2020 TETAF Annual Report

Page 1

TABLE OF CONTENTS 2 3 4 5 6 7 8 9 10 11 12 13 13 14 15 16 17 18 19 20 21 22 22 23 24 25 26 26 26 27 27 28 29 30 31 32 33 34 35 36 37 38

Our History and Our Purpose A Message from the President/CEO A Glimpse at 2020 TETAF Survey Service Lines Surveying During a Pandemic 2020 Vision on Quality Assurance Trauma TETAF's Trauma Service Line Receives Top-Level Satisfaction Scores from Hospital Partners Stroke TETAF Plans to Rebuild its Stroke Survey Process Neonatal Training the Texas Perinatal Services Surveyors A New Era in Surveying Maternal Successfully Closing in on a Complete Maternal Survey Cycle The Power of Partnerships Expanding our Focus on Maternal Mortality and Morbidity Advocacy A Pandemic Interim TETAF President/CEO Named to National Trauma Advocacy Committee Regional Advisory Councils Responding to All Calls A Pilot Project: Patient Tracking Wristbands Texas TQIP Texas Trauma Quality Improvement Program Collaborative (Texas TQIP) - A TETAF Sponsored Initiative Education Keeping a Focus on Education TETAF Enters New Partnership to Continue Certified Nurse Education TETAF Hospital Data Management Course Goes Virtual A Virtual Library for Learning Anytime, Anywhere Texas Perinatal Forum Shares Expert Knowledge Financials TETAF Fiscal Year 2019-2020 Budget About Us TETAF Executive Leadership TETAF Board of Directors TETAF Board of Directors (cont.) A Legend in Trauma - Dr. Kenneth Mattox Steps Down After 30 Years as Chief of Staff General Assembly Elects New Members to the TETAF Board of Directors Our Hospital Partners Surveyed in 2020 - Trauma and Stroke Our Hospital Partners Surveyed in 2020 - Maternal and Neonatal Remembering Our Legacy

01 | TETAF Annual Report 2020

OUR HISTORY In the early 2000s, the need for survey services in Texas was expanding significantly however, the Texas Legislature needed to streamline the state's budget. The Texas Department of State Health Services (DSHS) was no longer able to provide survey services due to a reduction in funds. The American College of Surgeons (ACS) was the only option for Level III trauma surveys and there was not an option for Level IVs, plus hospitals voiced concerns regarding the cost of surveys from ACS. Additionally, there was a strong desire to have a community of trauma, EMS, and acute care advocates to speak louder with a centralized voice for advocacy. These concerns and needs led the 22 Regional Advisory Councils (RACs) and the Texas Trauma Community to support the launch of Texas EMS, Trauma and Acute Care Foundation (TETAF). As a 501(c)(3) nonprofit organization, TETAF provides operational support and fills the gap where federal, state, and local governments, and private entities cannot provide statewide services. In 2008, DSHS granted TETAF the authority to provide verification surveys for Level III and Level IV designated trauma facilities. The first TETAF staff members were hired in 2009 to fully implement TETAF's mission. The following year, TETAF's role expanded to provide Level III stroke verification surveys. In 2015, TETAF expanded its reach and was approved to provide neonatal verification surveys. In August 2016, TETAF launched neonatal leveling surveys in Texas and provided more than 100 surveys in the first 3-year cycle. Following closely behind neonatal, in August 2018 TETAF launched maternal leveling verification surveys along with the creation of TETAF’s Texas Perinatal Services division. Texas Perinatal Services continues to lead the state in perinatal verification surveys. Today, with 122 credentialed surveyors, TETAF and Texas Perinatal Services provide verification surveys for trauma, stroke, neonatal, and maternal in more hospitals than any other entity surveying. Driven by our mission, TETAF continues to ensure comprehensive, quality care is provided to patients in Texas.

OUR PURPOSE To support the role of the Texas Regional Advisory Councils (RACs) as the leaders of system development of regional health care delivery in time-sensitive human conditions. To facilitate collaboration among all components of regional health care delivery systems and other organizations by providing a forum to build consensus on policy that supports the access to and provision of high-value care, based on cost-effective, timely, and evidence-based methods. To advocate for effective public policy for patient care and regional health care delivery, including sufficient funding to preserve, support, and enhance system components. To work with the State of Texas to coordinate and integrate regional health care delivery systems. To increase public awareness and promote the value of regional health care delivery systems. To provide timely information relevant to regional health care delivery systems. To serve as a resource for consultation and verification surveys of organizations seeking specialty designation or recognition. To provide targeted education and consultative services for regional health care delivery systems and their stakeholders. To operate exclusively for charitable, scientific, and educational purposes within the meaning of Section 501(c)(3) of the Internal Revenue Code of 1986 (the "Code"), as amended, and Texas Tax Code 11.18(d), as amended. 02 | TETAF Annual Report 2020

