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EVEN MORE
Mock Tracers
EVEN MORE
Mock Tracers
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ii
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Table of Contents
Introduction ..........................................................................................................1
How to Conduct a Mock Tracer ............................................................................5
Tracer Scenario Grid by Topic ............................................................................15
Section 1: Tracer Scenarios for Hospital and Critical Access Hospital ..............17
Scenario 1-1. Individual Tracer: Large Urban Hospital ..................................................................19
Scenario 1-2. System Tracer: Midsize Community Hospital ..........................................................21
Scenario 1-3. System Tracer: Small Rural Hospital ......................................................................24
Scenario 1-4. System Tracer: Large Teaching Hospital ................................................................26
Scenario 1-5. System Tracer: Critical Access Hospital ..................................................................29
Scenario 1-6. System Tracer: Outpatient Clinic at Large Urban Hospital........................................31
Scenario 1-7. System Tracer: Midsize Community Hospital ..........................................................32
Scenario 1-8. Program-Specific Tracer: Small Community Hospital ..............................................34
Scenario 1-9. Program-Specific Tracer: Military Medical Center ....................................................36
Scenario 1-10. Program-Specific Tracer: Suburban Teaching Hospital ..........................................38
Sample Tracer Worksheet: Scenario 1-3 ......................................................................................41
Section 2: Tracer Scenarios for Ambulatory Care and Office-Based Surgery ....45
Scenario 2-1. Individual Tracer: Ambulatory Surgical Center ........................................................47
Scenario 2-2. Individual Tracer: Office-Based Surgery Practice ....................................................49
Scenario 2-3. System Tracer: Ambulatory Surgery Center ............................................................51
Scenario 2-4. System Tracer: Office-Based Surgery ....................................................................53
Scenario 2-5. System Tracer: Urgent Care Center ........................................................................54
Scenario 2-6. System Tracer: Diagnostic Imaging Center..............................................................56
Scenario 2-7. System Tracer: Family Practice Primary Care Facility ..............................................58
Scenario 2-8. Program-Specific Tracer: Ambulatory Care Organization ........................................59
Section 3: Tracer Scenarios for Behavioral Health Care ....................................65
Scenario 3-1. Individual Tracer: Therapeutic Boarding School ......................................................67
Scenario 3-2. System Tracer: Community Mental Health Center ....................................................68
Scenario 3-3. System Tracer: Residential Treatment Center ........................................................70
Scenario 3-4. System Tracer: Community Mental Health Center ....................................................72
Scenario 3-5. Program-Specific Tracer: Continuity of Therapeutic Foster Care ..............................73
Scenario 3-6. Program-Specific Tracer: Youth Group Home ..........................................................75
Scenario 3-7. Program-Specific Tracer: 24-Hour Adult Mental Health Setting ................................76
Scenario 3-8. Program-Specific Tracer: Residential Drug and Alcohol Treatment Program ............78
Section 4: Tracer Scenarios for Home Care ........................................................83
Scenario 4-1. Individual Tracer: Home Health Agency ..................................................................85
Scenario 4-2. Individual Tracer: Home- and Facility-Based Hospice Care Agency ..........................87
Scenario 4-3. Individual Tracer: Home Care Program with Personal Care Services ........................89
iii
Even More Mock Tracers
Scenario 4-4. System Tracer: Deemed Status Home Health Agency ..............................................91
Scenario 4-5. Program-Specific Tracer: Pharmacy Mail-Order Service ..........................................93
Scenario 4-6. Program-Specific Tracer: Home Medical Equipment Organization ............................95
Scenario 4-7. Program-Specific Tracer: Medicare-Certified Home Health Agency with
Deemed Status ......................................................................................................................98
Scenario 4-8. Program-Specific Tracer: Home Health Agency with Infusion Pharmacy ................100
Sample Tracer Worksheet: Scenario 4-6 ....................................................................................102
Section 5: Tracer Scenarios for Long Term Care ..............................................105
Scenario 5-1. Individual Tracer: Small Nursing Facility ..............................................................107
Scenario 5-2. System Tracer: Transitions of Care Between Agencies ..........................................109
Scenario 5-3. System Tracer: Midsize Facility Providing Behavioral Health Services ....................111
Scenario 5-4. System Tracer: Long-Stay Nursing Facility ............................................................113
Scenario 5-5. Program-Specific Tracer: Small Nursing Facility with Rehabilitative Care................114
Scenario 5-6. Program-Specific Tracer: Large Nursing Facility ....................................................116
Section 6: Tracer Scenarios for Laboratory ......................................................123
Scenario 6-1. Individual Tracer: Laboratory in a Large Teaching Hospital ....................................125
Scenario 6-2. Individual Tracer: Laboratory in a Rural Hospital ..................................................127
Scenario 6-3. Individual Tracer: Outpatient Clinic ......................................................................129
Scenario 6-4. Individual Tracer: Community Hospital ..................................................................131
Scenario 6-5. Individual Tracer: Critical Access Hospital ............................................................133
Section 7: Tracer Scenarios for Environment of Care ......................................139
Scenario 7-1. System Tracer: Security ......................................................................................141
Scenario 7-2. System Tracer: Utility Systems ............................................................................143
Scenario 7-3. System Tracer: Environmental Safety ..................................................................144
Scenario 7-4. System Tracer: Fire Safety ..................................................................................146
Scenario 7-5. System Tracer: Interim Life Safety Measures ........................................................148
Scenario 7-6. System Tracer: Hazardous Materials and Waste ....................................................149
Scenario 7-7. System Tracer: Medical Equipment Storage ..........................................................151
Scenario 7-8. System Tracer: Endoscope Processing Procedure ................................................153
Section 8: Tracer Scenarios for International ..................................................157
Scenario 8-1. Individual Tracer: Large Hospital ..........................................................................159
Scenario 8-2. Individual Tracer: Long Term Care Facility ............................................................161
Scenario 8-3. Individual Tracer: Ambulatory Care Center ............................................................164
Scenario 8-4. System Tracer: Midsize Hospital ..........................................................................166
Scenario 8-5. System Tracer: Primary Health Center ..................................................................168
Scenario 8-6. System Tracer: Private Hospital ............................................................................170
Scenario 8-7. System Tracer: Primary Care Facility in Hospital ..................................................172
Appendix A: Priority Focus Areas ....................................................................177
Appendix B: Mock Tracer Worksheet Form ......................................................181
Appendix C: Comprehensive Organization Assessment Form..........................185
Index ................................................................................................................189
iv
Introduction
Tracer methodology is an integral part of the on-site accreditation survey process used by The Joint Commission and Joint
Commission International (JCI). Surveyors use tracers to evaluate the care of an individual or to evaluate a specific care
process as part of a larger system. A surveyor reviews an individual’s record and follows the specific care processes the individual experienced by observing and talking with staff
members in areas where the individual received care. This
methodology provides the surveyor with an opportunity to assess the organization’s systems for providing care and services
and its compliance with accreditation requirements. This
book, part of a series that focuses on familiarizing health care
staff with tracer methodology, can help an organization learn
to conduct simulated—or mock—tracers that mimic actual
tracers. The mock tracer is conducted by someone in the organization who performs the role of an actual surveyor.
Benefits of Understanding Tracers
Health care organizations that educate staff about tracers will
have a better understanding of the overall survey process, especially since an on-site surveyor can typically devote up to 60%
of his or her time conducting tracers. In addition, an organization that understands tracers can use mock tracers as a tool to
assess its compliance with standards and make improvements
before a surveyor arrives. For example, if an organization wants
to analyze how well a specific aspect of a system on a specific
unit functions—such as the security in the neonatal intensive
care unit of a hospital—it can conduct a mock tracer of that
system. Although its purpose would be to learn more about
how systems function in that particular unit, a mock tracer
would also provide important information that could identify
broader issues for improvement.
Types of Tracers
Surveyors currently conduct three types of tracers:
• Individual: An individual tracer follows the actual experience of an individual who received care, treatment, or services in a health care organization (that is, a patient, a
resident, or an individual served). To select individuals to
trace in U.S. health care organizations, surveyors take into
account an organization’s clinical/service groups (CSGs)
and its top priority focus areas (PFAs) identified through
The Joint Commission’s Priority Focus Process. The CSGs
categorize care recipients and selected services into distinct
populations for which data can be collected. PFAs are
processes, systems, or structures in a health care organization that significantly impact safety and/or the quality of
care provided (see Appendix A). The organization’s specific
CSGs and PFAs inform the choice of what types of areas,
units, services, departments, programs, or homes to visit
initially to conduct an individual tracer; the CSGs, in turn,
help the surveyor select an individual to trace. Although information from the Priority Focus Process may help surveyors select the first individuals and areas to trace, a surveyor
may trace the experience of additional care recipients based
on the initial findings during the on-site survey.
• System based: A surveyor may use a system-based tracer to
analyze a high-risk process or system across an entire
organization to evaluate how and how well that system
functions. Currently, there are three topics explored during
the on-site survey using the system tracer approach: medication management, infection control, and data management. To analyze a medication management or infection
control system, a surveyor can follow an individual’s actual
1
care experience through the organization and assess how
well that particular system functioned related to that individual’s care. But to analyze a data management system, the
surveyor conducts a group meeting session and focuses on
assessing an organization’s use of data in improving safety
and quality of care. The goal of a data management system
tracer is to learn about an organization’s performance improvement process, including the organization, control, and
use of data. There is no individual care recipient to follow;
however, data from performance improvement are used and
evaluated during the course of individual tracers throughout a survey.
• Program specific: A surveyor may use a program-specific
tracer to analyze the unique characteristics and relevant issues of a specific type of organization. The goal of this type
of tracer is to identify safety concerns in different levels
and types of care. For example, a patient flow tracer is a
program-specific tracer used in hospitals, whereas a continuity of care tracer is a program-specific tracer used in an
ambulatory care organization.
A survey may also include an environment of care (EC)
tracer. Like a system tracer, this type of tracer examines organizational systems and processes—in this case, systems related
to the physical environment.
Second Generation Tracers
During any type of tracer, a surveyor may see something involving a high-risk area that requires a more in-depth look. At
that point, the surveyor may decide to conduct a second generation tracer, which is a deep and detailed exploration of a
particular area, process, or subject. These types of tracers are a
natural evolution of the existing tracer process.
The following are high-risk topics in hospitals and critical access hospitals that surveyors might explore in more detail using
a second generation tracer approach: cleaning, disinfection,
and sterilization (CDS); patient flow across care continuum;
contracted services; diagnostic imaging; and ongoing professional practice evaluation (OPPE)/focused professional practice evaluation (FPPE).
Future second generation tracers will include clinical/health
information systems and therapeutic radiation. Additional
areas could be developed as they are identified.
2
Tracers Used Internationally
Tracer methodology is being used to assess health care orga-nizations beyond the United States. Health care organizations that
undergo JCI accreditation also experience tracer methodology
when surveyors visit their facilities. The concept is essentially the
same for both domestic and international organizations; however, there are slight differences. Whereas U.S. surveyors use
such elements as PFAs and CSGs to select care recipients to
trace, these criteria do not apply to international surveys. JCI
surveyors use information provided in the organization’s accreditation survey application to select tracer subjects from an active
care recipient list. Subjects typically selected are those who have
received multiple or complex services because they, most likely,
have had more contact with various departments of the organization, providing a greater opportunity for the surveyor to assess
how systems work in the organization. Furthermore, programspecific tracers are done as part of “undetermined survey activity” appropriate to an organization, as defined in the JCI Survey
Process Guide. Also, international organizations refer to the EC
tracers as “facility management and safety” tracers and to data
management system tracers as “improvement in quality and patient safety” tracers.
Conducting Mock Tracers
The best way to understand all types of tracers is through practice—that is, through conducting mock tracers. This involves
developing some basic skills, such as learning how to ask good
questions. An actual tracer is not performed by one person in
isolation. It involves talking with multiple staff members and,
in the case of individual tracers and some system tracers, the
care recipient and even family members (if possible) to learn
details about an individual’s health care experience or how a
particular system functions in an organization. All important
details about the individual’s care or the system’s function can
be explored by asking simple questions in succession. And how
a question is asked is particularly important. A surveyor poses
questions in a manner that encourages the staff member or
care recipient to share as much information as possible. Observation of the surroundings or attention to how a respondent
answers one question can lead to other related issues and can
trigger additional questions.
Skills in analysis and organization are also involved, particularly in planning a mock tracer, and of course, analysis is nec-
Introduction
essary to evaluate and prioritize the results of a mock tracer.
Similar skills are involved in the reporting of the results and in
the follow-up on any consequent plans for improvement based
on the results. Often, an organization will institute a mock
tracer program that will train participants for optimum outcomes to these practice tracers. The benefits that result from
mock tracers support and enhance the continuation of such
teams.
How to Use This Book
Even More Mock Tracers is designed to help staff members in all
health care settings better understand how the different types
of tracers work and how to conduct mock tracers:
• “How to Conduct a Mock Tracer” follows this Introduction. It provides step-by-step instruction on performing a
mock tracer.
• The “Tracer Scenario Grid” on pages 15–16 lists some key
topics that are addressed throughout this workbook. It can
be used to quickly locate mock tracers that feature these
topics.
• Each section of this workbook includes example tracers,
called scenarios, that are specific to a type of health care setting (such as home care and behavioral health care).
• Each scenario is preceded by a list of the PFAs that emerge
during the scenario. For scenarios in an international setting, this summary also explains the criteria for the tracer
subject selection. Then, a narrative describes how a surveyor
might analyze a particular system or use an individual’s
record as a road map through the organization.
• Sample tracer questions follow each scenario. They show
the types of questions a surveyor might ask staff members
or other individuals for the specific scenario. These questions are keyed to the narrative to show how and when they
might occur during the scenario.
• Each section also includes an example of a tracer worksheet
that utilizes the sample tracer questions from one scenario
and shows how the worksheet might be completed during
mock tracer activities.
• Appendixes describe the PFAs and provide forms that are
helpful in developing a mock tracer program.
Terms Used in This Book
This publication is divided into sections that are health care
setting–specific, so each section will use terminology appropriate for its setting. For example, patient will be used for hospital, ambulatory care, and home care settings; individual will be
used for behavioral care settings; and resident will be used for
long term care settings. The term health care in this workbook
refers to all types of care, treatment, or services provided
within the spectrum of the health care field, including physical, medical, and behavioral health care.
Acknowledgments
Joint Commission Resources (JCR) is grateful to the multiple
reviewers and content experts for their feedback to ensure that
the overall content about tracers is accurate and relevant to the
numerous health care settings. A special thank you is extended
to Dana Dunn, RN, MBA, CNOR, CASC, Surveyor, Ambulatory Health Care Accreditation, The Joint Commission; Ann
Fonville, RN, MPH, EdD; Cheryl S. Frenkel, RN, MS, GNP,
LNHA; Virginia Maripolsky, MSW, RN, Assistant CEO,
Nursing Affairs, Bangkok Hospital, Bangkok, Thailand;
Aneita Paiano, MBS, MT (ASCP), Surveyor, Laboratory Program, The Joint Commission; Genie Skypek, PhD, Surveyor,
Behavioral Health Care Accreditation, The Joint Commission;
David Sladewski, LSCS, MS, CHSP, CPM, Surveyor and Life
Safety Code® Specialist, The Joint Commission; and Joyce
Whitten, RN, MSN, Surveyor, Home Care Accreditation Program, The Joint Commission. We also extend our gratitude to
writer Julie Chyna for her dedication and diligence in writing
this book.
