Tracer Methodology
Maintaining JCAHO Standards Compliance

JCAHO Standards Compliance

Unannounced Surveys
Process for Interim Evaluation of Compliance
The Environment in Which Care is Provided

Reaching the Culture of Compliance

Focus on Standards vs. the Survey
Integrating the Standards into Policies, Documents, Forms
Relating JCAHO Standards Compliance to Quality and Safety
Reaching the Goal of Not Preparing for Surveys

Tracer Methodology

Definition and Purpose
Variations on What can be Traced (Patients/Systems)
Documents that Need to be in Place
Evidence of Continuum of Care
Evidence of Team Work
Evidence of Organizational Consistency
Use of Medical Record as the Tracer Map
Assessment of the Operations of the Organization

The Use of Mock Tracer Processes

Periodic Performance Review
Organizational Tracers as Part of Performance Improvement
Departmental Tracers as Part of Employee Performance Evaluations
Use of Tracers as Part of “Root Cause Analysis” Process
Communication of Patient and System Findings From Tracer Activities
Use of Data to Improve Processes, Care and Outcomes
Do We Need Any Other Performance Improvement Projects?
Communication of Patient and System Findings From Tracer Activities
Use of Data to Improve Processes, Care and Outcomes
Do We Need Any Other Performance Improvement Projects?

Preparation of Staff for Tracer Participation

Confidence in the Care and Services They are Providing
Comfort with Being Observed as They Work
How to Respond to Questions from the Persons Conducting the Tracer
Identification of Areas of Performance Needed Improvement
Confidence with Patient Hand-off Written and Verbal Communication
Understanding Teamwork Needed for Safe and Quality Patient Care

Tools to Support the Implementation of the Tracer Methodology

Findings from JCAHO Following the Use of the Tracer Methodology