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Are You Ready for the New JCAHO Tracer Methodology?
by Rick Martin, MSN, RN
The JCAHO accreditation process has changed significantly this year, and the new JCAHO tracer methodology accounts for about 60 percent of
that change. Tracer methodology impacts every department, manager and staff member – certainly including case managers – in a hospital or other
healthcare system. It is a major change that might seem daunting, but an understanding of the tracer methodology, plus maintaining a routinely high
level of readiness, will help case managers approach their next JCAHO survey with confidence.
The term “tracer methodology” is borrowed from radiation
physics. However, instead of tracing a radioactive isotope, JCAHO
surveyors are now tracing individual patients, residents and clients
within a hospital or other healthcare institution, using the person’s
medical record as a kind of road map to help assess and evaluate
the organization’s compliance with selected standards and its
systems of providing care and services. JCAHO tracer methodology
was implemented in 2004, so a number of institutions have already
experienced their first survey that included this innovation. But for
a great many others, the first such survey is still in the future, and
this article seeks to “demystify“ tracer methodology and provide
some useful information for case management RNs and social
workers about what to expect and how to prepare.
The tracer process actually begins before the actual survey.
Surveyors gather data in advance from the hospital’s Application
for Survey form, plus information already available to the public,
such as Core Measures reports and sentinel event levels. The
surveyors review Priority Focus Areas (PFAs), or key hospital
processes, systems or structures, as well as clinical or service
groups (such as Cardiology, Critical Care, etc.) and the level and
diversity of the patient populations served and services offered.
They focus survey activity on specific issues that appear most
relevant to patient safety and quality care at the specific hospital.
At the hospital, in preparation for individual tracer activity,
surveyors review the patient census and select several inpatients,
residents or clients to be “traced,“ as a representative sample of the
identified clinical or service groups. Individual tracers are chosen
in the top clinical or service groups and the Priority Focus Areas,
which may also be the high-volume or high-risk populations.
Typically, persons chosen for tracer activity have received multiple
or complex services at the facility.
A surveyor goes to each unit on which a tracer individual is
currently receiving care, reviews that person’s medical record, and
interviews physicians, nurses and other caregivers on the unit. The
surveyor may also speak to the patient, resident or client, if
appropriate. Patient permission is always obtained prior to any
conversation. In addition, the surveyor speaks with other healthcare
professionals in areas that fall under the organization’s scope of
service and that have provided care and services to the tracer
patient. Among these are Dietitics, Laboratory, Pharmacy, OR,
Physical Therapy, Radiology and Respiratory Care professionals. Also
visited are outpatient clinics and services, including but not limited
to Home Health, Hospice, Dialysis, Wound Care, and IV Infusion.
The number of individual tracers completed depends on the
length of the survey. An average three-day hospital survey,
performed by a three-member team, usually allows for completion
of about 11 tracers. However, the number can vary. The time needed
for one individual tracer typically will range from one to three hours.
4
PURPOSES, PROBLEM TRENDS
In tracer methodology, the individual medical record of a
patient, resident or client assists the surveyor in assessing and
evaluating a healthcare organization’s compliance with selected
standards, and its systems of providing care and services. During
tracer activity, compliance issues may be identified in one or more
elements of performance. Surveyors will also look for compliance
trends that might point to potential system-level issues in the
healthcare organization. While conducting tracer activity,
surveyors will find numerous chances to provide education for
staff members and leaders, and to discuss best practices from
other, similar healthcare institutions.
If problem trends are identified, the organization will receive a
Requirement for Improvement document. Currently (through
July 1, 2005), the organization has 90 days from the end of the survey
to submit Evidence of Standards Compliance and identify Measures
of Success to be used in assessing sustained compliance over time.
After July 1 this year, the time allotted for these responses will be
halved, to 45 days. Four months after JCAHO approval of the
Evidence of Standards Compliance, the organization will submit
data on its Measures of Success, to demonstrate a track record.
SYSTEM TRACERS
As JCAHO surveyors follow the course of an individual’s
treatment, they assess the healthcare organization’s compliance
with Joint Commission standards. This compliance assessment is
conducted as they review the organization systems for delivery of
safe, high-quality health care. Staff members will be asked to
discuss the system, sometimes including related policies and
procedures. In speaking with staff members, surveyors will look for
indications of the way individuals and departments collaborate to
reduce the probability of medical errors, especially during “care
handoffs” from one staff member or department to another.
LEVEL OF PREPAREDNESS
While tracer methodology is a major part of the updated JCAHO
survey procedure, it is not the only feature. The good news is that
the former 10 Continuum of Care Standards have been reduced to
five Provision of Care Standards. However, these five Provision of
Care Standards share a total of 24 Elements of Performance. The
importance of case managers’ becoming completely familiar with
these new terms, and understanding their meaning and intent,
cannot be overemphasized. Additional information can be
obtained at the Jayco link of the primary JCAHO Web site. (This
link is passcode-protected, and access is determined by each
individual healthcare organization.)
Regarding the new tracer methodology, good advice is to stay
current on JCAHO standards and be ready consistently. Ongoing
C O L L A B O R A T I V E
staff education is also a “must.” The JCAHO
offers various conferences, books, and
monthly satellite programs, all intended
to help healthcare professionals become
more knowledgeable and better prepared
for surveys.
