You can't bluff your way through patient tracers

Here are actual issues explored by surveyors

Don't think that your staff can fake their way through answers during the patient tracer section of an unannounced survey by the Joint Commission on Accreditation of Healthcare Organizations, says Nancy Hammes, patient care director in day surgery at Franciscan Skemp La Crosse (WI) Campus. Franciscan Skemp went through one of the Joint Commission's new unannounced survey process earlier this year.

"The nurse we got [as a surveyor] was, I think, with the Joint Commission the longest of any nurse they had," she recalls. "She was like an encyclopedia. You couldn't bluff your way through."

The physician surveyor wanted to know how they got patients ready, she says. For AM admit patients, he wanted to know how the day surgery staff communicated with the surgery staff and what they documented, Hammes reports. The surveyor looked at the patient chart, she says. "They went through every page and asked every question."

For same-day discharges, the surveyors wanted to know the discharge criteria. They challenged staff with hypothetical situations such as a patient ready for discharge who complained about having a headache or a patient whose prior medication may not have been reconciled. "They wanted to see documentation that you took the initiative by speaking to that patient or got the order from the physician so someone follows through on the medication they came in with but not one that necessarily the physician wrote to continue," Hammes says.

At Holyoke (MA) Medical Center's unannounced survey earlier this year, surveyors wanted to know how staff identified patients and surgical sites, and what else was included in the timeout procedure, says Brenda Loguidice, RN, MBA, CNOR, manager of perioperative services. While reviewing timeouts, the surveyors went into the OR and "watched every one of them," she says.

This approach was a dramatic contrast with previous surveys. Previously, surveyors sometimes came to outpatient surgery facilities at 4 p.m. when all the procedures were completed and the staff had gone home, Loguidice says.

At the accreditation survey for Algonquin Road Surgery Center in Lake In The Hills, IL, the surveyor asked recovery room nurses how they determined pain in patients and how they used pain scales, says Dee Weigel, RN, quality nurse. He asked the front desk staff what they would do if a patient presented them with a living will, she says. "He asked several questions back in the OR and sterile processing about how they do sterile processing, what the process is, and he talked to them at length about their lead aprons and how we test them for holes," she says.

The surveyor also was interested in testing of the medical equipment and asked about their putting all their medical equipment into risk categories.

No more scrambling and hiding

The unannounced surveys with patient tracers are a dramatic change from past surveys, says Loguidice. "In the past, direct care people would scramble and hide when the Joint Commission came, but now they are the focus, which is really good," she says. Her staff weren't intimidated, she says. "They were proud to be able to say, 'This is what I do for my patient.'"

Loguidice says she has worked in nursing for 30 years, "and this is the first time I really felt that the Joint Commission was really making an impact on the day-to-day nursing care of the patient."


For more information on patient tracers, contact:

  • Nancy Hammes, Patient Care Director, Day Surgery, Franciscan Skemp La Crosse Campus, 700 West Ave. S., La Crosse, WI 54601. Phone: (608) 795-0940, ext. 22441. E-mail:
  • Dee Weigel, RN, Quality Nurse, Algonquin Road Surgery Center, 2550 Algonquin Road, Lake In the Hills, IL 60156.