A MESSAGE FROM THE PRESIDENT/CEO Together, we make it possible to ensure there is quality health care in Texas. The Texas EMS, Trauma & Acute Care Foundation (TETAF) staff, the TETAF Board of Directors, and committees, surveyors, hospital partners, Regional Advisory Councils (RACs), and stakeholders work together to strengthen our health care systems, especially during a challenging year when our world was forever changed by a pandemic. TETAF has made tremendous strides in the verification of trauma and stroke hospitals in Texas. TETAF also provides unmatched experience in maternal and neonatal levels of care verification surveys through our Texas Perinatal Services division. In 2020, TETAF successfully achieved tremendous goals that include: The TETAF/Texas Perinatal Services team developed a plan, that includes a modified survey agenda, to continue surveys safely in hospitals during the pandemic. The TETAF/Texas Perinatal Services team also developed an alternate plan to customize the survey process with a hybrid (virtual and on-site) survey method to adapt to the unique circumstances for that hospital. TETAF added to the perinatal expertise of the TETAF Board of Directors with two perinatal leaders. Following the successful legislative session in 2019, TETAF's Advocacy team and legislators secured Account 5111 funding for the biennium. These efforts allocated 1% more of the Account 5111 funding for EMS providers and 1% more for the Regional Advisory Councils (RACs). The percentage increases secured for the RACs and EMS were included in the May 2020 contracts. Texas Perinatal Services exceeded its goal of contracts for maternal care surveys and captured more than 80% of the market in a short period. A virtual meeting of the TETAF Board of Directors was conducted for the first time. The TETAF Hospital Data Management Course was successfully conducted virtually for the first time providing a cost-effective methodology to deliver needed education in Texas. Three opportunities for this course are scheduled in 2021. Our team rose to the challenges that resulted from the COVID-19 pandemic and faced them head-on so we can ensure a strong trauma and emergency health care system for Texas well beyond 2020. I am proud of these efforts and I invite you to learn more about our successes in this annual report.

Dinah S. Welsh TETAF President/CEO

03 | TETAF Annual Report 2020

A GLIMPSE AT 2020 TETAF was the FIRST statewide surveying organization to develop and receive approval for the virtual survey process.

TETAF's advocacy team and legislators secured Account 5111 funding for the biennium which allocated 1% MORE of the Account 5111 funding for EMS providers and 1% MORE for the Regional Advisory Councils (RACs).

Texas Perinatal Services exceeded its goal of contracts for maternal care surveys and captured MORE THAN 80% of the market in a short period. Perinatal expertise was added with new members to the TETAF Board of Directors. Educational offerings went virtual resulting in a cost savings while continuing to provide quality education.

98% satisfaction scores in ALL SURVEY SERVICE LINES

04 | TETAF Annual Report 2020


TETAF provides verification surveys in trauma, stroke, neonatal, and maternal care in Texas.

05 | TETAF Annual Report 2020

SURVEYING DURING A PANDEMIC 2020 presented itself as one of the busiest years in TETAF history with a full calendar of surveys, consultations, educational events, advocacy, and conferences. Then the schedule came to a screeching halt when stay-at-home orders were enforced in March due to the COVID-19 pandemic. With less appointments on the calendar, TETAF strategically developed a survey plan to support our mission while mitigating exposures and limiting face-to-face surveys to ensure the safety of surveyors, hospital partners, and our staff. The first step was to cancel surveys and events scheduled for the remainder of March and April. During this time, the TETAF team developed a COVID-19 Safety Plan that includes a surveillance process to continuously monitor the developing crisis. The plan also includes a revised survey agenda that adds additional safety precautions and social distancing steps. It also ensures our surveyors were prepared to enter a hospital with appropriate protection. Our team also developed strategic communications to surveyors, hospitals, and the Texas Department of State Health Services (DSHS). Recognizing the seemingly unending public health crisis, in May the TETAF team created a virtual survey process. The team identified a platform ensuring HIPPA compliance and secure access, and created a training process for our surveyors and hospital partners. DSHS quickly approved an execution plan. TETAF became the first statewide surveying organization to develop and receive approval for the virtual survey process. Hybrid, or part in-person and part virtual, surveys were conducted. The TETAF survey team recognized the benefit of virtual surveys and how this method supported hospital efforts to maintain designations. The virtual surveys provided surveyors the information needed to ensure the hospital was meeting the standard of care and the ability to tell the hospital story completely and accurately. However, ideally, an in-person survey provides more opportunity for the hospital to demonstrate compliance to the rule and provide evidence to the surveyors. Throughout the pandemic, TETAF provided survey services using both on-site and virtual formats that earned high satisfaction rates from hospital partners. 06 | TETAF Annual Report 2020

2020 VISION ON QUALITY ASSURANCE TETAF continues to strive in delivering survey services that exceed the expectations of our hospital partners and the Texas Department of State Health Services (DSHS). In 2020, TETAF earned an average customer satisfaction score of 98% across all survey service lines. As TETAF and its perinatal program, Texas Perinatal Services, continued the initial cycle of launching our maternal survey service line, maternal hospitals chose Texas Perinatal Services over our competitors the majority of the time, resulting in our capturing 80% of the maternal survey market. This is a result of TETAF’s due diligence in quality by assuring our reviewing and reporting tools, our surveyor training, and building a better understanding of the DSHS criteria determination. With a full review of the components of our neonatal survey service line, plus opportunities to improve were realized and implemented, Texas Perinatal Services once again was the surveying entity chosen for 85% of the neonatal survey market for the second cycle of neonatal unit leveling. Texas Perinatal Services identifies opportunities through real-time and post-survey reviews, surveyor identification, DSHS reviews, and hospital feedback. TETAF and Texas Perinatal Services have more than 12 years of success in surveying. Using the TETAF trauma model that is based on a foundation of consistent, quality-driven processes, TETAF and Texas Perinatal Services have successfully proven that survey quality assurance is the driver to identifying best practice and optimal patient care. TETAF’s survey success leads to favorable hospital verification surveys and designations.

