TRACER METHODOLOGY

Frontline Strategies to Prepare for JCI Survey

Missi Halvorsen, RN, BSN
Patricia Pejakovich, RN, BSN, MPA, CPHQ
Reviewed by Gaurav Loria, Quality Systems Executive,
Apollo Health CityApollo Hospitals, Hyderabad, India
Missi Halvorsen, RN, BSN, Coauthor
Patricia Pejakovich, RN, BSN, MPA, CPHQ, Coauthor
Gaurav Loria, Reviewer
Frontline Strategies to Prepare for JCI Survey
TRACER METHODOLOGY
Tracer Methodology: Frontline Strategies to Prepare for JCI Survey, Global Edition, is published by HCPro, Inc.
Copyright 2008 HCPro, Inc.
All rights reserved. 5 4 3 2 1
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Commission, which owns the JCAHO and Joint Commission trademarks.
Missi Halvorsen, RN, BSN, Coauthor
Patricia Pejakovich, RN, BSN, MPA, CPHQ, Author
Gaurav Loria, Reviewer and Contributing Author
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List of Figures ..................................................................................................................................... vii
About the Coauthors ........................................................................................................................ viii
About the Contributing Author ......................................................................................................... ix
Introduction ......................................................................................................................................... x
Chapter 1: Tracer Methodology: An Evolution .............................................................................. 1
Background .......................................................................................................................................1
Focus areas ......................................................................................................................................5
Using focus areas in the survey process ....................................................................................8
Scoring guidelines ..........................................................................................................................9
Chapter 2: Types of Tracers ........................................................................................................... 13
Individual tracer .............................................................................................................................13
Tracer selection .............................................................................................................................14
System tracers and individual-based system tracers .............................................................20
Individual-based system tracer: Medication management ....................................................22
Individual-based system tracer: Infection control ...................................................................25
Chapter 3: Preparing for Tracers .................................................................................................. 29
Individual tracer activity ...............................................................................................................29
System tracers ..............................................................................................................................32
Chapter 4: Conducting Internal Tracers ....................................................................................... 35
Internal tracer tips .........................................................................................................................36
CONTENTS
Tracer Methodology, Global Edition
Tracer Methodology, Global Edition
Cont ent s
Chapter 5: Selecting and Maintaining Supporting Documents for Tracers .......................... 57
Patient and Family Rights .............................................................................................................58
Access to and Continuity of Care ................................................................................................59
Patient and Family Education .......................................................................................................60
Quality Improvement and Patient Safety ..................................................................................63
Governance, Leadership, and Direction ...................................................................................64
Facility Management and Safety .................................................................................................66
Prevention and Control of Infections .........................................................................................70
Staff Qualifications and Education ............................................................................................71
Management of Communication and Information ..................................................................72
Medication Management and Use .............................................................................................73
International Patient Safety Goals .............................................................................................75
Chapter 6: A Look at Tracer Methodology in Action ................................................................. 77
Surveyor arrival and preliminary planning session .................................................................77
Facility tour and session ...............................................................................................................79
Leadership session ........................................................................................................................82
Staff Qualification and Education Interview .............................................................................83
Staff Qualification and Education Interview
(Medical staff credentialing and privileging) ...........................................................................84
System tracers in action ..............................................................................................................89
Chapter 7: Avoiding Tracer Traps: Tips for Success .................................................................. 95
Dealing with surprises ..................................................................................................................96
Case Study: Apollo Hospitals, Hyderabad, India ........................................................................ 99
