Just When You Thought It Was Safe to Go Tracing

Just When You Thought It Was Safe to Go Tracing

Keeping up with the changing implications of The Joint Commission’s standards continues to be a challenge for many hospitals. Just when hospitals settle on tracer tools and checklists, word comes that The Joint Commission’s surveyors have developed a new “twist” on how they determine compliance on certain standards.

Keeping tracer teams up to date on the latest interpretations and survey methods is an ongoing challenge. Checklists can assist in addressing the static standards that have changed little since the early 1980s. But, the evolution of other standards and increasing pressure from the Centers for Medicare and Medicaid Services (CMS) will force tracer teams to be more knowledgeable and skilled to protect their hospitals from unexpected survey results.

Limitations of Checklists

If you don’t update your checklists every few months, you may be vulnerable. Some elements regarding fire equipment checks and security procedures may remain unchanged, but other standards interpretations change, and expectations become clearer over time. Out-of-date checklists often fail to address all of the requirements needed to comply with newer or changed standards.

Checklists are valuable tools. They provide a source for objective evaluation of specific items and assist in assuring reliability among observers. However, checklists should be reserved for evaluating standards and expectations that fit the following characteristics:

  • Items listed can be clearly defined in terms of expectations (yes/no, present/absent, in place or not)
  • Expectations leave limited room (or no room) for interpretation by the data collectors
  • Items listed have been stable over a period of time and are not likely to vary much in the future
  • Expectations can be evaluated though a clear cause and effect (if antibiotic was ordered, was it given within one hour of incision)

Individuals best suited for tracer teams that utilize checklists are those who are rules-driven and unlikely to deviate from the established checklist or give someone “the benefit of the doubt” in scoring compliance. These individuals can often be found outside of the traditional roles recruited for tracer teams (e.g., medical records, engineering, or IT).

Tracer Team Competency

To monitor compliance with new interpretations of old standards, new or evolving standards, and old standards applied to new or unique settings, you need tracer teams that understand the standards, rather than just following checklists. Evaluating compliance in these areas requires higher levels of familiarity and competency, since it introduces an element of subjectivity. This is where consistent communication of concepts underlying tracer activities becomes critical to success.

Consider the following.

  • What concept or principle is at work behind a “rule” or procedure in the hospital, and how does it relate to a regulatory standard? For instance, “no storage within 18 inches of the ceiling,” is not a regulatory standard. But, it is enforced by some hospitals to simplify compliance with the rule, “no storage within 18 inches of sprinkler heads.”
  • What minimum expectations have been set during orientation or in policy? Determining compliance by comparing “what I would do” vs. what was done will result in wide variety of compliant, and non-compliant practices.
  • What standards apply to this patient’s situation? Not all standards apply equally to all patients. Establishing which standards apply in which cases is often the greatest challenge for inexperienced tracer teams.
  • How should the standard apply in this situation? Often, what people identify as “standards” are really expectations that apply to the most common situations. For example, corridor clearance can be less than 8 feet in some cases. Knowing the expectations and the rules becomes important to assure that non-compliance is not inappropriately assigned by tracer teams.

Educating Tracer Teams

Educating tracer teams may not initially seem necessary, since every manager “should know” how to be compliant. However, this assumption is seldom correct. Establishing a baseline set of expectations and skills for tracer team members can mean the difference between a tracer team that occasionally stumbles on killer survey targets and teams that regularly identify and mitigate regulatory issues.

Recruiting and retaining tracer team members with a variety of skills also increases the scope and effectiveness of your tracer teams. Consider establishing one team of people to evaluate compliance through checklists and another comprised of people with more advanced tracer skills. This strategy is one way to ensure that tracer teams are utilized efficiently.

Keeping the skills of tracer teams up to date can be difficult, given the multiple demands on their time. Updating teams on the latest changes in the standards and survey process requires additional time from both the accreditation coordinator and the team members. Consider education options that make the most of educators’ and tracer teams’ time. For example, audio-conferences or individualized training for tracer teams can update skills efficiently and at a relatively low cost to hospitals.