Environment of Care®

Tracer
Workbook
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Environment of Care® Tracer Workbook

Executive Editor: Kristine M. Miller, M.F.A.

Project Manager: Bridget Chambers
Manager, Publications: Lisa Abel
Associate Director, Production: Johanna Harris
Executive Director: Catherine Chopp Hinckley, Ph.D.

Joint Commission Reviewers: George Mills, M.B.A., F.A.S.H.E., C.E.M., C.H.F.M., Senior Engineer, Standards Interpretation
Group; Jerry Gervais, C.H.F.M., C.H.S.P., Associate Director/Engineer, Standards Interpretation Group; John Fishbeck, R.A.,
Associate Director, Division of Standards and Survey Methods; Lynne Bergero, M.H.S.A., Project Director, Department of Stan-
dards and Survey Methods; Jerry Dykman, Surveyor, HAS; Stephen Turner, C.H.S.P., Life Safety Code Specialist, Accreditation
and Certification Operations

Joint Commission Resources Reviewer: Lisa Abel, Manager, Publications

Joint Commission Resources Mission
The mission of Joint Commission Resources is to continu-
ously improve the safety and quality of care in the United
States and in the international community through the provi-
sion of education and consultation services and international
accreditation.
Joint Commission Resources educational programs and publica-
tions support, but are separate from, the accreditation activities
of The Joint Commission. Attendees at Joint Commission Re-
sources educational programs and purchasers of Joint Commis-
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treatment in, or confidential information about, the accredita-
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The inclusion of an organization name, a product, or a service
in a Joint Commission publication should not be construed as
an endorsement of such organization, product, or service, nor
is failure to include an organization name, a product, or a ser-
vice to be construed as disapproval.
This publication is designed to provide accurate and authorita-
tive information regarding the subject matter covered. Every at-
tempt has been made to ensure accuracy at the time of
publication; however, please note that laws, regulations, and
standards are subject to change. Please also note that some of the
examples in this publication are specific to the laws and regula-
tions of the locality of the facility. The information and exam-
ples in this publication are provided with the understanding that
the publisher is not engaged in providing medical, legal, or other
professional advice. If any such assistance is desired, the services
of a competent professional person should be sought.
© 2011 by the Joint Commission on Accreditation of Health-
care Organizations
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Table of Contents

Introduction ........................................................................................1
How to Conduct a Mock Tracer ..........................................................5
Overview: Environment of Care Tracers ..........................................15

Section 1: Tracer Scenarios for Safety ............................................ 17

Scenario 1-1. Staff Back Injuries..................................................................................................19
Scenario 1-2. Patient Falls ..........................................................................................................21
Scenario 1-3. Snow Removal ......................................................................................................23
Scenario 1-4. Eye-wash Stations ................................................................................................25
Scenario 1-5. Elevator Safety ......................................................................................................27
Sample Tracer Worksheet: Scenario 1-1. ....................................................................................30

Section 2: Tracer Scenarios for Security ..........................................35

Scenario 2-1. Infant and Pediatric Security ..................................................................................37
Scenario 2-2. Pharmaceutical Security ........................................................................................40
Scenario 2-3. Security of Radioactive Material ............................................................................42
Scenario 2-4. Security of the Helistop ..........................................................................................44
Sample Tracer Worksheet: Scenario 2-3. ....................................................................................47

Section 3: Tracer Scenarios for Hazardous Materials and Waste ....51

Scenario 3-1. Laboratory Safety ..................................................................................................53
Scenario 3-2. Responding to a Spill ............................................................................................55
Scenario 3-3. Infectious Waste Disposal ......................................................................................57
Scenario 3-4. Radiation Safety ....................................................................................................59
Sample Tracer Worksheet: Scenario 3-3. ....................................................................................62

Section 4: Tracer Scenarios for Fire Safety ......................................67

Scenario 4-1. Fire Plans ..............................................................................................................69
Scenario 4-2. Response to a Real Fire ........................................................................................71
Scenario 4-3. Fire Drills ..............................................................................................................73
Sample Tracer Worksheet: Scenario 4-2. ....................................................................................75

Section 5: Tracer Scenarios for Medical Equipment ........................79

Scenario 5-1. Medical Equipment Maintenance ............................................................................81
Scenario 5-2. Product Recalls ....................................................................................................83
Scenario 5-3. Responding to a Safe Medical Devices Act (SMDA) Incident ....................................85
Scenario 5-4. Sterilizer Maintenance ..........................................................................................87
Sample Tracer Worksheet: Scenario 5-4. ....................................................................................90

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Environment of Care® Tracer Workbook

Section 6: Tracer Scenarios for Utilities ..........................................93

Scenario 6-1. Utility Outages ......................................................................................................95
Scenario 6-2. Generator Testing ..................................................................................................97
Scenario 6-3. Mapping Utilities ....................................................................................................99
Scenario 6-4. Heating, Ventilating, and Air-Conditioning (HVAC) Systems ..................................101
Sample Tracer Worksheet: Scenario 6-2. ..................................................................................104

