Accreditation

Setting up a tracer training program

Accreditation Insider, November 10, 2015

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Editor's note: The following is an excerpt from the HCPro book Staff Training and Survey Readiness: Preparing Your Organization for Accreditation and CMS Compliance. Visit here for more information.
 

Here we will focus specifically on tracer training and implementation: the "who," "what," and "when" of this key component of a continuous survey readiness plan.

There is no magic structure, and one size does not fit all, but there are some general guidelines that can be helpful in structuring a tracer training program, implementing tracers, and reporting tracer findings. Much depends on how big the organization is, or is not, and the number of resources that are available.

Tracer teams can be organized by chapters in the accreditation manual, by functional teams, or by priority focused areas, or a combination of all of these. However, there is a need for an oversight team, usually led by the accreditation director, to:
•    Facilitate completion of the focused standards assessment (FSA)
•    Facilitate action plans and correction of noncompliant findings from the FSA
•    Train the tracer teams
•    Develop the tracer schedules and tools
•    Compile and present reports from tracer findings
•    Provide education on an ongoing basis
 
It should be noted, again, that structure and duties will depend on the size of the organization, and the oversight team might be the quality committee or senior management.

This is an excerpt from an article in the monthly training resource Briefings on Accreditation and Quality. Click here to log in or subscribe.



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