medical directors and trauma program managers who are trained to survey Level III and Level IV Texas hospitals.

Hospitals are evaluated for Trauma Center Designation requirements, as defined by Texas Administrative Code §157.125. Services available include initial designation surveys, focused surveys, and consultation surveys.

TETAF Trauma Survey Package

The TETAF Trauma Survey Package includes: 

  • Prompt survey scheduling
  • Pre-Survey Questionnaire (PSQ) - The PSQ is a document that organizes program components for the surveyors and begins the first phase of the survey process. Hospital partners have stated the PSQ initiated them to review their program plans and identified early opportunities for improvement.   
  • Access to TETAF survey operations and leadership team - TETAF has provided surveys in Texas since 2008. With years of experience in program development, program management, and the survey process, the TETAF team is always available to support you before, during, and after your hospital's survey.
  • Pre-survey conference to ensure preparation 
  • Carefully trained and managed surveyors who complete didactic training, skills labs, observations, and real-time surveyor training to become a credentialed TETAF surveyor. 
  • Consistency in the survey process, including the on-site review, reporting tools, and medical record reviews. 
  • Open evaluations of TETAF's process and surveyors to continuously improve based on your experience.
  • Timely delivery of digital reports, medical record reviews, and a consultation supplement to support your development of a Corrective Action Plan, if indicated.
  • Virtual educational opportunities 
  • Ongoing advocacy with an expert lobby team to continuously ensure your hospital needs are kept at the forefront in the legislative arena.

Trauma Consultation Survey

Our affordable consultations provide recommendations for improvement and identify potential deficiencies before a designation survey. Fewer contingency surveys are scheduled as a result of the consultations prior to a designation survey.

TETAF provides consultations to hospitals seeking Level III or Level IV trauma designation. The consultation is $7,000 and includes a nurse consultant.

TETAF Survey Scheduling Timeline

Our example survey timeline guides you through the survey and the steps to take during the process.

12 months PRIOR to designation expirationContact DSHS**
  • Begin state application for designation or redesignation
  • Review application submission instructions on DSHS website
  • Submit state application to DSHS
  • Receive approval from DSHS for survey
Early January 2023
Dates based on January 1, 2024 expiration date
Request Designation Survey through TETAF
  • Complete and submit TETAF’s online Request for Survey form
  • Include 4-week preferred date range for survey
    • Clear date range with medical director and hospital leadership. Their participation is expected.
    • Receive confirmation from TETAF survey scheduling team
  • Receive, complete, and return TETAF business agreements
  • Receive and begin work on Pre-Survey Questionnaire (PSQ)
Late January 2023Confirm Survey Date with TETAF
  • Receive survey date confirmation and calendar items from TETAF scheduling team
  • Receive preliminary survey agenda
  • Receive TETAF invoice and arrange for payment
February – April 2023Prepare Hospital Documentation
  • Complete PSQ
  • Electronically submit PSQ to TETAF scheduling team by secure email or file sharing site (Ex: Dropbox)
  • Organize program documentation – including program policies, QAPI plan and processes, educational materials
  • Ensure TETAF payment has been processed and delivered
May 2023Prepare for Survey
  • Agenda review discussion with TETAF scheduling team • Conference call/Zoom meeting 2-4 weeks prior to survey
  • Provide arrival instructions for survey team
  • Create admission records log – Do not pre-select records
June 1-2 2023
5-6 months PRIOR to the expiration date
Pre-Survey Record Review and Survey
  • Pre-Survey Medical Record & Documentation Review
  • Survey (including opening conference, department walk-through, and exit conferences)
Late June 2023Receive Survey Documentation
  • Receive digital copies of the survey report, record review packet, and TETAF exclusive consultation supplement including program strengths and recommendations for improvement
  • Complete online TETAF evaluation
July-September 2023Review Survey Report and Create Action Plan
  • Review received documents from TETAF
  • Prepare action plan (if potential deficiencies are identified) Submit Documentation to DSHS
  • Submit survey report, record review packet, and action plan (if needed) to DSHS for final designation approval
  • Please do not hold survey report/documents. The report should be submitted as soon as possible after receipt from TETAF. The action plan will be in progress - not necessarily completed.
  • Materials should be submitted to DSHS at least 90 days prior to the designation expiration date
January 1, 2024Designation Expiration Date

** TETAF is an independent, 501(c)(3) nonprofit organization based in Austin, Texas. TETAF and Texas Perinatal Services are not affiliated with the Texas Department of State Health Services (DSHS).


TETAF has exceptional surveyors. They become part of your team to help your program grow as well as display your strengths and achievements.

CHI St. Joseph Health Burleson Hospital