3
4
How to Conduct a Mock Tracer
The main activity during a Joint Commission
or Joint Commission International (JCI) survey
of any type of health care organization is the
tracer (see the sidebar “Tracers at a Glance,” at
right). A mock tracer is a practice tracer meant
to simulate an actual tracer. During a mock
tracer, one or more people may play the role of
a surveyor. Some organizations develop teams of
such “surveyors” and repeatedly conduct mock
tracers as part of an ongoing mock tracer
program.
Tracers at a Glance
Duration: A Joint Commission individual tracer (see
“Individual tracers” on page 6) is scheduled to take 60 to
90 minutes but may take several hours. During a typical
three-day survey, a surveyor or survey team may
complete several tracers; during a single-day survey, it
may be possible to complete only one or two tracers.
Tracers constitute about 60% of the survey.
Survey team: A typical Joint Commission survey team
includes one or more surveyors with expertise in the
Mock tracers are done for several reasons:
• To evaluate the effectiveness of an organization’s policies and procedures
• To engage staff in looking for opportunities
to improve processes
• To be certain the organization has addressed
compliance issues and is ready for survey at
any time
organization’s accreditation program. For domestic (not
international) hospitals and critical access hospitals, a
Life Safety Code®* Specialist is also part of the team. A
team leader is assigned for any survey with more than
one surveyor. A surveyor typically conducts a tracer on
his or her own and later meets up with the rest of the
team to discuss findings.
Tracer activity: During tracer activity, surveyors evaluate
What follows is a 10-step primer for how to
conduct a mock tracer. It addresses the process
in four phases:
• Planning and preparing for the mock tracer
• Conducting and evaluating the mock tracer
• Analyzing and reporting the results of the
mock tracer
• Applying the results of the mock tracer
Each step within these phases includes suggested approaches and activities. You might
want to use the “Mock Tracer Checklist and
Timeline” on page 7 to guide you through the
phases. The primer also explains how to use the
scenarios, sample worksheets, and appendixes in
this workbook to conduct mock tracers. Note
that the primer can be modified to suit any
health care organization.
the following:
• Compliance with Joint Commission standards and
National Patient Safety Goals and,
JCI
for
international organizations, JCI standards and
International Patient Safety Goals
• Consistent adherence to organization policy and
consistent implementation of procedures
• Communication within and between
departments/programs/services
• Staff competency for assignments and workload
capacity
• The physical environment as it relates to the safety of
care recipients, visitors, and staff
(continued)
* Life Safety Code is a registered trademark of the National Fire
Protection Association, Quincy, MA.
5
Tracers at a Glance (continued)
Environment of care tracers: Although the environment
of care (EC) tracer is not one of the defined Joint
Range of observation: During a tracer, the surveyor(s)
Commission system tracers, it is similar to those types of
may visit (and revisit) any department/program/service
tracers. Like system tracers, EC tracers examine
or area of the organization related to the care of the
organization systems and processes—in this case,
individual served or to the functioning of a system.
systems related to the physical environment, emergency
management, and life safety. Also, like system tracers, an
Individual tracers: Individual (patient) tracer activity
EC tracer is often triggered by something observed
usually includes observing care, treatment, or services
during an individual tracer, as surveyors notice
and associated processes; reviewing open or closed
environmental-, emergency management–, and life
medical records related to the care recipient’s care,
safety–based risks associated with a care recipient and
treatment, or services and other processes, as well as
the staff providing care, treatment, or services to that
examining other documents; and interviewing staff as
person. A surveyor may also be assigned to do an EC
well as care recipients and their families. An individual
tracer as part of a comprehensive survey process.
tracer follows (traces) one care recipient throughout his
Note that EC tracers are performed only in facility-based
or her care in the organization.
accreditation programs and do not apply to community-
System tracers: A system tracer relates to a high-risk
system or the processes that make up that system in an
organization. Currently, three topics are explored during
the on-site survey using the system tracer approach:
based programs and services, such as those provided by
some behavioral health care accreditation programs.
JCI
For international organizations, EC is referred to as
“facility management and safety.”
medication management, infection control, and data
Second generation tracers: A surveyor may see
management. The data management system tracer is
something during a tracer involving select high-risk areas
the only tracer that is routinely scheduled to occur on
that requires a more in-depth look. At that point, the
regular surveys for most organizations; it may include
surveyor may decide to conduct a second generation
evaluation of data for medication management and
tracer, which is a deep and detailed exploration of a
infection control, as well. Other system tracers take
particular area, process, or subject.
place based on the duration of the on-site survey; the
type of care, treatment, or services provided by the
organization; and the organization’s accreditation
history. Lab accreditation programs do not have system
tracers.
JCI
In international organizations, data system
tracers are called “improvement in quality and patient
safety” tracers and are not individual based.
Planning and Preparing for the
Mock Tracer
Program-specific tracers: These are tracers that
focus on topics pertinent to a particular accreditation
program and the associated care, treatment, or service
processes. These processes are explored through the
experience of a care recipient who has needed or may
have a future need for the organization’s care,
treatment, or services. Examples include patient flow in
a hospital or suicide prevention at a residential
program. Lab accreditation programs do not have
program-specific tracers.
6
Step 1: Establish a Schedule for the Mock
Tracer
Careful planning is necessary for any successful activity, including a mock tracer. Consider the following when establishing a schedule for mock tracers in your organization:
• Schedule by phase: Allow adequate time for each phase of a
mock tracer. The focus of each phase outlined in this
primer is shown in the checklist “Mock Tracer Checklist
and Timeline” (see page 7) with suggested time frames,
some of which may overlap. Suggested approaches and activities for each phase comprise the remainder of this
primer.
✔ Mock Tracer Checklist and Timeline
✔
✔
✔
✔
Planning and Preparing for the Mock Tracer
Step 1: Establish a Schedule for the Mock Tracer
Month 1
Step 2: Determine the Scope of the Mock Tracer
Month 1
Step 3: Choose Those Playing the Roles of Surveyors
Month 1
Step 4: Train Those Playing the Roles of Surveyors
Months 1 and 2
Conducting and Evaluating the Mock Tracer
Step 5: Assign the Mock Tracer
Month 2
Step 6: Conduct the Mock Tracer
Month 3
Step 7: Debrief About the Mock Tracer Process
Month 3
Analyzing and Reporting the Results of the Mock Tracer
Step 8: Organize and Analyze the Results of the Mock Tracer
Month 4
Step 9: Report the Results of the Mock Tracer
Month 4
Applying the Results of the Mock Tracer
Step 10: Develop and Implement Improvement Plans
Months 5–7
Note: To follow up on findings and sustain the gains, periodically repeat mock tracers on the same subjects.
• Make it part of your regular PI program: Make mock
tracers part of your ongoing performance improvement (PI)
program. Schedule mock tracers for different departments/programs/services several times a year.
• Share the plan with everyone: Let everyone in your organization know about the mock tracers being planned. No
set dates need to be given if the mock tracers are to be
unannounced, but communication about planned and ongoing mock tracers is necessary for recruitment of those
who will play the roles of surveyors and for cooperation
from all departments/programs/services.
• Understand the Joint Commission survey agenda: A mock
tracer typically simulates only the tracer portion of a survey,
which constitutes the foundation of the survey. By understanding the survey activities, however, those who are play-
ing the roles of surveyors can better simulate tracers to help
your organization prepare for a survey. Joint Commission
surveys follow a tight agenda. Check the Survey Activity
Guide (SAG) for your accreditation program(s). The guide
outlines what happens in each survey activity. All accreditation program SAGs are posted on the Web site for The Joint
Commission. They are also available on your Joint Commission Connect™ extranet site if yours is an accredited health
care organization or an organization seeking Joint Commission accreditation. JCI International organizations should
consult the International Survey Process Guide (SPG), which
is sent to applicants seeking international accreditation and
is also available to order on the JCI Web site.
• Relate it to the date of the last survey: Joint Commission
surveys are typically conducted on a regular, triennial basis.
For most accredited organizations, the survey will occur
7
within 18 to 36 months after an organization’s last survey, although laboratory surveys and certification program reviews
are on a two-year cycle. With the exception of critical access
hospitals and office-based surgery practices, organizations accredited by The Joint Commission must conduct Periodic
Performance Reviews (PPRs) between full surveys.* The PPR
is a management tool that helps the organization incorporate
Joint Commission standards as part of routine operations and
ongoing quality improvement efforts, supporting a continuous accreditation process. A mock tracer can help by giving
the organization more insight into compliance issues. Conducting the mock tracer before a survey date allows time to
address compliance issues prior to the PPR deadline; conducting a mock tracer shortly after the last survey is helpful for assessing compliance with problems highlighted in that recent
survey. Note that the PPR is not applicable to the Medicare/
Medicaid certification–based long term care accreditation program. JCI For international organizations, the survey will
occur within 45 days before or after the accreditation expiration date. International certification programs are on a threeyear review cycle. Also, although international organizations
are not required to complete PPRs, JCI recommends that organizations do a self-assessment of compliance between surveys. (International certification programs have a required
intra-cycle review process.)
Step 2: Determine the Scope of the Mock Tracer
Assess your organization to determine where to focus attention.
By listing problems and issues in your organization, the scope of
the mock tracer—whether comprehensive or limited—will become clear. One or more of the following approaches may be
used to determine a mock tracer’s scope:
• Imitate the Priority Focus Process: The Priority Focus
Process (PFP) provides a summary of the top clinical/service
groups (CSGs) and priority focus areas (PFAs) for an organization. The CSGs categorize care recipients and/or services
into distinct populations for which data can be collected.
The PFAs are processes, systems, or structures in a health
care organization that significantly impact safety and/or the
quality of care provided (see Appendix A). The PFP is accessible on the Joint Commission Connect site for domestic organizations and provides organizations with the same
information that surveyors have when they conduct on-site
evaluations. Address all or some of the areas generated in
that report. JCI International organizations do not have
PFPs; however, it may be helpful and important to look at
your last survey results and target areas of greatest concern.
*The Joint Commission’s intracycle monitoring process will be changing in 2013.
Please see “The Accreditation Process” (ACC) chapter in the 2013 comprehensive
accreditation manuals for more information.
8
• Reflect your organization: Start with your organization’s
mission, scope of care, range of treatment or services, and
population(s) served. Choose representative tracers that
support and define your organization. You might want to
use an assessment tool, such as the Comprehensive Originization Assessment, to gather this data. (See Appendix C).
• Target the top compliance issues: Review the Joint Commission’s top 10 standards compliance issues, published regularly
in The Joint Commission Perspectives® (available for subscription and provided free to all accredited organizations). Also
check any issues highlighted in Sentinel Event Alerts, which
are available on the Joint Commission Web site, at
http://www.jointcommission.org/sentinel_event.aspx. Address
compliance issues that are also problem prone in your organization. Be especially mindful to note if any of these top compliance issues have been noted in current or past PPRs. JCI
International organizations can request top compliance issues
from this address: [email protected].
• Review what is new: Address any new Joint Commission
or JCI standards that relate to your organization. New standards and requirements are highlighted in the binder version (although not in the spiral-bound book version) of the
most recent update of the Comprehensive Accreditation
Manual for your program. Also focus on any new equipment or new programs or services in your organization.
Consider mock tracers that will allow opportunities to evaluate newly implemented or controversial or problematic organization policies and procedures and how consistently
they are being followed.
• Start with the subject: Look at typical tracers from any
past surveys and choose several common or relevant examples for the types of tracers defined in the Introduction to
this workbook. Or, if your organization has never had a survey, consider the guidelines described in the sidebar
“Choosing Tracer Subjects” on pages 9–10.
• Cover the highs and lows: Focus on high-volume/high-risk
and low-volume/high-risk areas and activities. Ask questions about demographics for those areas or activities to
help determine whether care, treatment, or services are targeted to a particular age group or diagnostic/condition category. Then pick corresponding tracer subjects.
• Target time-sensitive tasks: Look at time-sensitive tasks,
such frequency of staff performance evaluations, critical result reporting, and the signing, dating, and timing of physi-
cian orders, including whether they are present and complete. These are often challenging compliance areas.
• Examine vulnerable population(s): Review the risks in serving particularly vulnerable, fragile, or unstable populations in
your organization. Select tracer subjects (care recipients, systems, or processes) that might reveal possible failing outcomes. Address related processes of care, treatment, or services
that are investigational, new, or otherwise especially risky.
Choosing Tracer Subjects
Individual tracers: For individual mock tracers, adopt
the way actual surveyors choose care recipients. In
U.S. health care organizations, select them based on
criteria such as (1) whether they are from the top
CSGs in the PFP; (2) whether their experience of
care, treatment, or services allows the surveyor to
Step 3: Choose Those Playing the Roles of
Surveyors
access as many areas of the organization as possible;
If your goal is to conduct more than one mock tracer, either
concurrently or sequentially, you will want to develop a mock
tracer team. Careful selection of those playing the roles of surveyors is critical. A general guide for a mock tracer team is to
follow the number and configuration of your last Joint Commission or JCI survey team (see the sidebar “Tracers at a
Glance” on pages 5–6). However, you might want to involve
more people or have multiple mock tracer teams; try to allow as
many people as possible to be exposed to the tracer process and
to learn more about the surveyors’ angle on the process. If your
organization has not had a survey yet, aim for five to eight team
members, or select one team member for each department/program/service in your organization plus one for each type of system tracer and one for the EC. Consider the following when
choosing those who will play the roles of surveyors:
• Include administrators: Administrators, managers, and
other leadership should be not only supportive of mock tracers but also involved. Include at least one administrator or
manager on the team. Include executive-level leaders in the
early stages to provide input and model team leadership.
Also, staff may need time off from their regular duties to
participate in various phases of a mock tracer, so team members should be sure to get the approval of their managers.
accreditation program–specific tracer topic areas; or
(3) whether they qualify under the criteria for any
(4) whether they move between and receive care,
treatment, or services in multiple programs, sites, or
levels of care within your organization. Also, consider
tracing care recipients who have been recently
admitted or who are due for discharge.
JCI
In
international organizations, use information provided
in your organization’s accreditation survey application
to select tracer care recipients from an active list that
shows who has received multiple or complex services.
System tracers: Care recipients selected for tracing a
system typically reflect those who present
opportunities to explore both the routine processes
and potential challenges to the system. For example,
to evaluate medication management systems, select
care recipients who have complex medication
regimens, who are receiving high-alert medications, or
who have had an adverse drug reaction. To evaluate
infection control, select someone who is isolated or
who is under contact precautions due to an existing
infection or compromised immunity. These same care
recipients could be the subjects for data management
system tracers, as each might be included in
• Select quality-focused communicators: Sharp, focused professionals with excellent communication skills are needed to
play the roles of surveyors. Recruit people who are observant, detail oriented, and committed to quality and professionalism. Those playing the roles of surveyors should be
articulate, polite, personable, and able to write clearly and
succinctly. They should be comfortable talking to frontline
staff, administrators, and care recipients and families.
performance measurement activities such as infection
control surveillance or adverse drug-reaction
monitoring data.
