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Topic: Create a tracer team to prepare for unannounced surveys

HIM Connection, June 5, 2007

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A good strategy for departmental training to prepare for an unannounced survey is to create a tracer team. This team will conduct tracers on a regular basis by following patients throughout the organization, much like The Joint Commission surveyors will do at the time of a real unannounced survey. And like real unannounced surveys, the tracer team should not let departments know in advance that it is coming.

For example, if you conduct a mock tracer review of your radiology department, here's a typical process to consider:

• Talk to the radiology techs. Go through the National Patient Safety Goals--ask whether they use two patient identifiers, for example.
• Look in the medical record for documentation of invasive procedures. Make sure there is documentation of consent, a history and physical, etc.
• Conduct environment rounding to make sure staff have tested their equipment and the extinguishers on a monthly basis. They should have clean refrigerators and keep a refrigerator log.
• Check for proper security of medications and contrast media.
• Determine whether pharmacists are reviewing orders for medications.
• If your hospital uses an electronic health record system, have a staff member operate the computer to make sure he or she is properly entering information into the record and can find the right pieces of information in the patient's chart.

If you use the tracer team approach as part of ongoing record reviews or as a supplement to other reviews, remember to report your findings and established accountability. Senior leadership from the HIM department is a good candidate for holding these departments accountable. And remember to maintain a regular schedule for tracer team practice runs.

To have success during an actual survey, it's crucial to perform regular tracers. Include leadership as part of the team, include a comprehensive tool, and provide immediate feedback to departmental managers to assure success. It's better to be prepared ahead of time than not be ready when the surveyor visits the department or nursing unit.

Editor's note: This article was adapted from HCPro's book Ongoing Records Review, Fifth Edition. For more information, click here.

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