Appendix A: Sample Survey Questions ...................................................................................... 107
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Figure 1.1: Before and After ..........................................................................................................2
Figure 1.2: Challenges .....................................................................................................................4
Figure 1.3: Sample Tracer-Patient Selection Worksheet ........................................................11
Figure 2.1: Sample JCI Survey Agenda ......................................................................................27
Figure 3.1: Suggested Participation for System Tracers .........................................................32
Figure 4.1: Tracer Audit Form for Assessment of Patients .....................................................38
Figure 4.2: Tracer Audit Form for Equipment Use .....................................................................40
Figure 4.3: Tracer Audit Form for Prevention and Control of Infection .................................42
Figure 4.4: Tracer Audit Form for Physical Environment ........................................................44
Figure 4.5: Tracer Audit Form for Credentialed Practitioners ...............................................46
Figure 4.6: Tracer Audit Form for Staffing .................................................................................48
Figure 4.7: Sample Tracer Findings Recording Form ..............................................................49
Figure 6.1: Environment of Care Plan Matrix Tool ....................................................................80
Figure 6.2: Sample Medical Staff Credentialing File Checklist ..............................................87
Case Study Figure 1.1: Operative/Other Invasive Procedures Audit Tool ..........................103
Case Study Figure 1.2: Operating Room/Catheter Lab Tracer ..............................................105
LIST OF FIGURES
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ABOUT THE COAUTHORS
Missi Halvorsen, RN, BSN
Missi Halvorsen, RN, BSN, is the senior consultant for accreditation and compliance for Baptist
Health, a five-hospital healthcare system in northeast Florida, U.S.A. Ms. Halvorsens respon-
sibilities include Joint Commission preparation for adult and pediatric inpatient, outpatient,
ambulatory, behavioral-health, and home-care services. She chairs Baptist Healths systemwide
accreditation committee, which is dedicated to continuous readiness, and sits as an advisor on
patient safety, environment of care, compliance, and magnet steering committees. In addition,
she manages the compliance program for Baptist Health.
A nurse for more than 24 years, Ms. Halvorsen has experience in critical care, home care,
quality, and performance improvement. She has been actively involved in Joint Commission
survey preparation since 1998.
Patricia Pejakovich, RN, BSN, MPA, CPHQ
Patricia Pejakovich, RN, BSN, MPA, CPHQ, is a senior consultant for The Greeley Company,
a division of HCPro, Inc., specializing in quality and performance improvement, accreditation,
utilization management, credentialing, and data management and design. She brings 30 years
of experience in nursing and healthcare that includes more than 20 years of expertise in quality
and performance improvement.
Prior to becoming a full-time consultant for The Greeley Company, Ms. Pejakovich served
in administrative roles in hospitals, a health plan, and a healthcare consulting company. She
has lead hospitals, health plans, credentialing verification organizations and ambulatory
facilities to achieve accreditation from The Joint Commission, the National Committee for
Quality Assurance, and other accrediting organizations. She has also provided educational
presentations to healthcare entities and professional organizations on such topics as
credentialing, performance improvement, and quality management.
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ABOUT THE CONTRIBUTING AUTHOR
Gaurav Loria
Gaurav Loria is Executive of Quality Systems/Joint Commission International Survey at Apollo
Health CityApollo Hospitals Hyderabad, a 300-bed with more than 50 specialties and 10
Centers of Excellence in Hyderabad, India. Apollo Hospitals Hyderabad was one of the first
JCI-accredited hospitals in India. Mr. Loria coordinated the JCI accreditation process for Apollo
Hospitals Hyderabad and for Apollo Hospital in Ludhiana, and other hospitals, as well as JCI
Disease Specific Accreditation for Acute Stroke at Apollo Hospitals Hyderabad (the first hospital
to be certified for stroke care outside United States).
Mr. Loria coordinates the hospitals Quality Steering Committee and oversees initial develop-
ment, implementation, and sustainment of quality improvement processes to ensure compli-
ance with JCI standards, including development of documentation and medical-related forms,
training, and monitoring in all areas. He is also responsible for development of quality monitor-
ing parameters for every department of the hospital and six secondary care centers, along with
monitoring, training, and further analysis of these parameters.
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x Tracer Methodology, Global Edition
INTRODUCTION
By now, you are probably aware of the definition of tracer methodology. The concept is rela-
tively simple to explain: Tracer methodology requires surveyors to select active patients and
trace their care through departments or services of the hospital. In doing so, Joint Commission
International (JCI) surveyors observe the patients continuum of care, review systems of care,
and talk to staff and patients about the care provided. The bottom line is that surveyors are
looking for how well we as healthcare providers perform our roles in caring for patients. By
conducting patient tracers, surveyors can determine how well a hospital has implemented its
policies and procedures.
Tracer methodology is also used to assess key systems such as data use, infection control, and
medication management. Information regarding each system is obtained during discussions with
a group of selected staff. During individual-based system tracers, the surveyors assess how well
the system processes have been implemented into patient care practices.
Tracer methodology is used in all JCI accreditation and certification programs as a means of
assessing compliance with standards, applicable national regulations, and organizational policies.