07 | TETAF Annual Report 2020


Trauma is the original service line to TETAF and continues to serve as the guiding model for the additional service lines TETAF offers.

08 | TETAF Annual Report 2020

TETAF'S TRAUMA SERVICE LINE RECEIVES TOP-LEVEL SATISFACTION SCORES FROM HOSPITAL PARTNERS TETAF continues to earn stellar evaluations from hospitals within all service lines, including trauma. With 77 Level IV trauma centers surveyed and 23 Level III trauma centers surveyed, TETAF received 98% satisfaction scores from our hospital partners evaluating our process and our surveyors throughout the year. The TETAF Mission is always the central focus of the surveying process. Recognizing the strength in the regional health care delivery systems, TETAF understands the critical need for rural health care. The challenges facing Texas rural hospitals are ongoing and impact access to care. A combination of physician availability, resource shortages, and reductions in reimbursement continue to negatively impact systems of care and reduce the availability of health care in many communities. Bringing their expertise into rural hospitals of Texas, TETAF surveyors work closely with hospital partners to provide guidance and support to ensure patients in non-urban areas continue to receive accessible, quality care. Keeping the TETAF mission in mind with every hospital partner and every survey leads to not only satisfied hospitals, but also a continuous endeavor for the best patient outcomes.

09 | TETAF Annual Report 2020


Acute care has been part of TETAF’s mission since its beginning. TETAF’s focus on early and optimal stroke care remains an important commitment to our work.

10 | TETAF Annual Report 2020

TETAF PLANS TO REBUILD ITS STROKE SURVEY PROCESS Stroke surveys are the second service line TETAF offers to hospital partners. The stroke program supports hospitals that are focused on providing good stroke care and desiring Level III designation as stroke centers. Driving this aspect of the TETAF mission is the recognition that the number one mortality and morbidity risk in Texas is stroke and cardiac disease. With very experienced stroke surveyors, TETAF provides stroke verification services for 19 rural Texas hospitals in a 3-year cycle. In 2021, TETAF plans to rebuild its process based on the 2020 Governor’s EMS and Trauma Advisory Council (GETAC) approved Stroke Committee recommendations endorsing the utilization of the Brain Attack Coalition Guidelines. TETAF will continue working with our hospital partners to support access to optimal stroke care in these smaller, rural hospitals in Texas.

11 | TETAF Annual Report 2020

NEONATAL SURVEY SERVICES TETAF expanded its services into the perinatal world in 2016 and created Texas Perinatal Services the following year. With a focus on quality care for newborn Texans, the first service line to launch was neonatal.

12 | TETAF Annual Report 2020

TRAINING THE TEXAS PERINATAL SERVICES SURVEYORS TETAF and Texas Perinatal Services require comprehensive training sessions for all surveyors to ensure they have a full understanding of the Texas Administrative Code. All surveyors are expected to fairly and consistently evaluate hospitals in Texas using the tools and resources provided by TETAF. Prior to the COVID-19 stay-at-home orders, Brenda Putz, TETAF vice president, and Carla Rider, perinatal program director for Texas Perinatal Services, led a two-day intensive training session for new maternal and neonatal surveyors. The training was held in January at John Sealy Hospital on The University of Texas Medical Branch campus in Galveston. As the pandemic put a halt to travel and large gatherings, Texas Perinatal Services continued training new surveyors through a virtual platform.

A NEW ERA IN SURVEYING For the first time in TETAF history, TETAF and Texas Perinatal Services expanded the eligibility for surveyors who reside and practice outside of Texas. Several Arkansas-based physician surveyors who were receptive to joining our survey teams were credentialed by TETAF and Texas Perinatal Services in 2020. All surveyors whether they are based in Texas or Arkansas receive the same training to ensure consistency in surveys. Expanding the opportunity to train out-of-state surveyors allows TETAF and Texas Perinatal Services to meet the growing demand for surveys.

13 | TETAF Annual Report 2020

MATERNAL SURVEY SERVICES Texas Perinatal Services expanded its services in 2018 with the creation of the maternal service line. In its second year, the maternal service line continues to grow and develop strong partnerships with other perinatal organizations to bring timely and important education to our partners.

