Tracer methodology focuses on care, not paper

Pay less attention to manuals, more to safety goals

Mid-cycle self-assessments, tracer methodology, and less emphasis on examination of policy books are all signs that the new survey process implemented by the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations is truly different from the survey process of the past. Although any change in a process to which people have become accustomed is uncomfortable, home health managers who have undergone surveys in 2004 report positive reactions to the new process.

"I like [the survey process] better this year than in previous years," says Laura Hieb, RN, MBA, administrator of Bellin Home Health in Green Bay, WI. "Surveyors used to focus on policy manuals and documents without any pattern or real objective," she says. "Now, everything the surveyor asks to see is based upon the patient who is being followed," she explains.

The use of a tracer methodology for a survey means that the surveyor "follows" the path of a patient throughout the patient’s encounter with the home health agency. This might mean that the surveyor starts with the patient’s records from the hospital, then follows the patient through referral, admission, care, and discharge. As the surveyor follows the patient’s record, he or she talks with employees who were responsible for different aspects of the patient’s encounter.

One of the Bellin Home Health patients who was "traced" was a patient who received services from the home health agency, the durable medical equipment company, and IV services. "The surveyor rode to the patient’s home with the driver delivering the IV product, then stayed with the patient a good part of the day while our home health nurse and the IV nurse made their visits," says Hieb. "Throughout the surveyor’s stay, she asked nurses how they handle different situations that might arise with a patient’s care. She also talked with the patient, asking questions about who should be called for assistance with equipment or medications," she explains. It was clear from the patient’s responses that the home health agency, along with the other services, had done a good job of educating the patient and making sure the correct phone numbers were handy, she adds.

It is still important to keep employee records up to date, points out Hieb. "Although the surveyor didn’t look through all of our personnel records, she did ask to see the files of four or five employees who were involved in the traced patients’ care," she explains.

Because the new process focuses more on actual patient care than on paper documents, staff members have more direct contact with surveyors and are questioned more often than managers. Of all health care-related staff, home health employees may be the best prepared to interact with surveyors, points out Judy Falkowski, RN, BSN, director of Bay Area Hospital Home Health Care in North Bend, OR. "Home health staff members are accustomed to unannounced visits from state surveyors all the time," Falkowski says. "My staff has learned that the best way to show off the quality of care we offer is to do so while riding with a surveyor on a visit," she adds.

Questions that surveyors ask are prompted by what they see in the documentation or by what the staff member or patient says is being done, points out Falkowski. For example, when medications for a diabetic patient are discussed, the surveyor asks what education is provided and whether other services are consulted for advice and information, she explains.

Patient safety is high priority

Surveyors are also focusing on National Patient Safety Goals, says Falkowski. "They want to see that staff members, physicians, and clients understand safety and know what to do if an alarm on a pump goes off, for example," she explains. "The surveyors aren’t looking for perfection; what they do want to see is that your agency has systems in place to promote safety and to protect patients," she adds.

In one of the open forums held by the surveyors with representatives from all departments of the hospital, surveyors did not ask people to describe how they were meeting the goals. Instead, they asked, "What do you know about the National Patient Safety Goals?"

"That question led into other questions about how we address medication safety or improve communications," Hieb says.

While some home health agencies may feel let down that the surveyors don’t spend as much time in home health as they did when surveys were conducted separately, Hieb says the survey of her durable medical equipment company was the most extensive she’s ever seen. "One of our surveyors happened to be a respiratory therapist, so our logs for equipment checks were reviewed, and he went on visits with the respiratory therapist," she says. In the home health agency, there were two surveyors who spent about four hours each looking at different patients, she adds.

Don’t forget that, even when your home health agency is part of a hospital, you still need to have your own emergency management plan in place, warns Falkowski. "I am used to no recommendations or conditions in my surveys, so I was surprised to be hit with a recommendation related to E.C. 410, the standard that states that the organization must have an emergency management plan," she says. "My plan that I relied upon was basically the hospital’s plan, with a few modifications for home health," she says. "The surveyor pointed out that because home health differs from the hospital, it should have its own unique plan that does tie into the hospital’s plan," she explains.

Hazard analysis tool pinpoints risk

By using a hazard analysis tool, Falkowski was able to identify the most likely emergencies that her agency would face and develop a plan to address them. (See editor’s note for information about how to obtain a hazard analysis tool from the American Society of Healthcare Engineering.) Within her plan, Falkowski addressed the possibility of receiving large numbers of admissions from the hospital as the hospital prepared to receive victims of an emergency. "We looked at how we would handle these admissions with and without power," she adds.

Infection control is another area upon which the surveyors focus, says Falkowski. On one of the patient visits, the surveyor asked the home health nurse if she had protective equipment for drawing blood. Although the nurse did have the equipment, she did not have a hard container in which to transport used sharps, she says. "The nurse was not scheduled to draw any blood that day, so she did not have the container," she explains. Falkowski suggests that any employee who might draw blood be prepared with all of the equipment, including containers, regardless of which patients may be scheduled on that day.

While the survey itself may be easy for most home health agencies, the periodic performance review (PPR) — the mid-cycle self-review now required by the Joint Commission — presents more of a challenge, says Jodi Brown, RN, BSN, director and administrator of Alcovy Home Care in Covington, GA. "It is very time-consuming, especially for a small agency," she says.

"We have received feedback that home health agencies find the PPR difficult," admits Maryanne L. Popovich, RN, MPH, executive director of the Joint Commission’s home care accreditation program. Although the review is time-consuming, many organizations find it helpful as they target areas for improvement prior to the Joint Commission’s survey.

"I went through the online tool, reading every section to determine which ones applied to us," says Brown. For the standards that apply to home care, she either completed the form stating whether the agency met the standard and how it did so, or she pulled out sections for her nurses to complete if they were better qualified to complete the form. "My nurses weren’t excited about the extra work, but it was the only way to complete it," she says.

Although the work to complete the self-assessment was split up, Brown says the staff discussed the completed information as a group. She says this is one way to ensure that all of the information is accurate and to identify areas for improvement and develop plans of action.

[Editor’s note: To obtain a copy of the Hazard Vulnerability Analysis from the American Society of Healthcare Engineering (ASHE), current ASHE members can go to To request a hard copy of the document, go to and request document number 055920. The cost of a hard copy for ASHE members is $25, and the cost for non-members is $35.]