5/23/2011

Speaker
 Sue Dill Calloway RN, Esq. CPHRM
Joint Commission Tracers  AD, BA, BSN, MSN, JD
2011  President
 Patient Safety and Education
 5447 Fawnbrook Lane
What Hospitals Need to Know  Dublin, Ohio 43017
 614 791-1468
 [email protected]

Tracer Methodology
 The surveyors follow actual experience of a sample
of patients as they interact with their health care
team
 The surveyors evaluate the actual provision of care
provided to these patients
 Looks at how the individual components of the
hospital interact to provide safe, high quality patient
care
 System tracer examine in detail specific high risk
components of the hospital like medication
management
 The proof is in the pudding and this makes great
sense
3 4

Introduction to Patient Tracers Introduction to Patient Tracers

 Purpose is to evaluate compliance with the  The majority of the action (survey activity) occurs at
standards as they relate to the care and treatment the point where care is provided
of a patient 1
 The term “individual tracer’ denotes the survey
 Tracers are integral to the on-site survey process method used to evaluate how the hospital is
and often referred to as the corner stone of the complying with the standards provided to an
Joint Commission survey (no longer called JCAHO) individual patient
 Practicing tracers are a great way to prepare for  Will identify hospital-based physicians and ask if
your survey
they would like to accompany the surveyor on an
 Tracers can provide you with information and ability individual tracer
to increase patient safety and improve clinical
outcomes  Surveyor will target units with negative outcomes for
 1 Tracer Methodology: Tips and Strategies for Continuous System Improvement, 2 nd edition, TJC patient tracer selection
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2011 Survey Activity Guide TJC Survey Activity Guide

www.jointcommission.org/2011_survey_activity_guide/

http://www.jointcommission.org/2011_survey_activity_guide/
7 8

Document List for 2011 Introduction to Patient Tracers

 Individual Tracers can be program specific such as
fall reduction and hospital readmission for OME
(home care) or patient flow and lab integration for
hospitals
 Violence prevention, elopement, and suicide
prevention for BHC, Continuity of care for AHC etc.
 New tracer in 2011 for psychiatric hospitals that
participate in Medicare and Medicaid
 Multiple activities tied to the CoPs
 Focused tracers occur during time designated for
individual tracer activity in 2011
9 10

Introduction to Patient Tracers Individual Patient Tracers

 In 2011 added reminders in the individual tracers  Selects tracers based on several things such as the
addendum, Data Management and Infection Control clinical services groups (CSG) accreditation
System Tracer, and the Competence Assessment program specific categories of patient services
guides to explore aspects of employee health (hospital ones such as cardiology, oncology,
 Remember the patient centered communication vascular surgery, etc.)
standards in the individual tracers and competence
 Top PFAs (Priority Focus Areas) generated from
assessments
using the pre-survey data from multiple sources
 Many of the program specific activities are designed
to take place during the individual tracer activity  These two help to highlight areas of priority focus,
 Surveyor selects patients for tracers using the  Priority focus process (PFP) that integrates
Priority Focus Areas (PFA) and clinical/service organization specific data to help surveyors focus on
groups area relevant to your hospital,
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Looks at 14 Priority Focus Areas Introduction and Surveyor Planning Session

 Looks at the 14 priority focus areas (PFA)  In surveyor preliminary survey planning session
discusses logistical needs
 PFA (priority focus areas) are: assessment and
care/services, communication, credentialed  Session lasts about 30-60minutes and individual
practitioners, equipment use tracer is 60-120 minutes each day of survey
 Infection control, information management,  Surveyor needs workspace to use as their base for
medication management, organizational structure, the duration of the survey
orientation and training  Phone, desk or table, access to plug
 Patient safety, physical environment, quality  Need name and phone number of key person to
improvement, rights and responsibilities, and assist them in planning and their tracer selection
staffing
 This is done to plan for tracer activity
13 14

Introduction Introduction
 Surveyor will begin planning for tracer shortly after  Documents such as the organizational chart,
they arrive contact person to assist surveyor, and map
 Will describe priority focus processes and describe  List of all sites eligible for survey, list of services at
system tracer they will conduct each site, PI data, and infection data,
 They will review the documents provided  EOC data with Statement of Conditions and any
Plans for Improvement (PFI)
 Readiness Guide lists the documents needed so
make sure you have these ready to go  Patient lists of scheduled for deliveries, surgeries
and procedures, patient roster and measure of
 Integrate tracers findings into Periodic success data
Performance Reviews (PPR)

15 16

Individual Tracer Individual Tracer

 Duration of individual tracer activity varies but  Individual tracer starts in unit where the patient and
typically is about 60-120 minutes the medical record are located

 Practice multiple mock tracers before the survey so  Starts by reviewing a medical record with the
staff are prepared and comfortable person caring for the patient

 Surveyor will assure confidentiality and privacy and  If staff person is not available may ask for
supervisor
may use more than one patient
 Want to see the ease with which the staff navigate
 Purpose of using the medical record is to follow through the medical record to located the requested
care provided information
 Surveyor evaluated compliance with standard as  Will explore how well record supports the care
they apply to the care the patient received provided
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Individual Tracer Individual Tracers LIPs Physicians

 May traces the care from preadmission through post-
 May need to plan meeting on another day or arrange for
discharge
a phone call at the convenience of LIPs
 Majority of survey activity occurs during individual tracers
 Will evaluate the communication and care with other
 May select patients with more complex situation and more LIPs
contact with various parts of the organizations to assess
continuity of care issues  May ask about consulting physicians, attending and what
information is communicated to other hospitals when the
 Surveyor to assess relationship between departments and patient is transferred
services
 Or discharge home to the care of a different physician
 Be sure to include compliance with NPSGs since this are hit
hard during the survey  Will look at roles and responsibilities related to the EOC
including how to prevent and response to incidents
 Surveyor is to evaluate all of the NPSGs during  Including how to report events that do occur
the course of the survey
19 20

Patient Interviews Patient Interviews

 Surveyor will ask patients: Surveyor will ask patients:
 How their oral and written communication needs Response time for call cord
were met including how language services were
provided Perception of services
 Involvement in decision making about their care Understanding of discharge instructions
 Informed consent prior to surgery
If staff inquired as to race and ethnicity
 If information on right to have support person was
given If staff complied with NPSGs
 Education provided
21 22

Individual Tracer Surveyor Observes Individual Tracer Surveyor to Observe

Surveyor observes care in the following: Surveyor observes care in the following:
 Medication process (preparation, administration,  Potential EOC issues as it related to patient safety
storage and security)
 Care planning process with timing of the patient
 Infection control issues (hand hygiene, sterilization assessments
of equipment, disinfection, food sanitation, and
housekeeping)  Staff use of resources and tools to identify patient
communication needs and if interpreter needed
 Care planning process which means looks at care
being provided to patients by staff and physicians  Use of teach back to address health literacy needs
 Observe patient access to the call button

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Surveyor to Observe During Individual Tracer Individual Tracer

 Observe surgical procedure from ante-room with During survey, surveyor interviews staff about:
patient permission
 Processes and compliance with the standards and
 Will go to surgery to observe a procedure and will PFAs
make sure time out done and hand hygiene  Communication among departments to coordinate
guidelines are followed care
 Lab (quality control, maintenance and testing  With attention to hand offs
performance)
 Patient education process
 Observe hand off communications including ability
 Orientation, training, and competency testing
to ask questions and respond to question

