UAB Synopsis, Vol. 24, No. 4, February 7, 2005
Opening "Silos"
The Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) new Tracer methodology is proving a major challenge for hospitals nationwide. Organizations that function with "silos" of operation, fragmented services, and little alignment among programs and services are finding it difficult to demonstrate "seamless patient flow and service delivery integration," notes Deborah Grimes, RN, JD, UAB director of JCAHO & Regulatory Affairs.
"Tracer methodology has made a big impact on the way that we prepare for JCAHO surveys. It is critical that everyone in our facility receive training and be ready for questioning from the surveyors," she says. "Health-care institutions surveyed this year report dozens of physicians were questioned or observed during the survey. It's more crucial than ever that each and every staff member — from physician leaders to the admissions department — be ready."
Most intimidating may be that Tracer methodology, and its unpredictable nature, contain the biggest "unknowns": Which patients will be traced? What questions will surveyors ask? Which divisions will be visited? "With Tracer methodology accounting for up to 90% of the new survey process, staff preparation is key to a successful survey."
The new process
Under the new process, surveyors select 8 to 12 active patients and review their care through Tracer methodology, using that individual's record as a road-map to assess and evaluate the organization's compliance with selected standards and its systems of providing care and services, Grimes continues.
Tracer patients are typically selected from an active patient list; often they have received multiple or complex services. In short, instead of visiting units and programs, surveyors select a number of charts and then follow each patient's journey through the system, visiting departments involved in the patient's care. On each unit, surveyors observe care, review policies and procedures, and question patients (with their permission) and staff. The chart-focused journey is designed to make discontinuities apparent.
The best way to prepare, according to Grimes, involves holding mock tracer events and focusing on areas surveyors are likely to scrutinize. Comparing an organization's strategic areas of priority with patient data enables some insight into the types of patients whom surveyors would likely trace. "Because every patient is unique and every area of care is different, preparing for Tracer surveys can be daunting," she notes.
In upcoming Synopsis issues, physicians, nurses, and other caregivers will receive mock-patient Tracer examples and possible questions a surveyor might ask.
If problem trends are identified, surveyors issue a Requirement for Improvement. The organization has 90 days from the survey's end to submit Evidence of Standards Compliance and identify Measures of Success it will use to assess sustained compliance over time. (After July 1, 2005, the organization will have 45 days from the survey end to submit Evidence of Standards Compliance and to identify Measures of Success.) Four months after approval of the Evidence of Standards Compliance, the organization will submit data on its Measure of Success to demonstrate a track record.