14 | TETAF Annual Report 2020

SUCCESSFULLY CLOSING IN ON A COMPLETE MATERNAL SURVEY CYCLE Two years after launching the neonatal survey service line, Texas Perinatal Services added maternal leveling to its mission in August 2018. Months later during the 86th Texas Legislative Session, the passage of Senate Bill 749 led to a slowing of maternal surveys. As the maternal survey team worked with our hospital partners by providing education, direction, and ongoing support, 37 maternal surveys were completed. Those include 28 Level II, 14 Level III, and nine Level IV. Additionally, the team conducted four of our newly developed survey consultations. The current cycle of maternal verification surveys in Texas continues into 2021. Texas Perinatal Services proudly announces that when the cycle ends next year, our maternal survey team will complete 116 maternal hospital reviews. This is 80% of all surveyed maternal hospitals in Texas.

15 | TETAF Annual Report 2020

THE POWER OF PARTNERSHIPS Texas Perinatal Services is one of many organizations committed to its ongoing focus on maternal mortality through educational opportunities aimed at reducing perinatal health disparities. There are other organizations, such as the Institute for Perinatal Quality Improvement (PQI), that are placing the necessary emphasis on this important issue. Partnering with other entities is essential for learning and working to improve maternal care. Texas Perinatal Services has partnered with PQI for educational opportunities in the past and worked with the organization to bring a virtual event focused on maternal mortality and racial bias. The "SPEAK UP ChampionsŠ Implicit and Explicit Bias Conference" will be a two-part, live, virtual conference in 2021. This will be one of several opportunities Texas Perinatal Services plans to offer for our hospital partners that will be focused on providing quality equitable care to mothers.

16 | TETAF Annual Report 2020


Texas Perinatal Services was proud to be a sponsor of the Texas Collaborative for Healthy Mothers and Babies (TCHMB) 2020 Summit. The event was held in February in Austin and was well-attended. The theme for the conference was, “Making Quality Improvement Local.” The keynote speaker was Michael C. Lu, M.D., MS, MPH, dean of the University of California Berkeley School of Public Health and former director of the federal Maternal and Child Health Bureau (MCHB). His speech focused on, “Ending Maternal Mortality in Texas.” Texas Perinatal Services will continue its focus on providing educational opportunities and partnering with other organizations that are focused on maternal mortality so together we can all learn how to eradicate this issue in Texas.

17 | TETAF Annual Report 2020

ADVOCACY Since 2009, TETAF has been active at the Texas Capitol providing services in the advocacy, public policy, communications, and regulatory arenas. TETAF has become the go-to source for lawmakers on trauma and emergency health care.

18 | TETAF Annual Report 2020

A PANDEMIC INTERIM The COVID-19 pandemic changed everything, including the interim ahead of the 87th Texas Legislative Session. The TETAF Advocacy team started the year with an initial strategy and a timeline. When meetings did not happen, plans and priorities changed. However, this did not stop the TETAF Advocacy team from securing Account 5111 funding for the biennium. During the 86th Texas Legislative Session, TETAF was successful in its efforts to repeal the Driver Responsibility Program (DRP) and replace the funds it generated for trauma. The legislation also modified the distribution of the Account 5111 money which allocated 1% more of the funding for EMS providers and 1% more for the Regional Advisory Councils (RACs). While the actual appropriations bill did not reflect the increases, TETAF's Advocacy team worked for months with state leaders to direct the additional money that collects in the account as a result of the fee changes. The RACs and EMS will see an increase in funding during the 2020-21 biennium due to the 1% to 2% change for RACs and 2% to 3% change for EMS. The increase is estimated to be just over $800,000 per year for the RACs and $800,000 for EMS. The TETAF Advocacy team continued having conversations with legislators, and monitored online meetings and website updates from the Texas House and Senate. TETAF conducted two surveys, the COVID-19 Impact Survey for stakeholders and a survey for the 22 Regional Advisory Councils (RACs), to determine how to best meet trauma and perinatal needs during the upcoming session. TETAF also participated in many meetings with the Texas Department of State Health Services (DSHS). Texas Perinatal Services was invited by the Perinatal Advisory Council (PAC) chair, Dr. Emily Briggs, to participate in the perinatal rule revisions during a meeting in March. The invite was prompted by a letter from Texas Perinatal Services to Dr. Briggs that provided input for the rule revisions. Advocating for trauma and perinatal needs remains a focus for TETAF at all times. Despite an unorthodox interim, TETAF is prepared to advocate these needs during the 87th Texas Legislative Session.

19 | TETAF Annual Report 2020

TETAF PRESIDENT/CEO NAMED TO NATIONAL TRAUMA ADVOCACY COMMITTEE TETAF President/CEO Dinah Welsh was named to the Trauma Center Association of America's (TCAA) Advocacy Committee. As a member of this committee, Welsh has the opportunity to share insight at the federal level about the Texas Trauma System and its needs. In early 2020, Welsh attended the TCAA Advocacy Day in Washington, D.C. on behalf of her role as a TCAA committee member and trauma care advocate. During Advocacy Day, Welsh visited with members of Congress along with former trauma patients who are doing well and serving as a testament to the trauma system.

20 | TETAF Annual Report 2020

REGIONAL ADVISORY COUNCILS Regional Advisory Councils (RACs) are the administrative bodies responsible for trauma system oversight within the bounds of a given Trauma Service Area in Texas. Since its beginning, TETAF has advocated for and worked directly with the RACs to strengthen the trauma system in Texas.

