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TRACER METHODOLOGY: A NEW APPROACH TO THE ACCREDITATION SURVEY Prepared by: Abier Hamami. RPH.CPHQ

Abstract: Tracer Methodology was implemented lately by the Joint Commission on Accreditation of Healthcare Organizations JCAHO, and other international accrediting agencies as a new enhanced patient-focused accreditation survey process. Patients are traced through the entire continuum of care from their point of entry through post discharge, allowing surveyors to better assess the facilitys compliance with standards, and reviewing systems for their delivery of safe, quality healthcare. Introduction Definition The Joint Commission on Accreditation of Healthcare Organizations JCAHO Defines Tracer methodology as an evaluation method in which surveyors select a patient, resident or client and use that individuals record as a roadmap to move through an organization to assess and evaluate the organizations compliance with selected standards and the organizations systems of providing care and services. It was first implemented by the JCAHO on 2004, as a result of input from accredited healthcare organizations, state hospital associations, and JCAHO advisory committees in analyzing the survey techniques and considering changes. Later it was implemented by the Joint Commission International JCI on 2007. It may seem at first glance that little can be learned from a single patient that could be of benefit to the entire organization, or even a unit, but that's not really the case. Tracers help the organization discover a whole host of problematic practices, such as fragmented care, communication failures, ineffective hand-offs, and documentation deficiencies. Thus tracer methodology goal is not to have individuals at healthcare organizations preparing to participate in a survey but to embed the best processes in their facility to ensure patient safety and the highest quality of care. Objectives: Follow the course of care and services provided to the patient. Assess relationships among disciplines and important functions. Evaluate performance of relevant processes. Identify potential vulnerabilities in care processes.

Benefits Compared to the old accreditation survey process there are a lot of benefits of tracer methodology as following: Focusing less on paper and more on the actual experience of patients. Working as a team instead of preparing one particular area for a survey independent of other departments. Reporting less time on areas such as document review and more time on tracing patients stays in the facility. Following patient through the entire continuum of care instead of visiting separated care areas, and services. Reviewing care concurrently, rather than retrospectively. Creating opportunities to observe many other different activities while tracing. The Individual Patient Tracer : Focus on individual patient and sequentially follow the course of care and services received by the patient from pre-admission through post- discharge. During a patient tracer, the surveyors go to different patient care areas such as the Emergency Department ED, Operating Room OR, Outpatient Clinc OPC, Nursing, Treatment areas, Laboratory and Radiology Diagnostic areas. They will look at services provided by various individuals and departments within the organization, as well as hand-offs between them. This type of review is designed to uncover systems issues while concentrating on organizations individual components, and how they all interact to provide safe and quality patient care. Selection of Patients : Surveyors evaluate what types of patients to select from data they collect prior to the on-site survey. Usually admitted individuals who have received complex or multiple services are generally chosen as tracers. Such as: A patient on dialysis. A psychiatric patient. A pediatric patient. A patient receiving imaging services. A patient receiving rehabilitation services. Patients related to system tracers such as infection control and medication management. Patients who cross programs (e.g. patients scheduled for a follow-up in ambulatory care, or home care). Patients due for discharge that day or the next day The number of patients followed under the Tracer Methodology will depend on the size and complexity of the organization, and the length of the on-site survey. As an example, in a three-day, three-surveyor survey for a hospital, there are about 11 tracers, and they can be 90 minutes or more each. In a

small organization, perhaps one where there's only one surveyor for one day, there would probably be two or three tracer activities. Tracer activities Tracer activities include examining the current clinical patient record for documentation and coordination of care. In addition, observing direct patient care, equipment use, medication process, infection control issues, environmental safety, and care planning process. All standards chapters may be addressed during this activity, and surveyors may ask to interview any staff who cared for the selected patient. Including physicians, nurses, social workers, housekeepers, pharmacists, dietitians, and physical and respiratory therapists. Surveyors will ask the staff member(s) about how they do their jobs, and how they provide care or service to the patient. Such questions are: How do you perform a particular task, such as prepare medications, or deliver meal trays? How frequent you assess your post operative patient? How do you assess your patient pain level? What determines staffing on your unit or in your department? What is your unit scope of service? How you ensure you have the correct patient before performing a test? What data you collect and how you improve? What was your training and your competencies to do your job? How you communicate with other departments?

Most of times, and after permission of patients, surveyors may also interview patients and their family to evaluate their perception of care, and level of satisfaction. Surveyors may request copies of hospital or department policies and procedures to make sure that the practice described is consistent with policy. Also they may request to see staff personnel files, along with the files of co-workers who do similar work. The System Tracer : Focus on important organization wide high risk processes or functions, and include visits to related areas or departments. Such functions are; Infection Control, Data Use, Medication Management. System tracer activity may also trace the path of patients, and evaluates how staffs follow different standard processes within these systems. Medication Management System Tracer :

Focus on organizations medication management as well as potential risk points in the system. This activity determines compliance to medication management standards, traces the path of medications through the organization, and addresses various medication management processes as: Selection and Procurement Storage Ordering and Transcribing Preparing and Dispensing Administering Monitoring Also it evaluates processes of reporting medication errors or adverse drug reactions, and assures implementation of International Patient Safety Goals recommendations. Surveyors may follow different methodology in conducting this tracer activity as explained below. The Group Discussion: usually a group representing the full spectrum of medication management system is involved in this activity. Such as, nurse, physician, therapist, dieticians, pharmacist, clinical pharmacist, biomedical staff, quality professional, and patient education staff. Surveyors will ask questions related to the different medication management processes, and international patient safety goals as following: Do you have a system for after hours medication supply? Do you have a hospital formulary? Or a list of available medications? Do you have a list of unapproved or prohibited abbreviations? How do you assure medications stored appropriately? Do you keep a record of medications errors/ what is your process to improve? What is your process of a non-formulary drug? How do you identify patients before you administer medications? How do you monitor compliance with hand hygiene? How do you handle illegible and incomplete physicians orders? What performance improvement PI Activities youve been involved recently? The Focused-Tracer Activity may take place prior to or after the group discussion. Surveyors explore the path of a selected medication in the organization using a current medical record. The surveyor then focuses on medication management processes informed by prior survey activities such as the medication management group discussion or observations made during previous patient tracers. During medication management tracers, surveyors usually request to see certain pertaining documents and policies as medication management system flow chart, list of high alert medications, list of look-alike and sound

alike medications, and lists of prohibited abbreviations. In addition to, related performance improvement projects and medication safety activities. Infection Control System Tracer Focus on organizations infection control process, and potential areas of concern for improvement. The Activity Will start at a patient care area identified by the surveyor(s), and may move to other settings as appropriate and applicable to trace infection control processes, and observe staff infection control practices across the organization. Then a group meeting with individuals responsible for the organizations infection control program will take place, during which surveyors will assess the degree of compliance with relevant standards, and review organizations infection control surveillance data, and other infection control related data Discussion includes the following : How patients with infections are identified by the organization? How patients with infections are considered within the context of the infection control program? Current and past surveillance activity (taking place in the last 12 months or more for re-surveys and four months or more for initial surveys). Type of analysis being conducted on infection control data, including comparisons. Reporting of infection control data (frequency and audience). Prevention and control activities (e.g., staff training, education of patient/resident/client population, housekeeping procedures). Physical facility changes, either completed or in progress, that have an impact on infection control. Actions taken as a result of surveillance and the outcomes of those actions. The tracer also includes a review of patient record that have: Fever of unknown origin. Post operative infection. Patients placed on some form of isolation or precaution because of being immunocompromised , or with any of the following diagnosis; varicella, pulmonary tuberculosis, invasive haemophilus influenzae, meningococcal disease, drug-resistant pneumococcal disease, pertussis, mycoplasma, mumps, rubella, Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant Enterococci VRE, Clostridium difficile, Respiratory syncytial virus (RSV), enteroviruses, skin infections (impetigo, lice, scabies).

Data Use System Tracer Focus on the organizations use of data in improving safety and quality of care. Also in small organizations and where only one system tracer activity is scheduled, surveyors could asses the data use related to medication management, and infection control. The activity A multidisciplinary team of clinical staff, information management, leadership, and quality professionals involved in the organizations performance improvement activities will be invited to attend this activity. Current performance measures and the resultant improvements will mainly be the focus of this discussion. Surveyors will discuss all quality monitors required in the Quality Improvement Patient Safety QPS Chapter extensively, in regards to the basics of data gathering and preparation, including: Selection of measures. Data collection and aggregation. Data analysis and interpretation. Dissemination/transmission of findings. Taking action. Monitoring performance/improvement. Also, surveyors will discuss how performance improvement methods are used throughout the organization. Facility Management and Safety System Tracer Focus on the organizations performance for managing risk within the facility management and safety program (FMS). The Activity: Individuals from the organization selected for participation in this activity are those responsible for safety, security, utilities, medical equipments, and emergency preparedness, in addition to head of the safety committee. The tracer activity is conducted through three parts as following: Part 1 (The Group Discussion): It involves review of the annual FMS management plans, and the FMS multidisciplinary team meeting minutes for previous twelve months. Information identified from previous surveys, and observations related to FMS made by other members of the survey team is also discussed In this activity the group will discuss for the six FMS risk categories, general safety and security, hazardous materials and waste, emergency management, fire safety, medical/laboratory equipment, and utilities, how

the organization uses the FMS Risk management processes, Plan, teach, implement, respond, monitor, and improve, in addressing those identified risks. Also, the organizations performance in addressing the emergency management requirements of standards FMS.6 and FMS.6.1 will be reviewed. Table 1 Risk Manageme nt Processes Plan Teach Implement Respond Monitor Improve FMS Risk Matrix Risk Categories Safety Hazardou /Security s Materials Fir e MED/LAB Equipment s Utilitie s Emergency Manageme nt

Part 2(Observation Guidelines) It occurs after the group discussion, and uses the FMS Risk Matrix ( see table 1) in selecting a particular management process or risk category to explore. Surveyors will observe the implementation of those particular management processes determined to be potentially vulnerable or, will trace a particular risk(s) in one or more of the FMS risk categories the organization manages. Usually surveyors will begin at the risk starting point (Incident location or hazardous entry) and allow staff to demonstrate their roles and responsibilities for minimizing the risk. They will assess any physical controls for minimizing risk, and evaluate the emergency preparedness plan. Part Three (Conclusion) The surveyor summarizes any potential areas of concern in the management process or risk category observed. Staff responsible for managing that particular process or risk reviewed provides information regarding their role in addressing any areas of concern observed.