Accreditation

The evolution of mock survey tracers

Accreditation Connection, November 2, 2007

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For facilities that had their most recent announced Joint Commission (formerly JCAHO) survey in 2005, the last year before unannounced surveys were put into effect, 2008 looms large-this is the year for their first unannounced survey.

The concept of developing a tracer tool is not a new one. But creating the sort of tool that can respond and evolve with standards changes, and with the facility, is a matter of constant practice, review, and vigilance, says Margaret Martello, RN, director of risk management and regulatory affairs at Mount Auburn Hospital in Cambridge, MA.

"We first started using this in January of this year, but started developing it at the end of 2006," says Martello. "We had asked ourselves, 'How are we going to make our own assessment and measure where we are, what areas we need to work on?' Finally we asked, 'Why don't we mimic what the Joint Commission [surveyors do] when they come to survey?' "

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