25 26

Interview Staff During Individual Tracer Individual Tracers Selection Hospitals

 Patient flow through the hospital (see later section)  Consider criteria in selecting a patient:
 Workload issues that may effect patient care  Patient with infections

 If present will look at staffing plans, variance  Patients that cross programs like admitted to or
discharged from an ambulatory care setting or
reports, manager interviews and additional staff outpatient care setting
interviews
 Potential role of infections in the cause of death,
 Awareness of content of APR.09.02.01 delay in treatment, lack of appropriate follow
 Any individual who provides care can report through with the organ donation guidelines/lack of
safety or the quality of care concerns to TJC timely communication with the OPO
without retaliatory action from the hospital  May look at deceased patient to determine if
evaluated coordination with OPO
27 28

Patient Centered Communication Patient Centered Communication

 During each individual tracer surveyor will interview  During each individual tracer surveyor will interview
staff about the following: staff about the following:
 What the hospital is doing to minimize risk  Hospital support of patient’s right of access to
 How the hospital is collecting race and ethnicity data advocate or support person during hospitalization
 How are the staff asking patients about their  Will interview interpreters and translators about their
communication needs training, experience, and qualifications
 How staff identify if patients have oral or written  This includes employed staff, bilingual staff, and
communication needs and how these are address volunteers
 Access to language interpreters and translated  Remember the 2011 TJC five patient centered
documents and involvement of interpreter on the care communication standards in 4 different chapters
team
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Retrospective Autopsy Review Complaint Resolution Process

TJC implemented standard since a CMS CoP  Surveyor will discuss how hospital handles the
requirement complaint process with staff
 How are complaints reviewed and resolved?
Surveyor will review the hospital’s policy on
autopsies  Is a written letter sent for significant complaints

Will do a closed medical record review  Will interview patient to makes sure got information
on who to contact to file a complaint and right to
 This is being done to verify that the hospital policy notify the state agency
was followed regarding autopsy appropriate
deaths  Will review the complaint P&P to confirm it includes
patient’s right to report without negative
consequences
31 32

Contract Services Tracer Contract Services Tracer

 Will talk to a patient who received care from a contracted
provider Know how you monitor contracted services
 Be sure to should know the scope and nature of contract
and contracted individuals
services and how they were oriented to the hospital’s
processes
Be sure to know the PI you are doing on
contracted services and individuals
 Surveyor will interview leaders on their oversight for
contracted services Surveyor may review contracts
 LD.04.03.09 has the ten elements of performance which
hospitals should make sure they are in compliance with Consider having all contracts in one place
 Leaders need to monitor contract services and evaluate and have log of all contracts
these contracts
 Review as part of PI process and surveyor will review
contracts
33 34

Emergency Services Emergency Services Tracer

 During each individual tracer surveyor will Discuss immediate availability of services,
interview staff about the following: equipment, personnel, and resources for
 Who is responsible for direction of services providing patient care
 Who supervises emergency services
Integration and communication of emergency
 How emergency services are integrated with other services with other departments such as lab,
departments or services of the hospital
ICU, and diagnostic services
 How the hospital provides for medical and nursing
personnel qualified in emergency care to meet the Provision of follow up care to patients not
needs anticipated by the facility admitted or transferred
 MS involvement in the ED and responsibility for the ED
Process for MS review of P&P (new)
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Emergency Services Tracer Hand Hygiene Tracers

 Process or length of time it takes to transport ED  Surveyor will observe staff and physicians as they
patients to another department and get them back provide care
 Will observe all opportunities for hand hygiene as
 This is also important with CMS so patients do not
outlined in the CDC or WHO guidelines
sit around waiting to be brought back to the ED
 Will observe before contact with patients, before putting
 Time it takes to get interventions or tests done on gloves to insert central line, IV, or Foley
 Time it takes to deliver equipment and supplies to  Will observe after when contact with intact skin (taking
the ED BP or pulse, turning patient or giving medication) and
after removing gloves and having contact with bodily
 Will review P&P to appraise emergencies, provide fluids
initial treatment, and refer patients when needed in
 Before putting on sterile gloves when performing surgical
hospitals that do not provide emergency services procedures
37 38

PI PI
 Data collection processes and responsibilities  Applicable undesirable patterns or trends in
performance that are being aggregated and
 medication management
analyzed
 blood and blood product use
 How to identify and implement changes to reduce
 restraints and seclusion the risk of sentinel events
 behavior management and treatment  Process to take appropriate action if planned
improvements are not achieved or sustained of data
 Inclusion and monitoring of contracted services and from outside sources to determine if variability or
individuals unaccepted level of performance
 Use of data analysis in the identification and  Core measure implementation and process
implementation of process improvements changes
39 40

PI Active Review of Discharge Planning Tracers

Changes in PI activities to accommodate  There is one on active review of discharge planning
urgent events such as patient health and another on retrospective review
outcomes, high-volume, high-risk, or problem  Have a list of those patients to be discharged
prone processes, adequacy of staffing,  Review medical record for discharge order
significant changes in the internal or external
 If home health or transfer to LTC will verify list was given
environment to patient
Proactive activities for identifying and  Discuss the discharge evaluation and planning process
reducing unanticipated adverse (UO) events  May observe a nurse do the discharge
and safety risks to patients are being
performed  Surveyor will ask the hospital to obtain the patient’s
permission to observe the discharge process
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Discharge Instructions Should Include Discharge Instructions Should Include

 Survey will look for the following things so make  Nurse needs to repeat back information to confirm
sure discharge instructions include: patient’s understanding
 Activity, diet, and medications to take post  The surveyor is review the written discharge
discharge instructions given to the patient
 Plans for physician follow up  Surveyor will review the discharge planning P&P
 Wound care if applicable  Make sure written in language patient can
understand
 Signs and symptoms to be aware of (fever,
medication side effects, etc.)  The issue of low health literacy
 20% of patients read at a fifth grade level
 Name and phone number of doctor to call if there is
a question or problem  Necessary to prevent unnecessary readmissions
43 44

Discharge Instructions Should Include Discharge Instructions

Surveyor will interview patient to make sure they Surveyor will interview patient to make sure they
understand the following: understand the following:
 Purpose of taking any medication  Changes in diet or dietary restrictions or supplements
 S&S of problems and who to call
 How to take the new medication including dose
and frequency  Self care information (wound care, activity)

 Possible side effects of the medication  Arrangement for follow up such as with physician or home
health
 Contraindications with OTC and prescribed  Hand off communication
medications
 Medication reconciliation
 When to continue or discontinue medications
taken prior to hospitalization  Surveyor may interview nurse to check the origination of
discharge information (nurse-physician communication)
45 46

Discharge Planning Retrospective Review Infection Control

 Will look at list of patients discharged in last 48  Surveyor will observe clinicians and physicians to
hours make they comply with the CDC or WHO hand
hygiene guidelines
 Will review for discharge order and any written
instructions given to the patient  Will interview staff and observe about the following:
 Will call patient at home and interview  Employee health requirements

 Purpose is to get patients perception of  Sterilization of equipment and disinfection

discharge instructions and were they given all  Food sanitation
the information they needed  Housekeeping cleaning process and
 Will review discharge planning P&P  Other means to limit the spread of infection
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Staffing Tracer Staffing Tracer