JCAHO surveyors can be expected to
check whether the resources case managers
have put in place are meeting the needs of
patients. One area in which the surveyors
will almost certainly question case
managers involves the timing and process
of discharge planning, as well as referrals to
facilities other than the patient’s home.
Being able to demonstrate that the Case
Management department is referring
patients to high-quality care facilities is
critically important.
Another excellent way to prepare for a
JCAHO survey (and to feel more confident
when it happens) is to have periodic mock
reviews, including mock tracers. These can
be conducted either internally or by an
external consulting group.
Although it’s understandable to
experience some “butterflies” in
contemplating one’s first JCAHO survey with
tracer methodology, here’s a comforting
thought: Case management departments
which already have quality outcomes will
perform well with this new procedure, and
will be a credit to their institutions when the
time comes for the final report.
SOME ‘TOOLS FOR SURVIVAL’
If this year or next your hospital will be
undergoing its first JCAHO survey with the
new tracer methodology, following are some
“survival suggestions” to help prepare for the
experience and render it less stressful.
• Have case management or social worker
staff members available at tracer points.
• Request that your Human Resources
department pull identified staff members’
personnel files for review.
• Provide an escort for each surveyor.
• Have a list of patients in mind whose
charts should be pulled for the tracer list.
• At the daily debriefing, if a deficiency has
been found, ask the surveyor to cite the
C A S E M A N A G E M E N T
Advice from the Ffi ield
exact standard and Element of Barb Quick is a quality management
Performance. Correct the deficiency while specialist at DePaul Health Center in St. Louis,
the surveyor is on site, if possible. MO. She experienced her first JCAHO survey
• Don’t hesitate to respectfully challenge with tracer methodology in February 2004, as
surveyors if you don’t agree with their a hospital-based case management director
findings, or if you can provide additional at another large healthcare institution.
information related to the topic in question. “Case managers are key in the new
process,” said Ms. Quick. “Surveyors arrive
• Go the Jayco link on the JCAHO Web site
with a structured list of the types of patients
(www.JCAHO.org) and carefully review the
they need, and their first charge is to identify
Survey Activity Guide. (Reviewing it once is
patients who meet these specifications. Often,
good, but multiple times would be better!).
the admission diagnosis alone is not sufficient
basis for selection, so they turn to case
LOOKING AHEAD: ANOTHER JCAHO CHANGE
managers to help choose tracer patients.”
Starting Jan. 1, 2006, another JCAHO
With this in mind, Ms. Quick advises case
change will add the element of surprise to
managers: “Know your patients. Case
the triennial process by conducting all
managers have an excellent opportunity, in
regular accreditation surveys on an
this situation, to show their knowledge level
unannounced basis. This change was made
and to validate the integral part they play on
public in April 2003. During 2004,
the health care team.”
unannounced surveys were pilot-tested in
She said it is important to be able to
volunteer organizations, and this testing will
discuss with surveyors the discharge
continue through 2005. A list of the
planning assessment for each tracer patient,
healthcare organizations participating in the
as well as steps taken to meet patients’
pilot unannounced surveys can be found on
psychosocial needs. “Make sure to include
the JCAHO Web site.
multidisciplinary staff, as appropriate, and
The “old way” – a months-long flurry of
make sure you’re meeting the
intensive preparation for an announced
documentation standards of the
survey, with photocopying machines
departments,” she added.
running nonstop – will become obsolete.
Another key area in which case managers
The new way will dictate a constant state of
need to be prepared, said Ms. Quick, is
awareness and readiness. Case managers,
length of stay. “Surveyors expect case
social workers, and all other hospital
management documentation standards to
employees will cope well if they make a habit
reflect reasonable follow-through
of keeping up with all required standards
expectations based on the hospital’s average
and incorporating them into daily practice
length of stay, particularly for initial
and performance, rather than viewing
assessment,” she stated. “For example, a
them as an “additive layer.” At least initially,
hospital with an average LOS of 4.5 days
this will be a huge challenge. But the
should not have a policy that the initial case
ultimate result will be immensely rewarding:
management assessment must be
a higher level of safety and an opportunity to
completed within 72 hours, as the patients
demonstrate the quality of care your
will be nearly ready for discharge. This
healthcare organization provides to patients,
hospital should expect all patients to be
residents and clients.
assessed within 48 hours.”
Rick Martin has been in healthcare 27 years, One more point: documentation should be
the past 12 as Vice President of Patient Care consistent for all seven days of the week, Ms.
Services and Chief Nursing Officer at Hoag Quick pointed out, adding, “Surveyors do not
Memorial Hospital Presbyterian in Newport want to see policies based on weekdays only.”
Beach, CA. He holds a BSN degree from West That first JCAHO survey with tracer
methodology is “a great opportunity for case
Virginia University, Morgantown, and an
managers to shine,” concluded Ms. Quick,
MSN from the University of Virginia,
Charlottesville. Mr. Martin was employed five “and to show how valuable they are to the
years by JCAHO as a field surveyor. health care team.”