Accreditation

Mock patient and system tracers 'key component' to unannounced survey success

Briefings on The Joint Commission, August 1, 2006

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After reading this article, you will be able to

1. list some survey preparation practices

2. name two types of mock tracers

3. describe a benefit of involving staff in all aspects of survey preparation

If you're bracing for your first unannounced survey, Patricia Garvey, MSN, RN, can't overemphasize the importance of doing mock tracers. And not just mock patient tracers, but mock system tracers, too.

"Mock tracers were the key component to our success," says Garvey, director of quality management and education at Fairlawn Rehabilitation Hospital in Worcester, MA. "If you're starting survey preparation efforts from scratch, I highly recommend them."

Garvey says weekly mock tracers gave all staff at the 100-bed acute-care rehabilitation facility ideas about what to expect during an actual survey. The strategy worked so well during Fairlawn's June survey that she plans to continue using them to maintain continuous survey readiness, although they'll be monthly until at least the 18-month window when surveyors could arrive for another unannounced survey.

Mock tracer strategy

"We weren't sure how to conduct them at first," Garvey admits. Reading about what other organizations were doing was helpful in designing a system.

For mock patient tracers, nurse managers in Fairlawn's three nursing units were given a heads-up when the mock tracer team would arrive. Garvey said this gave the nurse managers an opportunity to plan with their staff who should participate (i.e., those who were tied to the care of the patient being traced).

For system tracers, Garvey worked with managers from pharmacy and infection control to prepare for what surveyors might want to know and go over data sets for which they might ask. In the pharmacy, for example, Garvey had talked to staff about the troublesome standards and potential surveyor focus areas, (e.g., medication safety and storage). Those two areas were also identified as weaknesses in the periodic performance review (PPR).

"The surveyors were impressed that frontline staff could speak to data interpretation," Garvey says. For example, staff could describe how they picked indicators. The education not only helped on survey day, but Garvey believes that it will have a lasting effect on the synergy between nursing and departments such as pharmacy.

"A lot of things fall on nurses by default, but even the surveyors were suggesting to us to take a different approach when it comes to nursing-not to put everything on nursing but get the pharmacists out of the pharmacy and get them involved in medication reconciliation and have them teach nurses about drugs," she says.

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on The Joint Commission.

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