 Surveyor may interview staff nurse individually about the  Surveyor to validate there is an RN on duty at all
workload, elicit information about the work hours,
frequency of missed lunch breaks and overtime
times
 May ask what do you do when someone calls in sick or  Surveyor may interview CNO about staffing
rapid turn over of patients problems and turn over
 May ask about recent weekend or holiday staffing  Surveyor may review meeting minutes, staffing
pattern plans, and variance reports
 Surveyor may follow up with nurse manager individually
and look at a sample staffing schedule for one week  Surveyor will look for negative outcomes as result
of staffing and explore if system wide
 Instructed to explore issues of insufficient staffing,
budgeting process, recruitment and retention  Surveyor may ask staff knowledge about the
patients they are assigned
49 50

Selection Behavior Health Care Lab

Care provided to:
 Patient sample testing in laboratory sections
 Programs and services (i.e., hematology, chemistry, microbiology,
blood bank)
 High risk population such as R&S, restraint use, or
suicidal  Policy and procedures that guide testing
performance of patient samples
 Vulnerable population such as very young or very
old or MR/DD patients  Maintenance of laboratory equipment
 Patients with long length of stay  Pre- and Post- analytical procedures
 Additional reference slides at end on elopement,
suicide, violence etc.
51 52

Program Specific Tracers Lab Integration CAH HAP

 There are program specific tracers done under  Must be evaluated in every survey
individual tracer times  Surveyor will look at exchange of information such as
 Example is for ambulatory healthcare programs specimen collection and handling and specimen
there is one on continuity of care identification
 Will look at ones related to hospitals  Surveyor will look at point of care testing and cleaning
of glucose meters
 Example is elopement which is specific to
behavioral health care which has 24 hours care  This tracer is not about quality control, technical
settings competence or proficiency testing but communication
 This could include addiction treatment, residential and integration
treatment, group homes, development disabilities  Will trace a patient who received blood or blood
centers, mental health, or foster homes
product or patient with a critical lab value
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Lab Integration Lab Integration

 Will interview the med tech and person who
Trace lab component of patient’s experience
transported the blood separately
by walking from each area where activity
 Will look at flow of information from lab to the took place and talking with those involved in
hospital unit the activity
 Will begin with test order
Interview lab staff who drew the blood or
 Will move through physician’s actions based on reported the results
testing results
Interview person who ran the tests
 Will ask about process for look back program
 Will review agreement with blood supply agency Interview person who hung the blood or
received the critical test results
55 56

Blood Transfusion Blood Transfusion

 Will interview lab staff in the blood bank and the Will interview lab staff in the blood bank and
person hanging the blood about the following: the person hanging the blood about the
 Protocol for ordering and issuance, including: following:
 Communication from unit about need for Protocol for unused blood products
blood Evaluation and maintenance of administration
 Patient identification equipment
 Blood product identification Data collection, communication and use
 Patient evaluation of adverse reactions, Storage when blood is not being used
reporting, discovery, notification and process
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Patient Flow CAH and HAP Programs Patient Flow Tracer LD.04.03.11
 Surveyors are to interview staff during each of the
individual tracers on what patient flow processes  Look at patient flow and back flow issues
are being measured  Evaluate process issues leading to back flow
 What other PI measures are in use  Identify temporary holding area such as are patients
 What has the hospital learned? held in the emergency department or waits for
surgery or critical care units
 How has this data been used to make
improvements  Treatment delays, medical errors and unsafe
practices can thrive in presence of patient congestion
 Surveyor will look for variability in workload during
the day and between days of the week  TJC hospitals are expected to identify and correct
patient flow issues
 Ask about wait, boarding, and turnaround times
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Patient Flow Tracer LD.04.03.11 Triggers Indicative of Patient Flow Problems

 Delay in blood draws or x-rays
 Look at how the hospital plans for staffing and
trains staff about differences in emergent and  Delay in communication such as reporting
hospital care handoff from one area to another
 What you have done to improve and plan for  Delay in discharge due to discharge processes
diversion
 Delay in OR scheduling
 Look at past data collection
 Hospital process that stop flow of patient in ED
 How do you identify problems and implement such as work up in ED or housekeeping
improvements
protocols
 LD needs to share accountability with MS
 Misuse of ED for direct admits
61 62

Triggers Indicative of Patient Flow Problems

 Increase length of stay in the ED
 Insufficient support and ancillary staffing
 Misuse of ED for low acuity patients and direct
admits
 Patients experiencing delays with transfers
 Indicators such as MI get ASA and beta blockers on
arrival and fibrinolytic with 30 minutes and PCI
within 90 minutes
 Pneumonia patients blood cultures and antibiotics
timely?
63 64

Patient Rights Tracer Patient Rights Tracer

 Staff discussion and observation on communication Surveyor should assess patient and family
between shifts and departments
understanding of the following:
 Education of patient needs with culture and
language diversity, and physical and cognitive  Rights including advance directives
challenges Make sure given rights prior to receiving care
 Use of R&S (CMS has 50 pages of standards and
TJC is more closely aligned in 2011) Process and right to register a complaint or
grievance (CMS has grievance standards)
 Process when patient refuses care
Patient safety and privacy of health
 Process to inform family, surrogate, or another
physician of admission when requested by patient information
(CMS)
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Transplant Safety TS Chapter in 2011 Tissue Storage and Issuance Tracer

 Will trace a patient who has had tissue
implanted or transplanted
 Active or discharge patient

 Will review the medical record

Interview lab staff to determine the following:
 Oversight responsibility assignment to one
of more staff for acquisition, receipt,
storage, and issuance of tissue
(TS.03.01.01 EP1)
67 68

Tissue Storage and Issuance Tracer Tissue Storage and Issuance Tracer
Interview lab staff to determine; Physical environment (EP 8, 9, and 10) should
 Process for ensuring source is licensed include the following:
and federally registered with FDA (EP3 &  Daily records to show tissue temperature when
11), control is needed and document
 Coordinate tissue ordering, receipt, storage  Storage with continuous temperature of refrigerator
as per manufacturer instructions and policy and freezer is maintained and documented
(EP4&5)  Refrigerators and freezers and storage equipment
 Process for logging all tissue and used to store tissues at controlled temperature has
functional alarms and emergency back up plan
documenting receipt and make package
integrity is met and transport temperate  Acceptance of tissue from the source with process to
was controlled (EP 6&7) ensure package integrity and temperature
69 70

Tissue Storage and Issuance Tracer Tissue Storage and Issuance Tracer
 Record keeping (TS.03.02.01 EP 5 & 6) includes Will look at adverse event investigation for the
tissue records on storage temperatures, outdated following (TS.03.03.01 EP5):
procedures, manuals and publications are kept for
10 years  Written P&P to investigate adverse events related
to tissue use or donor infections
 Records are kept on tissues suppliers
 Tracking and investigation of tissue transplant
 Records are kept on source facility information, pre infections
transplant (such as materials and instructions to  Reporting of infections or adverse event to the
prepare tissues) and post transplant documentation tissue supplier
(tissue type and its unique identifier) and return
information (return tissue usage information cards  Tissue recipient notification of infection risk or
donors subsequently found to have HIV or hepatitis
requested by tissue supplier)
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Organ, Tissue and Eye Procurement OPO Organ, Tissue and Eye Procurement OPO
 OPO conversion rate for patients who died who  Hospitals in tier 1 regardless of size
wanted to be organ donors and were eligible
 IC and or ED patient tracer
 For hospitals in Tier 1 (conversion rate <50%)
 The hospital’s communication and coordination
 Tier 2 (conversion rate between 51-74%) with more with the OPO and discussions about:
than 150 beds
 The organization’s definition of imminent death
 Staff knowledge about identification criteria and process
 Process for communication and coordination with the OPO  Roles and responsibilities of different staff relative
(24/7) to the pursuit of organ donation opportunities
 Associated traceable issues, e.g. Advance Directives,  The organization’s position about asystolic recovery
language barriers, spiritual issues, data collection, etc.
of organs
 Hospital position about asystolic recovery of organs
73 74

