Accreditation

Hospital learns informed staff are essential to system tracers

Briefings on Accreditation and Quality, April 1, 2005

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Assume staff don't know your hospital's policies and procedures and assume they haven't read them.

That advice comes from Debra Hudmon, BSN, quality improvement and patient safety coordinator at Lanier Health Services in Valley, AL. Hudmon learned this lesson when not all of her staff could verbalize policies and procedures to surveyors during system tracers at the 115-bed facility's December survey. In one instance, it earned Lanier a requirement for improvement (RFI).

"Give staff the information that they need to make you successful," says Hudmon-sound advice, considering one of the JCAHO's stated goals for 2005 is to develop surveyors' skills with system tracers, now called "patient system tracers" by the JCAHO.

Focus on the system tracer

Unlike a patient tracer, during which surveyors follow the path of a patient's care from department to department, a system tracer analyzes a hospital's processes.

Smaller hospitals typically have system tracers in data and environment of care, while larger hospitals typically have those plus human resources (HR)/competency and infection control. Each tracer lasts about an hour.

One source close to the JCAHO says the focus on system tracers this year is due in part to the comfort level surveyors have with patient tracers more than a year into the new survey process.

"My experience with the system tracer was that it was more of a discussion, a roundtable discussion between key players in the process down to the staff level," Hudmon says.

It also tied into the patient tracer, she says, because surveyor findings during patient tracers were brought up during the system tracers. Hudmon says this surveyor strategy was welcome because it gave her and her staff another opportunity to discuss a process and to satisfy surveyors that the hospital's policies are sound.

Surveyors conducted three system tracers at Lanier: medication management, data use, and HR/competency. The medication management tracer proved most intense.

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