JCI
In international organizations,
data system tracers are called “improvement in quality
and patient safety” tracers and are not individual
based.
Program-specific tracers: The focus for these
tracers may include programs such as foster care,
• Draw from committees: Often the best choices for those who
will play the roles of surveyors have already been identified
and serve on various committees in your organization. Draw
from committee members to find top-notch candidates.
patient flow, continuity of care, fall reduction, and
suicide prevention. For example, to evaluate a
(continued)
9
Choosing Tracer Subjects (continued)
falls reduction program in a long term care facility, you
would select a resident identified as being at risk for
falls to trace components of the program, such as care
recipient education, risk assessment, and falls data.
Environment of care tracers: Subjects for an EC
mock tracer may include systems and processes for
safety, security, hazardous materials and waste, fire
safety, utilities, and medical equipment. For example,
an EC mock tracer might examine the security in the
neonatal intensive care unit, the safety of hazardous
materials that enter through the loading dock, or the
installation of and maintenance for new medical
equipment. Be sure also to include emergency
management and life safety issues as topics for mock
tracers.
JCI
In international organizations, EC is
referred to as “facility management and safety.”
Second generation tracers: Subjects for second
generation tracers grow naturally out of tracers
involving high-risk areas because this type of tracer is
a deeper and more detailed exploration of the tracer
subject. Areas subject to second generation tracers
include cleaning, disinfection, and sterilization (CDS);
patient flow across care continuum; contracted
services; diagnostic imaging; and ongoing
professional practice evaluation (OPPE)/focused
professional practice evaluation (FPPE).
• Don’t forget physicians: Because they are a critical part of
any health care organization, physicians should be involved
in mock tracers—and not always just as interview subjects.
Recruit physicians to perform the roles of surveyors. This
angle of participation will not only allow them to apply
their expertise and experience but will also allow them to
add to that expertise and experience.
• Draft from HR, IM, and other departments or services:
Those playing the roles of surveyors may also be drafted
from among the staff and managers of nonclinical departments, including human resources (HR) and information
management (IM). Housekeeping and maintenance staff
are often valuable as “surveyors” for their unique perspective of daily operations.
10
Step 4: Train Those Playing the Roles of
Surveyors
All staff trained to portray surveyors need to have both an
overview and more detailed knowledge of tracers as part of
their training. Even those who have been through a survey
need training to play the role of a surveyor. Those who will be
acting as surveyors should do the following as part of their
training:
• Get an overview: Take some time to learn the basics of
tracers. The Introduction to this workbook provides a good
overview. As a next step, read the Survey Activity Guide for
your program, which is posted on the Web site for The
Joint Commission and on Joint Commission Connect. The
guide explains what surveyors do in each part of the different types of tracers. JCI The JCI Survey Process Guides are
provided to international organizations applying for accreditation and are also for sale on the JCI Web site.
• Learn the standards: Challenging as it may be, it is essential
that those who are playing surveyors become familiar with
current Joint Commission requirements related to the targeted tracer. They must gain a solid understanding of the related standards, National Patient Safety Goals, and
Accreditation Participation Requirements. To learn about
changes and updates to Joint Commission standards and how
to interpret and apply them, they should read the monthly
newsletter Joint Commission Perspectives (available for subscription and provided free to all domestic accredited organizations). Be particularly careful to give those who are playing
surveyors sufficient time to learn the standards for the department or area in which they will conduct a mock tracer. At
least one month is advised (see the sidebar “Mock Tracer
Checklist and Timeline” on page 7). JCI International organizations should be familiar with JCI standards and International Patient Safety Goals, as outlined in the current relevant
JCI accreditation manual. Updates, tips, and more are provided free via the online periodical JCInsight.
• Welcome experience: Staff and leaders who have been
through a tracer can be valuable resources. Invite them to
speak to the tracer team about their experiences with tracers
and with surveys in general.
• Examine closed medical records: Closed medical records
are an excellent practice tool for individual tracers and individual-based system tracers. Examine closed (but recent)
records and then brainstorm the types of observations, document review, and questions that a surveyor might use to
trace the subject of the record.
• Study mock tracer scenarios: Tracer scenarios, like those
in this workbook, will help familiarize team members
with the general flow of a tracer as well as the specific and
unique nature of most tracers. The questions that follow
each tracer scenario in this workbook can be used to populate a form for a mock tracer on a similar subject in your
organization (see Appendix B). The sample tracer worksheet at the end of each section in this workbook provides a model for how someone playing the role of a
surveyor might complete a worksheet based on such questions. JCI Note that scenarios with international content
appear in the final section of the workbook, but issues
addressed in scenarios for domestic settings may be transferable to international settings.
Interviewing Techniques
• Take your time. Speak slowly and carefully.
• To help set the interview subject at ease, try
mirroring: Adjust your volume, tone, and pace to
match those of the person to whom you are
speaking. (If the subject is nervous or defensive,
however, use a quiet and calm approach to
encourage that person to match your example.)
• Use “I” statements (“I think,” “I see”) to avoid
appearing to challenge or blame the interview
subject.
• Ask open-ended questions (to avoid “yes/no”
• Practice interviewing: Since a large part of a tracer is spent
in conversation, people who are filling the roles of surveyors
should practice interviewing each other. Although these
people should already be good communicators, a review of
common interview techniques may be helpful (see the sidebar “Interviewing Techniques” at right).
answers).
• Pause before responding to a subject’s answer to
wait for more information.
• Listen attentively, gesturing to show you
understand.
• Listen actively, restating the subject’s words as
necessary for clarification.
Conducting and Evaluating the
Mock Tracer
Step 5: Assign the Mock Tracer
A mock tracer team may have one member play the roles of
surveyor in a specific mock tracer, or the team members may
take turns playing the role during the tracer. With repeated
mock tracers, every team member should have the opportunity to play a surveyor. Consider these options when assigning role-playing surveyors to mock tracers:
• Match the expert to the subject: Match a “surveyor”
who is an expert in a department/program/service to a
mock tracer for a similar department/program/service—
but for objectivity, do not assign them to the same
specific department/program/service in which they work.
• Mismatch the expert to the subject: Match a “surveyor”
to a department/program/service that is new to him or
her. This may enhance the objective perspective. Of
course, that person will have to prepare in advance to
become familiar with the requirements for that new
department/program/service.
• Pair up or monitor: Pair “surveyors” so they can learn
from and support each other, or allow one “surveyor” to
follow and monitor the other for additional experience.
• Manage your reactions to difficult situations and
avoid using a confrontational tone, even if your
subject sets such a tone. Take a deep breath and
wait at least three seconds before responding.
• Always thank your interview subject for his or her
time and information.
One of those in the pair might be the mock tracer team
leader.
Step 6: Conduct the Mock Tracer
All departments/programs/services in your organization should
already have been notified about the possibility of staff conducting mock tracers. Unless mock tracers are announced,
however, there is no need to notify interview subjects when the
tracer is scheduled to occur. During the mock tracer, team
members should do the following:
• Collect data: Like real surveyors, those playing the roles
of surveyors must collect data that help to establish
whether your organization is in compliance with applicable accreditation requirements. They should do this by
taking notes on their observations, conversations, and review of documents. Notes may be entered on an electronic form (using a laptop computer) or on a paper
form.
11
• Be methodical and detail oriented: To help establish
and simulate an actual tracer, those portraying surveyors
should strive to be as methodical and detail oriented as
actual surveyors. The following techniques may be useful:
◦ Map a route through the mock tracer, showing who
will be interviewed in each area. It is helpful to interview the person who actually performed the function
targeted by the tracer, but any person who performs
the same function can be interviewed.
◦ Identify who will be interviewed in each area, using
specific names (if staffing schedules are available) or
general staff titles. For example, if you have singled
out a particular care recipient to trace, identify which
staff members cared for that care recipient. Of course,
this may not be possible to do because staff to be interviewed may depend on what is found in the targeted area, where the care recipient travels within the
organization, and what procedures are performed.
◦ Note the approximate amount of time to be spent in
each department/program/service. That will help keep
the tracer on schedule. Notwithstanding any tentative
scheduling of the tracer, however, you may uncover
unexpected findings that will necessitate either spending more time in a particular location or going to locations that were unforeseen at the time the tracer
started. Flexibility is a key attribute of a good surveyor
doing tracers.
◦ Take notes on a form, worksheet, or chart developed
by the team for the purpose of the mock tracer. (The
mock tracer worksheet form in Appendix B can be
used for this purpose.)
◦ Surveyors are directed to be observant about EC issues. Some EC issues may be photographed for the
record, provided that no care recipients are included in
the photos.
• Share the purpose: Whenever possible, remind tracer interview subjects of the purpose of tracers and mock tracers: to learn how well a process or system is functioning
(not to punish a particular staff member or department/
program/service).
• Maintain focus: Keep the process on track and continually
make connections to the broader issues affecting care recipient safety and delivery of care, treatment, or services.
12
• Be flexible and productive: If a person playing the role
of a surveyor arrives in an area and has to wait for a particular interview subject, that time can be filled productively by interviewing other staff and making relevant
observations and notes. If more than one mock tracer is
scheduled for the same day—as in a real survey—“surveyors” may cross paths in an area. One “surveyor” should
leave and return at a later time.
• Address tracer problems: Be prepared to identify and
address any problems with the mock tracer process encountered during the mock tracer, including practical
arrangements (such as the logistics of finding appropriate staff ), department/program/service cooperation,
team dynamics, and staying on schedule. Decide in advance whether to address such problems in an ad hoc
fashion (as they are encountered) or as part of a debriefing after the mock tracer to prepare for subsequent mock
tracers.
Step 7: Debrief About the Mock Tracer
Process
After each mock tracer, and particularly after the first few,
meet as a team as soon as possible to evaluate and document
how it went. (Note: This debriefing session should focus on
the mock tracer process, not what the mock tracer revealed
about your organization’s problems or issues. That will be
done in Step 8: “Organize and Analyze the Results of the
Mock Tracer”; see page 13.) You may choose to use one of
the following approaches:
• Hold an open forum: An open forum should allow all
team members to discuss anything about the tracer, such
as methods, logistics, and conflict resolution. For a
broader perspective, invite interview subjects from the
mock tracer to participate.
• Let each member present: In a direct, focused approach,
team members can present their feedback to the rest of
the team, one at a time. Each person playing the role of a
surveyor can be given a set amount of time to present,
with questions to follow at the end of each presentation.
• Fill out a feedback form: Team members and mock
tracer participants can complete a feedback form in
which they record their impressions of the mock tracer
and suggestions for improvement of the process. These
can be vetted and then discussed at the next team meeting to plan for the next mock tracer.
Analyzing and Reporting the
Results of the Mock Tracer
Step 8: Organize and Analyze the Results of
the Mock Tracer
Conducting a mock tracer is not enough; the information
gained from it must be organized and analyzed. The problems and issues revealed in the mock tracer must be reviewed, ranked, and prioritized. You might want to use one
or more of the following suggested methods to do this:
• File the forms: If the mock tracer team used forms—
either electronic or paper (such as the form in Appendix
B), those can be categorized for review. The forms might
be categorized by types of problems/issues or by department/program/service.
• Preview the data: Those who played the roles of surveyors should be the first to review the data (notes) they collected during the mock tracer. They should check for and
correct errors in the recording of information and highlight what they consider to be issues of special concern.
• Rank and prioritize the problems: The team, led by the
team leader, must carefully evaluate all of the team’s data.
Critical issues or trends can be identified and then ranked
by severity/urgency with regard to threats to life or safety,
standards noncompliance, and violations of other policies. Prioritizing is the next step and will require considerations such as the following:
◦ What is the threat to health or safety? What is the degree of threat posed by the problem—immediate, possible, or remote?
◦ What is the compliance level? Is the problem completely out of compliance? That is, does the problem
relate to a standard that always requires full compliance (that is, Category A standards) or one for which
you may be scored partially compliant or insufficiently
compliant (that is, Category C standards)?
◦ What resources are required? How much staff time
and resources will likely be needed to correct the problem? Depending on the threat to health or safety and
compliance level, there may be a time limit imposed
on how soon the problem must be corrected (for example, immediately or within 45 or 60 days).
Step 9: Report the Results of the Mock Tracer
An organization’s reaction to a mock tracer will depend largely
on the results of the mock tracer, including how—and how
well—the results are reported. In all reports, it is important to
avoid having the tracer appear punitive or like an inspection,
so do not include staff names or other identifying information.
Following are several ways to report results effectively:
• Publish a formal report: Compile all documents and carefully edit them. Determine which documents most clearly
summarize the issues. Submit a copy of the report to the
appropriate leadership.
• Present as a panel: Invite leadership to a panel presentation in which team members present the results of the
tracer—by department/program/service or by other
arrangement (for example, problems with staffing, infection
control, handoff communication, or transitions in care,
treatment, or services).
• Call a conference: Set up an internal conference event in
which you present the results. They could be presented on
paper, delivered by speakers from a podium, and/or delivered using audiovisual formats. Invite leadership and everyone who participated in the mock tracer. Keep the
conference brief (no more than two hours), being considerate of attendees’ time. Make the content easier to digest by
color-coding the level of priority and using other keys to
signal the types of problems and their severity. Open up the
conference to feedback with breakout brainstorming sessions on how to address the problems.
• Post for feedback: Post the results on a secure organization intranet and ask for feedback and suggestions from participants
and others in your organization. A bulletin board in the
lunchroom works, too. After a week, remove the report and
incorporate any new information to present to leadership.
• Report in a timely way: One goal of a mock tracer is survey
preparedness via standards compliance, so addressing problems before a survey is vital. All reports should therefore be
made within one month after completion of a mock tracer
to allow plenty of time to correct compliance problems.
• Accentuate the positive: Remember to pass on positive
feedback that comes to light during the mock tracer and
data analysis. To encourage continued success as well as future positive interactions with the mock tracer process, reward or acknowledge departments and individuals that
participate or are especially cooperative and responsive.
13
Applying the Results of the Mock
Tracer
Step 10: Develop and Implement
Improvement Plans
Your reports should indicate which problems must be addressed immediately and which can wait, which require
minimal effort to correct and which require extensive effort.
Employ one or more of the following improvement plan approaches to help address corrective actions:
• Hand off to managers: Hand off any easily addressed
corrective actions that are particular to one department/
program/service to the relevant managers. Inform them
of your estimates of time and resources necessary to address the problem. Offer to work with them on more
complex corrective actions. Offer to repeat mock tracers
to confirm findings.
• Work with PI: Most of what will need to be done will require integration into your organization’s PI program. Follow the required approach in addressing corrective actions.
• Check your compliance measures: Be sure to check
which elements of performance (EPs) for a Joint Commission standard require a Measure of Success (MOS).
These are marked with an . At least one measure
demonstrating the effectiveness of recommended changes
should be included in the Plans of Action addressing
compliance for those EPs with an , and it must be included if the findings will be integrated into a PPR.* JCI
There is no MOS for JCI standards. Standards are Fully
*The Joint Commission’s intracycle monitoring process will be changing in 2013.
Please see “The Accreditation Process” (ACC) chapter in the 2013 comprehensive
accreditation manuals for more information.