Radiology Tracer and Nuclear Med Radiology Tracer

Discuss things such as patient and staff  Dissemination of reports
safety (shielding, lead aprons, badges,  Maintenance of printouts, films, and scans
pregnant patients, radiation safety, chemical  Identification and follow-up communication about critical
storage) results and findings

 Process for assuring shielding equipment is properly  Process for annual equipment maintenance and
maintained qualifications of staff that perform maintenance
 Request documentation of annual equipment maintenance
 Frequency of radiation exposure monitoring
 Observe EOC to assure safety precautions are being followed
 Qualifications, role, and responsibility of director and
workers must be checked periodically, by the use of  Observe radiation exposure monitoring equipment
exposure meters or badge tests, for amount of  Observe access and use of appropriate shielding equipment by
radiation exposure staff and patients.
75 76

Rehab Tracer Rehab Tracer

 Is there an order in the chart? Review and discuss the following:
 Who provides rehab care and what qualifications
 Process for developing a plan of treatment
are required
 Who orders the service
 Document Medicare patient plan of treatment prior
to beginning of treatment  Type and duration of service
 If speech pathology and audiology are part of rehab  Identification of measurable goals
services will ask the staff how they are enlisted by
the care team as a resource to communicate with  Changes in patient’s response to therapeutic
patients intervention

 Role of inter-disciplinary team

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Surgery and Anesthesia Tracer Surgery and Anesthesia Tracer

 Remember the CMS changes to the anesthesia  Discuss P&P for post operative care including
changes February 14, 2011 responsibilities of staff, discharge protocols, and
patient teaching
 Observe 2011 Universal Protocol in action
 Who may administer anesthesia and in what
 Patient permission is required for surveyor
settings; do they apply in all hospital locations
Discuss and review P&Ps for the following: where anesthesia services are provided
 Informed consent and make sure obtained before  Discuss protocol for supportive life function such as:
surgery for non-emergency surgery  Cardiac and respiratory emergencies
 Pre-operative care, including responsibilities for staff  Resuscitative techniques

 Procedural monitoring  Availability emergency drugs, supplies and equipment

 Process for handling a DNR status
79 80

Surgery and Anesthesia Tracer Verify That Surgery and Anesthesia Tracer
 H&P and consent on chart before surgery  Preanesthesia assessment to include (continued);
 Presedation or pre-anesthesia evaluation is done  Notation of anesthesia risk according to established
within 48 hours prior to the delivery of the first dose standards of practice (e.g., ASA classification of risk)
of medication given to induce anesthesia for the  Identification of potential anesthesia problems,
surgery or a procedure requiring anesthesia particularly those that may suggest potential
services; complications or contraindications to the planned
procedure (e.g., difficult airway, ongoing infection,
 Verify the pre-anesthesia assessment includes, at limited intravascular access)
a minimum
 Additional pre-anesthesia evaluation, if applicable
 Review of the medical history, including anesthesia, drug
and as required in accordance with standard practice
and allergy history;
prior to administering anesthesia (e.g., stress tests,
 Interview and examination of the patient additional specialist consultation)
81 82

Surgery and Anesthesia Tracer Intraoperative Anesthesia Record to Include

 Preanesthesia assessment to include (continued);  Name and hospital id number of the patient
 Development of the plan for the patient's anesthesia care,  Name of practitioner who administered
including the type of medications for induction,
maintenance and post-operative care and discussion with anesthesia, and as applicable, the name and
the patient of the risks and benefits of the delivery of profession of the supervising anesthesiology or
anesthesia operating practitioner
 Patients must be monitored during and immediate  Name dosage, route and time of administration
after moderate or deep sedation for the following of drugs and anesthesia agents
are in the Intraoperative anesthesia record
 Note that deep sedation is in the anesthesia bucket for  Technique used and patient position, including
CMS the insertion/use of any intravascular or airway
devices
83 84

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Intraoperative Anesthesia Record to Include Surgery and Anesthesia Tracer

Name and amounts of IV fluids, including  Supervision by the surgeon/practitioner performing
blood or blood products, if applicable the procedure or the anesthesiologist occurs when
anesthesia is administered by someone other than
Timed-based documentation of vital signs as a physician
well as oxygenation and ventilation  Operative reports are dictated or written
parameters immediately after the procedure and signed off by
the surgeon
Any complications, adverse reactions, or
problems occurring during anesthesia,  Surveyor will verify that the postanesthesia
including time and description of symptoms, evaluation was done by one of the five groups
vital signs, treatments rendered, and patient's qualified to administer anesthesia
response to treatment  Must be done within 48 hours after hit recovery room
85 86

Post Anesthesia Evaluation Must Include Surgery and Anesthesia Tracer

 Respiratory function including respiratory rate,  All of the above protocols must be documented
airway patency, and oxygen sat
 OR and PACU assess is restricted
 Cardiovascular function, including pulse rate and  OR register information is in the medical record
BP
 Resuscitation equipment is available, properly
 Mental status maintained, and staff responsible in the use of the
 Temperature equipment are competent
 Pain  Practitioner performing procedure is appropriately
privileged
 Nausea and vomiting
 Appropriate supervision of LPNs and surgical
 Postoperative hydration technologists occurs by RNs
87 88

Sample Hospital Surgery Tracer Respiratory Care Tracer

 Patient identification process Discuss the following:
 Sentinel event/safety hotline  Safety practices, including infection control
measures for equipment, sterile supplies, bio
 Universal protocol; time out documented hazardous waste, posting of signs and gas line
 Infection control; Wound classification documented identification
and Flash sterilization (immediate use steam)  Medication storage, ordering, dispensing, and
 Assessment; bone and tissue implants administration
 Medication Management  Who orders the service

 Labeling of medications  Procedure for treatment of adverse reactions

 Verbal order and read back  Review preventive maintenance logs

89 90

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Respiratory Care Tracer Medical Record Tracer

Review and observe the following; Surveyor will verify the following:

 Handling, storage, and dispensing of therapeutic  Information is filed in the MR in a timely manner
gases  This includes advance directives, lab reports, consults,
assessments etc.
 Cardiopulmonary resuscitation
 MR entries need to dated and TIMED and authenticated
 Testing protocols such as pulmonary function
testing, mechanical ventilation, bronchopulmonary  Complete informed consent needs to be on the
drainage, aerosol, humidification, and therapeutic chart and dated and timed and done prior to
gas administration nonemergency surgery

 Documentation of orders in the medical record  Validate the H&P and update was done in
appropriate timeframe
91 92

Medical Record Tracer Medical Record Tracer

Surveyor will review MR for the following:  Data on patient communication needs, including
preferred language for discussing health care
Sufficient information to identify the patient,
 Data on how patient communication needs are
support the diagnosis, justify the being or were addressed, including if a language
hospitalization, describe the patient’s interpreter was used or translated documents were
progress, and response to care provided
Authentication of H&P, operative report,  Data on patient race and ethnicity
consults and discharge summaries  Inclusion of appropriate information for discharge
That none of the unapproved abbreviations  Will interview MR staff to validate process and
are used timeliness to grant access to records
93 94

Waived Lab Testing Tracer Waived Lab Testing Tracer

 Patients who self test are exempt from CLIA  Identification of tests completed by non-
laboratorians in the specified location such as ED or
 During the individual tracer need to identify a patient
ICU
who is undergoing waived testing (Accucheck,
hemocult, gastrocult etc.)  Implementation of the waived testing quality control
plan including responsibilities
 Trace the hospital process by:
 Validation that the organization completed quality
 Reviewing documentation elements in the patient
control testing for the patient’s waived tests you are
record (quantitative result and acceptable range)
tracing
 Interview nurse or clinician about testing process
 Follow-up process when results are obtained
including orientation and training about the
equipment use and testing process
95 96

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Waived Lab Testing Tracer Food and Dietetic Services

 Will identify and interview the waive testing  Surveyor during survey to identify the national
director standards used for recommended dietary
allowances
 Surveyor to review the quality control plan and
other planning document such as P&P  Surveyor will observe hygiene practices and kitchen
sanitation
 Evaluate the personnel files to make sure staff
 Surveyor is to discuss the following:
trained and competent for each type of test used
 Safety practices for handling food
 Review additional data and trace where the data
 Assessment process to determine patient dietary needs
flows and its use in PI
 Process for prescribing and evaluating therapeutic diet
 Instrument maintenance orders
97 98

Food and Dietetic Services Dietetic and Food Services Tracer

 Surveyor is to discuss the following:  Objective is to assess and determine compliance
with standards and EPs related to nutrition care
 Process for accommodating special and altered diet
schedules  Objective to increase awareness of risk in nutrition
care practices and food service operations
 Follow-up process when the patient refuses food
served  Tracer begins where patient is located
 Qualifications of dietitian and dietary services  Surveyor to look for specific diet order from doctor
director  Will look for nutrition screening and dietician
 And verify availability of a current therapeutic diet assessment
manual for reference  Look for evidence that dietician written
recommendations are being followed
99 100

Surveyor Will Observe Topics Dietary Tracer

 Meal being served to patients; patient receives assistance
with eating, when needed; staff monitoring patient food Assessment, care planning and instruction
consumption
by qualified staff
 Staff practices relative to food safety such as monitoring
food temperatures, transportation practices, potential food
borne infections, etc. Identification of nutrition risk
 Kitchen and food preparation areas focusing on sanitation, Nutrition screening criteria (CMS has also)
maintenance, and safety
 Food preparation (recipes, special diet preparation, food Timeframes for nutrition assessment and re-
nutrient retention considered in preparing) and serving
(portion size served, system staff follows to serve correct evaluation of nutritional risk
diet)
 Therapeutic diet meal preparation process (e.g., fat free, Measuring food consumption (methods for
low salt, restricted/increased calorie count) or mechanical
preparation (e.g., pureed, thickened) doing, responsible staff, use of the data
101 102

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Topics Dietary Tracer Topics Dietary Tracer

 Specific population needs, such as patients that Nutritional adequacy of patient diets
are NPO, receiving hyperalimentation, on vents, in
isolation, suffering from burns Discharge education plans and referrals
 Process for obtaining meals for patients after food Dietetic service staff training (departmental
service hours and interdepartmental)
 Procedures followed for patients refusing meals Communication between dietitians and food
 Consultations and referrals service if not considered the same
department
 See PC.02.02.03, HR.01.04.01, HR.01.05.03
Dietitians included and participating in care
planning process
103 104

Topics Dietary Tracer Topics Dietary Tracer

 Surveyor will speak with dietary director about  Contracts for services, food, and nutrition services
day to day operations including  Emergency disaster planning for patients and staff
 Qualifications of dietary director  Hospital diets and menus (selective or
nonselective, nourishment choices, foods common
 Responsibilities of dietary and food services to community)
leadership and management
 Sanitation and infection control (pest control,
 Involvement with others for P&Ps (MS, chemicals)
Nursing)
 PI activities, PI process, standards of practice
 Scheduling of food being followed and food preparation and storage
procedures
 Safe food handling and health of dietary staff
105 106

Food and Dietetic Services Tracer Chapter on Emergency Management

Maintenance of space and equipment

Process for prescribing and evaluating
therapeutic diet orders
Processes for accommodating special
and altered diet schedules
Follow up process when the patient
refuses food services

107 108

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Emergency Management Environment of Care

 During the survey the surveyor will ask various staff  During the survey process will observe the condition
members to explain their role in fire management of the hospital used by patients
and in disaster management  Clean, safe, functional, and comfortable
 Surveyor will discuss the following;  Survey will discuss the following
 Staff knowledge and training on roles and responsibilities in the event
of an emergency  The process for conducting environmental tours to
 Supplies, medical equipment, communication equipment, personal identify environmental deficiencies, hazards, and
protective equipment (PPE), decontamination stations available in unsafe practices
emergencies
 Interview unit/department leadership to evaluate knowledge of chain  Management of hazardous materials and waste
of command and communication processes in the event of an
emergency. Evaluate understanding and planning for emergency  Staff knowledge and training on how to report
incidents that last greater than 96 hours problems or incidents
109 110

Environment of Care/EM Tracer HAP CAH

 Duration varies per agenda for 2 parts; EOC and EM
tracer
 Surveyor will look at annual evaluation of the EOC
management plan and EOC team meeting minutes
for previous 12 months on re-survey
 Surveyor will review EOC risk categories as set forth
in the matrix below (general safety and security, haz
materials and waste, fire safety, utilities, and
medical/lab equipment)
 Will look at safety data analysis and actions taken by
the hospital
111 112

Part 1 EOC
 Part 1 is 70% of time and be prepared to discuss
how the various 6 risk categories (fire safety,
general safety and security, etc.) and construction
activities
 Are addressed in the six management processes
 Plan
 Teach
 Implement
 Respond
 Monitor, and improve
113 114

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Part 2 EOC EOC Tracer Example Patient Fall

 Part 2 is about 30% of session time  Patient care unit with higher than expected fall rate
 Surveyor will select an EOC risk category based on the  What is process to assess patient for fall risk and when is
EOC sessions discussion, individual tracer activity a patient a fall risk?
observations, or high risk area based on the hospital and
 Who is responsible to maintain and monitor the
services provided
technology
 Begins with where risk is encountered such as security  What orientation and education to staff including transport
incident or piece of medical equipment is used or staff
hazardous material enters your hospital
 Communication among staff on fall risk
 Who is responsible to manage technology and what to do
if it fails, and who to report the incident to  May interview transport staff to determine how they know
fall risk, process to prevent falls, orientation given
 Staff must describe their role and responsibility to
minimize the risk  How is the fall rate reported and tracked
115 116

EOC Tracer Patient Diagnostic Testing Falls EOC Tracer Radiation Tandem & Ovoids Tx
 Second tracer location may be diagnostic testing  The HDR tandem and ovoid (T&O) implant
center such as radiology or ultrasound procedure is used to treat patients with uterine or
cervical cancer in nuclear medicine
 How are you informed patient is a fall risk?
 What is the process for preparing radioactive source
 Who is process to prevent a fall when undergoing a material
test?
 What technology is utilized to minimize exposure risk to
 What orientation and training do staff receive staff
 What is the process for responding to radioactive material
 How was this fall risk information communicated? exposure
 Was there a process put in place to prevent patient  Who is responsible for maintaining the lead aprons and
falls? other shielding devices

117 118

EOC Tracer Radiation Tandem & Ovoids Tx Patient Care Area Tandem & Ovoid
 Who is responsible to monitor the proper use of the  May interview the physician or the physicist or
shielding devices radiation therapist
 What is the process for reporting the radioactive  What is the process for handling radioactive source
exposure material from the time/place of delivery, patient
administration, through source retraction and
 What orientation and education is required
removal from inpatient unit
regarding the safe preparation of radioactive source
material  What is the process for responding to a source
retraction failure or other treatment emergency
 Surveyor will observe the radioactive material
preparation and disposal area and Proper personal  What is the process for reporting an emergency
dosimeter exposure counter usage by staff related to tandem and ovoid treatment
119 120

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Patient Care Area Tandem & Ovoid EOC Tracer Tandem & Ovoid
 Will ask what orientation and education did you  Will also interview housekeeping
receive on the safe handling of radioactive source
 What is the process for removing radioactive
 May interview nursing fro process for radioactive waste from the patient care unit to final disposal
material safety including providing direct care
 What is the process for responding to a
 Same questions as above with process for radioactive waste spill or staff exposure
responding to an emergency, how to report an
 What is the process for reporting a spill or
emergency related to tandem & ovoid treatment
exposure
 Will interview patients and ask what education did
 What orientation and/or education did you receive
you receive, what did staff wear when you started
regarding the safe handling of radioactive waste
and stopped your treatment
121 122

EOC Issues EOC Issues

Patient falls, MRI hazard, suicide  Violence in the ED and other places

Operating Room Fires and laser fires  Control contraband in the ED and behavioral health
 Medical equipment failures and water used in
Fire hazards during construction hemodialysis
Patient smoking if permitted  Isolation rooms
Hazmat radiation and hazardous vapors  Disruption of utility such as water, gas or generator
Glutaraldehyde, ethylene oxide, cauterizing  Construction bariatric patients and infection control
vapors during construction projects

Infant abduction
123 124

125 126

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Emergency Management EM HAP CAH Emergency Management

 Time varies per agenda  May ask about staff assignments to decontamination
functions, on site inventory of N95 respirators and
 Life safety code surveyor does this session surgical masks
 The surveyor will evaluate the Hazard Vulnerability  Will review the EM activities
Analysis (HVA), the Emergency Operation Plan,
 Inventory the assets and resources that on site that
 Annual evaluation of the Emergency Operation would be needed in an emergency
Plan from the previous year, and Emergency
Management (EM) drills and after action reports  If an emergency happened tomorrow would the
hospital be prepared
 Will initiate discussion around four emergency
management categories: mitigation, planning,  Had meetings, trained their staff, board had on their agenda
response, and recovery.  Budgeted for the necessary things
127 128

Emergency Management Tracer Emergency Management Tracer

 Earthquake in Haiti is example of a disaster or  Need to plan performance in 6 critical functions:
flooding and hurricane in Louisiana  Communication (including backup
 How do you work with your community and other communications capabilities)
healthcare facilities  Resources and assets
 Inventory of assets on hand in case of an  Safety and Security
emergency
 Staff responsibilities (including
 Response efforts and capabilities when hospital can orientation/competency/training of staff
not be supported by local community for at least 96
hours  Utilities management
 See TJC Activity Guide for more detailed information  Patient and clinical support activities
129 130

Emergency Management Tracer EM Questions

What is the hospital’s process for disaster  Questions to ensure compliance and understanding of the
privileging of LIP? emergency management planning standards
 Ask staff to explain their role in fire management or disaster
How do you verify practitioners (doctors, management
nurses) who are required to have a license  Availability of supplies and equipment such as PPE
or certificate?
 Any recent improvements or lessons learned from your EM
Do you learn any lessons from your exercises
emergency management exercises?  Are you regularly testing your emergency management plan
so staff know what to do
Any recent improvements to the emergency  Will use different disaster scenarios to see how well this is
operations plan? done and what training you have provided
131 132

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Data Collection Tool EM Data Collection Emergency Operation Plan

133 134

EM Exercises
 Fire and collapse of public building
 Natural disaster like tornado
 Heat wave and persistent drought
 Severe winter storm
 Truck or suicide bomber
 Toxic industrial accident
 Chemical spill in transit
 Terrorist attack using chemical agent
135 136

EM Exercises Outpatient Tracer

Botulism outbreak
Make sure inpatient and outpatient are
Anthrax outbreak, integrated
Tularemia or smallpox outbreak This would include medical records, lab, x-
ray, EOC, medication management, surgery,
Emergence of tuberculosis or resurgence of
anesthesia, and infection control
influenza
Explore the mechanisms for communication
Accident at nuclear power plant
between inpatient and outpatient services
Detonation of a radiological device

137 138

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System Tracers 2011 Survey Activity Guide System Tracers

There are three system tracers for hospitals;
Data management or DM
All programs except lab
Infection control or IC
AHC, BHC, HAP, LTC, and OME
Medication management or MM
 AHC, BHC, HAP, LTC, and OME
http://www.jointcommission.org/2011_survey_activity_guide/
139 140

System Tracers System Tracer

Surveyor to learn about your PI process DM tracer is 30-90 minutes
including the use and management of data  DM is only system tracer that takes place during
survey as MM and IC is covered in this discussion
Data Management (DM) use and emphasis will
be on the step the hospital is struggling with; IC and MM tracer is 60 minutes each and
 Planning- how you identify and prioritize measures occurs in surveys greater than 3 days in
 Collection-to ensure data is collected as planned duration
 Aggregation and analysis to turn it in to useful information Part 2 focus on MS involvement in PI, verify
 Use of data to understand how you use the information board specifies frequency and detail of data
 *These are discussed in part one of the data tracer collection, patient flow, organ procurement
and blood transfusion reactions
141 142

Data Management Data Reviewed During a Survey

 Additional topics that may be discussed:  Examples: ORYX (core measures), MM, IC,
staffing effectiveness, NPSG, and other data
• Core Measures collection (see document list at beginning)
• Infection Control
 Autopsies performed
• Medication Management
 Blood and blood product use
• National Patient Safety Goal data
 Complaints, staff perception of risk and
• Organization directed data collection
suggestions for improving patient safety
• Proactive risk assessment
 Restraint and seclusion use
• Regulated data collection, e.g.OASIS, MDS, etc.
 Sentinel events
• Staffing issues
 Patient perception of care
143 144

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Data Reviewed During a Survey Selection of Measures and Collection of Data

TJC has specific elements of data collection :
 Record delinquency
 Measures of success data Staffing effectiveness
 Staff opinions and needs Organ donation
 Risk management Practitioner specific data
 Hand hygiene monitoring rate Patient flow
 Patient perception of care
Authentication in MR
 Benchmarking internal and external
Reprioritization of data collection
 Organ donation and conversion rates
145 146

System Tracers Medication Management (MM) Tracer

 Other issues are infection control, core measures,  Approximately 60 minutes (HAP,BHC,CAH etc.)
medication management, infection control, FMEA  Surveyor to learn about hospital’s medication
(now proactive analysis), hand hygiene, staffing management process
effectiveness and NPSGs data, patient satisfaction
data  Will look at data on high risk medications, medication
errors and ADR
 Medication management will look at activity of
 TJC has separate chapter on MM and several areas in
tracing a patient who is receiving a high risk NPSGs including medication reconciliation
medication and evaluating the process
 Will look at medication through the process to
 California see page 22 for unique system tracers; monitoring
MS function/regulatory, MS leadership, Dietetic and
 Will evaluate the medication reconciliation process during
Food Service, and Pharmaceutical and Clinical Unit “hand-off” from one level to another if medication prescribed
inspections 147 148

Medication Management Tracer Medication Management Tracer

When was the last time the unit was informed Surveyor to seek an understanding of the
of a drug recall? medication processes such as patient
How were you notified specific information required, how to select
procure drugs, how to store drugs, ordering,
Surveyor will look for recent recall notices transcribing, administration, monitoring and
evaluations
Will check the FDA website for safety alerts
and recall notices at www.fda.gov/medwatch  These are the standards for the MM chapter

You can sign up at FDA to get notices and  Also pharmacy review of medications, use of
NPSG requirements and assimilation of literature
ASHP has information on their website
149 150

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Medication Management Tracer Medication Management Tracer

 Will go to the pharmacy and explore storage,  Will review the role of lab in the evaluation of
dispensing etc including LASA, drug security, and medications
working with other departments
 What is the trigger for lab testing relative to
 Will look at the process to review specific medication being used
medications
 Explore the role of dietary on the evaluation of
 Will look at oversight of this drug such as the medications
formulary, P&T committee, reviews etc.  Identify tools such as antibiogram or patient lab testing
 How does the pharmacy handle recalls?  Warehouse/Materials Management for review of
 Review after hours including review of the night equipment or devices, if applicable to the
cabinet medication being traced
151 152

Medication Management Work Tool Medication Management Tracer Topics

 Process for reporting errors, system breakdowns, near
misses, or overrides
 Review any loss of controlled substance and if was reported
to the CEO and pharmacist
 Data collection, analysis, systems evaluation, and PI
initiatives
 Medications brought into the hospital by the patient served
 Education of staff and patient
 Information management systems related to MM
 Patient involvement in MM
 Process for responding to ADE, errors and incompatibilities
153 154

Infection Control (IC) Tracer HAP BHC Infection Control Tracer Parts
 Approximately 60 minutes  First part is prior to the session while conducting
the individual tracer
 Surveyor will look at performance reports on IC
 Identify a high risk patient with a HAI such as C-
 Need quiet area for brief interaction with infection
diff, a drug resistant organism, or other
preventionist and staff who oversee IC process
communicable disease
 Surveyor will learn about planning, implementation,
 Part two is 15-30 minutes in the meeting room
and evaluation of your IC program
 Current and past surveillance activity
 Remember: TJC has 8 page chapter on IC and
 Learn about IC program and how outbreaks are
CMS hospital CoP has 12 pages of standards
managed
 CMS gets $50 million dollar grant to enforce IC  Part 3 is moving through the organization 45
standard in 2010 and 2011 minutes
155 156

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Infection Control Infection Control Topics

 Part 3 will talk to staff about infection control  Reporting of IC data
committee, training and education, surveillance,  Prevention and control activities (housekeeping
staff exposure, reporting IC data, food sanitation, procedures, organization wide hand hygiene, food
housekeeping, see long list sanitation, and the storage, cleaning, disinfection,
sterilization and/or disposal of supplies and equipment)
 Was a pro-active risk assessment done?
 Staff orientation
 May be known as Failure Mode and Effects Analysis or
FMEA  Staff training
 National Patient Safety Goals including monitoring  Physical facility changes that can impact infection
of CDC or WHO hand hygiene compliance control
 Monitoring staff compliance with employee health  Actions taken as a result of surveillance and outcomes
screening requirements of those actions
157 158

Infection Control Tracer Flash Sterilization (Immediate Use)

 Hand Hygiene, PPE availability / use
 Medication administration
 Equipment cleaning – between patient use, floating
equipment
 Housekeeping processes
 Sterilization, reuse of disposable instruments, use of
flash sterilization (immediate use)
 Reusing single use devices, Cleaning and disinfecting
 Flu vacination staff and LIPs

159 160

Now Called Immediate-Use Steam

http://www.aorn.org/News/View/03A1334C-
ADE2-CF8F-B329DD5F7E9B71B2/
161 162

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Immediate-Use Steam Sterilization Additional Resources

www.aami.org/publication/standards/ST79_Immediate_Use_Statement.pdf  See the CDC Guideline for Disinfection and
Sterilization in Healthcare Facilities, 2008 1

 AORN in the Perioperative Standards and

Recommended Practices has a chapter on
sterilization and disinfection including many on
steam sterilization
 APIC is good source of information 2

 1 http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf
 2 www.apic.org

163 164

Medical Staff (MS) Credentialing/Privileging Medical Staff Tracer

 For CAH and HAP so all hospitals  Surveyor to ask about process to collect data
relevant to appointment decisions,
 Lasts about 60 minutes
 What is process to grant and delineate privileges?
 Surveyor will request specific credential files of
practitioners identified from tracers, OR logs, ICU  Will evaluate the credentialing and privileging
and special procedure unit logs process
 Will request high risk and non-physician specialties,  Suggest president of MS, medical director, and MS
hospitalists, moon lighters, practice outside the coordinator, or MS credentials committee
usual scope of practice and low volume specialists, representatives be present
emergency services director and individuals who
 May look at services provided such as emergency
are authorized to give anesthesia including deep
services and anesthesia services
sedation
165 166

Medical Staff Tracer Topic Medical Staff Tracer Topic

 How does the hospital collects data used in making  Verify MS establishes criteria for the director of
decisions on appointment, granting and delineating
privileges anesthesia
 Is there inconsistent implementation of the credentialing and  Determine if the state is an opt out for CRNA
privileging process for the MS and other LIPs who are
privileged through the medical staff process? supervision and look at P&P on supervision
 Processes for granting privileges and the delineation of  Will ask about qualifications of others who furnish
privileges
anesthesia services to determine if consistent with
 Whether practitioners practice within the limited scope of
delineated privileges hospital policies
 The link between peer review and focused monitoring to the  Verify that MS determines the qualifications of
credentialing and privileging process
radiology staff and nuclear med director
 Potential concerns in the credentialing, privileging, and
appointment process  Verify care telemedicine are C&P by originating site
167 168

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NPSG Tracers 2011 2011 NPSG Chapter Outline

 Many hospitals create a form to review the

NPSG as a tracer
 Did the clinician use two patient identifiers
before invasive procedures, blood, medication
administration
 Were critical values obtained and was process
documented and physician notified
 Are case conferences documented discussing
plan of care between disciplines
169 170

2011 Hospital NPSG How many sections left? NPSG Tracers

1. Patient identification 2  Were critical values obtained and was process

documented and physician notified
2. Communication among caregivers 1  If practitioner wash their hands?
3. Medication safety/anticoagulant therapy 2  Were medication reconciled?
Medication Reconciliation 5  Is there a checklist for central line insertion?
 Is there anticoagulation training for patients and
7. Health care-associated infections 4
staff?
15. Suicide Risk 1  Process for safety of suicidal patients?

171 172

The End Elopement Behavioral Health

 Look at effectiveness of process to prevent elopement
Are you up to the  How many episodes of elopement
challenge?
 Surveyor select record of patient who eloped
Additional slides on  Evaluate the physical environment and security
what others have done systems
on tracer activities and
can you tell which ones  Interview patient about episode of elopement , causes
contain the right and treatment, and use of restraints
elements?  Ask patients about any elopement prevention activities
that they are aware of
 Ask patients about guidance from staff to prevent
escalations in the future
173 174

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Suicide Prevention BHC HAP Suicide Prevention

 BHC and hospital with inpatient psych unit  What does hospital mean by suicide precautions?
 To evaluate effectiveness of facility’s suicide prevention  Care planning process from assessment to individual
strategy care plan relative to suicide risk
 Will select high risk patient for suicide  Continuum of care with evaluation communication
 Will review the medical record of patient served, and coordination with other staff, family and
significant others relative to suicide risk
 Look at crisis process
 Look at initial assessment process with planning and focus  Education provided to patient and family about
on suicide risk and prevention (PC.03.03.09) suicide risk and information for crisis situation
 Reassessment and trace triggers for and frequency of  HR should evaluate orientation, training, and
assessments of risk for suicide competency of staff to evaluate risk for suicide and
self inflicted harm
175 176

Suicide Prevention Behavioral Health Violence Behavioral Health Care BHC

 Staffing and will trace staffing levels to implement  Surveyor will evaluate hospital process to control
safety checks, evaluate training and competency violence and ensure safety of all

 Information management with access to information  Will select patient with repeated episodes of
in a timely manner by those who need to know violent behavior

 NPSG.15.01.01 in 2011 Identifying patients at risk  With or without injury to self, staff, or others
for suicide and inpatient suicides is number two SE  Evaluate the physical environment that could make
and occurs every 16.6 minutes and 11th most violent behavior possible
frequent cause of death
 Evaluate measures taken to ensure security

177 178

Violence Behavioral Health Violence Behavioral Health

 Evaluate security systems such as cameras and Will interview staff about:
alarm mechanisms  Episodes of violent behavior
 Will interview patient and family about their  Communication to other care givers
perception of violent behavior and use of R&S  Identifying the risk and prevention of violent
 Will ask patient if guidance was provided from behavior in patients served
staff to prevent further violence  Risk assessment process
 Will ask patient about violent behavior prevention  Restraint use
activities  Orientation and training of staff about violent
behavior risks
179 180

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Psychiatric Hospital CoP Hospital Readmission Certified Home Health

 Psych hospitals with a distinct part certified program
 Will look at what action has been taken to reduce
 Variable time but about 8 ours hospital readmission rate
 To make sure hospital is in compliance with the  Evaluate the accuracy of medication lists and
CMS CoPs education
 Identify processes and system issues
 Evaluate the degree and intensity of treatment and
contributing to a high re-hospitalization rate
ensure properly documented in the medical record
 Surveyor to interview case manager about entry
 Will collect and document required information into care, assessment, care planning process,
related to discharge planning and death record coordination of care among provides an
review education of patient
 See the activity guide for more detailed information
181 182

Hospital Readmission Certified Home Health www.hret.org/hret/programs/content/Readmission_Guide.pdf

 Surveyor will conduct a home visit and interview

patient or the caregiver about:
 Conditions leading to re-hospitalization
 Review medication
 The patients understanding about their medical
condition and treatment.
 Educational materials received from your
organization

183 184

Home Medical Equipment BHC ASC

 Home medical equipment will request manufacturer,
model, and serial numbers for all medical equipment
provided by the hospital
 Traces medical equipment mail orders
 Will also look at walk in business for patients
obtaining home medical equipment
 Has separate section for ambulatory health care,
office based surgery, pain management, primary
health care, waived testing, equipment maintenance,
etc.
 Good topics to conduct mock tracers in following
(page 40)
185 186

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Hospice Services Foster Care Behavioral Health

 Will select a patient receiving care in the facility in  Surveyor to evaluate the effectiveness of the foster
the past 12 months care agency’s process surrounding number of
foster home placement of children
 Patient receiving continuous care or respite care  To assess safety issues in the home
 Patient getting infusion therapy  Problems with placing child in multiple foster
 Pediatric patient homes (alienations, isolation)
 Interview social worker and parents about the
 Patient receiving alternative complementary care placement process
 Patient undergoing pain management  Look at criteria for placement and assess process
 See page 71 for more information
187 188

Infection Control Tracer Clinical Tracer of Priority Focus Areas

189 190

191 192

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193 194

HIPAA Tracer Medical Record Tracer

195 196

Lab Tracer Medication Management Tracer

197 198

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Medication Management Tracer Cont. Medication Management Tracer Cont.

199 200

Tracer Worksheet Tracer Worksheet Cont.

201 202

Patient Care Unit Tracer Form Patient Care Unit Tracer Form Cont.

203 204

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Patient Care Unit Tracer Form Cont. Patient Care Unit Tracer Form Cont.

205 206

Dietary Tracer Environmental Services Tracer

207 208

Patient Centered Tracer Patient Centered Tracer Cont.

209 210

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Patient Centered Tracer Cont. Patient Centered Tracer Cont.

211 212

TJC Sells Tracer Workbook for EOC TJC Sells Tracer Workbook for EOC

http://www.jcrinc.com/B
ooks-and-E-
books/ECTW11/3286/

213 214

Selection Home Care Patient Selection Home Care Patient Cont.

Will select a patient: Will select a patient (Continued):

 Who is on high risk medication or piece of  Receiving blood
equipment
 Undergoing acute care and re-hospitalizations
 Receiving ventilation
 Receiving personal care and support services
 Receiving maternal child care
 Receiving alternative complementary care
 Receiving IV therapy
 Receiving oxygen therapy
 Terminal patient

215 216

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Staffing Tracer Falls Hospice Home Health

Surveyor may ask staff about:  To see how the organization evaluates the risk for
falls
Orientation and training provided to staff
 What do you do to reduce risk of falling?
Recruitment and hiring practices  What is your plan to reduce the risk of injury if a fall
should occur?
Changes in P&P, mission, vision and  Surveyor will interview direct care give about;
expectations
 Risk assessment process for falls
Perception of issues related to staff turn  Identification of in-home environment
over  Care planning process
217 218

Falls Hospice Home Health Prevent Falls in Older Patients Resource

 Coordination of care and communication to internal  One third of Americans over 65 fall each year and
and external customers 10-20% have moderate to severe injuries
 Fall reduction education to the patient and caregiver  Guideline updated 2010 from American Geriatric
Society (AGS) and looked at new evidence
 The surveyor will conduct a home visit and interview available (see also CDC resources)
the patient and/or care giver
 Ask if has fallen in past year, frequency, and if
 Any unsafe environmental issues that could lead to a experiences difficulty walking or with balance
fall
 If risk of falling then need assessment of home and
 Medication potential for falls interventions to eliminate fall risk factors
 Knowledge about their fall risk status and preventive  Updates guidelines from American Academy of
techniques to remain safe in the home Orthopedic Surgeons published in 2001
219 220

www.americangeriatrics.org/education/summ_of
_rec.shtml

221 222

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www.cdc.gov/HomeandRecreationalSafety/Falls/
index.html

223

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