21| TETAF Annual Report 2020

RESPONDING TO ALL CALLS The state’s 254 counties are divided into 22 Trauma Service Areas with oversight provided by Regional Advisory Councils, or RACs. Originally tasked with developing, implementing, and monitoring a regional emergency medical service Trauma System Plan, the RACs continue to expand their health care role to include cardiac, stroke, and perinatal systems of care. In addition, recognizing the gaps in data collection in Texas, the RACs innovatively developed a data collection collaborate, the RAC Data Collaborative to support stroke and perinatal care in Texas. This year was a challenge unlike any other as the RACs coordinated and responded to the needs during the COVID-19 pandemic, in addition to other trauma system needs. Since the beginning of the pandemic’s spike in Texas, the RACs have worked with the Texas Division of Emergency Management (TDEM) to coordinate the distribution of supplies, including personal protective equipment (PPE), to local entities. The RACs have also worked with local hospitals and the Texas Department of State Health Services (DSHS) to manage hospital bed capacity. Coordination of these efforts is a tremendous task and the work of the RACs has been in the national spotlight.

A PILOT PROJECT: PATIENT TRACKING WRISTBANDS During the 86th Texas Legislative Session, Senate Bill (SB) 500 passed which appropriated additional “emergency” funds to trauma. Of the $17 million appropriated, $2 million is dedicated to RACs for “improving emergency management services.” In late 2019 and early 2020, TETAF coordinated and hosted several strategy meetings to discuss the best ways to utilize this funding. One of the options widely discussed was patient tracking wristbands. The pilot patient wristband project launched in December utilizing funding from SB 500. The Regional Advisory Councils (RACs) participating in the pilot project are Border RAC, North Texas RAC, North Central Texas Trauma RAC, Central Texas RAC, Heart of Texas RAC, Southwest Texas RAC, Texas J RAC, Coastal Bend RAC, and Concho Valley RAC. Data will be collected and the first update will be provided in early 2021.

22 | TETAF Annual Report 2020

TEXAS TQIP Since 2016, the Texas Trauma Quality Improvement Program (Texas TQIP) collaborative has worked to strengthen the quality of care for trauma patients in Texas trauma centers. TETAF proudly sponsors and supports the Texas TQIP.

23| TETAF Annual Report 2020


The Texas TQIP collaborative continued its efforts in 2020 to define best practice guidelines for Texas trauma centers. Working with the American College of Surgeons’ Trauma Quality Improvement division, the Texas collaborative focused on multiple initiatives aimed at improving trauma care in Texas. The collaborative conducted a survey of its trauma centers that focused on venous thromboembolism (VTE) events, which demonstrated that Texas centers outperformed 70% of trauma centers nationwide. Texas TQIP also formed three workgroups for its members focusing on specific quality improvement initiatives including: Dead on Arrival (DOA) and Died in Emergency Department (DIED) Acute Kidney Injury (AKI) Unplanned Returned to the Operating Room These will continue to be a focus in 2021. TETAF recognizes the mission driven dedication of this collaborative and will continue to support their efforts to improve trauma patient care through data-driven best practice development. Learn more about the Texas TQIP leadership team and its developments at https://tetaf.org/tx-tqip-about/.

24 | TETAF Annual Report 2020


TETAF is consistently focused on achieving excellence in the delivery of trauma, emergency, neonatal, and maternal patient care. This effort includes offering educational opportunities throughout the year.

25 | TETAF Annual Report 2020

KEEPING A FOCUS ON EDUCATION Another important element of TETAF's mission is education. TETAF continues to provide Certified Nurse Education (CNE) hours for Texas Trauma Coordinators Forum’s (TTCF) quarterly meetings. Topics include presentations on trauma care, program development, and quality assurance.

TETAF ENTERS NEW PARTNERSHIP TO CONTINUE CERTIFIED NURSE EDUCATION With the unfortunate demise of the education division of the Texas Nurses Association, TETAF’s education coordinator worked with the Louisiana State Nurses Association (LSNA) to ensure TETAF could continue to provide CNE. TETAF is now approved through LSNA to provide CNE through its educational offerings.

TETAF HOSPITAL DATA MANAGEMENT COURSE GOES VIRTUAL For the first time, the TETAF Hospital Data Management Course was held virtually. The twoday course was well-attended. Continuing education credits were given to those who completed the course. Top data and trauma leaders presented on topics such as data abstraction, data entry, trauma validation and patient information, trauma coding, and case reviews. The course was so successful that more classes will be offered virtually in 2021. For more information on future classes and other educational offerings, visit https://tetaf.org/tetafeducation/.

