Educating staff on tracer methodology is a must

Survey results depend on it

Are staff at your facility skeptical that surveyors from the Joint Commission on Accreditation of Healthcare Organizations really will ask them the questions during your next survey?

You’ll need to prepare staff for major changes in the survey process, including the new tracer methodology, which will be a key part of the 2004 surveys when Shared Visions — New Pathways goes live. In addition, the performance of organizations accredited after the beginning of this year, will be reported in the new Quality Report format, and all regular accreditation surveys will be unannounced as of January 2006.

"For several years now, we have told everyone that surveyors are going to be talking more to staff," says Catherine M. Fay, RN, director of performance improvement at Paradise Valley Hospital in National City, CA. "But in actuality, the numbers of staff who surveyors talked to in previous surveys were very small. So I don’t think they really believe us this time."

But the Joint Commission’s claims aren’t just idle talk or empty promises, according to Angie King, BSN, CPHQ, quality management director at Tift Regional Medical Center in Tifton, GA. "Unit staff are definitely the ones surveyors are going to be talking to," she reports.

King’s facility participated in the pilot survey process for the Joint Commission’s Shared Visions — New Pathways initiative. "We chose to participate because we wanted to have the opportunity to put our 2 cents in. Since we heard there were going to be sweeping changes, we wanted to have some live interaction to say what was good and what wasn’t."

Overall, the new survey process is a definite improvement, King says. "It is, by far, a much more educational process," she says, adding that the process is a "real silo-buster," breaking down walls between departments and services within the facility.

"Hospitals are comprised of many silos, even within the nursing department itself," King notes. "With this type of methodology, staff get to see the whole continuum of care."

Here are key aspects of the pilot survey at Tift Regional:

• You’ll have less control during the survey.

Due to the new tracer methodology’s unpredictable nature, there is a loss of control for both the organization and the surveyors, King says.

This means that it will be more difficult to ensure key individuals participate in the survey process, she notes. "Our chief of surgery certainly did not put any patient at risk, but he chose to delay his start time because he wanted to spend time with the surveyors. Had he known when they were coming to the OR [operating room], he could have changed his schedule accordingly, because he wanted to participate."

Similarly, if you have one nurse manager who is responsible for two different departments, it could be difficult to ensure that individual is present, King adds. "If two different surveyors are there at the same time, and they are tracing back and forth, it’s kind of difficult to coordinate schedules."

Since you can’t predict exactly who will be in a given department when surveyors arrive, it’s even more important that every staff member is ready to answer questions if needed, King says.

It also is tougher to ensure that you are present to step in if needed, she explains, and adds that it may be difficult to get used to the idea that you can’t control where the surveyor is going next.

• Surveyors may not cover every area during the survey.

Since surveyors are tracing a patient’s path through the facility, some departments or ancillary services may not come up during the survey itself, such as pharmacy, King notes. "They may not be able to see everything they need to in the hospital, so unless that is scheduled for a separate site visit, they will have to come back and do that after hours."

• Surveyors made good choices when selecting patients to trace.

The surveyors asked for a list of all patients, where they are, what their diagnoses are, and how long they have been there. "Based on that, they made their patient selections," she says. "I think that they made good choices. Those were also the patients they interviewed."

One of the chosen patients was a child who had come in through the emergency department (ED), spent time in critical care, and was on the pediatric unit. "They looked at the competency of staff since we had ICU [intensive care unit] nurses taking care of pediatric patients, but we don’t have a pediatric ICU," King says. The questions asked of patients were focused on continuum of care, she states. "For example, they would say, Your care started in the ED; did you feel like that continued when you came up here? Was it explained to you? What happened when you got up here?’"

The pediatric patient had been given a nebulizer treatment, so surveyors asked the respiratory therapist who was responsible for teaching this to the patient. "The therapist said it was their function. So the surveyor asked, Can you show me how that’s communicated so nursing knows you’ve done it?’" King adds. "The surveyor then asked the nurse the same question, How do you look to see that they have been successful in teaching it?’ and asked to see where they would look for this in the record."

• Staff got more educational benefit from the survey.

King gives the example of a surveyor discussing a patient’s care with a nurse on the pediatric unit. "There was a question that came up about the patient’s care in the emergency department, and the surveyor asked, Is the ED nurse here today, and if so, can she come up here?" she recalls. "That was great, because that ED nurse sat there with the pediatric nurse and together they answered the surveyor’s questions. Afterward, she said it gave her a much greater understanding of what happens outside the walls of the ED."

One of your top priorities to prepare for the new survey process is ensuring that every staff member understands how to answer surveyor questions based on the new tracer methodology; but many managers feel they’re flying blind.

"We have struggled with this. Since no one has actual experience with the tracer methodology, preparing the staff is difficult," Fay says.

In the past, getting ready for surveys centered around three things: standards considered to be hot-button issues with surveyors that year, new standards, and previous survey findings, she says. "That won’t work this time because this year, we anticipate a process unfamiliar to any of the hospital staff," she says. "So we had to come up with a new way of preparing for our May 2004 survey."

