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Hospital Makes the Most Out of Mock Surveys

Matt Phillion, for HealthLeaders Media, May 12, 2009

Constructing a tracer process from scratch for a 645-bed hospital is no simple matter, but that was precisely the task before the facility's survey readiness committee, says Carol Carach, RN, BSN, MPH, regulatory and accreditation survey supervisor at Medical City Dallas (TX) Hospital.

"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.

The facility did have a survey readiness committee, however, which decided it would institute mock drills and tracers.

"That's where we got started," says Carach. "We did maybe three units as part of our initial drill, and then instituted a more formal tracer."

An initial signup 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. "We don't surprise the unit, we invite them to participate in the learning process."

Medical City has a 35 two-person tracer teams roving the halls to cover the facility's 645 beds. Maintaining those teams can be somewhat of a challenge.

After the first round of recruiting, Medical City had 25 teams and started running tracers for all units that had teams assigned to them, while simultaneously looking to fill in the blanks.

"There was some recruiting at first, but we got very good participation generally," says Carach.

There were certain areas that required more active recruiting, and in more challenging cases, unit managers selected or assigned their team members.

The team members were educated on the tracer process and then took this knowledge back to their own units. They were then assigned to trace another department.

"Part of the set-up 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.

The turnover rate has been small but regular, leading Carach to actively recruit new managers or staffers recently assigned to a leadership role to see if they want to be a part of the tracer team.

Carach had previously helped implement a tracer program at another institution, but the process, she has found, is extremely different from facility to facility.

"The process has to be designed specifically for your facility," she says.

In addition, Carach recommends the following:

  • Divide up the labor on each tracer team by area of expertise. Often, the non-clinical member of the team focuses on Environment of Care issues, for example. Allow for individuality among the various tracer teams.
  • As a leader, occasionally join a tracer team. This is not only an opportunity to observe the unit but to educate the team as well, answer questions about process or requirements. This is especially important for teams with newer members.

Matt Phillion, CSHA, is senior managing editor of Briefings on The Joint Commission and senior editorial advisor for the Association for Healthcare Accreditation Professionals (AHAP).

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