Standard of the month: Making tracers work for you

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After reading this article, you will be able to:

  • Discuss the benefits of tracer methodology
  • Identify the building blocks of a good tracer tool
  • Describe nontraditional methods for tracer methodology

Editor’s note: This feature explores problematic Joint Commission standards with expert advice from BOJ advisors. This month’s edition is written by Jodi Eisenberg, MHA, CPMSM, CPHQ, CSHA, program manager of accreditation and clinical compliance at Northwestern Memorial Hospital in Chicago.

Tracer methodology, used by The Joint Commission since 2004, has increased the focus on the patient care process at the point of care. During many surveys, the frontline staff nurse becomes one of the most critical players in not only the tracer process, but also in the survey itself. To me, that makes sense, because frontline staff nurses spend the most time with patients.

This can be a major advantage because surveyors are tracing the actual services and care patients receive. Surveyors have an opportunity to observe care in various locations depending on the complexity of the patients, their length of stay, and the services they received.

Tracer methodology allows surveyors to determine whether there is consistent provision of appropriate care, treatment, and services. By viewing care across the organization, surveyors can validate consistency, safety, and uniform performance of care, treatment, and services.

Lastly, the tracer process provides a view of communication throughout the continuum of care and at discharge and/or transfer to another level of care, whether to the patient’s home or another type of facility.

We all have access to some traditional tracer tools that map out the elements of performance we find in the standards (see “Tracer tips” on p. 9). The focus of these tools is on factors such as general admission, assessment, treatment, reassessment, documentation, education, and staff competency. Tracers can be built around the priority focus areas. Clinical service groups can also be targeted as those highlighting the types and categories of patients.

Now that this methodology has been around for several years, the challenge is keeping it useful and pertinent to our organizations. Tracers can be chosen by nursing unit, length of stay, complexity of the case, or through random selection. It is important to include tracers for the environment, emergency management, medication administration, infection control, and data use.

Tracer methodology is not simply a review of medical records; it should incorporate observations of staff members, physicians, and patients. It can include review of policies, personnel records, and other documentation. Most importantly, it should involve discussions with staff members about how care is provided.

Nontraditional methods

At the 3rd Annual Association for Healthcare Accreditation Professionals conference May 14–15, which took place in Las Vegas, some untraditional strategies for building and completing a tracer were presented. The most important thing to remember is to go with your gut.

As a survey coordinator or quality improvement director, you know your organization’s internal and external issues. Focus on a sentinel event, near miss, performance improvement project, or a newly revised procedure to build a tracer tool. This will give your organization an opportunity to see possible breakdowns in the process or an inconsistency from unit to unit across the organization. Don’t limit yourself to the standard tracer tools.


Shadowing is another great way to trace patient care and other important processes. Shadow a transporter to observe the handoff communication process, shadow a housekeeper to determine whether appropriate and consistent procedures are being followed from room to room, or shadow the dietary process from patient order to tray assembly to delivery.

Informal tracers are acceptable and incite great open forum conversations and staff involvement throughout the organization, not only in patient care areas.

As the surveyor, how do you know that care is being provided per regulation, standard, and policy? Look for patterns of consistency organizationwide. If you note an inconsistency, ask the staff members you are observing to pull the policy or procedure for you.

Policies should say what we do, and practice should mirror what we say we do in policy. If you note an inconsistency, dig further into that particular issue. Through the tracer, you may be able to identify barriers to compliance, unclear directions in procedures, and other issues that you can correct to improve care for your patients.