EVEN MORE Mock Tracers

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EVEN MORE

Mock Tracers

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Introduction ...1

How to Conduct a Mock Tracer ...5

Tracer Scenario Grid by Topic ...15

Section 1: Tracer Scenarios for Hospital and Critical Access Hospital ...17

Scenario 1-1. Individual Tracer: Large Urban Hospital ...19

Scenario 1-2. System Tracer: Midsize Community Hospital ...21

Scenario 1-3. System Tracer: Small Rural Hospital ...24

Scenario 1-4. System Tracer: Large Teaching Hospital ...26

Scenario 1-5. System Tracer: Critical Access Hospital ...29

Scenario 1-6. System Tracer: Outpatient Clinic at Large Urban Hospital ...31

Scenario 1-7. System Tracer: Midsize Community Hospital ...32

Scenario 1-8. Program-Specific Tracer: Small Community Hospital ...34

Scenario 1-9. Program-Specific Tracer: Military Medical Center ...36

Scenario 1-10. Program-Specific Tracer: Suburban Teaching Hospital ...38

Sample Tracer Worksheet: Scenario 1-3 ...41

Section 2: Tracer Scenarios for Ambulatory Care and Office-Based Surgery ....45

Scenario 2-1. Individual Tracer: Ambulatory Surgical Center ...47

Scenario 2-2. Individual Tracer: Office-Based Surgery Practice ...49

Scenario 2-3. System Tracer: Ambulatory Surgery Center ...51

Scenario 2-4. System Tracer: Office-Based Surgery ...53

Scenario 2-5. System Tracer: Urgent Care Center ...54

Scenario 2-6. System Tracer: Diagnostic Imaging Center...56

Scenario 2-7. System Tracer: Family Practice Primary Care Facility ...58

Scenario 2-8. Program-Specific Tracer: Ambulatory Care Organization ...59

Section 3: Tracer Scenarios for Behavioral Health Care ...65

Scenario 3-1. Individual Tracer: Therapeutic Boarding School ...67

Scenario 3-2. System Tracer: Community Mental Health Center ...68

Scenario 3-3. System Tracer: Residential Treatment Center ...70

Scenario 3-4. System Tracer: Community Mental Health Center ...72

Scenario 3-5. Program-Specific Tracer: Continuity of Therapeutic Foster Care ...73

Scenario 3-6. Program-Specific Tracer: Youth Group Home ...75

Scenario 3-7. Program-Specific Tracer: 24-Hour Adult Mental Health Setting ...76

Scenario 3-8. Program-Specific Tracer: Residential Drug and Alcohol Treatment Program ...78

Section 4: Tracer Scenarios for Home Care ...83

Scenario 4-1. Individual Tracer: Home Health Agency ...85

Scenario 4-2. Individual Tracer: Home- and Facility-Based Hospice Care Agency ...87

Scenario 4-3. Individual Tracer: Home Care Program with Personal Care Services ...89

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Scenario 4-4. System Tracer: Deemed Status Home Health Agency ...91

Scenario 4-5. Program-Specific Tracer: Pharmacy Mail-Order Service ...93

Scenario 4-6. Program-Specific Tracer: Home Medical Equipment Organization ...95

Scenario 4-7. Program-Specific Tracer: Medicare-Certified Home Health Agency with Deemed Status ...98

Scenario 4-8. Program-Specific Tracer: Home Health Agency with Infusion Pharmacy ...100

Section 5: Tracer Scenarios for Long Term Care ...105

Scenario 5-1. Individual Tracer: Small Nursing Facility ...107

Scenario 5-2. System Tracer: Transitions of Care Between Agencies ...109

Scenario 5-3. System Tracer: Midsize Facility Providing Behavioral Health Services ...111

Scenario 5-4. System Tracer: Long-Stay Nursing Facility ...113

Scenario 5-5. Program-Specific Tracer: Small Nursing Facility with Rehabilitative Care...114

