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Understand the tracer methodology survey

HIM Connection, January 23, 2006

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Accurate, complete, legible, and timely medical records will continue to be essential elements for periodic performance reviews (now an annual requirement-effective Jan. 1, 2006) and on-site surveys, particularly as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) rolls out its new unannounced survey process and continues with its tracer methodology.

The tracer methodology uses actual patients to assess care and compliance with relevant standards. Medical records play an important role in this new process. Surveyors will randomly select patients--and subsequently, their medical records--at the beginning of the survey. The surveyors will visit the units, sites, or departments in the exact sequence, when possible, the patients experienced.

For example, a patient is admitted through the emergency department (ED) and admitted to the cardiology unit, where he has a cardiac catheterization. He receives x-rays, lab work, and medications; is put on a special diet; and is transferred to the cardiac rehabilitation unit after discharge. The surveyor would follow--or trace--the path of the patient and talk to the direct caregivers who provided care and treatment to the patient.

Surveyors will generally select open records for this review; however, it is possible for a surveyor to request closed records if a patient was a recent readmission. Other closed records requests could result from the inability to locate enough patients hospitalized at the time of survey--if surveyors wish to trace patients in restraints, for example, and none are available. Open or closed, quality medical records have never been more important.

The JCAHO can better assess compliance with standards related to operational systems and processes based upon the actual experience of the patient. Surveyors do so by looking at the entire sequence of care provided to the patient, rather that by reviewing a few records in each department against a check-off list, as was the format in previous surveys.

How documentation fits in
Because the JCAHO will use the medical record as the road map to identify what treatments the patient received and who the caregivers were, documentation must be as timely and complete as possible. The medical record should accurately reflect the patient's care from start to finish. Late or illegible entries and otherwise poor documentation do not contribute to the quality and safety of patient care and will not contribute to a successful survey under the new process.

At the time of your survey, JCAHO surveyors will also perform system tracers, such as medication management, information/data flow, and infection control. Surveyors will use the medical record to assess the effectiveness of the processes and systems the hospital has in place. For example, a telephone order for medication is called to the ED by the attending physician when her patient presents for treatment. The medication is administered without review by the pharmacist or the ED doctor. The patient has an adverse reaction, and it is not properly reported. When the surveyor reviews the medical record, the documentation reveals that the telephone order is not verified and the patient has received the wrong medication. The record documents the medication reaction, but when the surveyor talks to the caregiver, the surveyor learns that reaction was not reported according to policy. In this scenario, there is definitely a problem with the management of medication, and the review of the record has validated a broken process in a system tracer.

This example also illustrates how important it is for organizations to conduct mock patient and system tracers. If it had done so, the organization in the example would have found the problem before the surveyor did. It also would have familiarized staff with the new methodology, helped improve documentation, trained staff to speak up, identified opportunities for improvement, and helped develop well-functioning clinical and treatment terms.

Editor's note: Stay tuned for next week's HIM Connection to learn how to work tracer methodology into ongoing record review.

This article was adapted from the book Ongoing Records Review: A Guide to JCAHO Compliance and Best Practice, Fourth Edition. 

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