Section 7: Tracer Scenarios for Monitoring and Improving

Performance....................................................................................109
Scenario 7-1. Performance Monitors ..........................................................................................111
Scenario 7-2. Reviewing Environment of Care Management Plans ..............................................113
Sample Tracer Worksheet: Scenario 7-2. ....................................................................................115

Section 8: Tracer Scenarios for Emergency Management ..............119

Scenario 8-1. Activating and Operating an Incident Command Center ........................................121
Scenario 8-2. Retracing an Emergency Response ......................................................................123
Scenario 8-3. Planning for an Emergency ..................................................................................126
Scenario 8-4. Disaster Privileging ..............................................................................................128
Sample Tracer Worksheet: Scenario 8-3. ..................................................................................131

Section 9: Tracer Scenarios for Life Safety ....................................135

Scenario 9-1. Touring a Construction Project ..............................................................................137
Scenario 9-2. Interim Life Safety Measures (ILSM) ....................................................................140
Scenario 9-3. Building Tours ......................................................................................................142
Sample Tracer Worksheet: Scenario 9-2. ..................................................................................146

Appendix A: Priority Focus Areas ..................................................149

Appendix B: Mock Tracer Worksheet Form ....................................153

Index ..............................................................................................157

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Introduction
Tracer methodology is an integral part of the on-site accredita-
tion survey process used by The Joint Commission and Joint
Commission International (JCI). Surveyors use tracers to eval-
uate the care of an individual or to evaluate a specific care
process as part of a larger system. A surveyor reviews an indi-
vidual’s record and follows the specific care processes the indi-
vidual experienced by observing and talking with staff
members in areas where the individual received care. This
methodology provides the surveyor with an opportunity to as-
sess the organization’s systems for providing care and services
and its compliance with accreditation requirements. This
book, part of a series that focuses on familiarizing health care
staff with tracer methodology, can help an organization learn
to conduct simulated—or mock—tracers that mimic actual
tracers. The mock tracer is conducted by someone in the or-
ganization who performs the role of an actual surveyor.
Benefits of Understanding Tracers
Health care organizations that educate staff about tracers will
have a better understanding of the overall survey process, espe-
cially since an on-site surveyor can typically devote up to 60%
of his or her time conducting tracers. In addition, an organiza-
tion that understands tracers can use mock tracers as a tool to
assess its compliance with standards and make improvements
before a surveyor arrives. For example, if an organization wants
to analyze how well a specific aspect of a system on a specific
unit functions—such as the security in the neonatal intensive
care unit of a hospital—it can conduct a mock tracer of that
system. Although its purpose would be to learn more about
how systems function in that particular unit, a mock tracer
would also provide important information that could identify
broader issues for improvement.
Types of Tracers
Surveyors currently conduct three types of tracers:
• Individual: An individual tracer follows the actual expe-
rience of an individual who received care, treatment, or
services in a health care organization (that is, a patient, a
resident, or an individual served). To select individuals to
trace in U.S. health care organizations, surveyors take into
account an organization’s clinical/service groups (CSGs)
and its top priority focus areas (PFAs) identified through
the Joint Commission’s Priority Focus Process. The CSGs
categorize care recipients and selected services into distinct
populations for which data can be collected. PFAs are
processes, systems, or structures in a health care organiza-
tion that significantly impact safety and/or the quality of
care provided (see Appendix A). The organization’s specific
CSGs and PFAs inform the choice of what types of areas,
units, services, departments, programs, or homes to visit
initially to conduct an individual tracer; the CSGs, in
turn, help the surveyor select an individual to trace. Al-
though information from the Priority Focus Process may
help surveyors select the first individuals and areas to
trace, a surveyor may trace the experience of additional
care recipients based on the initial findings during the on-
site survey.
• System based: A surveyor may use a system-based tracer
to analyze a high-risk process or system across an entire
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Environment of Care® Tracer Workbook
organization to evaluate how and how well that system
functions. Currently, there are three topics explored during
the on-site survey using the system tracer approach: med-
ication management, infection control, and data manage-
ment. To analyze a medication management or infection
control system, a surveyor can follow an individual’s actual
care experience through the organization and assess how
well that particular system functioned related to that indi-
vidual’s care. But to analyze a data management system,
the surveyor conducts a group meeting session and focuses
on assessing an organization’s use of data in improving
safety and quality of care. The goal of a data management
system tracer is to learn about an organization’s perfor-
mance improvement process, including the organization,
control, and use of data. There is no individual care recipi-
ent to follow; however, data from performance improve-