26 | TETAF Annual Report 2020

TEXAS PERINATAL FORUM SHARES EXPERT KNOWLEDGE As TETAF surveyors and staff travel the state providing maternal and neonatal survey services to hospitals in every region, they have a unique opportunity to identify knowledge deficits and educational opportunities in program development, quality assurance, and best practice. During these visits, our surveyors and staff recognized innovative approaches to monitoring and ensuring optimal perinatal patient care in Texas. This led to TETAF creating a monthly virtual opportunity, the Texas Perinatal Forum, to share knowledge from our surveyors and hospital partners. With the mission of supporting quality assurance and program development that assures the health and safety of moms and babies in Texas, the TETAF team works to identify educational needs through the survey process and provide ongoing education that is exclusive for our hospital partners. In 2020, the forum grew with regular attendance of more than 100 program managers and physicians located across the state. With continuous compliments to the content and opportunity, this monthly virtual education has proven value, supports the mission, and provides a coach to success culture in our state.

A VIRTUAL LIBRARY FOR LEARNING ANYTIME, ANYWHERE Ahead of the pandemic and before nearly everything became part of the virtual world, Texas Perinatal Services launched its Virtual Library. This library is an exclusive resource available for all customers. The Virtual Library is accessible on the Texas Perinatal Services website using a secure login. The Virtual Library houses dozens of videos that include past Texas Perinatal Services Monthly Forums and Virtual Training Manual Resources. This library is one of the many commitments TETAF/Texas Perinatal Services has to provide educational opportunities for its customers and partners in perinatal care.

27 | TETAF Annual Report 2020


TETAF is solely supported by verification survey fees, subscription fees, educational program fees, and taxdeductible donations.

28 | TETAF Annual Report 2020

TETAF FISCAL YEAR 2019-2020 BUDGET FY 2019-2020 Total Operating/Direct Expense Budget $1,763,616 Administrative & Professional 9%

General Operating Expenses 5%

Program Related 4% Salary and Benefits (Opex/Direct) 45%

Survey Direct Expenses 37%



Salary and Benefits (Opex/Direct) Survey Direct Expenses Program Related Administrative & Professional General Operating Expenses

$787,725.00 $650,799.00 $68,207.00 $163,705.00 $93,180.00 $1,763,616.00

FY 2019-2020 Revenue $813,175.00

Trauma/Stroke Survey


Maternal Care Survey


Neonatal Survey Subscription



$23,218.00 $0

29 | TETAF Annual Report 2020






Ensuring quality care in trauma, stroke, maternal, and neonatal takes a team. Together, our team, our Board of Directors, and our hospital partners share the same mission and goals to give Texas patients the best outcome.

30 | TETAF Annual Report 2020


Dinah S. Welsh President/CEO

Brenda Putz, BSN, RN Vice President of Operations

Dinah Welsh has been with TETAF since it was established in 2009. She has more than two decades of experience advocating for health care issues in Texas in areas such as trauma and emergency health care, maternal care, and neonatal care. Her efforts have secured a steady funding stream for the trauma and emergency health care system.

Brenda Putz joined TETAF in 2009 after more than 20 years in the trauma and emergency health care community as a trauma program manager, trauma surveyor, and educator. She is responsible for the successful development and oversight of the neonatal and maternal care survey processes, and the processes for trauma and stroke designations.

Carla Rider, DNP, MSN, MBA, RNC-LRN Perinatal Program Director

Erin Moore Communications Director

Carla Rider joined TETAF and Texas Perinatal Services in 2017 and oversees the maternal and neonatal verification survey programs. She has more than 25 years of experience in women’s and children’s nursing. She has developed several protocols and initiatives during her career that have resulted in improved patient outcomes and enhanced staff development.

Erin Moore joined TETAF in 2019 and has more than 20 years of communications experience including journalism, public and media relations, and marketing. She previously worked in health care communications for Christus Santa Rosa Hospital San Marcos and the Texas Department of Assistive and Rehabilitative Services.

