The Joint Commission
Mock surveys make a difference in staff education
After reading this article, you will be able to:
- Describe methods for setting up a tracer program in a large hospital
- Discuss the benefits of staff education on the tracer process
- Identify ideas for ensuring tracers are performed regularly
Constructing a tracer process from scratch for a 645-bed hospital is no simple matter, but that was precisely the task before Medical City Dallas Hospital’s survey readiness committee, says Carol Carach, RN, BSN, MPH, regulatory and accreditation survey supervisor at the facility.
“When I arrived in November of 2006, we didn’t have any sort of formal readiness process, and we were up for our Joint Commission survey in 2007,” says Carach.
However, the facility had a survey readiness committee that decided it would institute mock drills and tracers.
“That’s where we got started,” says Carach. “We [looked at] maybe three units as part of our initial drill and then instituted a more formal tracer.”
An initial sign-up sheet garnered teams for two patient care units immediately, and the facility was able to begin tracers in all units roughly six months later.
“We leave it up to the teams to schedule the tracers with their partners. They are encouraged to invite the unit manager or a designee,” says Carach.
“While managing 70 people for tracer teams may prove to be challenging, we have found so much value in the ability to spread knowledge about Joint Commission standards throughout the entire organization,” says Laura Weber, RN, MBA/HCM, director of quality management at Medical City.
Medical City has 35 two-person tracer teams roving the halls to cover the facility’s 645 beds. Maintaining those teams can be somewhat difficult. After the first round of recruiting, Medical City had 25 teams and ran tracers for all units that had teams assigned to them while it tried to fill in the blanks.
There were certain areas that required more active recruiting, and, in more challenging cases, unit managers selected or assigned their team members. Team members were educated on the tracer process and took this knowledge to their units. They were then assigned to trace another department. “Part of the setup is that you do not trace your own unit. You’ll pass over things that are not in compliance” simply because of familiarity, says Carach.
“Because it first started in the survey readiness committee, that is where the formal education began,” says Carach. “As the teams evolved, I had a formal education plan set up and continue to do formal education for new team members on an annual basis, at a minimum.”
The teams are also encouraged to communicate with one another. Twice per year, the 35 teams meet to share experiences and tips on running tracers.
And education isn’t only for the survey teams. “It is important to increase awareness of survey accreditation requirements, not only among the teams, but the staff and people they talk to while they are surveying the units,” says Carach. “The tracer teams become educators there. The staff feel more comfortable being interviewed, and they are better able to communicate the standards.”
Team reports can prove lengthy. “We used to have the teams verbally report the findings at the survey readiness meeting, but that became too time-consuming,” Carach says.
Medical City transitioned the reporting process into a database on a shared drive in the hospital. “Each team puts their findings into the database, and they leave a copy of their report with the manager of the unit,” says Carach.
Team members also send the names of staff members and physicians they interviewed to HR and medical staff departments so their files can be checked.
One challenge for the teams was making sure they blocked off sufficient time to conduct their tracers.
“People have very good intentions; they want to help out, and they’re very willing to do so. But at the end of the month, they find they’ve run out of time,” says Carach.
To prevent this, she sends messages reminding team members to schedule their monthly tracer.
How the teams handle their scheduling is up to them. Some have a standing appointment established. Others keep a more informal schedule to complete the tracer.
“We have a form intended to guide the team through the tracer,” says Carach. The form includes a chart review, so team members randomly choose a chart from the unit and look it over for specific items, including the:
- History and physical
- Time, date, and signature on medical record entries
- Home medication list
- Interdisciplinary patient education
The tool also includes a staff review section. Mock surveyors try to choose the nurse who is taking care of the patient for the reviewed chart, when possible. “We also ask National Patient Safety Goal–related questions to give staff the chance to practice answering the sort of questions they should expect when actual surveyors come,” says Carach.
The tracer tool lives on the shared drive, along with the reports from the teams to keep all teams working off the same version of the tool.
The semiannual team meeting serves the purpose of not only sharing information and lessons learned, but -also identifying excellence and improvement.
“We recognize the most improved team and unit, as well as the most consistent team and unit,” says Carach.
Honorees are rewarded with a small party and recognition in the hospital’s newsletter. The tracer team and unit share the reward as a method of building a sense of partnership. For the first two quarters, Medical City recognized consistent excellence on the orthopedic surgery floor and saw improvements on the pediatric unit.
Adapted from Briefings on The Joint Commission, January 2009, HCPro, Inc.