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Patient tracers involve environment-of-care standards

Accreditation Connection, May 10, 2004

One of the new survey tools used by the JCAHO is the tracer method in which a surveyor follows a patient or process throughout the hospital. During a recent survey at Sturdy Memorial Hospital in Attleboro, MA, three tracers involved environment-of-care (EC) standards, including one that took place during the interview session.

Here's some background: Attleboro, MA-based Sturdy Memorial Hospital operates a centralized area for high-level disinfection of certain medical equipment, such as ultrasound probes. This central spot allows the hospital to better control the use of glutaraldehyde and other sterilants.

The physician surveyor wasn't familiar with a centralized disinfection area and asked the administrator surveyor to follow up with the hospital about this setup. The administrator, in turn, chose to trace how an instrument made its way from a department to this area says Steven MacArthur, who served as interim safety officer at the hospital and is also a contributing editor for BHS.

Using proper protection measures, workers deliver instruments slated for sterilization from the departments to the central area in carts or hand-held baskets. The disinfection process satisfied the surveyor, who visited the sterilization area for about five minutes.

A nay in the x-ray room

The EC also came up during a patient tracer in an ambulatory clinic 25 minutes away from the hospital. The surveyor entered the x-ray room and asked to see the past year's fluoroscopic inspections of the lead aprons. These assessments ensure that the lead shielding in the aprons hasn't cracked.

Prior to the survey, staff members realized they hadn't included this equipment in annual fluoroscopic inspections as detailed in the hospital's policy. They checked the aprons at that point, but this close timing may have led the administrator surveyor to request the records for the inspections or a copy of the policy.

He issued a supplemental finding to the hospital for not completing these fluoroscopic inspections under EC.3.10 (handling hazardous materials risks). "They weren't in compliance with their own policy," MacArthur says.

Tracing paper

Back at the hospital, you could look at another review as a "document tracer," MacArthur says. The surveyor wanted to see maintenance records for linen chutes, emergency generators, and fire dampers.

His interest in the latter two items came from a review of the Statement of Conditions (SOC). The SOC's plan for improvement identified dampers that became inaccessible during construction projects over the years. The hospital plans to correct these conditions when possible during future work, which the surveyor found acceptable.

"He called it a tracer," MacArthur says. "But generator logs are something [surveyors have] looked at historically." The surveyor didn't visit the generators or inspect dampers as part of the tracer, though he did check the end points for each of the linen chutes.

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