The Joint Commission’s on-site survey process includes tracer methodology. Tracer methodology is an evaluation method in which surveyors select a patient, resident or client and use that individual’s record as a roadmap to move through an organization to assess and evaluate the organization’s compliance with selected standards and the organization’s systems of providing care and services. Surveyors retrace the specific care processes that an individual experienced by observing and talking to staff in areas that the individual received care. As surveyors follow the course of a patient’s, resident’s or client’s treatment, they assess the healthcare organization’s compliance with Joint Commission standards. They conduct this compliance assessment as they review the organization’s systems for delivering safe, quality healthcare.
While conducting tracer activities, the surveyor may identify compliance issues in one or more elements of performance. Surveyors will look for compliance trends that might point to potential system level issues in the organization. The tracer activity also provides several opportunities for surveyors to provide education to organization staff and leaders, as well as to share best practices from other similar healthcare organizations.
The number of tracers completed depends on the length of the survey; however, the average three-day hospital survey with a team of three surveyors typically allows for completion of approximately 11 tracers. Tracer patients, residents or clients are primarily selected from an active patient list. Typically, individuals selected for the tracer activity are those who have received multiple or complex services. The surveyor may speak to the patient, resident or client during the tracer activity, if it is appropriate. As always, the surveyor asks for patient permission before speaking to him or her.
If problem trends are identified, surveyors will issue the organization a Requirement for Improvement. The organization has 45 days from the end of the survey to submit Evidence of Standards Compliance and identify Measures of Success that it will use to assess sustained compliance over time. Four months after approval of the Evidence of Standards Compliance, the organization will submit data on its Measure of Success to demonstrate a track record. Any exchange of information between the healthcare organization and The Joint Commission will meet HIPAA requirements.