14
Met, Partially Met, Not Met, or Not Applicable. JCI requests that a Strategic Improvement Plan (SIP) be developed by the organization for any Not Met standard(s)/
measurable element(s) and/or International Patient Safety
Goal(s) cited in the survey report when the organization
meets the conditions for accreditation. International organizations do not complete PPRs. (See the discussion of
PPRs in “Relate It to the Date of the Last Survey,” under
“Step 1: Establish a Schedule for the Mock Tracer,” on
pages 7–8.)
• Share the plans: Make sure the entire organization is
aware of the corrective actions proposed as a result of the
mock tracer. Cooperation and support during future
mock tracers depend on awareness of their value and
follow-through. Activities and results can be shared in
internal newsletters or staff meetings.
• Monitor the plans: The mock tracer team is not responsible for completing all the corrective actions, but it is responsible for working toward that goal by monitoring any
plans based on findings from the mock tracer. Give deadlines to heads of departments/programs/services and others
involved in corrective actions (in accordance with any PI
policies). Check regularly on progress and make reports to
leadership and the PI program on progress and cooperation.
• Prepare for the next round: After a few mock tracers,
most organizations discover the exponential value of such
exercises. They then develop a mock tracer program that
allows for periodic mock tracers, sometimes with several
running at one time.
Tracer Scenario Grid by Topic
The grid on the following pages lists some of the important issues addressed in the tracer scenarios presented throughout Even
Topic
Abuse, signs and symptoms
life decisions
Communication (patient)
1-1
4-1
5-1
Discharge planning
Emergency management
responsibilities
2-6
7-1, 7-5
Equipment
5-5
4-1, 4-2, 4-5, 4-6, 4-7
6-1, 6-2, 6-4
5-1, 5-2
7-2, 7-4, 7-7
Facility safety
6-1
4-2, 4-8
7-4, 7-6
1-4
5-6
Fall prevention
2-4
7-2, 7-7
4-3, 4-6, 4-7
8-2, 8-6
1-6
3-1, 3-2, 3-8
4-3, 4-7
Hand hygiene
4-1, 4-5, 4-6, 4-8
5-4
High-risk medications
4-5, 4-8
5-3
5-2, 5-3, 5-6
1-4, 1-7, 1-8
8-1, 8-3, 8-4, 8-5, 8-6
2-4, 2-5
1-10
3-3
2-7
Infection prevention and
4-1, 4-4, 4-8
3-4, 3-6, 3-8
control
5-4
4-1, 4-5, 4-6, 4-7, 4-8
6-1
5-3, 5-5
7-8
6-1, 6-2, 6-3, 6-5
8-7
7-3
1-4
8-3, 8-7
Diagnostic imaging
4-2, 4-5
4-1, 4-6, 4-8
2-8
and privileges or clinical
5-2
1-3, 1-5, 1-9
1-1, 1-5, 1-9
Credentials, competencies,
1-1
1-10
4-3, 4-5, 4-7
Coordination of care
Scenario
8-2
3-5
Communication (staff)
Topic
Scenario
4-2
Advance directives/end-of-
More Mock Tracers. It can serve as your guide to quickly locating
mock tracers that feature a topic in which you have an interest.
1-2
2-6
Medication safety
3-5
4-2, 4-3, 4-4, 4-5, 4-8
5-3
15
Topic
Medications (storage)
Nutrition/dietary
Scenario
1-4, 1-5, 1-6, 1-8
4-5, 4-8
Education of patient or
individual served
16
2-1, 2-8
Rights and privacy of
individuals served
4-3
6-4, 6-5
5-1, 5-5
1-2, 1-4, 1-7
8-4, 8-5
2-2, 2-8
1-1, 1-4
3-1, 3-2, 3-3, 3-5
4-1, 4-2, 4-7
Safety of individuals served
4-1, 4-2, 4-3, 4-5, 4-6, 4-7, 4-8
5-1
5-3
6-1
8-1
7-3, 7-7, 7-8
1-4, 1-5
8-4, 8-5
2-2
2-3, 2-4, 2-5
4-1, 4-3, 4-5, 4-6, 4-7, 4-8
3-7
5-2
Patient flow
Scenario
4-1
2-1
Physical pain assessment
Topic
Performance improvement
4-4, 4-5
8-1, 8-3, 8-4, 8-6
5-1, 5-2
1-1, 1-5
6-4, 6-5
SECTION 1
Tracer Scenarios for
HOSPITAL AND
CRITICAL ACCESS HOSPITAL
NOTE: No Two Tracers Are the Same
Please keep in mind that each tracer is unique. There is no
way to know all of the questions that might be asked or
documents that might be reviewed during a tracer—nor
what all the responses to the questions and documents
might be. The possibilities are limitless, depending on the
tracer topic and the organization’s circumstances. These
tracer scenarios and sample questions are provided as an
educational or training tool for organization staff; they are
not scripts for real or mock tracers.
17
Section Elements
This section includes sample tracers—called scenarios—relevant to hospitals and critical access hospitals. Individual, system,
and program-specific tracers are represented. The section is organized as follows:
Scenarios: Each scenario presents what might happen when a
surveyor conducts a specific type of tracer. The scenarios are
presented in an engaging narrative format in which the reader
“follows” the surveyor through the tracer scenario. Within the
narrative are bracketed numbers that correspond to numbered
sample tracer questions following the tracer.
Sample Tracer Questions: After each scenario narrative is a list
of sample questions a surveyor might ask during that scenario.
These questions can be used to develop and conduct mock tracers
in your organization on topics similar to those covered in the
scenario.
Sample Tracer Worksheet: At the end of the section is a sample
worksheet that shows how the sample tracer questions for one
select scenario in the section might be used in a worksheet format.
The example shows how the worksheet might be completed as
part of a tracer for that scenario. A blank form of the worksheet is
available in Appendix B.
18
Section 1: Hospital and Critical Access Hospital
INDIVIDUAL
Tracer Scenario
SCENARIO 1-1.
Large Urban Hospital
Summary
In the following scenario, a surveyor traces patient flow at a
large urban hospital by following a geriatric patient who arrived in the emergency department (ED) after a fall at home.
Within the tracer, the surveyor explores issues relating to these
priority focus areas:
• Assessment & Care/Services
• Organizational Structure
• Communication
• Patient Safety
Scenario
The surveyor conducted this tracer at a large hospital in an
urban setting. The patient was an 81-year-old female, alert and
oriented, who was brought from home by ambulance and admitted to the ED after reportedly falling at home. She complained of shortness of breath and pain when drawing air into
her lungs, as well as pain in her left hip. Her vital signs indicated a slight elevation in temperature and elevated blood pressure reading 160/98.
The ED physician saw her shortly after arrival and made a tentative diagnosis of a left hip fracture and possible pneumonia.
He ordered blood work, a chest x-ray, and a pelvic and left hip
x-ray. A further physical exam revealed a decubitus ulcer on
her left elbow and some healing bruises on her torso.
During the course of this tracer, issues raised concerning patient flow across the organization’s care continuum necessitated additional tracer activity. Thus, this scenario includes
an example of a second-generation tracer, as the surveyor
takes an in-depth look at this high-risk topic (see Introduction, page 2).
(Bracketed numbers correlate to Sample Tracer Questions on page
21.)
Examining Delays in Radiology. On review of this patient’s record, the surveyor noted that there had been a two-
hour delay in radiology to get her x-rays done. She asked the
radiology director about the cause of the delay. [1] He said
that an unusually high number of patients had been sent to radiology that day. She then asked if there was a system for prioritizing procedures in such a situation. [2] The director said
that patients who were believed to have potentially life-threatening injuries were seen first, but that was the extent of the
prioritization. The director added that backups such as this
one were becoming more common. The surveyor asked to see
a recent assessment of delays in the radiology department, and
the director said that the last one had been conducted a few
years earlier. [3]
At this point, the surveyor decided that a deeper exploration of
the organization’s processes contributing to patient flow was
merited. She continued the tracer, incorporating an in-depth
focus on any additional operational bottlenecks.
Reviewing Patient’s Injuries with the ED Physician.
Records indicated that, after the patient’s x-rays were performed, the radiologist had called his results to the ED physician. The ED physician had confirmed the diagnosis of
pneumonia and also reported several rib fractures in various
stages of healing. The physician questioned the patient about
those injuries, and noted in her chart that she had attributed
them to clumsiness.
After reading those notes, the surveyor asked the ED physician
if he had any training in recognizing signs of elder abuse and
neglect. [4] He said that the ED physicians and nurses had an
in-service about once a year that addressed the signs and symptoms of abuse in patients of all ages. He added that it mostly
focused on children and victims of spousal abuse, but that
there was a small section of the program on elder abuse.
The surveyor then asked if a family and social history had been
obtained and documented, and the physician said that it had
been done by social services. [5] She asked if the patient’s family had been notified of her ED admission. [6] The physician
replied that the emergency medical services documentation indicated that her family had called the ambulance, but no family members had come to the hospital with the patient. The
surveyor asked to see a copy of the policy and procedures for
elder abuse and neglect, but the ED staff was unable to retrieve
the documents. [7]
Due to lack of bed availability, the patient had spent the night
in the ED. The surveyor noted that the patient’s record included the plan of care developed by the ED physician and a
19
fall risk assessment. The ED nurse had also conducted a pain
assessment and re-assessment. [8–10]
Discussing the Patient’s Care with a Medical-Surgical Unit Nurse. Twelve hours after admission to the ED, the
patient had been transferred to a bed on the medical-surgical
unit. The surveyor asked to see the nursing admission record
and saw that, although it documented the various injuries and
bruising, it did not specifically note any suspicions of abuse.
[11] The surveyor asked the medical-surgical nurse about her
knowledge of elder abuse, and the nurse referenced the in-service described by the ED physician. [12, 13] The nurse said
that she would contact the social work department with suspicions of abuse, and the surveyor asked if a social worker had
visited the patient. [14] The nurse said the patient’s record indicated that the ED nurse had ordered a consultation with a
social worker, but the social worker had not yet seen the patient. When the surveyor asked to see the policy and procedures on elder abuse, the nurse was able to retrieve them on
the computer after checking with another nurse. [15]
Talking About Care Coordination with Interdisciplinary Care Providers. The surveyor met with some of the
other care providers who were involved in this patient’s care,
including an orthopedic surgeon and a respiratory therapist.
She asked them if the care was organized into a consistent
plan. [16] The providers reported that they participated in interdisciplinary rounds on some patients, such as this one. They
each recorded their patient interactions in the medical record,
which was available to the other interdisciplinary team members. [17]
For example, the orthopedic surgeon stated that this patient’s ribs and hip injuries were not a candidate for surgical
repair, and bed rest was ordered for healing. He also ordered
a physical therapy consult, which was reflected in the
record.
Observing the Discharge Process with the MedicalSurgical Nurse. The patient was scheduled to be discharged
the day of the survey, so the surveyor asked the medical-surgical nurse about the discharge plan. [18] The nurse said that
she had reviewed the discharge plan with the patient and her
family, but the social worker still needed to discuss the patient’s injuries with the family and refer them to additional
counseling services. [19] She said that the social worker had
been delayed with another patient.
20
The social worker checked with the nurse again later in the
day, and learned that the patient and family had waited an
additional two hours before the social worker was able to
meet with them. The patient had been scheduled for discharge at 11 A.M. but did not actually leave the facility until
after 1 P.M. [20]
These delays in the patient’s discharge, in addition to the
earlier delays in radiology and in the bed assignment,
prompted additional questions and “thread pulling” by the
surveyor.
Discussing Patient Flow with the Admitting Office
Manager. The surveyor met with the manager of the admitting office to discuss some of the problems she had seen related
to patient flow. She asked about admission backups in the ED,
and the manager concurred that this had indeed become a
problem in recent months. [21] The manager added that her
staff often could not find an available inpatient bed, which was
why patients admitted to the ED had to wait to go to inpatient units. The surveyor asked if there was a staff member designated as bed control coordinator, and the manager said no
such role existed at this facility. [22] Finally, the surveyor
asked if there had been any formal analyses of patient flow and
admission delays, and the manager said that she was not aware
of any. [23]
Following her discussion with the admitting office manager
and just before the Daily Briefing, the surveyor had the opportunity to talk with several members of the hospital’s leadership.
In light of what she had learned in her previous discussions
about patient flow in the organization, she used the occasion
to ask a few last pertinent questions. [24–26]
Moving Forward. Based on the tracer findings, the surveyor may discuss areas for improvement in the Daily Briefing.
The discussion might address the following topics:
• Conducting an organizationwide patient flow assessment to
determine where the slowdowns are occurring
• Reviewing discharge processes to determine where time can
be reduced to make inpatient beds available in a more
timely manner
• Providing additional training on signs of abuse and how
staff should follow up
• Involving social workers in interdisciplinary rounds for patients identified as needing social work services
Scenario 1-1.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 1-1. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Radiology Director:
[1]
Why did this patient experience a long delay in
radiology?
[2]
Describe the system your department has in place
for prioritizing procedures in such a situation.
[3]
Please provide a recent assessment of delays in the
radiology department.
ED Physician:
[4]
What specific training have you received in
recognizing signs of elder abuse and neglect?
[5]
Please show me the family and social history that
was obtained.
[6]
At what point was the patient’s family notified about
her ED admission?
[7]
Please provide a copy of the policy and procedures
for elder abuse and neglect.
Medical-Surgical Nurse:
[18] Please provide this patient’s discharge plan.
[19] How does the social worker participate in the
discharge planning?
[20] When was the patient eventually discharged?
Manager of the Admitting Office:
[21] How long have admission backups in the ED been a
problem?
[22] Although not specifically required by The Joint
Commission, describe the duties of your facility’s
bed control coordinator. If you don’t have one, what
advantage do you think someone in that role might
bring to your organization?
[23] May I see any recent analyses of patient flow and
admission delays?
Hospital Leadership:
[24] What is your approach to managing patient flow?
[25] What reports or dashboard data do you review that
help you monitor and mitigate patient flow issues
that might occur on the various units and over time?
[26] How is the hospital preparing to provide patient flow
data to the Centers for Medicare & Medicaid
Services (CMS) on its inpatient ED measures?
Medical-Surgical Unit Nurse:
SYSTEM
[11] Please show me the patient’s admission record.
Tracer Scenarios
[12] Describe your understanding about the signs and
symptoms of elder abuse.
[13] To whom would you communicate suspicions of
abuse? How?
[14] At what point did a social worker come to see the
patient?
[15] Please provide a copy of the policy and procedures
for elder abuse and neglect.
Interdisciplinary Care Team:
[16] Explain how the patient’s care is organized into a
consistent, interdisciplinary plan between providers.
[17] How do you communicate your patient assessments
with the rest of the team?
SCENARIO 1-2.
Midsize Community Hospital
Summary
In the following scenario, a surveyor traces the way a community hospital emergency department provided care to an injured pediatric patient. Within the tracer, the surveyor explores
issues relating to these priority focus areas:
• Communication
• Information Management
• Medication Management
• Patient Safety
21
Scenario
The surveyor conducted this tracer at a community hospital.
The patient was an eight-year-old male who was admitted to
the ED by ambulance after an all-terrain vehicle (ATV) accident. The child had been riding with his father and had not
been wearing a helmet. The triage nurse found the child to be
conscious but combative, with a forehead laceration and the
left arm out of alignment with a suspected fracture. The ED
physician ordered a head magnetic resonance imaging (MRI)
scan and an x-ray of the left arm. Medication for pain was
postponed until the head injury could be evaluated.