Done right, tracer methodology works very well. Post-survey CEO opinion polls of accredited
organizations in the United States reveal that healthcare leaders believe that tracer methodology
is a better way of assessing the effectiveness of healthcare processes.
Frontline staff also appreciate being more involved in the accreditation process. Staff enjoy the
opportunity to share their accomplishments with the surveyors. With tracer methodology, the
staff carry the weight of the survey.
Because frontline staff are the driving force behind tracer methodology, they must be prepared
for any questions that surveyors ask during this process about the care that patients have
received. Although traditional methods of survey preparation continue to be useful when
striving for continuous readiness, the unpredictable nature of tracer activities proves challenging
for even the most experienced survey coordinator. Every patient experience is unique, every
department and service is different, and now all of them are fair game for surveyors.
xi Tracer Methodology, Global Edition
I nt r oduct i on
If youre getting your hospital ready for JCI accreditation or reaccreditation, now is the time to
understand what you need to do to accommodate tracers. Tracer Methodology: Frontline Strategies to
Prepare for JCI Survey, Global Edition, is intended to help you prepare your staff and organization
without increasing the need for
additional resources.
The information in this book has been organized into the following chapters:
Chapter 1: Tracer Methodology: An Evolution
Chapter 2: Types of Tracers
Chapter 3: Preparing for Tracers
Chapter 4: Conducting Internal Tracers
Chapter 5: Selecting and Maintaining Supporting Documents for Tracers
Chapter 6: A Look at Tracer Methodology in Action
Chapter 7: Avoiding the Tracer Traps: Tips for Success
Case Study: Apollo Hospitals, Hyderabad, India
Appendix A: Sample Survey Questions
While you read these chapters, ask yourself the following questions:
1. Does your organization embrace survey preparation as a continuous process?
2. Have you obtained leadership support?
3. Do you encourage the use of standards and regulations as part of your organizations everyday
operational plan?
4. Do you determine your organizations level of compliance with the standards and monitor it on
an ongoing basis?
5. Do you assist leadership with the development and implementation of corrective action plans
and monitoring/measurement tools?
6. Have you developed an accreditation-readiness team or committee that meets on a regular basis
to discuss compliance issues, new standard developments, or survey-process changes?
These are all daunting tasks, but this simple and useful guide will help prepare you for tracer
activities. The JCI will continue to refine and improve the survey process, and the tracer method-
ology itself will also continue to evolve as both survey coordinators and surveyors assimilate this
method of survey.
Customize the tools and charts for your hospital; you can also downloadable some of the tools
in this book from HCPros Global Web site, www.hcpro.com/gobal.
Background
Newcomers to the Joint Commission International (JCI) accreditation process often ask, What
is a tracer, and why must we conduct one?
The tracer process is not new: Many industries have long traced products or processes from
start to finish. Tracers can be a very effective way of finding process problems that might not be
readily apparent otherwise.
In healthcare, a tracer can follow a patient from admission to discharge, or can follow a care
regimen within one unit. Patient tracers allow hospital staff members to get a patients perspec-
tive of the care they provide. System tracers allow staff members and administrators to see how
well a unit, department, or entire facility is doing. Because tracers can be highly effective means
for process improvement, some hospitals are implementing the tracer process on their own,
ahead of organizational accreditation requirements.
With increasing media attention, more diverse patient populations, and growing public concern
over patient safety, The Joint Commission, the U.S.-based arm of the JCI, developed its accredi-
tation process and carefully pilot-tested the effectiveness of its methods in several healthcare
organizations prior to implementation.
The evolution of the survey process is included in Figure 1.1.
Tracer Methodology: An Evolution
CHAPTER 1
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Before and After
Figure 1.1
The Joint Commission, parent of the JCI, implemented tracers as part its changes to the U.S. hospital survey
process several years ago. This figure illustrates some of the changes that have taken place because of the
inclusion of tracer methodology.
Before changes Now
Surveys were announced every three years. U.S. hospital surveys are now unannounced. The
JCI works with hospitals to select a survey date.
Survey results were paper-based and required
filing/maintenance at the organization.
Survey and application information are available
online at www.jointcommissioninternational.com.
Surveys were scored and competitive. Surveys are scored, but the hospital does not
receive a numeric score; rather, the organization is
deemed Accredited or not.
Preparation for survey activities often took a
ramp-up approach.
Preparation for surveys must be ongoing and con-
tinuous in order to maintain JCI accreditation.
Surveys lacked self-assessment activities. Survey activities require self-assessment activity to
gauge standard compliance.
Surveys focused on leadership interviews. Surveys are less focused on leadership and discour-
age an entourage or cast of thousands during
survey activities.
Surveyors toured units for environmental issues,
but rarely engaged staff members.
Surveys focus more on staff members and their
application of standard compliance and provision
of safe care processes.
All units and departments were surveyed. Not all units may end up being visited by surveyors.
They are still required to visit all units with moder-
ate sedation or anesthesia, but the rest of the visits
are driven by the tracer activities.
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Before and After (cont.)
Figure 1.1
Tracers were added to The Joint Commissions U.S. survey practices as part of its Shared
VisionsNew Pathways initiative. This initiative included:
A complete review and revision of standards
Establishment of secure electronic communication between individual hospitals
and The Joint Commission
Periodic performance reviews (self-assessment by hospitals between surveys)

Before changes Now

Surveyors rarely interviewed patients. Surveyors often interview patients about the care
they receive.

Prepared presentations were expected. Prepared presentations are not a requirement for
accreditation.
Surveyors were inconsistent in their interpretation
of standards.
Surveyors are required to pass standard compe-
tency testing to raise the level of consistency in
standard compliance assessment.
Survey applications were paper-based. The application process has been made easier with
the introduction of the online application.
Postsurvey response consisted of an action plan to
be implemented at a later date.
Postsurvey response includes a detailed description
of what actions have been taken to achieve stan-
dards compliance; designated elements of perfor-
mance require measurement data to be submitted
subsequently as evidence of compliance.
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Revisions to survey agendas with a focus on priority issues and the use of methodologies
to trace individual patients through the healthcare system, and evaluation of compliance
with standards.
Most of the healthcare organizations involved in this process agree that this initiative has been
a positive change. But there are still challenges, as shown in Figure 1.2.

Tracers are also the foundation of JCI on-site surveys, and can influence care in a multitude
of ways at JCI-surveyed hospitals. They are also components of some nations healthcare
regulations and other agencies requirements.
The issues outlined in Figure 1.2 also apply to JCI-accredited hospitals. Overall the improve-
ments have been well received. However, it is important to fully understand the importance
of several of these issues, and fully understand how they relate to tracer activities. One of
the processes to which I refer is the priority focus process (PFP).
Though the process has started, it is still in its nascent stage and much training for the
organizational staff is still necessary.
Challenges
Figure 1.2
Surveyor inconsistency in interpretation of standards is still troublesome.
Departments that are not surveyed often feel left out of the process.
Results of the survey are not negotiable with the surveyors. You have to wait for your survey
results to be submitted by the surveyors and then complete a clarification request.
It can be difficult to determine whether youve passed or failed the survey until you receive the
final word from the JCI
Focus areas selected by the JCI may not appear to be related to the organization
Maintaining continuous survey readiness must be balanced with major projects, such as new
construction, installation of electronic medical records, initiation of new services, etc.

