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For other articles and previous issues click here. October 18, 2004 Ready, Set,
Survey — Is Your Facility Prepared for Tracer Methodology? JCAHO’s new survey process involves “tracing” the patient’s stay—from point of entry to postdischarge and all points in between. Today, healthcare facilities have to stay “survey ready” because of changes in methodology in accreditation surveys and state licensing procedures. This year, JCAHO is using the tracer methodology in accreditation surveys for the first time. For HIM professionals, these changes signal the need for even more coordination with other areas of their facilities to ensure that medical records meet the new requirements. Veteran HIM professionals remember a time when it was not too difficult to prepare for the survey process. The process was retrospective and it was easier to anticipate the survey team’s focus. Facilities that have been through a survey process using tracer methodology report less time on areas such as document review and more time on tracing patients’ stays in the facility. The document review process is more intense only if during the tracer a survey team identifies an adverse impact on patient care and safety. Kurt Patton, JCAHO’s executive director of the Hospital Accreditation Program, says this methodology provides a better assessment of healthcare facilities. “After a complex analysis, we determined that tracing a patient’s stay in a facility is real assessment of a hospital organization,” says Patton. The analysis included significant input from accredited healthcare organizations, state hospital associations, and JCAHO advisory committees. Patton explains that using the tracer methodology during the survey is only one part of the accreditation process that has changed. The goal is not to have individuals at healthcare organizations preparing to participate in a survey but to embed the best processes in their facility to ensure patient safety and the highest quality of care. Patton is aware that in the past, some health information departments scoured their medical records to make sure they were ready for a survey. “My best advice is not trying to prepare for tracer methodology,” he says. “The surveyors are not performing a closed record review.” He explains that if, while tracing a patient, the surveyors need to review something in particular, they may examine some closed records, but that is not the methodology’s focus. JCAHO is not the only accreditation organization focusing less on paper and more on the actual experience of patients. Some agencies at the state level are also analyzing their survey techniques and considering changes. The tracer methodology is new; it affects not just the health information department but the entire organization. Not many organizations have experienced a tracer-based survey since its implementation this year, so it helps to understand how the methodology works. In tracer evaluations, surveyors select a patient and use that individual’s medical record as a road map to move through the organization to assess and evaluate the facility’s compliance with selected standards and systems of providing care and services. Patients are “traced” from their point of entry through postdischarge. Surveyors assess patient care and safety by talking to staff in areas that provide service for the individual. The team follows the patient treatment path and assesses the facility’s compliance with JCAHO standards. Systems are reviewed for their delivery of safe, quality healthcare. Individuals who have received complex or multiple services are generally chosen as tracers. They are selected from recently discharged or active patients. Surveyors evaluate what types of patients to select from data they collect prior to the on-site survey. During tracer activities, the survey team may identify compliance issues in performance. Surveyors focus on system-level issues in the organization that arise from tracing individual patients. If appropriate, the surveyors may still ask for permission to speak to a patient as they did in the previous methodology. Requirement for improvement status is given to organizations with problem trends. From January 1, 2004, to July 1, 2005, healthcare organizations have 90 days from the end of the survey to submit Evidence of Standards Compliance and identify Measures of Success to ensure sustained adherence to standards. After July 1, 2005, facilities will have only 45 days from the end of the survey to submit their evidence of compliance and success measures. Four months after approval of standards compliance evidence, facilities must demonstrate the record of accomplishment in the success measures. During the exchange of information with a healthcare facility, JCAHO will comply with HIPAA requirements for patient privacy. Tracing patients through the continuum of care requires a healthcare organization to work as a team instead of preparing one particular area for a survey independent of other departments. Joint Commission Resources, Inc. (JCR) is a professional services firm providing consulting services, publications, and educational products. Despite being an affiliate of JCAHO, no client data are shared between the accreditation organization and JCR. Nanne Finis, JCR’s executive director of consulting services, says JCR is able to utilize tracer methodology in services they provide to clients. “Clients really like this tracer methodology and the feedback has been very positive,” says Finis. “This methodology makes sense to