31 | TETAF Annual Report 2020


Craig Rhyne, M.D. Chair Lubbock

Jeff Beeson, D.O. Fort Worth

Dudley Wait, EMT-P Vice Chair Schertz

Scott Christopher, BBA, BSN, RN, LP San Augustine

Ricky Reeves, EMT-P Secretary Lewisville

Nilda Garcia, M.D. Austin

Kathy Perkins, RN, MBA Treasurer Round Rock

Angela Gentry, RN, MSN, TCRN Temple

Eric Epley, CEM General Assembly Chair San Antonio

Wanda Helgesen, RN, MSN El Paso

32 | TETAF Annual Report 2020


Lisa Hutchins, RN-NIC Houston

Peyton Ware, BBA Lufkin

Kenneth Mattox, M.D., FACS Houston

David Weisoly, D.O. The Woodlands

Ed Racht, M.D. Austin

Kate Schaefer, RN, CEN, NREMT Amarillo

Danny Updike, RN, CCRN, EMT-LP San Angelo

33 | TETAF Annual Report 2020

A LEGEND IN TRAUMA - DR. KENNETH MATTOX STEPS DOWN AFTER 30 YEARS AS CHIEF OF STAFF Dr. Kenneth Mattox, a longtime member of the TETAF Board of Directors, started his journey into health care at the Baylor College of Medicine in 1960. At that time, emergency medicine was not the established field as it is today. During the past 60 years, Dr. Mattox has had a remarkably accomplished career and became a nationally recognized trauma expert. After serving 30 years as chief of staff at Ben Taub Hospital in Houston, Dr. Mattox announced his retirement from this role. He will continue his work at Baylor and in the Department of Surgery as special advisor to the president and CEO, Dr. Paul Klotman, and as associate vice chair of education in the Department of Surgery. Dr. Mattox has worked with many other notable physicians, including training under Dr. Michael DeBakey and observing Dr. Denton Cooley implant the first artificial heart. He was a competing trauma surgeon with Dr. James “Red” Duke from Memorial Hermann. Through the years, Dr. Mattox had a role in the operations of 70,000 Ben Taub patients. His methods became known as the “Mattox way.” Dr. Mattox is also an author and instructor. He will remain as a Baylor professor after retiring from Ben Taub. Dr. Mattox continues to serve as a member of the TETAF Board of Directors, lending his legendary mind and voice to TETAF.

34 | TETAF Annual Report 2020

GENERAL ASSEMBLY ELECTS NEW MEMBERS TO THE TETAF BOARD OF DIRECTORS The TETAF General Assembly met in December to elect new members to the TETAF Board of Directors. Five nominees were elected to the 2021 TETAF Board of Directors with terms that will expire in 2023. The General Assembly voted from a slate of 10 nominees. The individuals elected to the TETAF Board of Directors are: Diana Grimm-Mapp, RN, BSN, CEN, TCRN Ed Racht, M.D. (Re-elected) Ricky Reeves, EMT-P (Re-elected) Craig D. Rhyne, M.D., FACS (Re-elected) Dudley Wait, EMT-P (Re-elected) Additionally, Christine Reeves was nominated and unanimously elected as the chair of the General Assembly. The General Assembly chair also serves on the TETAF Board of Directors. The General Assembly also approved a revision to the TETAF Bylaws. This revision allows an elected board officer to continue serving out the officer term if he or she is not eligible to serve another board term.

Diana Grimm-Mapp, RN, BSN, CEN, TCRN Galveston

35 | TETAF Annual Report 2020

Christine Reeves Waco

OUR HOSPITAL PARTNERS SURVEYED IN 2020 TRAUMA AND STROKE Advent Health Central Texas Ascension Providence Ascension Seton Edgar B. Davis Hospital Ascension Seton Highland Lakes Hospital Ascension Seton Medical Center Austin Ascension Seton Northwest Ascension Seton Southwest Hospital Baptist Hospitals of Southeast Texas Baylor Scott & White All Saints Medical Center Baylor Scott & White Medical Center—Brenham Baylor Scott & White Medical Center—Lakeway Baylor Scott & White Medical Center—McKinney Baylor Scott & White Medical Center—Round Rock Baylor Scott & White Medical Center—Taylor Bellville Medical Center BSA Health Systems Cedar Park Regional Medical Center CHI St. Joseph Health Grimes Hospital CHI St. Joseph Health Madison Hospital CHI St. Luke's Health Memorial—Lufkin CHI St. Luke’s Health Memorial—Livingston Christus Good Shepherd Medical Center—Marshall Christus Hospital St. Elizabeth Christus Mother Frances Hospital—Jacksonville Christus Mother Frances Hospital—Sulphur Springs Christus Santa Rosa Hospital Christus Spohn Hospital Corpus Christi—South Christus Spohn Hospital—Beeville Christus St. Michael Health System Christus St. Michael Hospital—Atlanta Columbus Community Hospital Comanche County Medical Center Corpus Christi Medical Center—Bay Area Corpus Christi Medical Center—Doctors Regional Cuero Regional Hospital DeTar Healthcare Systems North Driscoll Children's Hospital Edinburg Regional Medical Center Faith Community Health System Fisher County Hospital Frio Regional Hospital Hardeman County Memorial Hospital HCA Houston Healthcare Kingwood HCA Houston Healthcare Mainland Hereford Regional Medical Center Hill Country Memorial Hospital Hunt Regional Medical Center Huntsville Community Hospital, Inc. Lake Granbury Medical Center Lamb Healthcare Center Limestone Medical Center Longview Regional Medical Center Lyndon B. Johnson Hospital Medical City Alliance Medical City North Hills Medical City Weatherford Memorial Hermann Greater Heights Memorial Hermann Katy Hospital Memorial Hermann Southwest Hospital

Memorial Hermann Sugar Land Hospital Methodist Hospital Methodist Hospital South Methodist Specialty and Transplant Hospital Methodist Stone Oak Hospital Metropolitan Methodist Hospital Midland Memorial Hospital Mission Trail Baptist Hospital Nocona General Hospital Northeast Methodist Hospital OakBend Medical Center—Jackson Street OakBend Medical Center—Williams Way OakBend Medical Center—Wharton Hospital Ochiltree General Hospital Odessa Regional Medical Center Palo Pinto General Hospital Pampa Regional Medical Center Parkview Regional Hospital Resolute Health Hospital Seton Medical Center Harker Heights Shamrock General Hospital Southwest General Hospital St. David's Medical Center St. Joseph Medical Center Stephens Memorial Hospital District Stonewall Memorial Hospital Sweeny Community Hospital Texas Children's Hospital—West Campus Texas Health Harris Methodist Hospital Alliance Texas Health Harris Methodist Hospital Stephenville Texoma Medical Center Throckmorton County Memorial Hospital TMC Bonham Hospital UTMB Clear Lake Campus Valley Baptist Medical Center – Brownsville Valley Regional Medical Center Wadley Regional Medical Center Wilbarger General Hospital Wise Health System Yoakum Community Hospital (Stroke and Trauma)

