A key part of The Joint Commission’s on-site survey process is the tracer methodology. The tracer methodology uses information from the organization to follow the experience of care, treatment, or services for a number of patients through the organization’s entire health care delivery process. Tracers allow surveyors to identify performance issues in one or more steps of the process, or interfaces between processes. The types of tracers used by The Joint Commission during the on-site survey are:
Individual tracer activity: These tracers are designed to “trace” the care experiences that a patient had while at an organization. It is a way to analyze the organization’s system of providing care, treatment, or services using actual patients as the framework for assessing standards compliance. Patients selected for these tracers will likely be those in high-risk areas or whose diagnosis, age, or type of services received may enable the best in-depth evaluation of the organization’s processes and practices.
System tracer activity: Includes an interactive session with a surveyor and relevant staff members in tracing one specific “system” or process within the organization, based on information from individual tracers. While individual tracers follow a patient through his or her course of care, the system tracer evaluates the system or process, including the integration of related processes, and the coordination and communication among disciplines and departments in those processes. The three topics evaluated by system tracers are data management, infection control and medication management. Whether all system tracers are conducted varies, but the data use system tracer is performed on every survey.
Accreditation program-specific tracers: The goal of these tracers is to identify risk points and safety concerns within different levels and types of care, treatment, or services. Program-specific tracers focus on important issues relevant to the organization. For example, clinical services offered and high-risk, high-volume patient populations.
Second generation tracers: These are a deep and detailed exploration of a particular area, process, or subject. A surveyor conducting any type of tracer might notice, for example, that a high-risk area requires a more in-depth look. High-risk issues include processes or procedures that, if not planned or implemented correctly, have significant potential for affecting patient safety. Examples of high-risk topics that surveyors might need to explore in more detail are: cleaning, disinfection, and sterilization; patient flow across the care continuum; contracted services; diagnostic imaging; therapeutic radiation; and ongoing professional practice evaluation (OPPE) and focused professional practice evaluation (FPPE).
Read more about the accreditation process