Scenario 5-6. Program-Specific Tracer: Large Nursing Facility ...116

Section 6: Tracer Scenarios for Laboratory ...123

Scenario 6-1. Individual Tracer: Laboratory in a Large Teaching Hospital ...125

Scenario 6-2. Individual Tracer: Laboratory in a Rural Hospital ...127

Scenario 6-3. Individual Tracer: Outpatient Clinic ...129

Scenario 6-4. Individual Tracer: Community Hospital ...131

Scenario 6-5. Individual Tracer: Critical Access Hospital ...133

Section 7: Tracer Scenarios for Environment of Care ...139

Scenario 7-1. System Tracer: Security ...141

Scenario 7-2. System Tracer: Utility Systems ...143

Scenario 7-3. System Tracer: Environmental Safety ...144

Scenario 7-4. System Tracer: Fire Safety ...146

Scenario 7-5. System Tracer: Interim Life Safety Measures ...148

Scenario 7-6. System Tracer: Hazardous Materials and Waste ...149

Scenario 7-7. System Tracer: Medical Equipment Storage ...151

Scenario 7-8. System Tracer: Endoscope Processing Procedure ...153

Section 8: Tracer Scenarios for International ...157

Scenario 8-1. Individual Tracer: Large Hospital ...159

Scenario 8-2. Individual Tracer: Long Term Care Facility ...161

Scenario 8-3. Individual Tracer: Ambulatory Care Center ...164

Scenario 8-4. System Tracer: Midsize Hospital ...166

Scenario 8-5. System Tracer: Primary Health Center ...168

Scenario 8-6. System Tracer: Private Hospital ...170

Scenario 8-7. System Tracer: Primary Care Facility in Hospital ...172

Appendix A: Priority Focus Areas ...177

Appendix B: Mock Tracer Worksheet Form ...181

Appendix C: Comprehensive Organization Assessment Form...185

Index ...189

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Tracer methodology is an integral part of the on-site accredita-tion survey process used by The Joint Commission and Joint Commission International (JCI). Surveyors use tracers to eval-uate the care of an individual or to evaleval-uate a specific care process as part of a larger system. A surveyor reviews an vidual’s record and follows the specific care processes the indi-vidual experienced by observing and talking with staff members in areas where the individual received care. This methodology provides the surveyor with an opportunity to as-sess the organization’s systems for providing care and services and its compliance with accreditation requirements. This book, part of a series that focuses on familiarizing health care staff with tracer methodology, can help an organization learn to conduct simulated—or mock—tracers that mimic actual tracers. The mock tracer is conducted by someone in the or-ganization who performs the role of an actual surveyor.

Benefits of Understanding Tracers

Health care organizations that educate staff about tracers will have a better understanding of the overall survey process, espe-cially since an on-site surveyor can typically devote up to 60% of his or her time conducting tracers. In addition, an organiza-tion that understands tracers can use mock tracers as a tool to assess its compliance with standards and make improvements before a surveyor arrives. For example, if an organization wants to analyze how well a specific aspect of a system on a specific unit functions—such as the security in the neonatal intensive care unit of a hospital—it can conduct a mock tracer of that system. Although its purpose would be to learn more about how systems function in that particular unit, a mock tracer would also provide important information that could identify broader issues for improvement.

Types of Tracers

Surveyors currently conduct three types of tracers:

• Individual:An individual tracer follows the actual experi-ence of an individual who received care, treatment, or ser-vices in a health care organization (that is, a patient, a resident, or an individual served). To select individuals to trace in U.S. health care organizations, surveyors take into account an organization’s clinical/service groups (CSGs) and its top priority focus areas (PFAs) identified through The Joint Commission’s Priority Focus Process. The CSGs categorize care recipients and selected services into distinct populations for which data can be collected. PFAs are processes, systems, or structures in a health care organiza-tion that significantly impact safety and/or the quality of care provided (seeAppendix A). The organization’s specific CSGs and PFAs inform the choice of what types of areas, units, services, departments, programs, or homes to visit initially to conduct an individual tracer; the CSGs, in turn, help the surveyor select an individual to trace. Although in-formation from the Priority Focus Process may help survey-ors select the first individuals and areas to trace, a surveyor may trace the experience of additional care recipients based on the initial findings during the on-site survey.

• System based:A surveyor may use a system-based tracer to analyze a high-risk process or system across an entire organization to evaluate how and how well that system functions. Currently, there are three topics explored during the on-site survey using the system tracer approach: med-ication management, infection control, and data manage-ment. To analyze a medication management or infection control system, a surveyor can follow an individual’s actual

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care experience through the organization and assess how well that particular system functioned related to that indi-vidual’s care. But to analyze a data management system, the surveyor conducts a group meeting session and focuses on assessing an organization’s use of data in improving safety and quality of care. The goal of a data management system tracer is to learn about an organization’s performance im-provement process, including the organization, control, and use of data. There is no individual care recipient to follow; however, data from performance improvement are used and evaluated during the course of individual tracers through-out a survey.

• Program specific:A surveyor may use a program-specific tracer to analyze the unique characteristics and relevant is-sues of a specific type of organization. The goal of this type of tracer is to identify safety concerns in different levels and types of care. For example, a patient flow tracer is a program-specific tracer used in hospitals, whereas a conti-nuity of care tracer is a program-specific tracer used in an ambulatory care organization.

A survey may also include an environment of care (EC) tracer. Like a system tracer, this type of tracer examines orga-nizational systems and processes—in this case, systems related to the physical environment.

Second Generation Tracers

During any type of tracer, a surveyor may see something in-volving a high-risk area that requires a more in-depth look. At that point, the surveyor may decide to conduct a second gen-eration tracer, which is a deep and detailed exploration of a particular area, process, or subject. These types of tracers are a natural evolution of the existing tracer process.

The following are high-risk topics in hospitals and critical ac-cess hospitals that surveyors might explore in more detail using a second generation tracer approach: cleaning, disinfection, and sterilization (CDS); patient flow across care continuum; contracted services; diagnostic imaging; and ongoing profes-sional practice evaluation (OPPE)/focused profesprofes-sional prac-tice evaluation (FPPE).

Future second generation tracers will include clinical/health information systems and therapeutic radiation. Additional areas could be developed as they are identified.

Tracers Used Internationally

Tracer methodology is being used to assess health care orga-niza-tions beyond the United States. Health care organizaorga-niza-tions that undergo JCI accreditation also experience tracer methodology when surveyors visit their facilities. The concept is essentially the same for both domestic and international organizations; how-ever, there are slight differences. Whereas U.S. surveyors use such elements as PFAs and CSGs to select care recipients to trace, these criteria do not apply to international surveys. JCI surveyors use information provided in the organization’s accredi-tation survey application to select tracer subjects from an active care recipient list. Subjects typically selected are those who have received multiple or complex services because they, most likely, have had more contact with various departments of the organi-zation, providing a greater opportunity for the surveyor to assess how systems work in the organization. Furthermore, program-specific tracers are done as part of “undetermined survey activ-ity” appropriate to an organization, as defined in the JCI Survey Process Guide. Also, international organizations refer to the EC tracers as “facility management and safety” tracers and to data management system tracers as “improvement in quality and pa-tient safety” tracers.

Conducting Mock Tracers

The best way to understand all types of tracers is through prac-tice—that is, through conducting mock tracers. This involves developing some basic skills, such as learning how to ask good questions. An actual tracer is not performed by one person in isolation. It involves talking with multiple staff members and, in the case of individual tracers and some system tracers, the care recipient and even family members (if possible) to learn details about an individual’s health care experience or how a particular system functions in an organization. All important details about the individual’s care or the system’s function can be explored by asking simple questions in succession. And how a question is asked is particularly important. A surveyor poses questions in a manner that encourages the staff member or care recipient to share as much information as possible. Obser-vation of the surroundings or attention to how a respondent answers one question can lead to other related issues and can trigger additional questions.

Skills in analysis and organization are also involved, particu-larly in planning a mock tracer, and of course, analysis is

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Introduction

essary to evaluate and prioritize the results of a mock tracer. Similar skills are involved in the reporting of the results and in the follow-up on any consequent plans for improvement based on the results. Often, an organization will institute a mock tracer program that will train participants for optimum out-comes to these practice tracers. The benefits that result from mock tracers support and enhance the continuation of such teams.

How to Use This Book

Even More Mock Tracersis designed to help staff members in all health care settings better understand how the different types of tracers work and how to conduct mock tracers:

• “How to Conduct a Mock Tracer” follows this Introduc-tion. It provides step-by-step instruction on performing a mock tracer.

• The “Tracer Scenario Grid” on pages 15–16 lists some key topics that are addressed throughout this workbook. It can be used to quickly locate mock tracers that feature these topics.

• Each section of this workbook includes example tracers, called scenarios, that are specific to a type of health care set-ting (such as home care and behavioral health care). • Each scenario is preceded by a list of the PFAs that emerge

during the scenario. For scenarios in an international set-ting, this summary also explains the criteria for the tracer subject selection. Then, a narrative describes how a surveyor might analyze a particular system or use an individual’s record as a road map through the organization.

• Sample tracer questions follow each scenario. They show the types of questions a surveyor might ask staff members or other individuals for the specific scenario. These ques-tions are keyed to the narrative to show how and when they might occur during the scenario.

• Each section also includes an example of a tracer worksheet that utilizes the sample tracer questions from one scenario

and shows how the worksheet might be completed during mock tracer activities.

• Appendixes describe the PFAs and provide forms that are helpful in developing a mock tracer program.

Terms Used in This Book

This publication is divided into sections that are health care setting–specific, so each section will use terminology appropri-ate for its setting. For example, patientwill be used for hospi-tal, ambulatory care, and home care settings; individualwill be used for behavioral care settings; and residentwill be used for long term care settings. The term health carein this workbook refers to all types of care, treatment, or services provided within the spectrum of the health care field, including physi-cal, mediphysi-cal, and behavioral health care.

Acknowledgments

Joint Commission Resources (JCR) is grateful to the multiple reviewers and content experts for their feedback to ensure that the overall content about tracers is accurate and relevant to the numerous health care settings. A special thank you is extended to Dana Dunn, RN, MBA, CNOR, CASC, Surveyor, Ambu-latory Health Care Accreditation, The Joint Commission; Ann Fonville, RN, MPH, EdD; Cheryl S. Frenkel, RN, MS, GNP, LNHA; Virginia Maripolsky, MSW, RN, Assistant CEO, Nursing Affairs, Bangkok Hospital, Bangkok, Thailand; Aneita Paiano, MBS, MT (ASCP), Surveyor, Laboratory Pro-gram, The Joint Commission; Genie Skypek, PhD, Surveyor, Behavioral Health Care Accreditation, The Joint Commission; David Sladewski, LSCS, MS, CHSP, CPM, Surveyor and Life Safety Code®_{Specialist, The Joint Commission; and Joyce}

Whitten, RN, MSN, Surveyor, Home Care Accreditation Pro-gram, The Joint Commission. We also extend our gratitude to writer Julie Chyna for her dedication and diligence in writing this book.