Message from the Quality Manager, Traci Major:

As your Quality & Risk Management Manager, I look forward to the opportunity to serve as your gatekeeper in ensuring that we remain updated and compliant with the regulatory measures mandated by Joint Commission, Medicare and the State of Texas. Education and follow through are my top priorities in the Quality Department.

While we are required to monitor regulatory compliance measures and data, the goal is to respond to this information and implement processes to continue to provide top quality care to our community. Our goal is to assist you with an interactive, hands-on approach.

Please feel free to contact me with any opportunities for improvement, as well as any questions or concerns with regard to Quality or Risk Management at Texas Health Southlake.

Availability of Interpreter Content:

Interpreters are provided free of charge for patients with limited English proficiency and for those who are hearing- or sight-impaired.

Your nurse or another caregiver can arrange for these services.

Advance Directives

Patients with decision- making capacity have the right to formulate and execute advance healthcare directives. This right includes the ability to:

Texas Health Southlake will honor a patient’s directive to the extent permitted by law and THS policy.

Important Definitions:

Advance Directive:

A statement (either oral or written) expressing a patient’s wishes relative to health care decisions; Commonly seen in such documents as “living wills” and DAPHC’.


A person designated to make healthcare decisions for a patient through the use of a Power of Attorney for Healthcare. The agent has the same authority to decide about most health care that the patient would have, subject to any limits or restrictions placed by the patient.


The ability to understand the nature and consequences of proposed health care and to make and communicate health care decisions. Unless otherwise demonstrated, a patient is presumed to have capacity.

Power of Attorney for Healthcare (PAHC):

A legal document designating an agent to make health care decisions for the patient. The document must be dated, signed, and either witnessed or notarized. It is presumed to be permanently valid (durable) until / unless it is modified or terminated.

Surrogate Decision Maker:

Any designated individual, who may or may not be related to the patient (who lacks decision making capacity), but who has had an ongoing relationship with the patient such that he/she is able to convey the patient’s previously expressed wishes or has some understanding of the patient’s values and probable choices. This individual may be formally appointed (e.g. by the patient in a PAHC, by the court in a conservator or guardian proceeding, etc), or in the absence of an appointment, may be informally authorized.