Become a Surveyor

Our Purpose

During the 2013 Texas legislative session, lawmakers passed new rules for hospitals that offer neonatal and maternal care. To receive designation for those specialties, hospitals must demonstrate compliance to the state rules and patient care policies/protocols must follow national evidenced-based standards. Verification surveys evaluate that hospitals meet certain standards for caring for babies and mothers based on designation level. Surveys document if the hospital met the criteria including standards of care, equipment, policies, and guidelines.

Texas Perinatal Services is a division of the nonprofit Texas EMS, Trauma & Acute Care Foundation (TETAF). In 2015, TETAF established its Texas Perinatal Services division which specializes in neonatal levels of care and maternal verification surveys for hospitals across Texas.

Summary of Activities and Ongoing Requirements

• The maternal surveyor will evaluate the surveyed facility’s compliance with the designation criteria, as defined in the Texas Administrative Code 133.201-133.210 via the following:
  • Review of medical records (10 record reviews per surveyor on each site visit)

     

  • Review of staff rosters and schedules
  • Review of the program plan, policies, and procedures
  • Review of documentation of quality assurance program activities (including peer review)
  • Interviews with facility personnel
  • Evaluation of appropriate use of telemedicine capabilities where applicable
  • Review of equipment and the physical plant
  • Review of additional supporting documentation relevant to maternal care in the facility
• Meet expectations of training and associated proctoring based on Texas Department of State Health Services (TDSHS) guidelines, including successful completion of an approved maternal facility site surveyor course and an approved site survey internship with successful re-credentialing every 4 years
• A physician or nurse surveyor must be employed by a facility that maintains a level III or IV maternal designation in good standing with no contingencies
• Willingness to commit to a minimum of two site surveys per year outside their Perinatal Care Region (PCR) and in facilities at least 100 miles from the surveyor’s place of employment
• Approved surveyors and their employers cannot have a business or patient care relationship or any potential conflict of interest with the facility being surveyed
• Must have a comprehensive understanding of Quality Assessment and Process Improvement (QAPI) program activities and associated loop closure
• Must be active participants in their Perinatal Care Region
• Must participate in training sessions implemented by TETAF and/or TDSHS that further development and consistency in maternal levels of care designation
• Must professionally conduct themselves and maintain strict confidentiality

TETAF Maternal Surveyor Application & Credentialing Requirements

Summary of Expectations and Responsibilities

• Meet expectations of training and associated proctoring based on Texas Department of State Health Services (DSHS) guidelines
• Willingness to commit to a minimum of two site surveys per year
• Must be an active participant in your Perinatal Care Region
• Must participate in training sessions implemented by TETAF and/or DSHS that further development and consistency in maternal levels of care designation
• Maintain professionalism and strict confidentiality

Qualifications and Requirements

• Licensure in good standing with relevant state licensing board
• Registered nurse (RN) candidates must be BSN prepared
• Physician candidates must be board certified or eligible
• 5 years (or greater) experience in the care of maternal patients requiring Level III or IV care
• Active in professional organizations supporting maternal care
• Active in the management of maternal patients and active in the QAPI plan and process at your facility
• Experience in leading a facility through two successful designation surveys (contingent or probationary designation surveys do not meet this requirement)
• Must have completed a PIPS/QAPI course in the last 4 years and not received any weakness or requirements not met related to PIPS/QAPI in their facility’s site survey
• Surveyors outside of Texas must be from the same or higher level of verified/designated facility or from a state with a certification program or categorization program requiring a survey process, and your facility has had two successful designation surveys

Thank you for your interest in becoming a surveyor with TETAF’s Texas Perinatal Services program.

Our Purpose

During the 2013 Texas legislative session, lawmakers passed new rules for hospitals that offer neonatal and maternal care. To receive designation for those specialties, hospitals must demonstrate compliance to the state rules and patient care policies/protocols must follow national evidenced-based standards. Verification surveys evaluate that hospitals meet certain standards for caring for babies and mothers based on designation level. Surveys document if the hospital met the criteria including standards of care, equipment, policies, and guidelines.

Texas Perinatal Services is a division of the nonprofit Texas EMS, Trauma & Acute Care Foundation (TETAF). In 2015, TETAF established its Texas Perinatal Services division which specializes in neonatal levels of care and maternal verification surveys for hospitals across Texas.

Summary of Activities and Ongoing Requirements

• The neonatal surveyor will evaluate the surveyed facility’s compliance with the designation criteria, as defined in the Texas Administrative Code 133.181-133.190 via the following:
  • Review of medical records (10 record reviews per surveyor on each site visit)
  • Review of staff rosters and schedules
  • Review of the program plan, policies, and procedures
  • Review of documentation of quality assurance program activities (including peer review)
  • Interviews with facility personnel
  • Evaluation of appropriate use of telemedicine capabilities where applicable
  • Review of equipment and the physical plant
  • Review of additional supporting documentation relevant to maternal care in the facility
• Meet expectations of training and associated proctoring based on Texas Department of State Health Services (TDSHS) guidelines, including successful completion of an approved maternal facility site surveyor course and an approved site survey internship with successful re-credentialing every 4 years
• A physician or nurse surveyor must be employed by a facility that maintains a level III or IV maternal designation in good standing with no contingencies
• Willingness to commit to a minimum of two site surveys per year outside their Perinatal Care Region (PCR) and in facilities at least 100 miles from the surveyor’s place of employment
• Approved surveyors and their employers cannot have a business or patient care relationship or any potential conflict of interest with the facility being surveyed
• Must have a comprehensive understanding of Quality Assessment and Process Improvement (QAPI) program activities and associated loop closure
• Must be active participants in their Perinatal Care Region
• Must participate in training sessions implemented by TETAF and/or TDSHS that further development and consistency in maternal levels of care designation
• Must professionally conduct themselves and maintain strict confidentiality

TETAF Neonatal Surveyor Application & Credentialing Requirements

Summary of Expectations and Responsibilities

• Meet expectations of training and associated proctoring based on Texas Department of State Health Services (DSHS) guidelines
• Willingness to commit to a minimum of two site surveys per year
• Must be an active participant in your Perinatal Care Region
• Must participate in training sessions implemented by TETAF and/or DSHS that further development and consistency in maternal levels of care designation
• Maintain professionalism and strict confidentiality

Qualifications and Requirements

• Licensure in good standing with relevant state licensing board
• Registered nurse (RN) candidates must be BSN prepared
• Physician candidates must be board certified or eligible
• 5 years (or greater) experience in the care of maternal patients requiring Level III or IV care
• Active in professional organizations supporting maternal care
• Active in the management of maternal patients and active in the QAPI plan and process at your facility
• Experience in leading a facility through two successful designation surveys (contingent or probationary designation surveys do not meet this requirement)
• Must have completed a PIPS/QAPI course in the last 4 years and not received any weakness or requirements not met related to PIPS/QAPI in their facility’s site survey
• Surveyors outside of Texas must be from the same or higher level of verified/designated facility or from a state with a certification program or categorization program requiring a survey process, and your facility has had two successful designation surveys

Thank you for your interest in becoming a surveyor with TETAF’s Texas Perinatal Services program.