SDS Accreditation Update: Unannounced surveys begin for some SDS programs

New tracer methodology will be used

It’s a good thing that Patti Moore, RN, director of River View Surgery Center in Lancaster, OH, stays current on her reading. She perused with interest the January 2004 newsletter produced by the Joint Commission on Accreditation of Healthcare Organizations, which included a description of tracer methodology. Ten days later, her surgery center became the nation’s first freestanding ambulatory surgery center to undergo an unannounced survey conducted to test the unannounced process and the tracer methodology.

"We have always worked toward continual regulatory readiness, and in most ways we were ready, but my staff was not prepared to be interviewed to the extent they were," says Moore. "The greatest change in the new approach to surveys is the fact that surveyors are talking directly to the people providing the care, while the manager stands back and acts as a support person."

Because her experienced staff always remembered surveys as taking place behind closed doors, with surveyors poring over paperwork and policy books, the first few staff members who were approached by the surveyors did have a "deer in the headlights" look on their faces, Moore admits. Once staff members realized that the surveyor was just asking about how they did their jobs, they were able to relax and talk with pride about how they ensured patient safety and good outcomes, she adds.

Moore found that she and her staff were better prepared for an unannounced survey than they realized when the surveyor arrived at a time in the morning prior to Moore and another manager arriving, and during the small window of time that the manager on duty had gone to the bank to make a deposit. "My staff members knew how to reach me and were able to immediately help the surveyor begin," she says. Not surprisingly, one of Moore’s recommendations is that you prepare staff members for a situation in which they have to begin the survey without a manager.

The surveyor did "trace" three patients throughout the day, says Moore. "The patients were traced one at a time, and the surveyor was here for between seven and eight hours," she says. First the surveyor chose a patient to follow. Then, using the patient’s chart, the surveyor went to each staff member who might have had contact with the patient, she says. The questions focused upon issues such as patient identification, how a recovery room nurse would know which medications had been administered, and what specific training a staff member received on equipment. As questions are answered, the surveyor would occasionally ask to see documentation of things such as credentialing or certification, but most of the review involved the medical record, says Moore.

"My nurses liked the tracer methodology, because it is more interactive with the staff members who are providing the care, and it makes sense," says Lorri G. Smith, RN, BSN, director of clinical services accreditation specialist for AmSurg, a Nashville-based national company that manages or owns more than 120 single-specialty surgery centers. "In the past, surveyors might head off in a direction that made little sense as they asked for different documents, but the tracer methodology keeps everything on track, and the documents that they may want tie directly back to the patient being traced," she says.

Same-day surgery staff at Paradise Valley Hospital in National City, CA, were well prepared for the tracer methodology due to a program that has been in place since 2003.

"We have the department manager pull a patient’s chart and walk through the process just as a surveyor will do," says Catherine M. Fay, RN, director of performance improvement at the hospital. The process can be done as a group at a staff meeting, with the director starting with the patient’s preadmission and asking the admission nurse what information is given in the initial call, Fay says.

"Same-day surgery managers can choose a specific chart or pick a procedure off the surgical schedule, such as knee arthroscopy, and ask staff members to talk about what this patient needs before admission, what information we need upon admission, how we ensure that the patient is properly identified and that the surgical site is verified, and what medications and instruction are needed for discharge," she explains. If a patient requires a breathing treatment prior to surgery, staff members are asked who will administer the treatments, what type of training have they had, and how they will evaluate the patient after the treatments, she adds.

At first, staff members are uncomfortable answering questions that a surveyor may ask, but they soon relax when they realize that they already know the answers, says Fay.

"The greatest benefit to this ongoing process is that staff members are comfortable answering questions about the process used to care for patients as they move from one area to another," she says.


For more information about unannounced surveys and tracer methodology, contact:

  • Patti Moore, RN, Director, River View Surgery Center, 2401 N. Columbia St., Lancaster, OH 43130. Telephone: (740) 681-2700. E-mail:
  • Lorri G. Smith, RN, BSN, Director of Clinical Services Accreditation Specialist, AmSurg, 20 Burton Hills Blvd., Fifth Floor, Nashville, TN 37215. Telephone: (615) 665-3558. E-mail:
  • 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: