February 24, 2006

Ready for JCAHO: MGHers learn about tracers

As MGHers continue their efforts to be ready for the upcoming unannounced survey by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to take place some time this year, employees and staff are learning about a new survey tool the JCAHO will be using called the tracer methodology. With this new process, surveyors will focus on how services are perceived from the patient's point of view and on how well the organization coordinates care.

As part of this new process, JCAHO surveyors will select patients who have gone through a variety of services at the hospital — including inpatient and outpatient areas and the health centers — and "trace" compliance with JCAHO standards at each stop along the patient's journey through the system. For example, a tracer could begin with a patient's arrival in the emergency room and follow his or her path of care to the timeof discharge from a patient care unit. In an outpatient setting, a tracer could begin with a primary care practice and include visits to specialists. Along the way, surveyors will ask questions about the care that each patient received, and the steps the hospital took to ensure patient care was safe and of high quality. The surveyors will want to talk with front-line staff rather than just leaders about how specific policies and procedures affect the patients they are tracing.

There are certain priority areas that the surveyors will focus on throughout the tracers and some additional areas will be identified as they learn more about the hospital. Generally, the surveyors will begin by examining issues such as communication among caregivers, equipment use, infection control, assessment and care/services,credentials of practitioners, lab procedures, staffing, rights and ethics, information management, orientation and training, patient safety, physical environment, medication management, organization structure and quality improvement expertise.

"When being interviewed by a surveyor during a tracer, staff should remember to relax and answer the questions as best as they can," says Maryanne Spicer, director of Compliance and chair of the hospital's JCAHO Operations Committee. "If they don't know an answer to a question, it is OK to say that they don't know. They can tell the surveyor what resources are available to find the answer. Tracers are an opportunity to show the surveyors the excellent work that is done throughout the MGH."

For example, if a surveyor asks a question that an employee doesn't know the answer to, he or she can respond: "I don't know that specific answer, but our clinical resource nurse is available to help," or "I'm not sure of that, but I would look in our online policy manual to find that specific information."

For more information about the survey, visit the hospital's JCAHO website at www.massgeneral.org/jcaho.