Tracer tactics to survive a Joint Commission survey

Remember that the tracer methodology is not a static process; it is evolutionary. As organizational priorities, standards, and systems change, so will your tracer tools—and so will the process for conducting your tracers. Regardless of the method or tools your organization uses, supporting a culture of patient safety requires use of the tracer methodology at regular intervals. Don’t forget that a tracer can be applied to any process, whether it’s the patient care process or the processes that support the provision of care. If tracer methodology is new for you, it may take a few revisions to find what works best for your organization. Just think of it as your very own performance improvement project.
When developing your plan, remember to utilize the 10 tracer tactics:

• Tactic 1: Focus on priorities. Select a patient, process, or system that is important to the provision of patient care. Consider including high-risk/low-volume and high-risk/high-volume procedures, new policies or equipment, known gaps, and the National Patient Safety Goals.
• Tactic 2: Bring in members of your leadership team to hospital tracer activities. If leadership expresses an interest in being part of the patient and system tracers, others will find value in participating, too.
• Tactic 3: Interview the people who can make a difference and who know the process or system in question; ask them what improvements they would like to see. Not only do they have the power to create
change, but you are also preparing them to be interviewed by a Joint Commission or Centers for Medicare & Medicaid Services surveyor.
• Tactic 4: When investigating, thoroughly use the power of observation. The difference between what we say we do and what we actually do can be significant.
• Tactic 5: Zero in on problematic, recurring themes found during tracer activities.
• Tactic 6: Maintain focus on care planning, medication management, infection control, confidentiality,emergency management, and data management.
Tactic 7: Get meaning from the data. Report the results to the appropriate leaders, integrate findings into the ongoing Focus Standards Assessment process, require action plans, and monitor those plans through resolution of noncompliant issues.
• Tactic 8: Appreciate opportunities to learn, and welcome teachable moments.
• Tactic 9: Gather information; take names of staff members and physicians to validate competence; and collect, collate, and aggregate the results. Identify a central repository for this information.
• Tactic 10: Celebrate! Let’s face it: Consistently looking for and finding flaws is not going to feel good for anyone on the receiving end. That makes it even more crucial to recognize great work and the individuals or teams that are making it happen.

Keep in mind that the tracer methodology is just one method for identifying issues. Effective quality programs produce the same type of information through analysis of data. Use the work from your quality program, your medical record review, your environmental rounds, your adverse event reporting system, and any other assessments to ensure organizational readiness. Remember, too, that there is no perfect tracer tool. For every tracer tool, there are 10 others that might produce the same results. It may take a few tries, but eventually you will find the tool that is just right for your organization. We’ve provided some sample tools and tracer case studies in this chapter for you to view, use, and revise. We hope that they will produce some value for you and your organization.

This is an excerpt from 17th Edition of The Joint Commission Mock Tracer Made Simple. Visit HCPro Marketplace for more information and to order.