36 | TETAF Annual Report 2020

OUR HOSPITAL PARTNERS SURVEYED IN 2020 MATERNAL AND NEONATAL Maternal Hospitals (cont.) Texas Health Presbyterian Dallas Texas Health Presbyterian Hospital Denton Texas Health Presbyterian Hospital of Plano The Woman's Hospital of Texas United Regional Health Care System University Medical Center Wadley Regional Medical Center Wilson N. Jones Regional Medical Center

Neonatal Hospitals

Maternal Hospitals Baptist St. Anthony Health System Baylor Scott & White All Saints Medical Center Baylor Scott & White Centennial Medical Center Baylor Scott & White Medical Center—McKinney Baylor Scott & White Medical Center Lake Pointe Baylor Scott & White Medical Center—Hillcrest Baylor Scott and White Medical Center—Lakeway Baylor Scott and White Round Rock Medical Center CHI St Luke's Health Memorial – Livingston Christus Spohn South Hospital Citizens Medical Center City Hospital at White Rock Covenant Children's Hospital Dallas Regional Medical Center Doctors Hospital of Laredo Fort Duncan Regional Medical Center Harlingen Medical Center HCA Houston Healthcare Tomball Houston Methodist Baytown Hospital Houston Methodist Hospital Houston Methodist Sugar Land Hospital Houston Methodist The Woodlands Hospital Houston Methodist West Hospital Houston Methodist Willowbrook Hospital Lake Granbury Medical Center Laredo Medical Center Medical City McKinney Metropolitan Methodist Hospital Nacogdoches Medical Center OakBend Medical Center—Williams Way Seton Medical Center Harker Heights South Texas Health System—McAllen South Texas Health Systems Edinburg St. David's Medical Center Texas Health Arlington Memorial Texas Health Huguley

37 | TETAF Annual Report 2020

Ascension Providence Health Center Baylor Scott & White All Saints Medical Center Baylor Scott & White McLane Children's Medical Center Baylor Scott & White Medical Center—Grapevine Baylor Scott & White Medical Center —Hillcrest Baylor Scott & White Medical Center—Irving Baylor Scott and White Medical Center—McKinney Baylor University Medical Center CHRISTUS Good Shepherd Medical Center CHRISTUS Mother Frances Hospital—Tyler CHRISTUS Santa Rosa Hospital San Marcos CHRISTUS Southeast Texas St. Elizabeth CHRISTUS Spohn South Corpus Christi Medical Center—Bay Area El Paso Children's Hospital HCA Houston Healthcare Clear Lake HCA Houston Healthcare Kingwood HCA Houston Healthcare Tomball Houston Methodist Sugar Land Hospital Knapp Medical Center Longview Regional Medical Center Medical City Arlington Medical City Lewisville Memorial Hermann Katy Hospital Memorial Hermann Memorial City Medical Center Memorial Hermann Southwest Memorial Hermann The Woodlands Methodist Charlton Medical Center Metropolitan Methodist Hospital Mission Regional Medical Center Northwest Texas Healthcare System Odessa Regional Medical Center Rio Grande Regional Hospital Shannon Medical Center Southwest General Hospital St. David's Medical Center St. David's North Austin Medical Center St. David's Round Rock Medical Center St. David's South Austin Medical Center St. Joseph Hospital Texas Health Arlington Memorial Hospital Texas Health Presbyterian Hospital of Plano The Woman's Hospital of Texas United Regional Health Care System University of Texas Medical Branch Hospital Wadley Regional Medical Center

REMEMBERING OUR LEGACY Judy England 1942-2020 Judy England recognized the need for improved trauma care from her early days as a charge nurse and flight nurse. She was instrumental in the development of the Texas Trauma System created in 1989. As one of the first trauma surveyors, Judy traveled throughout Texas sharing her knowledge and offering guidance to trauma centers. Joining her colleagues from Dallas, Judy was one of the founding members of the Texas Trauma Coordinators Forum (TTCF), a professional organization providing support and education to trauma coordinators across Texas. Judy was a member of the Piney Woods Regional Advisory Council (TSA G) and served as RAC chair for many years. In frequent attendance at the Governor’s EMS and Trauma Advisory Council (GETAC) meetings in Austin, Judy was a voice and an advocate for both urban and rural trauma centers of Texas. Dedicating more than two decades to the improvement of the Texas Trauma System, Judy was a founding member of TETAF. Her loss as a friend and colleague will long be felt, but her legacy will live on through the tremendous work she did to improve trauma care in Texas.

38 | TETAF Annual Report 2020

Texas EMS, Trauma & Acute Care Foundation 3400 Enfield Road Austin, Texas 78703 (512) 524-2892 www.tetaf.org www.texasperinatalservices.org info@tetaf.org