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Focus areas
Priority focus areas (PFA) are not followed strictly by many surveyors internationally, but the
priority focus process is definitely a good practice and a baseline to prepare your organization
for the survey. Most of the time, though, focus areas are decided based only on the application
form or competencies of the surveyors (for example, a nurse might be more interested in an
infection control tracer, while an administrator will look more into facility issues).
Assess your organizations presurvey data (if you are going in for re-accreditation or for focus
surveys). Are there areas that you know require improvement?
Determining your focus areas is an integral part of tracer methodology. The JCI defines focus
areas as processes, systems, or structures in a hospital that significantly affect quality and
safety of care. Focus areas guide standards compliance assessment in relation to the patient/
resident/client tracer activities.
The JCI will identify focus areas specifically for your organization and then use them to select
patient tracers. Surveyors tracer findings provide focus for additional tracers and influence the
selection of others. Therefore, predicting your focus areas is a good first step in determining
which patients to select for your mock patient tracers. Mock tracers are discussed in more
detail in Chapter 4.
When determining whom and what to trace, JCI surveyors also consider your organizations spe-
cific patient populations and the services that you provide. These are called clinical service
groups. These groups are program-specific and defined as categories of patients or services for
which data are collected. These groups are derived from your accreditation application (for
example, from the top five diagnoses and top five surgeries) and other data used to select focus
areas. This aids in consistency with the surveyors selection for tracer activities.
Dont wait for the JCI to look at these areas for you: Use the following questions to help guide
your selection:
Has your hospital been cited for issues in a given area? If so, then you should select that area.
If comparable hospitals in your area or in your healthcare system have recently been
surveyed, what tracers did the surveyors conduct at those facilities?
What are the JCIs hot topics for survey? Depending on your region, these might include:
1.
2.
3.
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Patient safety
Communication
Credentialed practitioners
Staffing
Patient safety would be a logical choice because the International Patient Safety Goals (IPSGs)
are a primary focus of the JCI. Other focus areas may be based on previous survey findings or
external data sources and outcomes monitoring efforts. Keep an eye on the JCI Web site,
national healthcare reports, and news from other local hospitals to help you determine addi-
tional areas on which to concentrate. For example, if you know that the JCI is focusing on pain
assessment, then the Assessment of Patients (AOP) standards are another good choice for
tracer selection.
Lets look at some of these focus area criteria more closely.
Outcomes data
To determine your organizations priority focus areas, the JCI uses several types of outcomes
data. With each of these data sources, look for spikes or outliers in data information. Also
pay close attention to trends in data over time (e.g., increased lengths of stay for particular
diagnoses or patient populations, readmission rates, and less-than-desirable outcomes of
patient care).
Using a rules-based system, the JCI evaluates the following organizational information:
Accreditation application information
Quality indicators shown to surveyors
Complaints received by the JCI Quality Monitoring System (QMS)
Lab proficiency testing failures
It is critical to monitor following outcomes on an ongoing basis to determine potential system-
and patient-tracer focus areas:
Hospital demographics
Admission rates

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Readmission rates
Observation status
Average daily census
Volumes
Complication rates
Lengths of stay
Infection rates
Medication error rates
Incident reporting
Inpatient days
Most countries do not have an advanced public reporting system as in the United States, so
surveyors will look at any data that are available as per the standards of that particular country
or state.
The type of information that might interest them depends on:
The hospitals use of computerized drug-order entry
Intensive care unit staffing ratios
Volume
Outcomes ratings for high-risk procedures, or conditions such as
coronary artery bypass graft
percutaneous coronary intervention
abdominal aortic aneurysm repair
esophagectomy

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pancreatic resection
high-risk deliveries and neonatal ICU admissions
Even the report cards developed by organizations as a part of their quality improvement and
patient safety plans can serve as data points to determine the tracer activities.
Using focus areas in the survey process
Before the surveyors arrive at your organization, they will already have access to your applica-
tion and they will have gone to your Web site. If its a re-accreditation process, they also will
have looked into your previous areas of noncompliance.
Just after the opening conference of the survey, the surveyors might discuss focus areas with
your organization. They might confirm with your organization that the focus areas are used
To convert presurvey data into focused organizational information
To aid in determining the survey activities
In tracer selection criteria during the initial stages of the survey
To improve consistency in survey activities for organizations with similar pre-survey data
To individualize the survey activities to suit the needs of each organization
Once tracer patients are selected, your focus areas will initially drive the surveyors assessment
activity. Questions directed at leadership and staff will center around the focus areas. As the
survey progresses, the surveyors may be satisfied that the focus areas identified are no longer
problematic or they may confirm that the focus areas are true issues for your organization.
In addition to focus areas, understand how the JCI scores elements of performance and, subse-
quently, standards based on findings from tracer activities. During the tracer activity, surveyors
will evaluate all of the priority areas without letting you know about them.