clinicians because it does look at care from a patient’s perspective.” A major component to the tracer methodology is the patient’s record. “The medical record is important because it is a key piece of information in the survey and provides the documentation, whether it is electronic or on paper, of the patient’s care from one healthcare provider to another,” Finis notes. She explains that the medical record also documents recommendation for patient care from one provider to the next. “One of the links to ensure patient safety is the documentation from one care provider to the next,” says Finis. As part of JCR’s overall patient safety assessment, Finis says their consultants review infection control, medication management, care and assessment in the healthcare environment, and communication and team dynamics. Another major change to the on-site survey is the priority focus process (PFP), which helps surveyors zero in on the patient safety and quality-of-care issues most relevant to the organization being surveyed. The surveyors determine which issues the on-site survey will focus on by collecting and analyzing information, which may include statistical data, demographic information, and data from past surveys about the healthcare facility before the visit. The PFP could indicate which patients are traced during the on-site survey. Finis explains that beyond focusing on the on-site survey process, their consultants assess compliance with standards, how standards are implemented, and the quality of education programs devoted to best practices. She stresses patient safety as the goal of JCR’s assessments. “We are complying with the National Patient Safety Goals, and the accreditation standards roll into that evaluation,” says Finis. Even though patient safety standards have been a part of the JCAHO accreditation standards for some time, additional focus in this area has been heightened over the past four years. Terri Brown, RHIA, director of medical records at Jackson Park Hospital in Chicago, recently completed her first JCAHO survey, which was closely followed by a survey from the Illinois Department of Public Health (IDPH). “Both survey processes are still a lot of pressure, but I did not have too much interaction in the JCAHO survey that used the tracer methodology,” says Brown. She also completed a report prior to the survey and JCAHO performed a data tracer in addition to the patient tracer. Brown says the IDPH survey was more traditional and involved pulling more charts. Survey-Savvy Tips HIM professionals can help lead the way for their organizations by ensuring that everyone is aware of and familiar with the new tracer methodology. It is important to make others aware that, even though JCAHO is currently the main agency using the tracer method, other accreditation and licensing entities may soon adopt the same system. As the popularity of the tracer methodology spreads, its patient-care focus will make it more likely to become the norm. Another strategy to stay “survey ready” is to take the initiative and meet with clinical staff to discuss tracer methodology and its effects on the organization. Health information works as part of an interdisciplinary team during the tracer process. It is a mistake to think everyone in healthcare is aware of the new methodology. Healthcare facility department managers should understand how tracer works and why the trend may spread to other accrediting organizations and state health departments. In the JCAHO model, physicians have a more involved role in the accreditation process. Still, the HIM department remains a cornerstone of the process. HIM managers should make sure their employees understand how JCAHO standards apply to their jobs and emphasize the heightened visibility of the medical record in the tracer methodology. There are fewer records involved in a survey using a tracer, and there is concern that having a lower denominator of records could potentially lower scores during the survey. Because organizations will not have a large number of records reviewed, if there are problems with a few, you cannot reason they are just a small percentage. HIM departments will also play a significant role in ensuring that clinicians document accurately and in a timely manner. Ultimately, the facility’s quality services professionals and senior management will be responsible for maintaining a heavy emphasis on continuous survey readiness. This will ensure that the organization is well-prepared and avoids a crisis mentality when unannounced JCAHO surveys begin in 2006. HIM leaders are integral in this new methodology and should take a lead role to ensure that their staff members understand accreditation changes and how they affect their organization. The entire HIM department should assume accountability for its role in maintaining medical records that provide accurate documentation of a patient’s experience in their facility. While moving to the tracer methodology is one component of JCAHO’s new accreditation process, it is important to increase awareness and begin planning for the future. There are additional changes coming in JCAHO accreditation, including the move to unannounced surveys in 2006. The time to start thinking about and planning for these changes is now. — Brenda L. Johnson, SPHR, is an Indianapolis-based writer, consultant, and public speaker. She can be reached through www.4innovations.com. — Valerie R. Davis, RHIA, is the director
of health information and records at Provident Hospital of Cook
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