Surveyors also may use the tracer methodology to examine how National Patient Safety Goals are addressed. On the surgical unit, a surveyor may observe a nurse giving medications ordered by the hospitalist. The surveyor would spend time talking with the nurse and hospitalist about the patient selected for the tracer, perhaps asking for the unique identifiers used for the patient. Other queries may include: What is the patient’s diagnosis? How is the hospitalist caring for this patient? What was the admission date? The surveyor would note whether any of the “do not use” abbreviations related to medications are used and talk with the hospitalist about this issue. How are healthcare-acquired infections addressed?
The patient tracer process takes surveyors across a wide variety of departments and involves practitioners and other caregivers in the accreditation process, asking them to describe how they carried out their work. Instead of asking the hospitalist about particular standards, surveyors explain the purpose of the tracer and engage in an educational as well as an evaluative process. This approach moves the on-site survey away from high-level conferences with administrators about policies and procedures to focused discussions with those actually delivering care. The idea is to create an atmosphere that allows for an open exchange of information and ideas between surveyors and the hospitalist and other staff.
These discussions with hospitalists, other staff, and patients—combined with review of clinical charts and the observations of surveyors—make for a dynamic survey process that provides a complete picture of an organization’s processes and services. In other words, the tracers allow surveyors to “see” care or services through the eyes of patients and staff and then analyze the systems for providing that care, treatment, or services.
As surveyors use the tracer methodology to determine standards of compliance as they relate to care delivered to individual patients, they also assess organizational systems by conducting patient-system tracers. The concept behind the patient-system tracers methodology, which focuses on high-risk processes across an organization, is to test the strength of the chain of operations and processes. By examining a set of components that work together toward a common goal, the surveyor can evaluate its level of efficiency and the ways in which an organization’s systems function. This approach addresses the interrelationships of the many elements that go into delivering safe, high-quality care and translates standards compliance issues into potential organization-wide vulnerabilities.
The system tracers provide a forum for discussion of important topics related to the safety and quality of care at the organization level. Surveyors use the system tracers to understand organization findings and to facilitate an exchange of educational information on key topics such as data use for infection control and medication management.
While some of the patient system tracer activities consist of formal interviews, an interactive session, which involves a surveyor and relevant staff members, is an important component of the process. Discussions in this interactive session with the hospitalist and other staff include:
- The flow of the processes, including identification and management of risk points, integration of key activities, and communication among staff/units involved in the process;
- Strengths in the processes and possible actions to be taken in areas needing improvement;
- Issues requiring further exploration in other survey activities; and
- A baseline assessment of standards compliance.
PPR and the Hospitalist
Beyond the onsite survey, JCAHO’s accreditation process is designed to help organizations maintain continuous compliance with the standards and use them as a daily management tool for improving patient care and safety. This represents a paradigm shift for the hospitalist, who may be more accustomed to organizations ramping up before an on-site survey. This frenzy of activity prior to an on-site survey did not meet the goals of JCAHO accreditation in that it drew physicians and staff away from providing care and managing performance improvement over time.