During the course of this tracer, issues raised concerning diagnostic imaging processes necessitated additional tracer activity.
Thus, this scenario includes an example of a second generation
tracer, as the surveyor takes an in-depth look at this high-risk
topic (see Introduction, page 2).
(Bracketed numbers correlate to Sample Tracer Questions on pages
23–24.)
Examining Pediatric Services in the ED with an
ED Nurse. The surveyor reviewed the patient’s medical
record, including the history taken by the ED physician. [1]
The record also indicated that there was a previous ATV accident that had resulted in a fracture nearly one year earlier,
when the child had also been riding with the father and neither had been wearing safety gear. The surveyor pointed this
out to the nurse, who said that she had seen that note as well,
and the physician had ordered a consultation with social work.
[2]
The surveyor examined the area for pediatric emergency
equipment, such as a pediatric crash cart. The ED nurse reported that the department did have a pediatric crash cart, but
it took her about five minutes to find it. [3] She said that they
rarely had use for it. The cart appeared to have pediatric defibrillator paddles, but when asked, the nurse could not fully explain how to attach them. [4]
The surveyor asked if the facility held pediatric code drills, and
the nurse said that they did have code drills but did not remember participating in one for pediatric patients. [5] The
surveyor asked about the procedure when a critical pediatric
patient arrived in the ED, and the nurse explained that an attending physician from pediatrics was called in when such a
patient arrived. [6] The surveyor asked how pediatric emergency drug doses were calculated, and the nurse said they had
charts based on the child’s weight for many of the more com-
22
monly used drugs. [7] She added that many drugs were available in a ready-to-administer form.
Reviewing Processes with the MRI Technicians. The
patient record showed that, when the patient arrived in the
MRI suite, he was restless and combative. Therefore, the staff
requested that an anesthesiologist come to administer moderate sedation.
The surveyor asked the MRI technician about the policy regarding sedation, and he said that, when children required sedation, anesthesia was always called to evaluate the patient and
administer the medication. [8] When the surveyor asked to see
the policy, the MRI technician was able to retrieve it quickly
on the intranet. [9]
The record included a copy of a checklist that the technician
had used for the pretest screening of the patient. This included
asking about tattoos, jewelry, implants, and other objects and
devices that might contain metals. [10] The surveyor asked the
technician if this part of the screening was different for pediatric patients, and he said that it was not. [11] She also asked
the technician to describe his next step, if the patient had a
positive response to any of the screening questions. He responded adequately and in detail. [12]
The anesthesiologist arrived and conducted a short assessment on the child, then provided the father with a consent
form to sign. The form was included in the patient record.
After administering the sedation, the anesthesiologist stayed
to oversee the imaging procedure and assess the patient afterward. The surveyor asked how the anesthesiologist obtained the necessary medications. [13] The technician said
that sometimes the anesthesiologist brought the likely medication with him, depending on how much he knew about
the patient in advance. Other times, he would call the pharmacy with his order and a pharmacy technician would bring
the medication.
The potential for safety problems in the MRI suite
prompted additional questions and “thread pulling” by the
surveyor.
The surveyor noted that the suite had appropriate signage—
outside and within the area—indicating the safety zones. [14]
She then interviewed staff about their training regarding safety
in the MRI suite. [15] The technician said that he had received training during his certification to become an MRI
technician. In addition, his staff orientation at this organiza-
tion included information about safety within the MRI suite,
such as the removal of IV poles, wheelchairs, and other metal
items from the MRI area. He said that he was so accustomed
to watching for metal items that it had become “second
nature.”
The surveyor then asked about staff training for an emergency
shutdown. [16] The technician said that they had never had to
implement a shutdown, but that they had monthly drills.
When asked, he said that he wasn’t aware of any procedural
changes made as a result of the drills, but he didn’t remember
any significant problems being uncovered during the drills.
[17]
Next, the surveyor asked about patient emergencies during an
MRI. [18] The technician said that the only emergencies he
was aware of were patient panic attacks, which were somewhat
common. The surveyor asked what happened when those occurred, and he replied that the technician would first attempt
to talk the patient through it. If that did not seem to work, the
procedure was stopped and an anesthesiologist was called to
provide sedation. [19]
When the surveyor asked to review the quality control documentation, she saw that the MRI equipment was tested daily
and weekly, and that those tests were appropriately documented. [20] She also asked to see the annual physicist’s report and noted that it was also appropriately completed.
[21]
Scenario 1-2.
ED Nurse:
[1]
Please provide the patient’s medical record for
review.
[2]
How would you handle this patient’s social/family
history?
[3]
Does the ED have a pediatric crash cart? What
medications are commonly stored on it? Where is
the cart located?
[4]
How are the pediatric defibrillator paddles attached?
[5]
Does the ED hold pediatric code drills? How
frequently are they held?
[6]
What are the typical procedures employed when a
critical pediatric patient arrives in the ED?
[7]
How are pediatric emergency drug doses calculated
and prepared?
MRI Technicians:
The patient’s MRI had showed no significant brain injury, and
the results of the MRI were communicated electronically to
the physician. [22] The technician explained to the surveyor
that the computer system automatically sent the physician an
alert when an MRI that he or she had ordered had been performed.
• Providing pediatric training to the ED clinical staff or
bringing a pediatric emergency specialist or pediatric nurse
coordinator on staff
• Following up with MRI staff after drills to discuss any necessary changes to procedures
[8]
What is the policy regarding sedation of MRI
patients?
[9]
Please provide the written policy for review.
[10] What does the MRI prescreening include?
[11] How is the screening different for pediatric patients?
[12] What is your next step, if the patient responds
affirmatively to any of the screening questions?
[13] How does the anesthesiologist obtain medications?
Describe the procedure.
[14] How are the safety zones marked in the MRI suite?
[15] What sort of training have you received regarding
safety in the MRI suite?
[16] What sort of training have you received for
emergency MRI shutdowns?
[17] What procedural changes were made as a result of
the drills?
(continued)
23
Scenario 1-2.
(continued)
[18] What types of patient emergencies have you
experienced in the MRI suite?
[19] What is the process for those patient emergencies?
[20] Please provide the quality control documentation for
review.
[21] Please provide the annual physicist’s report for
review.
[22] How are MRI results communicated to the ordering
physician?
ample, how was the nurse assessing the patient’s pain? [3, 4]
The nurse explained that the hospital had a “language phone
line,” but she had never used it. [5] Instead, she was using the
“faces” scale to assess pain. The surveyor noted that the pain
scores were fully documented in the medical record. [6] The
surveyor asked the nurse about her knowledge of the cultural
aspects of pain expression and management, and the nurse said
she had received some training on that topic in a pain management seminar a few years earlier.[7] The surveyor then asked if
the hospital had a policy regarding the use of family members
to convey health information. [8] She said that staff members
were encouraged to use the language line, but if a friend or
family member was present to interpret, most staff found it
easier just to communicate through that person.
Reviewing the Imaging Paperwork with the Radiologist. The patient had had several imaging procedures done,
SCENARIO 1-3.
Small Rural Hospital
Summary
In the following scenario, a surveyor reviews a small rural hospital’s ability to communicate effectively with its patient population. Within the tracer, the surveyor explores issues relating
to these priority focus areas:
• Communication
• Orientation & Training
• Patient Safety
• Rights & Ethics
Scenario
The surveyor conducted this tracer at a rural hospital. During
tracer activities on the medical-surgical unit, the care was reviewed for a 59-year-old female patient who was admitted
complaining of abdominal pain.
25–26.)
Discussing the Case with the Primary Nurse. The
surveyor asked to review the patient’s record and found that
the patient spoke only Russian; her daughter, who accompanied her, acted as the interpreter. [1] He talked to the patient’s
primary nurse to learn how she had communicated with the
patient. [2] The nurse stated that the daughter, who spoke
both Russian and English, had been staying at the bedside at
all times. The surveyor then asked what other resources the
nurse had, to meet the patient’s communication needs; for ex-
24
including an upper gastrointestinal (GI) series. When the surveyor reviewed the consent for those procedures, he saw that
the form and the name of the procedure were written in English. [9] The surveyor asked to see the hospital policy and procedures about consent forms. [10] He then located the
physician and the radiologist, and questioned them about their
conversation with—and explanation to—the patient, during
the consent process. [11] They indicated that the daughter
had acted as interpreter. When the surveyor asked about the
hospital’s policy and procedures for interpreters, they seemed
to be unaware of any such policy. [12]
Communicating with the Patient. The primary care
nurse asked the patient and her daughter if the surveyor might
speak with them, and they agreed. However, the surveyor insisted that the interview be conducted using the hospital’s established telephone interpretive service, per Joint Commission
requirements. It took a staff member a few minutes to secure
the dual-handset telephone designed for this purpose. Upon its
arrival and connection to an interpreter, the surveyor began a
brief three-way conversation with the patient. He asked if she
was comfortable with the way hospital staff cared for her and
spoke to her, and if she felt staff had explained her plan of care
adequately. [13] The patient expressed satisfaction with her experiences so far, and clearly described her understanding of the
plan of care and procedures. She indicated that everything had
been communicated through her daughter, however, and that
this was the first time the special telephone and interpreter had
been used.
Aware that the patient had signed a consent form, the surveyor
also asked if the purpose of that document was explained to
her before she was asked to sign it. [14] She indicated that its
purpose was indeed made clear—with interpretive help from
her daughter. The surveyor then asked the patient whether her
pain was being managed effectively and she said it had been.
[15] When he asked whether she had any special dietary or
other needs that had not been met that she thought would
make her feel more comfortable, the patient replied that she
did not have any unmet needs. [16]
Learning About Interpretation Education with the
Nurse Educator. The surveyor then interviewed the nurse
who conducted staff orientation and coordinated educational
activities. The nurse had evidence of classes taught by the language phone vendor when the system had been implemented
two years before. She added that the phone service was “mentioned” in orientation for new employees; however, she did
not know how staff physicians were informed of the presence
or function of the phone line. [17]
Talking About Performance Improvement Plans
with the Director of Nursing. During the data session, the
surveyor reviewed patient satisfaction data to learn if patients
were asked about their communication needs during their hospitalization. He asked the nursing director if any action plans
had resulted from this part of the survey, and she said they had
not. [18] The surveyor then asked how the hospital leadership
knew if staff members were effective in meeting the communication needs of their patients, especially their non-Englishspeaking patients, and she said that they had not explored
that. [19] Next, the surveyor asked whether multilingual employees ever served as interpreters. The director said that they
occasionally did; however, when the surveyor asked about
competency, she stated that the hospital did not assess staff
members’ language competency. [20, 21]
• Reviewing Joint Commission requirements regarding medical interpreters
• Educating staff regarding language interpretation resources,
as well as hospital policy and procedure
Scenario 1-3.
Nurse:
[1]
Please provide the patient’s record.
[2]
How were you able to communicate with the patient?
[3]
What other resources do you have for meeting the
patient’s communication needs?
[4]
How are you assessing the patient’s pain?
[5]
Does the hospital have a language phone line? How
it is used and how frequently is it used?
[6]
Are the patient’s responses being documented in
the medical record? Please provide an example.
[7]
Describe what you know about the cultural aspects
of pain expression and management.
[8]
What is the hospital’s policy regarding who may
interpret for the hospital when health information
needs to be communicated with a limited- or nonEnglish-speaking patient?
Radiologist:
[9]
Please provide the consent forms for the patient’s
imaging procedures.
[10] Detail the hospital’s policy and procedures regarding
consent forms.
[11] How were you able to obtain informed consent from
the patient using a form that is written in English?
[12] What are the hospital’s policies and procedures
regarding consent forms and interpreters?
Patient:
[13] Are you comfortable with the way staff cares for you
and speaks to you? What can you tell me about
their explanation regarding your plan of care?
[14] Did you understand the forms you signed before
your procedures? Who explained them to you? At
what point was it done?
(continued)
25
Scenario 1-3.
(continued)
[15] Is your pain being managed effectively? Please
explain why or why not.
[16] Do you have any dietary or other needs that have
not been met that you feel would make you more
comfortable? If they are not being met, please
explain what could be improved. If they are being
met, how has that been accomplished?
Nurse Educator:
[17] What sort of training has been conducted with
regard to the telephone interpretation system? How
were physicians included in that training?
Director of Nursing:
[18] What action plans were the result of the communication
portion of the patient satisfaction survey?
[19] How effective is your staff in meeting the
communication needs of their patients, particularly
those who do not speak English? Please describe
how improvements might be made in this regard.
[20] How do multilingual staff members fit into the patient
communication plan?
[21] How do you assess the language competency of
staff?
SCENARIO 1-4.
Large Teaching Hospital
Summary
In the following scenario, a surveyor conducts a medication
management tracer at a large teaching hospital. Within the
tracer, the surveyor explores issues relating to these priority
focus areas:
• Patient Safety
• Physical Environment
Scenario
This tracer took place in a 500-bed full-service teaching hospital. The patient was a 55-year-old woman who was directly admitted from her physician’s office for a second round of
26
chemotherapy to treat breast cancer. She required five days of
hospitalization, and this tracer took place on her second day of
chemotherapy. The focus of this tracer was medication management and safety for chemotherapy patients.
28–29.)
Interviewing the Patient. The surveyor asked the patient
about the consent process, asking what she had been told about
the risks, side effects, and effectiveness of the chemotherapy treatment she was to receive, and if she had been given the opportunity to ask questions. [1, 2] The surveyor then reviewed the
consent document to confirm the patient’s account and to ensure
that it was signed, witnessed, and marked with the date and time.
When the surveyor asked how the nurse confirmed her identity at
each chemotherapy session, the patient said that the nurse always
asked for her full name and date of birth before proceeding. [3]
When the surveyor asked about side effects, the patient explained that she did experience some of the expected side effects, such as pain and fatigue, and that the nurses had
responded with treatments to help alleviate some of those side
effects. [4] The side effects had been noted in the patient’s
chart, the surveyor found. The surveyor then asked whether
the caregivers had discussed chemotherapy safety issues with
the patient, including how to handle urine and waste. [5]
While looking at the patient’s chart, the surveyor saw that she
was on neutropenic precautions. This prompted the surveyor
to ask the patient if she understood what that meant and if she
had made any changes to her behavior as a result. [6, 7] She
also asked the patient if she knew how those precautions affected her visitors. [8] The patient was able to explain that her
visitors needed to wash their hands and put on a gown, gloves,
and mask before entering her room.
Finally, the surveyor asked about how the patient’s pain was assessed and how it was treated. [9] The patient reported that
the pain management interventions were effective most of the
time, and the caregivers had tried other pain management
methods when the interventions did not work. [10]
Consulting With the Nurse. The surveyor began by interviewing the nurse about her experience in administering
chemotherapy, and how the hospital had helped her develop
her competencies in that area. [11] She said that she had taken
a course on chemotherapy administration that included a clinical practicum.
