Tracer Methodology and the New Joint …

1 710 Home Healthcare MethodologyTracer Methodology is a termthat describes the new surveyprocess for home care and hos-pice surveys effective January 1,2004. This survey style focusesthe surveyor s activities onareas that the Joint Commissionhas determined to be para-mount to assure high-quality,safe care. These survey focusareas are individualized to thehome care and hospice programand based on output from thepriority focus process tool thatgenerates the patient categoriesthat the surveyor should selectto trace through their homecare and hospice the patient throughtheir care experience, the homecare or hospice surveyor willfurther focus on standards thatare applicable to the priorityfocus areas (PFAs) that are pre-selected by the Joint Commis-sion s central office. Based onthese PFAs, the surveyor followsthe patient s care from start ofcare to the patient s current sta-tus. These are called individualpatient surveyor will also con-ductsystem tracers.

2 These sur-vey activities focus onprocesses, systems, and func-tions that are influential to thepatient s care experience whilealso considering the outcomesand findings from the individualtracer activities. In the new sur-vey process, many survey activ-30 days notice of the first day foran announced survey becauseas of January 1, 2006, all surveyswill be unannounced. Approxi-mately 30 days in advance, theJoint Commission s account rep-resentative will send the surveyagenda and the surveyor(s) bio-graphical sketch via e-mail toboth the organization and allscheduled Phone CallThe surveyor will still call thecontact person identified on thesurvey application severalweeks in advance of the sched-uled survey to discuss travel lo-gistics and the scope of the sur-vey. When the presurveytelephone call is made morethan 2 weeks out from the firstday of survey , the surveyor willnot be able to discuss the se-lected Priority Focus Areas(PFA)s and Clinical ServiceGroups (CSG)s, as they will nothave been released from theJoint Commission s central of-fice reason that PFAs andCSGs are released only twoweeks in advance of the on-sitesurvey is the Joint Commissionis trying to reduce the gettingready that historically hasgone into preparing for a sur-vey.

3 This has also been the im-petus for all Joint Commissionaccreditation surveys to beunannounced in 2006 and be-yond. Tracer Methodology and the New Joint Commission HomeCare and Hospice survey ProcessPart 1 MARY MCGOLDRICK FRIEDMAN, MS, RN, CRNIU nless you ve been living undera rock for the last year, youprobably know the Joint Com-mission survey process haschanged for home care and hos-pice organizations. What youmay not know is how the newtracer Methodology works,what to expect, and how youshould prepare for a surveyunder the new process. If yourhome care or hospice programis a department of a hospital,you may be unsure of whathome care s role will be as thenew survey process is new home care and hos-pice survey process will be ad-dressed in this and the next twoAccreditation Strategies columns(appearing in the November andDecember issues, respectively).Parts 1 and 2 describe the newsurvey process and tracermethodology.

4 Part 3, in the De-cember issue, focuses onchanges in the new surveyprocess and its impact on hospi-tal-based home care and the SurveyThe survey process beginswhen the Joint Commission re-ceives the home care and hos-pice organization s request forsurvey and processes the appli-cation. If the survey is sched-uled before December 31, 2005,the home care and hospice or-ganization will receive at leastvol. 22 no. 10 October 2004 Home Healthcare Nurse711ities are the same (staff andfamily interviews, home visits);however, the specific activitiesand processes that comprisethe Tracer Methodology andnew survey process are differ-ent than the activities andprocesses of prior Focus ProcessToolBoth the organization and thesurveyor will receive the CSGsand PFAs electronically 2 weeksprior to the survey . Organiza-tion information is gathered andanalyzed electronically using aset of defined automated rulesor algorithms to produce theCSG and PFA outputs.

5 For homecare and hospice organizations,the following information is in-putted into the Joint Commis-sion s electronic priority focusprocess tool: Previous Joint Commissionsurvey findings, complaint and sentinel eventinformation that the JointCommission is aware of, application for survey infor-mation, and if the organization is aMedicare-certified homehealth agency, data gener-ated from Home Health Care and HospicePriority Focus AreasIf you were ever fortunateenough to have won the equiva-lent of the Joint Commissionlottery and were selected to un-dergo a random unannouncedsurvey (RUS), you ll recall thatfive grid elements were prese-lected for the surveyor to focusactivities on during the 1-daysurvey. The concepts of focus-ing on a specific set of stan-dards or PFAs are similar toWhat if a standard, not re-lated to a targeted PFA, isfound to be noncompliant? Does that mean that surveyorcannot write them up ?