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Scoring guidelines
One of the most challenging aspects of the entire survey process is not really knowing how you
are doing on your survey. Sometimes, surveyors will respond as if you are doing well with the
survey or they may state that some of their findings might turn out to be insignificant. But when
the surveyors compile their findings, you could end up with multiple noncompliances that you
did not anticipate.
The best way to combat this confusion is to have a good grasp of the scoring guidelines. Use
this information to aid you with mock tracer assessments and PPR requirements.
To understand the approach to scoring, first understand how the standards are formatted.
Each standard has the following three basic components:
The standard itself, which is a statement of the objective.
The intent, which explains why this is a reasonable objective.
The measurable elements, a list of the elements that the organization must demonstrate
to be deemed in compliance.
A hospital is accredited when it demonstrates:
Acceptable level of compliance with each JCI standard (i.e., a score of at least 5 on
each standard);
Acceptable level of compliance with standards in each chapter (i.e., an aggregate score
of at least 7 for each chapter);
Overall acceptable level of compliance (i.e., aggregate score of at least 8.5 on all
standards; and
Acceptable level of compliance with all IPSGs (i.e., a score of at least 5 on all goal
requirements).

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A hospital is denied accreditation when it is consistently not in compliance with JCI standards
and IPSGs, including:
One or more standards with a score of less than a 5;
An aggregate score of less than a 7 for each chapter;
An aggregate score of less than an 8.5 on all standards;
One or more requirements for IPSG scored at 0;
A follow-up focused survey does not result in acceptable compliance with the applicable
standards and/or IPSG requirements;
When the JCI withdraws accreditation for other reasons; or
When the facility voluntarily withdraws from the accreditation process.
Hospitals must demonstrate acceptable compliance with all standards and achieve a minimal
numerical score on these standards in order to be accredited by the JCI. Above this basic level
of standards compliance, the organizations numerical score indicates the overall standards
achievement level.
All of the JCI standards are evaluated during the course of tracer activities. Therefore, it is rec-
ommended that hospitals conduct mock tracerstracers that simulate a JCI visitto assess
their levels of compliance before the surveyors arrive, and throughout the year. See Figure 1.3
for a tracer-patient selection worksheet

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Sample Tracer-Patient Selection Worksheet
Figure 1.3
1. Identify your focus areas using previous tracer results or other informationwhat indicators have been
identified as opportunities for improvement?
Key measure: ____________________________________________________________________
_______________________________________________________________________________
Patient experience survey: ___________________________________________________________
_______________________________________________________________________________
Previous survey results: What were the issues?
_______________________________________________________________________________
_______________________________________________________________________________
2. Critical areas to survey: Use findings from the above to identify areas of opportunity for improvement.
Underline the areas that apply.
Assessment and care Communication
Credentialed practitioners Equipment use
Infection control Information management
Medication management Organizational structure
Orientation and training Physical environment
Rights and ethics Quality improvement activity
Patient safety Staffing
3. Identify clinical service group tracer information within the hospital (e.g., pulmonary, cardiovascular,
rehabilitative, emergency services, etc.).
a. ____________________________ i. _____________________________
b. ____________________________ j. _____________________________
c. ____________________________ k. _____________________________
d. ____________________________ l. _____________________________
e. ____________________________ m. ____________________________
f. ____________________________ n. ____________________________
g. ____________________________ o. ____________________________
h. ____________________________ p. ____________________________
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To make sure your mock tracers are accurate, it is recommended that you score your mock tracer
and periodic performance review assessments more toward noncompliant or partially compli-
ant, instead of giving your organization full credit. In addition, during hospital self-assessment
activities, staff members can present evidence of standards compliance to the organizations
accreditation committee when they are unsure about a borderline compliance issue.
When in doubt, lean toward partial compliance or noncompliance, which leaves plenty of room
for improvement and ensures follow-up on identified issues. The bottom line is to be harder on
your organization than you think the surveyors will be.
The next step is to apply the scoring guidelines to your mock tracer activities, the various types
of tracers, and other survey activities.
Sample Tracer-Patient Selection Worksheet (cont.)
Figure 1.3
4. Obtain an active patient list (including patient name, room number, diagnosis, and physician) and the daily
surgical/special procedures schedule.
On average, select four to six tracer patients per 50 beds.
To download customizable versions of this gure and others from the book, please go to
www.hcpro.com/global and click on Tools.