The fact that the surveyors’ whereabouts are unpredictable is another major change — a somewhat unsettling one for most quality managers. "Previously, a director or administrator would do their best to make sure a surveyor stays in one spot according to the schedule and doesn’t go anywhere else." Fay points out.

As a result, the director typically answered many of the surveyors’ questions, but that no longer will be the case, she acknowledges. "We are giving more and more information directly to the staff, because they are the ones the surveyors are going to be talking to."

Here are some effective strategies to educate staff about the new tracer methodology:

• Ask staff questions to reflect the new survey process.

At Tift Regional, staff were prepared by "walking ambassador" rounds and asked questions such as, "If you have a patient who complains of pain, what do you do?" and "Can you show me how you communicate with other departments?"

"My focus was to familiarize them with the type of questions that would be asked so they wouldn’t be scared," King says. "If you can eliminate fear, staff will be able to answer the questions, because they know what they are doing. They might not know one way to answer it, but they will know another."

• Explain that staff should focus on processes.

Previously, survey preparation revolved around policies, procedures, and documentation, Fay says. However, with the new tracer methodology, processes have become very important, and surveyors will expect to hear staff talk about patient care in those terms, she explains.

"The intent of JCAHO is to determine what are our processes, how well they are implemented consistently, and how we measure the success of the process," Fay says.

Education for the new survey process is directed at the staff-level employees, she emphasizes. Fay says the goal is that staff understand the following:

— Processes they use in carrying out the responsibilities of their positions.

— How those processes are linked to other positions or departments.

— Matching policies and procedures for the processes.

— How the department measures the effectiveness of the processes.

For all the above, staff must address hospitalwide processes that apply to all departments, such as the National Patient Safety Goals, infection control practices, and emergency preparedness, Fay says.

Surveyors are not going to come to a department and say, "This is Mr. Smith — what did you do for him?" she says. "If a study is done on a particular person, they will ask, How do you go about doing it, how do you inform them about it, how do you document it, and how do you determine who is qualified to do it?’ What they are looking for is consistent application of a process."

This means that staff no longer can use the excuse, "I didn’t take care of that patient," Fay says. "The Joint Commission isn’t buying that anymore. What they are saying is if you have these kind of patients, you need to know how to take care of them."

• Select your own patients to trace through the system.

Each month, department directors are choosing a patient to trace. The staff are walked through a "process identification exercise" to determine their level of understanding. Each director or manager pulls a patient’s chart or a given procedure, based on the type of care or service provided in the department.

For example, on the surgical unit, staff must be ready to discuss the process for any surgical procedure, Fay says. Radiology staff may be asked to discuss how they do a computerized tomography scan with contrast, and dietary staff may be asked to talk about the process of nutritional intervention for a patient who has been NPO (nothing by mouth) for four days.

Staff are asked the following questions:

What do we do for this patient first? "Staff then go through each process, including nutritional assessment or informed consent if they need it, and everything that is linked to whatever the diagnosis is," Fay says.

What is the policy for that process?

Can you get me a copy of the policy?

"Those are the steps that the Joint Commission is going to address," she adds.

• Identify problem areas.

Based on the results of the process identification exercise, managers identify areas where staff need improvement due to lack of knowledge or inconsistent answers, and these are addressed at the next staff meeting, Fay explains.

In addition, randomly selected department directors will report problem areas from their departments at the biweekly leadership team meetings, so that other directors can learn from their findings.

• Assess which types of patients are likely to be selected.

For the patient tracer exercises, Fay suggests departments select patients who are representative of the core measures the facility is collecting data on. "We believe that is where the surveyors will be going," she says. "We don’t have the performance improvement overview, and we don’t have the opportunity to talk about core measures. Congestive heart failure and community-acquired pneumonia are our top DRGs [diagnosis-related groups], and the surveyors will know that. So there is a pretty good chance that they will be asking about these patients."

Surveyors likely will base the patient selections on your services, census, and core measures, Fay says.

Surveyors also will consider patient populations at your facility, she adds. "We have a very small pediatric population, so they might look at that," she says. "The more you do things, the more you take shortcuts, and the less you do things, [the more] you tend to forget, so those are the two ranges of risk."

No matter what type of patient is chosen, all the processes should be the same, Fay emphasizes.

In the intensive care unit, you may have different competency levels depending on medications you are administering, and different procedures that you do, but the basic processes should be similar to other areas, she says. "So, I’m not as concerned about the diagnosis or how they select the patient. What is important is that the staff actually pick a patient and go through the process of learning — that they know the processes they use to care for the patient."


For more information on preparing staff for JCAHO surveyors, contact:

Catherine M. Fay, RN, Director of Performance Improvement, Paradise Valley Hospital, 2400 E. Fourth St., National City, CA 91950. Telephone: (619) 470-4283. Fax: (619) 470-4162. E-mail:

Angie King, BSN, CPHQ, Quality Management Director, Tift Regional Medical Center, 901 E. 18th St., Tifton, GA 31794. Telephone: (229) 386-6119. Fax: (229) 556-6390. E-mail: