Let's get organized and trace

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Let's get organized and trace

Editor's note: The following is an excerpt from the HCPro book Staff Training and Survey Readiness: Preparing Your Organization for Accreditation and CMS Compliance. Visit

Here we will focus specifically on tracer training and implementation: the "who," "what," and "when" of this key component of a continuous survey readiness plan.

There is no magic structure, and one size does not fit all, but there are some general guidelines that can be helpful in structuring a tracer training program, implementing tracers, and reporting tracer findings. Much depends on how big the organization is, or is not, and the number of resources that are available.

Tracer teams can be organized by chapters in the accreditation manual, by functional teams, or by priority focused areas, or a combination of all of these. However, there is a need for an oversight team, usually led by the accreditation director, to:

  • Facilitate completion of the focused standards assessment (FSA)
  • Facilitate action plans and correction of noncompliant findings from the FSA
  • Train the tracer teams
  • Develop the tracer schedules and tools
  • Compile and present reports from tracer findings
  • Provide education on an ongoing basis


It should be noted, again, that structure and duties will depend on the size of the organization, and the oversight team might be the quality committee or senior management.

The important thing to remember is that tracers are important. They validate compliance, identify opportunities to improve, educate staff and leaders, and promote continuous survey readiness and compliance.

Chapter 3 of the book defines The Joint Commission and Centers for Medicare & Medicaid Services (CMS) tracers and states that the other accrediting bodies holding deemed status must use similar methods to survey.


Support from leadership

For any tracer plan to work, you must have support from senior leadership and the medical staff and, if possible, their participation on teams. Many hospitals have identified a specific day of the week to focus on safety and regulatory compliance. Senior leaders, including physician leaders, participate, which sends a clear message to staff members that their leaders are part of a team that works together to improve patient care and safety and to meet regulatory requirements every day, not just during survey or because an accrediting organization says you have to.

Chapter 7 of the book gives an example of a nursing tracer program that designated Friday as "tracer day" for nurse managers to trace their units.

Regardless of whether you have a successful compliance readiness program in place, need to revise the plan, or just need to start over, take it to the leaders and get their involvement and support. The chart on p. 10 is an example of a presentation to senior leaders outlining the revised tracer plan.


The who, what, and when

Usually, the accreditation director will lead the tracer training and oversight team. If the hospital is small, the accreditation director could be the administrator, the chief nurse executive, the quality and performance improvement director, or whoever might be willing to put on another hat. Regardless of the lead, teams and/or training usually need to be implemented, revised, or rekindled. The example on p. 11 outlines a structure for a large hospital system that takes the chapter team approach and has tracer specialists and focused teams or just-in-time teams as needed.

The oversight team uses the "chapter captain" approach as follows:

  • Accreditation participation requirements: director, accreditation (also serves as team leader)
  • Environment of care: director/manager, facilities
  • Emergency management: safety officer
  • Management of human resources: director, human resources/personnel
  • Infection prevention and control: lead RN, infection prevention
  • Management of information: chief information officer
  • Leadership: CEO or chief operating officer
  • Life safety: director, engineering
  • Medication management: director, pharmacy
  • Medical staff: chief medical officer and medical staff coordinator
  • National Patient Safety Goals: director, quality and performance improvement
  • Nursing: chief nursing officer
  • Provision of care, treatment, and services: multidisciplinary team led by chief nursing officer or associate nursing officer, RN managers from perioperative services and anesthesia, expert in restraint/seclusion (behavioral medicine unit manager), nursing educator/clinical nurse specialist
  • Improving organizational performance: director, quality and performance improvement
  • Record of care, treatment, and services: director, health information management
  • Ethics, rights, and responsibilities: risk manager or other appropriate designee according to hospital structure
  • Transplant safety: whoever has responsibility for oversight of the transplant program
  • Waived testing: manager responsible for waived testing oversight and training for the organization


The chapter captains are responsible for scoring their chapters, developing and implementing corrective action plans, training, developing tracer tools, and reporting findings. They may participate on a tracer team or as observers during tracers.

Tracer specialists are individuals who have responsibility for performing the comprehensive individual patient tracers, much like a surveyor. Members of these teams must have good people skills, should represent the clinical and nonclinical staffs, and have experience in locating information in the medical record. If possible, partner clinical and nonclinical staff members on the patient tracer teams, e.g., a nurse manager and a quality and performance improvement department analyst. The patient tracer team members are also potentially good candidates to serve as scribes and escorts during surveys.

Ask for volunteers to join the specialist teams. You may be surprised at the interest. If staff members are available, it is a good idea to have tracer specialists performing tracers rather than members of the oversight team.

The focused teams are used for topics such as restraints/seclusion, comprehensive medical record documentation, patient flow (see Chapter 10 of the book for a tracer example), and anything that might need 100% review over time and will need experts in the topic to develop the tools and conduct the tracers.

A just-in-time tracer team may be implemented if a particular issue has been identified during tracers, performance improvement projects, the FSA, etc., or if compliance needs evidence. For example, rumor has it that no one is present when nuclear medicines are delivered to the ambulatory sites where this service is provided. A just-in-time tracer by one or more of the patient tracer teams could verify compliance.

Granted, this structure may be considered a luxury, and Chapter 9 of the book provides a best-practice example of a small hospital and how it organized to open the hospital, prepare for survey, become accredited within 30 days of opening, and continually stay ready all the time.

Training falls to the experts: the accreditation director, infection prevention nurses, clinical nurse specialists, safety officer, and information technology and health information management staff, to name a few. And, at least once per year, use an outside source to provide education to leaders, the medical staff, and clinical and nonclinical staffs. Often times, the same message the accreditation director has been saying for months will be better accepted or understood from an outside expert.

What about the tracer schedule? How often should tracers be conducted? This depends on the available staff. If you are part of a small hospital, you may be guided by the results of the FSA and concentrate on getting the noncompliant findings resolved, then conduct focused patient tracers to validate compliance with the action plans.

At least once per year, every unit and department should be traced for compliance using the comprehensive tool provided in this book. The health information director can be tasked with facilitating open and closed record reviews to ensure compliance with documentation. This should be done at least quarterly and more often if data indicate noncompliance (e.g., authentication of verbal orders, history and physical updates, postoperative progress notes, etc.). To be on the safe side, 100% review of restraints should be put in place since this is an oft-cited standard for noncompliance.