Next, the surveyor asked the nurse about the precautions that
were taken to protect the patient. She reported that the patient’s identity was confirmed by asking the full name and date
of birth. In addition, the chemotherapy administration process
was double-checked by two nurses with experience in
chemotherapy. [12]
Because chemotherapy spills are a significant safety concern,
the surveyor asked the nurse if she had ever had a spill. [13]
Although she hadn’t experienced a major spill, the nurse reported that she, like most nurses who administer chemotherapy, had experienced some smaller spills and leakage. When
this occurred, she used one of the spill kits that were stored in
the rooms where chemotherapy was administered to obtain a
double set of gloves, absorbent pads, and other cleanup supplies. The nurse also said that she had never gotten the
chemotherapy medication on her skin, but she was aware of
the procedure for scrubbing the skin clean with soap and water
and drying it thoroughly. When asked whether the hospital
had ever conducted a drill for a biohazard spill, the nurse reported that they had not, but that staff had been trained on
use of the chemotherapy spill kits. [14]
The surveyor then asked about the expected side effects with
this particular type of chemotherapy, whether there were any
interventions that could reduce them, and whether she had
discussed side effects with the patient. [15] The nurse said that
she had told the patient about the possible side effects, and the
surveyor noted that those discussions had been documented in
the patient’s chart.
A sign on the patient’s door indicated that she was at risk for
falls, so the surveyor asked the nurse if the patient had fallen
or nearly fallen. [16] The nurse responded that the patient had
not fallen, but the chemotherapy had made her feel weak. The
surveyor probed further and discovered that a formal falls risk
assessment had not been conducted. [17]
Upon reviewing the physician’s orders, the surveyor was surprised to find that they were handwritten. The surveyor asked
if this was the usual practice, and the nurse responded that the
physicians typically used preprinted protocols and she did not
know why this physician had written them by hand. [18] The
surveyor then asked what process the nurse followed if a physician’s order was illegible, and she reported that she contacted
the physician for clarification. [19]
The surveyor then asked the nurse to describe how the orders
got to the pharmacy, and how the medications were brought
to the unit. [20, 21] With further prompting from the surveyor, she also explained the safety precautions taken and how
the medication got to the patient’s bedside. The surveyor then
asked how the empty IV bag was safely disposed of. [22] In
the rooms in which chemotherapy was administered, the nurse
said, there was a chemotherapy waste container that was separate from the regular solid waste and infectious waste containers. IV bags, spill pads, and other disposable items that had
been in contact with chemotherapy agents were placed in that
waste container, and then removed by the same staff members
who collected the infectious waste containers.
Interviewing the Pharmacist. The surveyor visited the
pharmacy to observe how the pharmacy received chemotherapy orders and mixed the medication. In the case of this patient being traced, the order was handwritten, so the surveyor
asked the pharmacist about the protocol for such situations.
[23] He reported that the pharmacists consulted with the
physician on handwritten orders only if they were illegible or
incomplete.
The surveyor also asked about the education and training of
the pharmacy technician responsible for mixing the
chemotherapy medications. [24] The pharmacist explained
that the technicians were required by the health system to be
certified to handle hazardous drugs and chemotherapy agents,
so all had received the necessary certifications and kept them
up to date. The surveyor’s later review of competency records
found that to be the case.
The surveyor asked whether the pharmacy had ever experienced a biohazard spill. The pharmacist said that they had, a
few months earlier, when chemotherapy medication had
spilled due to a cracked case. [25] He said that the spill was
cleaned up using the items in one of the spill kits stored in the
pharmacy. This included the face mask, eye shield, and gown
required for larger spills. The surveyor asked whether the pharmacy had conducted a drill prior to the spill. [26] He responded that they had not, but the pharmacy staff had
received training on how to use the spill kits. The kits also
contained detailed instructions on their use.
The surveyor then asked the pharmacist specifically about the
hoods under which medications were mixed, and whether
there was one reserved for chemotherapy. She also asked about
maintenance and cleaning of the hood. [27] The pharmacist
said that they did have a hood designated for chemotherapy
use only, and it was cleaned at the end of each shift, according
to the manufacturer’s instructions. In addition, a representative
27
from the manufacturer came to maintain the hood annually
and to repair it as needed. Daily cleaning was part of the pharmacy technicians’ responsibilities and not regularly documented, but the forms showing the manufacturer
representative’s visits were kept in a binder next to the hood.
The surveyor confirmed the maintenance by reviewing the
forms. [28]
• Ensuring that physician orders are computer generated
(rather than handwritten) whenever possible
• Educating patients and visitors about safety precautions; for
example, providing signage reminding visitors to wash
hands and put on gowns, masks, and gloves before entering
the patient room
• Conducting regular formal drills for safe handling of
chemotherapy medications and appropriate response to
spills
Scenario 1-4.
[6]
Define what you think “neutropenic precautions”
means. Why do your caregivers take special
precautions with your immune system?
[7]
What behavioral changes have you made due to
what you have learned about chemotherapy and
your immune system?
[8]
How have the precautions affected your visitors?
[9]
How do the nurses and physicians check your level
of pain?
[10] Are the pain treatments effective? Explain why you
think they are or are not. If not, what do the
caregivers do next?
Nurse:
[11] How much experience do you have in administering
chemotherapy? How has this hospital helped you
enhance your competencies in administering
chemotherapy?
[12] What patient safety precautions are taken before
administering chemotherapy?
[13] Have you ever experienced a chemotherapy spill? If
so, how did you respond? If not, describe the
appropriate response.
[14] How often does the hospital conduct a drill for a
biohazard spill?
Patient:
[16] Please describe a situation where this patient had a
fall or a near-fall.
[1]
At the beginning of your treatments, what were you
told about the risks and side effects, as well as the
effectiveness, of receiving chemotherapy?
[2]
How did staff members encourage you to ask
questions about your treatment? What do you think
of the answers they gave you?
[3]
What does the nurse do to make sure that you are
the correct patient before administering your
chemotherapy?
[15] What are the typical side effects one can expect
with this type of chemotherapy? What are the
interventions that can help reduce these side
effects? How were these interventions discussed
with the patient and documented in the patient’s
chart?
[17] Please provide evidence of the fall risk assessment
conducted for this patient.
[18] What method do physicians use to create orders?
Handwritten? Computer generated?
[19] What process is followed when a physician’s order
is illegible or unclear?
[20] How do orders get to the pharmacy?
[4]
Have you had any side effects from the chemotherapy?
If so, how have the nurses responded?
[21] How does the medication get delivered to the unit
and then to the patient?
[5]
What did your caregivers say about chemotherapy
safety issues? What information did they provide
regarding the handling of urine and waste?
[22] How is the IV bag safely removed once it is empty?
28
Pharmacist:
[23] What is the protocol when you receive physician
orders that are handwritten?
[24] What types of training and education are required
for the pharmacy technicians who mix
chemotherapy medications?
[25] Has the pharmacy ever experienced a spill? If so,
how was it handled? Where is your spill kit located
in the pharmacy?
[26] How frequently are spill drills typically conducted?
When did the last drill take place prior to this
incident?
[27] Where is the hood reserved for mixing
chemotherapy medication? Who is responsible for
maintenance? How often is it maintained?
[28] May I see the maintenance documentation?
SCENARIO 1-5.
Critical Access Hospital
Summary
In the following scenario, a surveyor traces patient flow and
care at a critical access hospital by following a patient who arrived in the ED late at night. Within the tracer, the surveyor
explores issues relating to these priority focus areas:
• Patient Safety
• Rights & Ethics
for these conditions. The nurse drew labs and the ED physician ordered an electrocardiogram (EKG). The patient was
admitted to the intensive care unit (ICU) accompanied by
his partner, who was anxious but cooperative and insisted on
staying at the bedside. The ICU nurse received a detailed
handoff from the ED nurse who had helped transport the
patient.
30.)
Observing Patient Care with the ICU Nurse.
Upon reviewing the patient’s record, the surveyor saw that the
ICU nurse had received the critical lab report, which showed
normal values, and immediately reported this to the ICU
physician. This prompted the surveyor to ask for the hospital’s
policy and procedures on critical values and data, and the
timely reporting of results to the physician. [1]
Further diagnostic studies revealed a bleeding ulcer and a low
hemoglobin and hematocrit. The physician ordered a type and
crossmatch, and a unit of packed red blood cells. The record
showed that the nurse had drawn the blood sample; the surveyor asked why the phlebotomist staff had not done so, and
the nurse explained that phlebotomy staff came in at 4 A.M.
[2] To follow up, the surveyor asked about her familiarity with
blood-draw procedures. [3] The nurse said that she frequently
worked the night shifts, so she often drew blood samples herself and knew the procedures well.
Scenario
The surveyor asked if there were delays in receiving laboratory
test results on the night shift, and the nurse told her that there
usually were not; the lab had fewer staff on duty overnight, but
there were fewer tests being performed. [4]
The surveyor conducted this tracer in a critical access hospital.
At 10:10 P.M., a 60-year-old man arrived at the ED by ambulance complaining of chest pain. He was immediately triaged
to the cardiac treatment room, where he was placed on a cardiac monitor and labs were drawn. The nurse received the
handoff from the paramedics and learned that the patient had
experienced chest pain while at a ball game, and his partner
had called 911. The patient had received aspirin in the field,
had an IV started, and was attached to oxygen and a monitor
that showed normal sinus rhythm, then transported to the
local hospital.
The medical record showed documentation that the blood
transfusion ordered by the physician was started at 4 A.M. and
checked by two nurses; vital signs were taken prior to initiating the blood and every 15 minutes for an hour. [5] The surveyor obtained a copy of the facility’s policies regarding blood
transfusions and saw that the steps described in the patient
documentation matched the policy. [6] She then asked the
nurse about the hazardous materials procedures for disposing
of the blood bag and tubing after a transfusion, and the nurse
described the process according to facility procedure. [7]
On arrival, the patient was pale, diaphoretic, and hypertensive. He relayed a history of hypertension, hypercholesterol,
and smoking. The medication reconciliation showed drugs
The pharmacy at this small hospital was closed during the
night hours, and the physician had ordered medications for
this patient. The surveyor asked about the process for obtain-
29
ing prescriptions at such times, and the nurse said that she was
able to obtain the medications from the automated dispensing
system. [8] She explained that some of the more common
medications were stocked in the automated dispensers. The
surveyor asked what would happen if a patient needed a medication that was not in the dispensers, and the nurse said that
the hospital had a contract with an outside pharmacy to supply drugs at those times. [9]
Interviewing the Patient. At the time of the survey, the
patient had been transferred from the ICU to the medical-surgical unit. After the medical-surgical nurse sought and received
permission from the patient, the surveyor met with him and
his partner to ask about his admission and transfer. [10, 11]
The patient expressed understanding about why he was admitted to the ICU and was now in the medical-surgical unit. The
surveyor asked if his partner had been allowed to stay with
him overnight, and he said that he had indeed been allowed.
Although the ICU did not have sleeping accommodations for
family, the partner explained, the nurse had provided a pillow
and blanket so he could sleep in a chair at the bedside. The
surveyor then asked if the patient had received a plan of care,
and the patient said that it had not yet been discussed with
him. [12]
Discussing Plan of Care with the Medical-Surgical
Nurse. After the medical-surgical nurse coordinated the care
plan information to share with the patient, the surveyor asked
to see it. [13] She noted that it included information about
smoking cessation classes, as well as an order for a consultation
with the nutritionist who would be along later that morning.
The plan of care also included information about the medications prescribed, signs and symptoms that would require a call
to the physician, and details about follow-up appointments.
[14]
Scenario 1-5.
ICU Nurse:
[1]
Please show me the hospital’s policy and
procedures on critical values and data, and the
timely reporting of results to the physician.
[2]
Why was the blood sample drawn by a nurse
instead of a phlebotomist?
[3]
What are the blood specimen drawing and labeling
procedures?
[4]
How does the time frame for receiving lab results
differ on the night shift?
[5]
Please describe the procedure for setting up a blood
transfusion.
[6]
Please show me the policy for blood transfusions.
[7]
Describe the disposal process for the blood bag and
tubing, at the end of the transfusion.
[8]
How are you able to obtain prescription medications
for patients during night hours when the pharmacy is
closed?
[9]
How can you obtain prescription medications that
are not stocked in the automatic dispensing
machines?
Patient:
• Ensuring that staff are aware of the latest Joint Commission
requirements regarding the rights of patients and their
loved ones
• Reviewing night-shift pharmacy procedures to ensure that
no delays occur when the pharmacy is closed
30
[10] What were you told about your admission?
[11] What were you told about your transfer to this unit?
[12] What has your physician told you about your plan of
care?
[13] Please produce the plan of care for this patient.
[14] What is included in the care plan? Does it include
smoking cessation instruction? Does it include a
nutrition consult? Does the plan include information
about medications prescribed, as well as signs and
symptoms that would require a call to the physician?
SCENARIO 1-6.
Outpatient Clinic at Large Urban
Hospital
Summary
In the following scenario, a surveyor traces care processes and
patient safety at one of six outpatient clinics associated with a
main hospital, more than 25 miles away from the main site.
• Infection Control
• Patient Safety
• Quality Improvement Expertise/Activities
Scenario
The surveyor conducted this tracer at a general-medicine family practice clinic located in a rural area about 25 miles from
the main site. The clinic was staffed by two family practice
physicians and two nurse practitioners. There was a charge
nurse who was an RN, as well as three medical office assistants
and clerical staff in the front office. They saw patients from
newborn to geriatric. The clinic had a blood draw station but
no lab. Specimens were sent by courier to the main site.
ments of significant diagnoses, procedures, drug allergies, and
medications. The medical records also all appeared to include
medication reconciliations, including medications prescribed
by clinicians at other sites within the system.
The surveyor asked if the nurse or nurse practitioners ever accepted verbal orders, and she said that they usually did not. [5]
However, she added that, when verbal orders were occasionally
given, one of the clinical staff would later enter them into the
electronic record and the physician would need to approve
them.
The surveyor then asked the nurse how they handled nutrition
screenings. [6] She said that nutrition screenings were done
using a questionnaire. Depending on the patient’s medical
condition, certain responses to questions would trigger a consultation with a dietitian; for example, responses from a cardiac patient that indicated that his or her diet was high in fat
would result in a consultation with the dietitian to discuss
low-fat options. The surveyor asked how the consultation
would be arranged, and the nurse said that the nursing staff
would notify the dietitian. [7] However, patients would have
to go to the main hospital for an appointment with the dietitian.
Touring the Site with the Administrative Manager.
32.)
Reviewing Patient Care Processes with the Charge
Nurse. The surveyor asked to review several patient charts
that were representative of the facility’s patient population, including some from pediatrics, geriatrics, chronic disease, and
obstetrics. [1] The records were electronic, so the surveyor
asked how the records are protected. [2] The nurse explained
that clinic staff accessed the records with a password. This allowed the hospital to know who was accessing patient records
and eliminated the problem of making patient records available at multiple outpatient clinics as well as the main hospital.
The nurse also noted that the electronic system automatically
provided the standard accepted abbreviations.