6 No, all standards have the po-tential for review and, as neces-sary, scoring. Under the newsurvey process, if an individualor system Tracer activity doesnot identify any process or sys-tem vulnerabilities, the stan-dard/PFA does not need to beinvestigated further. An exam-ple is the testing of the on-callsystem. If the surveyor doesnot identify any issues with theon-call system, the on-call sys-tem need not be s right; the surveyordoesn t have to test the on-callsystem. Previously, the surveyprocess was very predictableand everyone knew that thesurveyor would test the on-callsystem between the openingconference and the last day ofthe survey . If the surveyor wereto test the on-call system, thetimeframes would be the same,but there is now the optionoftesting the Service GroupsClinical Service Groups are an-other output from the priorityfocus process tool. CSGs arecategories of patient services,selected by the Joint Commis-sion, to focus the surveyor s ac-tivities during the individual pa-that of a RUS, except in a RUSall the grid elements were pre-set per calendar year and thePFAs are individualized for theorganization.

7 Similar to the gridelements of years past, arePFAs listed in Figure weeks prior to the on-site survey , between four andsix PFAs are selected for the sur-veyor(s) to focus survey activi-ties on during the individual pa-tient tracers and system traceractivities. PFAs are theprocesses, systems, or struc-tures within a home healthagency or hospice that, accord-ing to the Joint Commission, cansignificantly impact the qualityand safety of care and if notfunctioning properly, can createthe greatest risk for a negativeoutcome (JCAHO, 2004b, GL-16).The titles of the PFAs can bemisleading as one PFA can crossmultiple chapters and numerousstandards and does not just in-clude one chapter or one subsetof standards in a chapter. For ex-ample, the Infection Control PFAis not just limited to the stan-dards in the Surveillance, Pre-vention, and Control of Infectionschapter; it also includes stan-dards from the chapters of Provi-sion of Care, Treatment and Ser-vices, Improving OrganizationalPerformance, Management of theEnvironment of Care, Manage-ment of Human Resources, andManagement of are the days when the director gave a formal stand up presentation with computer images to the surveyor(s).

8 In the new survey process, informationis to be shared as an interactive discussion and moreconversational than a stand up performance. 712 Home Healthcare tracers (JCAHO, 2004b,GL-3). During the surveyor plan-ning session the CSGs identifiedwill be used to select the tracerpatients from the active patientlist. The CSGs for home careand hospice are as follows: Home health: Home health services. Home personal care/sup-port services. Hospice: Facility-based respite care. Facility-based symptom relief. Hospice in-home care. For Medicare-certified homehealth agencies:patients having: acute care hospitalizations, confusion difficulties, emergent care, pain interfering with activity, stabilized needing: ambulation improvement, bathing assistance, oral medication management, toileting assistance, transferring assistance, upper-body dressing ConferenceThe on-site survey process be-gins with an opening conferencethat lasts approximately 15 min-utes.

9 At this time the surveyor(s)make introductions and becomeacquainted with the organiza-tion s staff. Then the surveyor(s)will discuss the PFAs and CSGspreselected and briefly describethe scheduled survey activities,review the agenda, and answerany questions. operational management; resource allocation andmonitoring; contract management andoversight; patient safety initiatives,including selection of Fail-ure Mode and EffectsAnalysis (FEMA) topic(s); implementation of NationalPatient Safety Goals; emergency managementplanning; performance improvementplanning, priorities estab-lished, ongoing measure-ment initiatives, and im-provements gained andmaintained; allocation of personnel toparticipate in performanceimprovement activities toinclude adequate time, in-formation systems, datamanagement, and stafftraining; and if applicable, approach tothe Periodic PerformanceReview and methods usedto address areas all these topicscannot be thoroughly discussedin 45 minutes.

10 Don t be sur-prised if discussion on sometopics is addressed duringother survey the home care direc-tor, others participating in thisorientation should include atleast one governing body mem-ber, the home care director ssupervisor, and any other keyhome care Team Meeting/Planning SessionThe surveyor planning ses-sion, which includes the fol-lowing surveyor activities, fol-lows the opening conferenceand orientation:When there are multiple sur-veyors, all surveyors are tobegin the survey together at thesame time; all are present forthe opening conference and or-ganization orientation so no du-plication of survey activities oc-curs. The survey agenda will bedeveloped as an overlay so thatall survey activities and timesare length of the scheduledsurvey will vary by surveyorand in some cases the survey -ors will not end at the sametime. At times (due to surveyorillness, etc.) changes may needto be made, but the intent is forall surveyors to begin day oneof the survey at the same s nothing to bring tothe opening conference, excepta smile.