ment are used and evaluated during the course of
individual tracers throughout a survey.
• Program specific: A surveyor may use a program-specific
tracer to analyze the unique characteristics and relevant is-
sues of a specific type of organization. The goal of this type
of tracer is to identify safety concerns in different levels
and types of care. For example, a patient flow tracer is a
program-specific tracer used in hospitals, whereas a conti-
nuity of care tracer is a program-specific tracer used in an
ambulatory care organization.
A survey may also include an environment of care (EC)
tracer. Like a system tracer, this type of tracer examines
organizational systems and processes—in this case, systems
related to the physical environment. This book focuses on
EC tracers.
Second Generation Tracers
During any type of tracer, a surveyor may see something in-
volving a high-risk area that requires a more in-depth look. At
that point, the surveyor may decide to conduct a second gen-
eration tracer, which is a deep and detailed exploration of a
particular area, process, or subject. These types of tracers are a
natural evolution of the existing tracer process.
The following are high-risk topics in hospitals and critical ac-
cess hospitals that surveyors might explore in more detail using
a second generation tracer approach: cleaning, disinfection,
and sterilization (CDS); patient flow across care continuum;
contracted services; diagnostic imaging; and ongoing profes-
sional practice evaluation (OPPE)/focused professional prac-
tice evaluation (FPPE).
2
Tracers Used Internationally
Tracer methodology is being used to assess health care organiza-
tions beyond the United States. Health care organizations that
undergo JCI accreditation also experience tracer methodology
when surveyors visit their facilities. The concept is essentially the
same for both domestic and international organizations; how-
ever, there are slight differences. Whereas U.S. surveyors use
such elements as PFAs and CSGs to select care recipients to
trace, these criteria do not apply to international surveys. JCI
surveyors use information provided in the organization’s accredi-
tation survey application to select tracer subjects from an active
care recipient list. Subjects typically selected are those who have
received multiple or complex services because they, most likely,
have had more contact with various departments of the organi-
zation, providing a greater opportunity for the surveyor to assess
how systems work in the organization. Furthermore, program-
specific tracers are done as part of “undetermined survey activity”
appropriate to an organization, as defined in the JCI Survey
Process Guide. Also, international organizations refer to the EC
tracers as “facility management and safety” tracers and to data
management system tracers as “improvement in quality and pa-
tient safety” tracers.
Conducting Mock Tracers
The best way to understand all types of tracers is through prac-
tice—that is, through conducting mock tracers. This involves
developing some basic skills, such as learning how to ask good
questions. An actual tracer is not performed by one person in
isolation. It involves talking with multiple staff members and,
in the case of individual tracers and some system tracers, the
care recipient and even family members (if possible) to learn
details about an individual’s health care experience or how a
particular system functions in an organization. All important
details about the individual’s care or the system’s function can
be explored by asking simple questions in succession. And how
a question is asked is particularly important. A surveyor poses
questions in a manner that encourages the staff member or
care recipient to share as much information as possible. Obser-
vation of the surroundings or attention to how a respondent
answers one question can lead to other related issues and can
trigger additional questions.
Skills in analysis and organization are also involved, particularly
in planning a mock tracer, and of course, analysis is necessary
to evaluate and prioritize the results of a mock tracer. Similar
skills are involved in the reporting of the results and in the
follow-up on any consequent plans for improvement based on
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the results. Often, an organization will institute a mock tracer
program that will train participants for optimum outcomes to
these practice tracers. The benefits that result from mock trac-
ers support and enhance the continuation of such teams.
How to Use This Book
We designed the Environment of Care® Tracer Workbook to help
staff members in all health care settings better understand how
EC tracers work and how to conduct mock tracers:
• “How to Conduct a Mock Tracer” follows this Introduction. It
provides step-by-step instruction on performing a mock tracer.
• The Overview that follows “How to Conduct a Mock
Tracer” goes into further detail about EC tracers.
• Each section of this workbook includes examples of tracers,
called scenarios, that address specific EC, emergency man-
agement (EM), or life safety (LS) topics.
• Each scenario is preceded by a list of the PFAs that emerge
during the scenario. Then, a narrative describes how a sur-
veyor might analyze the particular EC system.
• Sample tracer questions follow each scenario. They show
the types of questions a surveyor might ask staff members
or other individuals for the specific scenario. These ques-
tions are keyed to the narrative to show how and when they
might occur during the scenario.
Introduction
• Each section also includes an example of a tracer worksheet
that utilizes the sample tracer questions from one scenario
and shows how the worksheet might be completed during
mock tracer activities.
• Each scenario includes helpful sidebars that provide compli-
ance and mock tracer tips.
• Appendixes describe the PFAs and provide forms that are
helpful in developing a mock tracer program.
Acknowledgments
A work of this scope requires a concerted team effort. This
book, which we hope you find to be as useful as it is practical,
could not have been created without such a team. We are in-
debted to our writer, Kathleen B. Vega, for her attention to de-
tail and her outstanding professionalism.
We are also grateful to our Joint Commission reviewers
(see page ii) for their thorough and timely input.