Upon reviewing the charts, the surveyor asked the nurse who
would conduct the initial patient assessment. [3] The nurse
told him that it was usually she or one of the nurse practitioners. The surveyor asked if the assessment included a pain assessment, and the nurse said that she assessed the patient for
pain if that was part of the initial complaint. [4] The patient
records included summary lists, with the four required ele-
Next, the surveyor toured the clinic site with the administrative manager. Each practitioner had an office plus two or three
patient exam rooms, the manager explained. In addition to the
lab-draw station, there was a small medication room and a
treatment room. The surveyor asked to see one of the exam
rooms. [8]
The surveyor noted that the room included a sink with soap
and paper towels, as well as a hand sanitizer dispenser. He then
asked the manager how the facility monitored hand hygiene
compliance, and she said that they did not have any formal
monitoring process. [9] However, each exam room had a sign
over the sink reminding caregivers to wash their hands, and
hand hygiene was included in periodic training provided by
the main hospital.
When the surveyor asked the manager if medications were
stored in these rooms, she replied that they were not. [10] The
surveyor noted that the only instruments stored in these rooms
were the blood pressure cuff and the otoscope with its various
attachments. A sharps container hung on the wall near the
trash receptacles; however, the manager said that no needles,
syringes, or other sharp supplies were kept in the exam rooms.
31
All such supplies were kept at the nurses’ station.
The surveyor then asked if the clinic had a crash cart, and the
manager said that they did. [11] She showed it to the surveyor,
who noted that the supplies on the cart were all dated and initialed by a medical equipment staffer from the main hospital.
The surveyor asked who was responsible for checking and updating the medications, and the manager explained that employees from the main hospital came to the clinic regularly to
check expiration dates and supplies on the crash cart and other
equipment.[12]
Finally, the surveyor asked about the results of the last crash
cart drill. [13] The manager said that the last set of drills had
been a month earlier. The results were positive, she said, although the emergency response time in pediatrics had room
for improvement. The staff in that area was looking for ways
to shorten that time before the next drill.
• Implementing formal processes for monitoring hand hygiene compliance
• Including pain assessments as a part of all patient assessments, regardless of initial complaint
Scenario 1-6.
[6]
How do you handle nutrition screenings?
[7]
How are dietary consultations arranged?
Administrative Manager:
[8]
May I see one of the exam rooms?
[9]
How do you monitor hand hygiene compliance?
[10] Are any medications stored in the exam rooms?
[11] Does the clinic have a crash cart? Please show it to
me.
[12] Who is responsible for checking expiration dates of
medications stored on the crash cart?
[13] What were the results of your last crash cart drill?
SCENARIO 1-7.
Midsize Community Hospital
Summary
In the following scenario, a surveyor traces the obstetrics and
maternity processes at a midsize community hospital. Within
the tracer, the surveyor explores issues relating to these priority
focus areas:
• Patient Safety
• Rights & Ethics
Scenario
A 28-year-old pregnant patient was admitted in labor to the
hospital’s mother-baby unit. The patient had been examined
by the nurse midwife, who was concerned about the position
of the baby and lack of progress of the labor. The obstetrician
was called, and a diagnosis of “failure to progress” was made.
The obstetrician spoke with the parents, and together they decided to proceed with a C-section.
Charge Nurse:
34.)
[1]
Please provide several patient charts that reflect
your patient population.
[2]
How are the electronic records protected?
[3]
Who conducts the initial patient assessment?
[4]
Does the assessment include a pain assessment?
What other areas are included?
[5]
How do you manage orders given verbally?
32
Observing Operating Room Procedures. The C-section operating room (OR) was notified, and the patient was
moved to the OR holding area, where she was seen by the
anesthesiologist. The surveyor observed the anesthesiologist
completing the preanesthesia evaluation and having the anesthesia consent signed by the patient. The primary nurse then
approached the patient for permission for the surveyor to be
present during the procedure. [1] An IV was started, and the
patient was taken to the OR, where a urinary catheter was inserted. The surveyor later requested the written processes for
catheter-associated urinary tract infection (CAUTI) prevention
and noted that the nurse performed all appropriate steps. [2]
Later, the surveyor asked the nurse what the CAUTI rate was
for the unit. [3] The nurse looked it up and reported that it
was 2.3 per 1,000 catheter days. When the surveyor asked if
they’d undertaken any CAUTI-reduction efforts, the nurse
said that there had been an initiative but it had been at least a
year ago. [4] At that time, the surveyor also asked which measures the organization had selected for preventing CAUTIs, as
noted in National Patient Safety Goal (NPSG) 07.06.01. [5]
The nurse replied that they were working to limit the duration
of catheter use, but the data were still being collected and no
formal process had begun yet.
In the OR, the surveyor met briefly with the parents to confirm their consent for her presence and to explain her role. [6]
She asked the mother what she had been told to expect during
the C-section, and the patient seemed to have a good understanding of the procedure. [7] The surveyor then asked what
the nurse had told them about infant safety and security at this
facility. [8] The patient’s husband said that, when they had
toured the hospital a few weeks earlier, a nurse had told them
about the identification bands for parents and newborns, but
that no one had mentioned security during this visit.
In the OR, the surveyor observed that all basins on the back
table were labeled and the room was well-organized. All staff
members were appropriately attired and masked, and proper
sterile techniques were being observed. When the anesthesiologist entered the room, a preliminary time-out was conducted.
[9] Other OR staff stopped what they were doing in order to
participate in the time-out process. The surveyor asked the nurse
to describe the time-out steps as they were performed and found
that the medical staff took all appropriate time-out measures.
The nurse-anesthetist explained the spinal epidural process to
the patient, opened the tray, pulled up the medications and
prepped the lower spinal area. [10, 11] She allowed the prep
to dry before proceeding with the procedure, as required. The
surveyor asked the nurse to describe the process for ensuring
that correct medications are being used, and the nurse did so
as she waited for the prep to dry. [12] The surveyor noted that
both syringes on the field were properly labeled; the nurse also
said that if another medication were added to the field, the
medication would be identified both visually and verbally between the anesthesiologist and the circulating nurse.
After the epidural was in place, the circulating nurse helped to
position the patient on the table and began the prep of the abdomen. [13] The surveyor observed that the nurse allowed the
prep to dry—although not for a full three minutes, as required—before applying the drapes. When the obstetrician entered the OR, a second time-out was done, and the entire
team was attentive for the process. [14]
Another team was prepared to receive the infant. Immediately
after delivery, the infant was quickly assessed, dried, identified
with name band attached to his ankle, and handed to the father while the surgical team completed the mother’s surgery.
At the surveyor’s request, the nurse described these steps as
they occurred. [15] Identical bands were attached to the
mother and father before the infant left the OR, and a staff
member explained to the surveyor that the bands were for the
baby’s security. The father was invited to accompany the infant
to the newborn nursery for his initial assessment and to take
photos.
Discussing Infant Security with the Nursery Staff.
Later, the surveyor went to the nursery to meet with the staff
and discuss newborn security. She asked the staff to describe
the “Code Pink” process. [16] A nurse explained that, if a
baby were removed from the mother-baby unit without a parent’s identification tag nearby, an alarm would sound, setting
the Code Pink process in motion. An alert would be automatically sent to an operator, who would call “Code Pink” over the
facility’s public address system and then contact local law enforcement. [17] Meanwhile, all departments located on the
first and second floors would send at least one staff member to
the first floor to assist security in covering exits and searching
all people leaving the facility. [18] The procedure would continue until the child was found and the Code Pink was called
off.
The surveyor asked if the hospital conducted Code Pink drills
and, if so, how often. [19] She said that the hospital conducted monthly Code Pink drills. The surveyor asked to see
the evaluation of the most recent Code Pink drill and saw that
all steps were handled according to facility procedures. [20]
Moving Forward. Based on the tracer findings, the surveyor may discuss areas for improvement in the daily briefing.
• Ensuring that parents are fully informed about infant security and the importance of the name bands
• Using checklists for C-section prep to ensure that all preps
are given proper drying time
33
Scenario 1-7.
Nursery Staff:
[16] Please describe the Code Pink process.
[17] How would local law enforcement be contacted if it
became necessary?
[18] Which staff members are involved in the Code Pink
process?
[19] How often are Code Pink drills conducted?
[20] Please provide a copy of the most recent drill
evaluation.
Primary Care Nurse:
[1]
Please provide the patient’s record.
[2]
Describe the processes for catheter-associated
urinary tract infection (CAUTI) prevention, and
provide a written copy of those processes.
[3]
What is the CAUTI rate for your particular unit?
[4]
When was the last CAUTI-reduction initiative?
[5]
Please explain the measures your organization has
selected to prevent a CAUTI, as noted in
NPSG.07.06.01.
Patient:
[6]
What did the nurse tell you about my presence in
the OR? Do I have your consent to be here?
[7]
What did the nurse tell you about your C-section
procedure?
[8]
Tell me about the measures your nurse explained to
you about infant safety and security.
OR Nurse:
[9]
What is the time-out process for C-section
procedures?
Nurse Anesthetist:
[10] Describe the epidural process.
[11] What is the prep process for the lower spinal area?
[12] What is the process for ensuring that correct
medications are being used for the spinal epidural?
Circulating Nurse:
PROGRAMSPECIFIC
Tracer Scenarios
SCENARIO 1-8.
Small Community Hospital
Summary
In the following scenario, a surveyor traces a two-year-old patient admitted to a small community hospital that does not
have a specialized pediatrics unit. Within the tracer, the surveyor explores issues relating to these priority focus areas:
• Organizational Structure
• Patient Safety
Scenario
The surveyor conducted this tracer in a small community hospital that admitted a two-year-old boy via a satellite clinic,
where he had arrived with respiratory distress and fever. The
patient was admitted to a section of the adult medical-surgical
unit that was used for pediatric patients. The child was on respiratory/droplet isolation until pertussis could be ruled out.
36.)
[13] What is the process for prepping the abdomen?
[14] What is the process for the second time-out,
including the role of the obstetrician?
[15] What is the process for handling the infant after
delivery?
34
Reviewing the Patient Case with the Nurse. The surveyor asked to review the patient’s chart. [1] The family and
social history taken by the admissions nurse indicated that the
child had not been immunized for the usual childhood diseases. Further questioning had revealed that the parents had
reservations about the safety of vaccines for children, and one
of the patient’s two older siblings had not received immunizations either. [2] However, the oldest sibling had gone to the
satellite clinic several months earlier and had received two of
the required vaccinations in order to enter first grade.
Next, the surveyor asked the nurse about the infection control
precautions for a child suspected of having pertussis and
learned that the nurse had taken the necessary measures. [3]
She also asked the nurse to provide the written policy and procedures for pertussis infection control, and noted that the
nurse had followed the steps correctly. [4] The surveyor reviewed the medical record again and saw that the medical history taken by the clinic physician had explored the lack of
immunizations and had included questions for the parents
about any recent exposures. The parents, per the record, were
unaware of the child being exposed to pertussis.
Next, the surveyor asked to see the medical record for the sibling’s visit to the satellite clinic several months earlier, when he
received vaccinations. [5] A review of that record revealed that
the sibling had received Tdap, the adult strength of the tetanusdiphtheria-pertussis vaccine, instead of the DTaP (diphtheria,
tetanus, and acellular pertussis) vaccine, the pediatric form.
Further questioning found that the RN who had administered
the vaccine was a float nurse from the adult intensive care unit.
[6] The surveyor entered the name of the nurse for later check
of pediatric and medication competencies.
Learning About Handling of Look-Alike/SoundAlike Drugs from the Pharmacist. The surveyor then visited the pharmacy, where she talked with the pharmacy
director about how his staff dealt with look-alike/sound-alike
(LASA) drugs such as DTaP and Tdap. [7] Though drugs were
marked on the shelves, there was no method in place to designate the LASA drugs in the refrigerator or freezer. The surveyor then inquired if there was any special handling of
pediatric medications and dosages in the pharmacy. [8] He
said that the pediatric medications were kept in a separate area.
Next, the surveyor showed the director the patient’s sibling’s
record and asked how this medication error incident would be
handled in the pharmacy. [9] He replied that an error report
would be filled out and an investigation would take place. When
the surveyor asked what the investigation would entail, he said it
would include a review of the storage of the medications, as well
as conversations with the pharmacist who supplied the medication and the nurse who administered it. [10] He added that procedure changes might be made as a result of the investigation to
ensure that similar errors would not occur in the future. [11]
The surveyor requested the pediatric dosing competencies and
training files for the two pharmacists for review. [12] Finally,
she asked the director to describe the pharmacy’s role in medication education of the nursing staff. [13] He said that the
pharmacy conducted periodic training sessions but had not
held one on pediatric medications in a long time.
Talking About Nurse Education with the Nurse Executive. This small hospital did not have an education department, so the surveyor met with the nurse executive and asked
about the ongoing education of the nursing staff—particularly
how staff acquired and maintained pediatric competencies.
[14] The executive said that some nurses took part in pediatric
training as part of their ongoing education, but that there was
not a formalized effort. The surveyor asked to see the personnel files for the medical-surgical nurse, the float nurse, and the
admissions nurse on the medical-surgical unit to review their
pediatric and infection control competencies. [15]
Meeting with the Infection Control Nurse. The infection control (IC) nurse was a part-time position, so the surveyor arranged to interview the IC nurse during the combined
Data Use and Infection Control System tracer session. The IC
nurse was aware of the suspected case of pertussis and had
been in contact with the local health department. [16] The
health department had informed her that they had seen at least
two cases of suspected pertussis in area schools.
The surveyor then asked the IC nurse about reportable diseases
and how she submitted data reporting them. [17] The nurse
explained that the state agency had an online reporting form
that also included a list of the reportable diseases. Next, the surveyor inquired about the immunization/titer status of the medical, respiratory therapy, and nursing staff. [18] The IC nurse
replied that she tracked all staff immunizations, beginning at
the employee’s date of hire, to ensure that they were up to date.
As an additional safety measure, when a staff member was potentially exposed to an infectious disease, she checked their
records to make sure their immunizations were up to date.
• Formalizing the process for pediatric education among the
ED and medical-surgical clinical staff
• Educating staff on pediatric medications and dosage requirements, and how they differ from those for adults
35
Scenario 1-8.
Infection Control Nurse:
[16] Which authorities have been contacted?
[17] How do you submit data on reportable diseases?
Nurse:
[1]
Please provide the patient’s chart for review.
[2]
Has this child received his childhood vaccinations?
Why not?
[3]
What infection control precautions should be taken
for a child suspected of having pertussis?
[4]
Please provide a copy of the policy and procedures
for pertussis infection control.
[5]
May I see the medical record for the patient’s
sibling’s visit to the clinic a few months ago?
[6]
Who is the RN who administered the vaccine?
Pharmacy Director:
[7]
How do your staff manage look-alike/sound-alike
drugs?
[8]
Is there any special handling of pediatric
medications and dosages?
[9]
How will this medication error incident be handled in
the pharmacy?
[10] What would the investigation entail?
[18] How do you ensure that your staff’s immunizations
are up to date?
SCENARIO 1-9.
Military Medical Center
Summary
In the following scenario, a surveyor traces the surgical experience, including tissue processing, at a military hospital. Within
the tracer, the surveyor explores issues relating to these priority
focus areas:
• Credentialed Practitioners
• Patient Safety
Scenario
This survey took place in a hospital on a military installation.
The patient was a 26-year-old female active-duty sergeant who
had fallen approximately 15 feet while climbing an obstacle on
a leader reaction course and fractured her ankle. She had been
transported to the medical center via military ground ambulance after initial stabilization was rendered by the on-site
medic. The ankle fracture was confirmed, and the patient was
sent to the OR for repair. The tracer took place on the patient’s third postoperative day. The focus of the tracer was the
patient’s operative experience.
