SDS Accreditation Update

All in the details: Tracer method looks for thorough notes

Surveyors evaluate policy compliance throughout continuum of care

The days of accreditation surveyors flipping through policy books and interviewing management team members may not be completely gone, but the majority of information gathered about a same-day surgery program today comes from the surveyors’ review of patient charts.

As part of the Joint Commission on Accreditation of Healthcare Organization’s Shared Visions-New Pathways survey process that will take effect in 2004, surveyors will use patient charts to compare what you say you do and what you really do as you provide care to your patients. (For more information, see "JCAHO is turning your world upside down with you reporting deficiencies," Same-Day Surgery, December 2002, p. 145.)

Even though 2004 is not yet here, surveyors already are using patient charts to see if reality and policy match up, says Mary Ann Rhodes, RN, BSN, EMTP, surgical director for Cedar Surgical Associates in Cedar City, UT, a freestanding surgery program that recently underwent an initial survey.

"Although we did very well on the survey, I was surprised at some of the items the surveyor wanted to see in the charts," admits Rhodes.

Although the pain management policy requires that pre-op and post-op pain be checked, her nurses don’t always document the pre-op pain levels because patients report no pain, she says.

"The surveyor wanted to see a note that indicated the patient pre-op pain level," Rhodes adds.

Review of charts always has been a part of the survey process for the Accreditation Association of Ambulatory Health Care (AAAHC), says Sheryl Walker, MD, medical director of The Surgicenter of Baltimore in Owings Mill, MD, and AAAHC surveyor.

"We are only at the facility a short time, and we only see a snapshot of the operations in person, so it is important to look at charts," Walker says.

Another reason that tracing a patient’s progress through the process is important is that anyone can memorize and recite a policy, she adds. "We still ask questions of staff members to make sure they know the policies, but we look in the charts for proof that they are following policies," Walker explains.

Because the tracer method focuses on the continuum of care for patients, it’s important to document every contact, Rhodes points out. "In addition to looking for documentation on our pre-op contacts and instructions given at that time, the surveyor also checked for notes on the post-op assessment calls," she says.

Vanderbilt University Medical Center in Nashville, TN, also recently underwent an accreditation survey.

"Our surveyor wanted to see specific notes on our patients who were discharged to home care agencies," says Nancye R. Feistritzer, RN, MSN, assistant hospital director responsible for perioperative services.

The surveyor focused upon the smooth transfer of care from area to area, she says.

"Throughout the entire survey, he wanted to see that we clearly documented every intervention and response so that the next department or person responsible for the patient’s care had a complete picture and this included home care referrals," she adds. "Our surveyor looked closely at the surgeon’s post-op notes to make sure that it was clear that the patient was ready for the next level of care."

All of the charts that the surveyor followed
for Vanderbilt’s same-day surgery patients were "open" charts, or charts of patients that were still at the facility or had been discharged that day, Feistritzer says. This review gave the surveyor an opportunity to observe the staff following procedures to identify surgical sites correctly and assess pain levels in real time, she adds.

"I suggest that a same-day surgery program conduct a mock survey in which someone follows a patient just as the surveyor will," says Feistritzer. "You should invite someone from outside your department, such as a staff member from another location, to get a fresh perspective on what you are really doing."

The best advice as you prepare for your survey is to evaluate your policies carefully, says Walker. "Make sure your practice is in compliance with accreditation requirements, then make sure your policies reflect your actual practice," she suggests.

If your policy requires an action that is not practical or is outdated, take it out, Walker adds.

"This not only improves the results of your accreditation survey, but reduces your legal liability because you are liable if you don’t follow your policy," she says.

Sources and Resources

For more information about the tracer method in surveys, contact:

  • Sheryl Walker MD, Medical Director, The SurgiCenter of Baltimore, 23 Crossroad Drive, Suite 100, Owings Mill, MD 21117. Telephone: (410) 356-0300. Fax: (410) 356-0309.
  • Mary Ann Rhodes, RN, BSN, CMTP, Surgical Director, Cedar Surgical Associates, 1811 W. Royal Hunte Drive, Suite 3, Cedar City, UT 84720. Telephone: (435) 586-3402. E-mail:
  • Nancye R. Feistritzer, RN, MSN, Assistant Hospital Director, Vanderbilt University Medical Center, VUH 3108, 21st Ave., Nashville, TN 37232. Telephone: (615) 322-3354. E-mail:

• A "Priority Focus Process and Tracer Methodology" video is available from the Joint Commission on the Accreditation of Healthcare. To view the free video, go to:, click on "accredited organizations," choose "Shared Visions — New Pathways" in the JCAHO Shortcut column, then choose "video information series."