Priority Focus Process and Tracer Methodology
Carol J. Gilhooley
Director of Accreditation Process Improvement
In a nutshell, what the priority focus process does is it takes data and turns it into information, it helps focus the on-site survey activity, it does this in a consistent manner, so that individual bias is eliminated, and it really gets at what our health care organizations are looking for, and that's a survey that's customized to the specific unique characteristics of the organization being accredited.
Priority Focus Process Input
The priority focus process takes all relevant pre-survey information. That includes things like information that's provided in the electronic application for accreditation. It also takes previous accreditation history and recommendations, ORYX core measure information, it takes information that we get in our Office of Quality Monitoring. It also used Medpar information--external information specific to hospitals--and for long term care we'll be looking at MDS data and for home care, OASIS data. And it's important to remember too, that the priority focus process is evolving. And as we grow over time, additional information can serve as inputs to the priority focus process.
Priority Focus Process Output
Critical focus areas, one of the outputs of the priority focus process, are processes, systems or structures important to providing safe quality care in a health care organization. And in our first evolution of priority focus process, we have 14 critical focus areas. An example would be staffing, information management, infection control, medication management.
Clinical Service Groups
Clinical service groups are another output of the priority focus process. And really what they are is categories of patients, clients, residents or services for which data is collected. And as we give the surveyor the list of important clinical service groups for the health care organization being surveyed, the surveyor will use that information in selection of tracer patients.
Output Availability
The output of the priority focus process, which is the clinical service groups and the critical focus areas, will be available to the health care organizations when they have access to their periodic performance review. In other words, 15 months after their full survey when they have access to periodic performance review, they'll get their first access to the output from the priority focus process. We feel that the organizations can use that when they're conducting their periodic performance review. They will also then get an additional output from the priority focus process about a week to two weeks before their on-site survey.
Tracer Methodology
In the tracer methodology, the surveyor will select a patient and use that patient's medical record as a roadmap to assess and evaluate the services that that organization provides, not only the individual services, but the interaction of departments, services and functions with each other throughout the organization.
Selecting Tracers
During the first few hours of the survey activity, the surveyors have what we now call a survey planning meeting. During that planning meeting, they request an active list of patients from the health care organization. Using that active list of patients, as well as the output from the priority focus process, particularly the output regarding clinical service groups, the surveyors begin to select their tracer patients.
Tracer Activities in Ambulatory Care
An example of the tracer methodology in an ambulatory organization perhaps would be the physician surveyor goes in and selects a diabetic patient to trace. The surveyor would then go to see the physician, the clinic that saw that patient, may then go and visit the dietician who did the nutritional assessment, and may go to the laboratory to look at the glycosolated hemoglobin results and how the organization looked at all of those things together to provide health care and services to that diabetic patient.
Number of Tracers
The tracer activity is a significant part of the on-site survey activity under Shared Visions- New Pathways. In pilot testing last year and this year, about 50 to 60 percent of the time on-site was devoted to tracer activity. As an example, in a three-day, three-surveyor survey for a hospital, there are about 11 tracers, and they can be 90 minutes or more each. In a small organization, perhaps one where there's only one surveyor for one day, there would probably be two or three tracer activities.
Tracer Activity Questions
As part of the tracer activity, the surveyor will focus the questions to staff on the tracer patient. For example, let's pretend we have a patient, Mr. Smith, who has an open wound. The surveyor might say, "What things did you do while treating Mr. Smith to reduce infection control risk?" Let's say there were a number of people caring for Mr. Smith. The surveyor might ask, "How did you communicate with each other while you cared for Mr. Smith, specifically regarding verbal orders?"
Evaluating the Delivery of Care
The surveyors will actually be spending much more time observing direct care, they will be evaluating the actual delivery of care services, much less time on policies and procedures. What's important under Shared Visions-New Pathways is not that staff know what a Joint Commission standard is, but they need to know and be able to articulate to our surveyors how they provide care to the patients, clients, residents that they're caring for.