[11] What actions may result from the investigation?
[12] Please provide the pediatric dosing competencies
and training files for the two pharmacists for review.
[13] What is the pharmacy’s role in medication education
of the nursing staff?
Nurse Executive:
[14] How do the nursing staff acquire and maintain
pediatric competencies?
[15] Please provide personnel files for the medicalsurgical nurse, the float nurse, and the admissions
nurse on the medical-surgical unit.
36
38.)
Interviewing the Patient. After the surveyor reviewed
the patient record and the nurse obtained the patient’s consent, the surveyor met with the patient to talk about her preoperative care and procedures. He reviewed the surgery
consent form with her and noted that it was dated, timed, and
signed by the surgeon. [1] When he asked the patient who had
explained the procedure to her, she said that a nurse had come
to talk to her about the surgery and answered all of her questions. [2] The surveyor confirmed that the patient had a solid
understanding of the risks and benefits, as well as the alternatives to having the surgery. [3]
The surveyor asked whether the anesthesiologist had examined
her, and she said that she had. [4] She said that he had explained what the anesthesia would involve and what the risks
were. He had also asked her if she had any allergies and the patient had said that she did not.
The surveyor checked the patient’s medical record to ensure
that it included the admission history and physical, preoperative assessment by the surgeon, and preanesthesia assessment
and care plan (including airway assessment, American Society
of Anesthesiologists classification, history of problems with
anesthesia, documentation of allergies, and preinduction
assessment).
Discussing Transport. The nurse indicated that patients
were taken to the surgical area by a medic, so the surveyor
spoke with one of the medics. He first asked about the procedure for patient identification, and the medic said that a nurse
or other staff member would give him the patient files, confirm the patient’s name, and tell him where that person should
be taken. [6] The surveyor then asked about fall risks during
transport, and the medic explained that he ensured that patients were secured in the gurney, with the safety rails up. [7]
When arriving at the surgery area or other location, the transporter said, he would wait for a staff member to receive the
patient and the files. [8]
Discussing the Procedure with the Surgeon. The surveyor then interviewed the surgeon. He asked how the patient
had been identified when she had arrived in the patient holding area. [9] The surgeon said that the nurse had used two patient identifiers when the patient first arrived, then he had
done the same himself when he checked in with the patient
before the procedure. Then the anesthesiologist had identified
the patient one last time before administering anesthesia.
When the surveyor asked about site marking, the surgeon explained that he had marked the site earlier in the day, when
the patient was still being assessed in the medical-surgical
ward. [10] He had marked the surgical site with his initials,
which he noted was according to facility policy. If a patient
was able, he added, he would ask him or her to confirm that
the correct site had been marked.
to review the log and saw that the lot number matched the one
in the patient record. [12]
He then asked to see the refrigerator where the tissue was
stored. [13] The refrigerator was clean, and the temperature
was set within the required range indicated on the sheet posted
on the refrigerator door. The surveyor asked how staff would
know if the temperature rose above acceptable limits. [14] The
surgical nurse explained that a computerized system tracked
the temperatures, and the refrigerator had an alarm that would
go off if the temperature rose above the acceptable limits. The
nurse said that the alarm would sound in the room, and there
was also an alert at the nurses’ station. The surveyor asked
what would happen if the refrigerator failed, and she said that
the tissue could be moved temporarily to a refrigerator in the
laboratory area. [15]
Evaluating Tissue Receipt with the Purchasing Department. The surveyor then went to the purchasing department to learn about how tissues were received. [16] The staff
there explained the process. When tissue shipments came in, a
staff member responsible for tissue and blood products examined the package for integrity, compared the shipping receipt
to purchasing records, and logged it into the system. That person then contacted the surgical department so someone could
pick up the shipment to bring it to the refrigerator in the surgical area. [17] The surveyor asked what staff would do if
there were reason to believe that the tissue had become damaged or contaminated. [18] The purchasing staff said that they
would first contact the tissue supplier about another shipment.
If the supplier instructed them to destroy the damaged tissue,
they would dispose of it with the facility’s other biological
waste and record the disposal in the tissue log. [19]
• Creating checklists for pre- and postsurgical processes that
remain with the patient record to be accessible to all necessary staff
• Reviewing tissue refrigeration procedures to determine if
they provide process improvement opportunities
Reviewing Tissue Processes with the Surgical Nurse.
Next, the surveyor interviewed the surgical nurse. The patient
had received refrigerated tissue, so he asked about the process
for accepting and storing tissue. [11] The nurse said that they
recorded the lot numbers in the tissue log. The surveyor asked
37
Scenario 1-9.
[17] How does the tissue get taken to the surgical area?
[19] How would damaged tissue be disposed of?
Patient:
[1]
Did you sign a consent form? What was your
understanding of the form?
[2]
Who explained the procedure to you?
[3]
What were the risks and benefits of this surgery, as
they were explained to you?
[4]
Did the anesthesiologist examine you? What did he
ask you about your medical history?
Transporter:
[6]
How do you confirm a patient’s identity before
transport?
[7]
What do you do to minimize the risk of a fall?
[8]
Please describe your process for handing off the
patient at the new location.
Surgeon:
[9]
How is the patient identified when he or she arrives
in the patient holding area before surgery?
[10] When was the surgical site marked? How was it
marked?
Surgical Nurse:
[11] Describe the process for accepting and storing
tissue.
[12] Please provide the tissue log for review.
[13] Please show me the refrigerator used to store tissue
in the surgical area.
[14] What happens if the refrigerator’s temperature rises
above acceptable limits?
[15] What happens if the refrigerator fails?
Purchasing Department Staff:
[16] Describe the process by which tissues are received.
38
[18] What would you do if you believed the tissue had
been damaged or contaminated?
SCENARIO 1-10.
Suburban Teaching Hospital
Summary
In the following scenario, a surveyor traces a hospital’s process
for selecting and implementing a new type of IV pump.
• Equipment Use
• Patient Safety
Scenario
During the observation of an IV medication administration on
a general medical unit, the surveyor noted that the nurse
seemed unsure about how to set the IV pump. Following a few
extra manipulations, the pump was engaged.
39–40.)
Reviewing Pump Procedure with the Medical-Surgical Nurse. The surveyor questioned the nurse about his experience with the pump. [1] The nurse admitted that this was
a relatively new unit, so he didn’t have much experience using
it. He added that the presence of the surveyor had made him a
little nervous. The surveyor asked the nurse what he did when
he had difficulty with a pump, and he said that if he were unable to get it to engage on his own, he would ask another
nurse on the unit. [2]
Discussing the New IV Pump with the Nurse Manager. Next, the surveyor met with the nurse manager. She
began by questioning the nurse manager about how this particular pump was selected for use on their unit and how staff
members were trained on its use. [3, 4] The nurse manager explained that there was a committee that made those decisions,
and that staff had some input. Then the hospital’s education
department, aided by her unit-based educator, trained staff on
the use of the new pump. The surveyor asked how the proce-
dure manual was updated to reflect the new equipment. The
nurse manager said that, after the training, she and the unitbased educator reviewed existing procedures and made changes
where necessary. [5]
Learning About Equipment Purchasing with the
Chief Nursing Officer. The surveyor then met with the
chief nursing officer to ask how the purchase of new patient
care equipment took place. [6] She learned that there was a
Products Review Committee, and that nurses did have a
chance to test new products and give their preferences. Both
the departments of nursing and pharmacy had had reservations about the safety and effectiveness of the previous pumps,
and they had worked together to construct a capital budget request for the current model. [7]
When the surveyor asked about the pharmacy department’s involvement in the process, the chief nursing officer added that
the pharmacy director had also had concerns about the safety
of the old pumps with pediatric patients and with some of the
more potent drugs that they were using more routinely. [8]
She pointed out that the pharmacy director had an ad hoc seat
on the Products Review Committee for situations in which
pharmacy- and medication-related devices were being
considered.
Discussing New Equipment Education. Next, the
surveyor met with the director of the education department.
She asked whether the educators were involved in the selection
of new patient care equipment. [9] The education director
said that they usually were not involved. The surveyor then
asked how educators were informed when there was new
equipment for which they would need to provide training to
staff. [10] He replied that the Products Review Committee
sent him a notice when a new piece of equipment had been
approved for purchase, so he would be able to obtain educational materials ahead of time.
Next, the surveyor asked whether all new equipment training
passed through the education department, and the director
said that it did not. The surveyor asked how the training occurred, in those cases. [11] Some training, the director explained, was overseen by the manufacturer; a manufacturer’s
representative would sometimes come to the facility to conduct training. In other cases, formal training was not necessary
because the new process was not much different from the old
one; when those situations occurred, the nurse manager for the
affected units would usually conduct a brief training session at
a unit meeting. The surveyor asked if the director’s department
documented those training sessions, and he said that they did
not. [12]
The surveyor then asked about the training process for the
new pump, and the education director said that his department had coordinated the training sessions. [13] When asked
which staff participated in the sessions, the director said that
all nursing staff had been included. [14] The surveyor asked
for evidence of class attendance for the nurse she had observed
earlier and found that he had attended one of the classes. [15]
However, the documentation did not include evidence of any
competency testing for the class attendees. [16]
Interviewing Another Nurse About the IV Pump.
The surveyor then asked to see another patient who was receiving IV medications via the new pump. She observed another nurse setting up the pump, and she seemed to do so
smoothly. That nurse said that she had attended the training
conducted by the hospital’s education department.
Moving Forward. Based on the tracer findings, the surveyor may discuss areas for improvement in the daily briefing.
• Including formal competency testing in the training sessions provided by the hospital’s education staff
• Maintaining written documentation of all training on new
equipment, regardless of who is conducting the training
Scenario 1-10.
[1]
What is your previous experience with this IV pump?
[2]
What do you do when you have difficulties with the
pump?
Nurse Manager:
[3]
How was this particular pump selected for use on
this unit?
(continued)
39
Scenario 1-10.
(continued)
[4]
How were your staff trained on the use of this new
pump?
[5]
How does the procedure manual get updated to
reflect the new equipment?
Chief Nursing Officer:
Director of Education:
[9]
How are educators involved in the selection of new
patient care equipment?
[10] How are educators informed that there is new
equipment for which they will need to provide
training to staff?
[11] If training does not go through the education
department, how is it handled?
[12] How does your department maintain documentation
of training provided by other sources?
[6]
How does the purchasing of new patient care
equipment take place?
[13] How did your department handle the training for this
new IV pump?
[7]
How did the products review committee determine
that new IV pumps were needed?
[14] Which staff members participated in the training?
[8]
How was the pharmacy department included in this
process?
[15] Please provide attendance documentation for the
training sessions.
[16] Is there documentation of competency testing
conducted at the training sessions?
40
Sample Tracer Worksheet: Scenario 1-3.
The worksheet below is an example of how organizations can
use the sample tracer questions for Scenario 1-3 in a worksheet
format during a mock tracer. The bracketed numbers before
each question correlate to questions described in the scenario.
Tracer Team Member(s): Daryl Edwards
Subjects Interviewed: Miko Takahashi, Mark
Doolin, patient, Taylor Bosch, Cynthia Parker
Tracer Topic or Care Recipient: communication,
education
A correct answer is an appropriate answer that meets the requirements of the organization and other governing bodies.
An incorrect answer should always include recommendations
for follow-up.
Data Record(s): patient satisfaction surveys
Unit(s) or Department(s): ED, nursing, nurse
education
Interview Subject: Nurse
Questions
[1] Please provide the patient’s
record.
Correct
Answer
✔
communicate with the patient?
have for meeting the patient’s
Follow-Up
Needed
Comments or
Notes
✔
[2] How were you able to
[3] What other resources do you
Incorrect
Answer
Hospital staff should
try to find medical
interpreter and not rely
on family member
✔
Hospital has a language
interpretation line
✔
Using “faces” scale
communication needs?
[4] How are you assessing the
patient’s pain?
[5] Does the hospital have a
language phone line? How is it
✔
used and how frequently is it
used?
[6] Are the patient’s responses
being documented in the
Staff should be trained
to use the line instead of
using untrained family
member
✔
medical record? Please provide
an example.
[7] Describe what you know
about the cultural aspects of
pain expression and
✔
Need review to determine
if past education is still
adequate
management.
(continued)
41
Interview Subject: Nurse (continued)
Questions
Correct
Answer
Incorrect
Answer
✔
[8] What is the hospital’s policy
regarding who may interpret for
the hospital when health
Follow-Up
Needed
Comments or
Notes
Staff should be more
strongly directed to use
the phone line
information needs to be
communicated with a limited- or
non-English-speaking patient?
Interview Subject: Radiologist
Questions
[9] Please provide the consent
forms for the patient’s imaging
Correct
Answer
Incorrect
Answer
Follow-Up
Needed
Comments or
Notes
✔
A medical interpreter
should be available in
person or on the
language phone line for
this purpose
Family member
interpretation may be
inadequate
✔
Further staff education
is needed
✔
procedures.
[10] Detail the hospital’s policy
and procedures regarding
✔
consent forms.
[11] How were you able to
obtain informed consent from
the patient using a form that is
written in English?
[12] What are the hospital’s
policies and procedures
regarding consent forms and
interpreters?
Interview Subject: Patient
Questions
[13] Are you comfortable with
the way staff cares for you and
Correct
Answer
Incorrect
Answer
Follow-Up
Needed
✔
Comments or
Notes
Patient appears to
understand
speaks to you? What can you
tell me about their explanation
regarding your plan of care?
[14] Did you understand the
forms you signed before your
procedures? Who explained
them to you? At what point was
it done?
42
✔
A medical interpreter
should be available in
person or on the
language phone line for
this purpose
Daughter understands
form; may not have
communicated well to her
mother
Interview Subject: Patient (continued)
Questions
[15] Is your pain being managed
effectively? Please explain why
Correct
Answer
Incorrect
Answer
Follow-Up
Needed
Comments or
Notes
Incorrect
Answer
Follow-Up
Needed
Comments or
Notes
New hires need full
training session
All staff need refresher
Follow-Up
Needed
Comments or
Notes
✔
or why not.
[16] Do you have any dietary or
other needs that have not been
✔
met that you feel would make
you more comfortable? If they
are not being met, please
explain what could be improved.
If they are being met, how has
that been accomplished?
Interview Subject: Nurse Educator
Questions
Correct
Answer
✔
[17] What sort of training has
been conducted with regard to
the telephone interpretation
system? How were physicians
included in that training?
Interview Subject: Director of Nursing
Questions
Correct
Answer
[18] What action plans were the
result of the communication
Incorrect
Answer
✔
Review survey to develop
performance
improvement plans
✔
Conduct survey to find
areas for improvement
portion of the patient satisfaction
survey?
[19] How effective is your staff
in meeting the communication
needs of their patients,
particularly those who do not
speak English? Please describe
how improvements might be
made in this regard.
[20] How do multilingual staff
members fit into the patient
✔
communication plan?
(continued)
43
Interview Subject: Director of Nursing (continued)
Questions
[21] How do you assess the
language competency of staff?
44
Correct
Answer
Incorrect
Answer
✔
Follow-Up
Needed
Assess fluency of
interested staff members
and certify them to
interpret for patients
Comments or
Notes

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