EVEN MORE Mock Tracers

EVEN MORE Mock Tracers

Senior Editor: Robert A. Porché, Jr. Senior Project Manager: Christine Wyllie, MA Manager, Publications: Lisa Abel Associate Director, Production: Johanna Harris Executive Director: Catherine Chopp Hinckley, MA, PhD Joint Commission/JCR/JCI Reviewers: Patricia Adamski, RN, MS, MBA; Lynn M. Berry, JLA; Lynne Bergero, MHSA; Mary Cesare-Murphy, PhD; Caroline Christensen; Kathy Clark, MSN, RN; Christina Cordero, PhD, MPH; Beminda Datuin-Pal, RN, BSN, MSHSA, MBA; John Fishbeck, RA; John E. Gibson, MA, MT(ASCP)DLM; Donna M. Gillespie, MBA, CSSGB(ASQ), MT(ASCP)SM; Claudia J. Jorgenson, RN, MSN; Sherry Kaufield, MA, FACHE; Stephen F. Knoll, CRNA, MA; Michael Kulczycki, MBA, CAE; Margherita C. Labson, RN, MSHSA, CCM, CPHQ, CGB; Peggy Lavin, LCSW; Cynthia Leslie, APRN, MSN; Dana McGrath, RN, MSN, CASC; Pat McVeigh, RN, MSN, CEN; George Mills, MBA, FASHE, CHFM, CEM, CHSP; Stacy Olea, MBA, MLS(ASCP), FACHE; Mark G. Pelletier, RN, MS; Kelly L. Podgorny, RN, MS, CPHQ; Carol Ptasinski, RN, MSN, MBA; Paul Reis; Jennifer Rhamy, MBA, MA, MT(ASCP)SBB, HP; Mark E. Schario, MS, RN, FACHE; Edward Smith, RN, MSN; Laura Smith, MA; David Wadner, PhD; John Wallin, RN, MS; Joyce Webb, RN, BSN, MBA, CMPE; Merlin Wessels, MSW, LCSW, ACSW; Gina Zimmerman, MS Joint Commission Resources Mission The mission of Joint Commission Resources (JCR) is to continuously improve the safety and quality of health care in the United States and in the international community through the provision of education, publications, consultation, and evaluation services. Joint Commission International A division of Joint Commission Resources, Inc. The mission of Joint Commission International (JCI) is to improve the safety and quality of care in the international community through the provision of education, publications, consultation, and evaluation services. Joint Commission Resources educational programs and publications support, but are separate from, the accreditation activities of The Joint Commission. Attendees at Joint Commission Resources educational programs and purchasers of Joint Commission Resources publications receive no special consideration or treatment in, or confidential information about, the accreditation process. The inclusion of an organization name, product, or service in a Joint Commission Resources publication should not be construed as an endorsement of such organization, product, or service, nor is failure to include an organization name, product, or service to be construed as disapproval. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. Every attempt has been made to ensure accuracy at the time of publication; however, please note that laws, regulations, and standards are subject to change. Please also note that some of the examples in this publication are specific to the laws and regulations of the locality of the facility. The information and examples in this publication are provided with the understanding that the publisher is not engaged in providing medical, legal, or other professional advice. If any such assistance is desired, the services of a competent professional person should be sought. 2012 The Joint Commission Joint Commission Resources, Inc. (JCR), a not-for-profit affiliate of The Joint Commission, has been designated by The Joint Commission to publish publications and multimedia products. JCR reproduces and distributes these materials under license from The Joint Commission. All rights reserved. No part of this publication may be reproduced in any form or by any means without written permission from the publisher. Printed in the U.S.A. 5 4 3 2 1 Requests for permission to make copies of any part of this work should be mailed to Permissions Editor Department of Publications and Education Joint Commission Resources One Renaissance Boulevard Oakbrook Terrace, Illinois 60181 U.S.A. permissions@jcrinc.com ISBN: 978-1-59940-709-8 Library of Congress Control Number: 2012939306 For more information about Joint Commission Resources, please visit http://www.jcrinc.com. For more information about Joint Commission International, please visit http://www.jointcommissioninternational.org. ii

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 Sample Tracer Worksheet: Scenario 2-3...62 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 Sample Tracer Worksheet: Scenario 3-5...80 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 Sample Tracer Worksheet: Scenario 5-1...119 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 Sample Tracer Worksheet: Scenario 6-5...136 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 Sample Tracer Worksheet: Scenario 7-7...155 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 Sample Tracer Worksheet: Scenario 8-1...174 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

Even More Mock Tracers 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. 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- 2

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