406-R Rachel Chapman posted

406-R Rachel Chapman posted

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406-R Rachel Chapman posted

Offer three strategies for incorporating tracer methods in a healthcare facility. In your strategies, be sure to involve nursing staff, providers, and healthcare administration.


Peers response:


Rachel Chapman posted

Since implementation in 2004, the Joint Commission has been on a mission to ensure facilities stay in compliance; not just through words but proof. Thus, the inception of the tracer methodology.  Over the years, JACHO has revitalized how surveys are completed.  Currently, the focus is less on staff interaction but staff intervention (Fay, 2003). Tracer methodology is a system used by The Joint Commission to assess hospital standards and compliance by following patients through a healthcare facility (Siewert, 2018, p 131).  Upon survey, there are three areas assessed by tracers: individual tracer activity, system tracer activity, and accreditation-program specific tracer (Facts about tracer methodology, 2019). The introduction and application of tracer methods need to be a continual improvement process, not just eminent with an upcoming survey. The following are three suggestions I feel tracer methodology would be appropriate for my current facility:

1. From an outpatient surgical care management standpoint, I recommend running a report of patient times. Example: check-in, pre-op vitals, nursing assessment, pre-med order time, pre-meds provided, time between pre-med and time to OR, time in holding, time out of the OR, PACU, and recovery. Each of these benchmarks is easily traceable through documentation and can help determine delays in care and ineffective processes.  As a supervisor, this information would afford you the opportunity to create process improvement.

2. Durable Medical Equipment (DME) – Proper process flow and communication of DME or rehab supplies is critical to prevent avoidable days.  By tracking the ordering system (providers), patient notification, therapist intervention, ordering of supplies, and communication about delivery is an area that is necessary to ensure positive flow. Historically, communication is lacking with rehab and the interdisciplinary coordination team, so this method could help streamline patient care.

3. Pre-Admission planning – Since my facility is non-profit and responsible for housing and transportation for all international patients, tracking individual activity is vital to ensure federal compliance with visas and passports. Generated reports pulled by patient location origin, onset of planning process, delays in care, and follow up appointments will prevent delays in care and ensure patients’ needs are met in a timely, and legal, manner. Hospital administration is constantly working with consulates of other countries and a checks and balances system is necessary.



Facts about tracer methodology. (2019). Retrieved from https://www.jointcommission.org/facts_about_the_tracer_methodology/

Fay, C. (2003). Educating staff on tracer methodology is a must: survey results depend on it. Hospital Peer Review28(12), 161–165.

Siewert, B. (2018). The joint commission ever-readiness: Understanding tracer methodology. Current Problems In Diagnostic Radiology47(3), 131–135.


Peers Response:


Elizabeth Charlebois posted Tracers allow The Joint Commission to evaluate healthcare facilities for standards compliance and patient safety. Surveyors examine one or more steps of the care delivery process to identify performance issues. In addition, they interview healthcare workers to evaluate the quality and safety of the patient care process. This allows for less time devoted to examining written policies and procedures. (Jacott, 2006) Surveyors spend more than half of their time tracing the care of randomly selected patients. They do this to learn how interdisciplinary staff interact and communicate across departments to provide safe, high-quality care. This allows for the identification of performance issues during any step of the care process.

The types of tracers The Joint Commission uses when it surveys a healthcare facility are individual tracer activity, system tracer activity, and accreditation program-specific tracers. Individual tracer activities are intended to “trace” the care that patients experience while at an organization.  System tracer activity includes an interactive session with a surveyor and care providers. During this session, one specific “system” or process within the organization is traced. This is based on information from individual tracers.  The goal of accreditation program-specific tracers is to identify risk and safety concerns within the organization at different levels and types of care, treatment, or services. (The Joint Commission, 2019) In the patient tracer methodology, the surveyor follows a patient’s care record to assess and evaluate the services that the healthcare organization provides. Areas that the surveyor may focus on are how the patient was assessed by each of these departments the patient encountered, how the medical history obtained, the development of the care plan, treatment provided, and other issues related to infection control. (Jacott, 2006)

Surveyors interview hospitalists and other staff physicians to see how hospitals deliver safe, high-quality care. They may observe nursing staff during medication administration. Surveyors also may also examine how National Patient Safety Goals are addressed by using the tracer methodology. The patient tracer process encompasses a wide variety of departments. It involves practitioners and other caregivers in the process. Surveyors examine how they carried out their work. This allows for an open exchange of information.


Jacott, W. (2006). A Trace of Improvement. The Hospitalist(3). Retrieved from https://www.the-hospitalist.org/hospitalist/article/123081/trace-improvement

The Joint Commission. (2019). Facts about the Tracer Methodology. Retrieved from The Joint Commission: https://www.jointcommission.org/facts_about_the_tracer_methodology/

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