Accreditation

Surveyor's mastery of tracer methodology shows during lab survey, makes for educational experience

Briefings on Accreditation and Quality, February 1, 2007

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Tracers started at the end and ended at the beginning

After reading this article, you will be able to

1. describe how a surveyor may conduct a patient tracer

2. explain a way to meet the challenge of achieving hand-hygiene compliance

The biggest difference between LifeCare Hospitals of San Antonio's lab survey in 2003 and its survey in November 2006 was that The Joint Commission surveyor did more than just look at competencies-he knew and used the tracer methodology.

LifeCare hosted one surveyor for one day for an arterial blood gasses (ABG) and point-of-care testing lab survey. During the survey, the surveyor completed three tracers: transfusions, blood glucose, and ABGs. Despite his mastery of the tracer methodology, which enabled him to do a more thorough survey than LifeCare expected, the 34-bed specialty and transplant hospital-withina-hospital located in the South Texas Medical Center received zero RFIs.

"I learned from this guy," says Marilyn Dillon, RN, director of quality management and infection control. "This surveyor was very sure of himself, and it was clear to me that he knew the tracer methodology very well. It was an excellent survey experience because of this process."

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

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