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A Trace of Improvement


The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has dramatically redesigned and improved the value of its accreditation process. The new process includes revised standards, a periodic performance review (PPR), new survey techniques, and a revised decision process.

Known as Shared Visions-New Pathways and implemented in 2004, this transformation of the accreditation process has shifted the emphasis from survey preparation to continuous improvement of operational systems that contribute directly to the delivery of safe, high-quality care. The emphasis of the revised accreditation process is on how healthcare organizations normally provide care and use JCAHO standards as a framework to deliver safe care on a daily basis. There is a significant focus on clinical care.

This article explores the two major parts of this revised accreditation process: the patient tracer methodology that guides the on-site survey and the PPR, a self-assessment tool that results in corrective action plans. (These are particularly relevant for the hospitalist.)

Patient Tracer Methodology and the Hospitalist

The patient tracer methodology provides a framework for JCAHO surveyors to assess standards compliance and patient safety during on-site surveys. The process involves interviewing the caregivers to evaluate the quality and safety of the patient care process. By evaluating the actual delivery of care services, less time is devoted to examining written policies and procedures. Surveyors use 50%-60% of their time tracing the care of randomly selected patients to learn how staff from various disciplines work together and communicate across departments to provide safe, high-quality care.

One way surveyors look at how hospitals deliver safe, high-quality care is to interview hospitalists and other staff physicians. In the patient tracer methodology, the surveyor selects a patient and uses that patient’s care record as a roadmap to assess and evaluate the services that the healthcare organization provides. This type of interaction, coupled with an emphasis on continual compliance with standards such as infection control and medication management (which address issues crucial to good outcomes for patients), is exactly what physicians have told JCAHO they desire from the accreditation process.

The goal is not for the hospitalist to memorize JCAHO standards, but instead to be able to discuss patient care systems and processes. This is already an area with which hospitalists are familiar. Hospitalists are a vital part of the organizational structure and play a large role within the care systems. Hospitalists can help surveyors understand processes used within their healthcare organizations.

JCAHO’s evolving accreditation process represents a paradigm shift for the hospitalist, who may be more accustomed to organizations ramping up before an on-site survey. Such activity prior to an on-site survey didn’t meet the goals of JCAHO accreditation in that it drew physicians from providing care and managing performance improvement over time.

How Patient Tracers Work

Surveyors begin the patient tracer by starting where the patient is currently located. They then move to where the patient first entered the organization, and to any areas in the organization where the patient received care. Each tracer takes from one hour to three hours to complete. A three-day survey includes an average of 11 individual tracers.

For example, a surveyor might select a patient admitted to a hospital’s emergency department with cardiac disease. The patient went to cardiac cath, to the operating room for a CABG, and then to the intensive care unit. The patient had complications and ventilator-associated pneumonia. The surveyor would trace the patient’s path through the emergency department, cardiac cath area, operating room, post-anesthesia care unit, and intensive care unit.

The surveyor might focus on how each of these departments assessed the patient, obtained a medical history, developed the care plan, provided treatment, and addressed issues related to infection control. The surveyor also would return to the unit where the patient resides to discuss the findings as they explore the care processes. It may be that a new theme or area of focus—such as assessment and care/services—emerges from this tracer process. The surveyor would then explore this new area more thoroughly and ask other surveyors at the hospital to explore assessment and care/services in their tracers to determine if similar findings exist in other tracer patients.

Surveyors also may use the tracer methodology to examine how National Patient Safety Goals are addressed. On the surgical unit, a surveyor may observe a nurse giving medications ordered by the hospitalist. The surveyor would spend time talking with the nurse and hospitalist about the patient selected for the tracer, perhaps asking for the unique identifiers used for the patient. Other queries may include: What is the patient’s diagnosis? How is the hospitalist caring for this patient? What was the admission date? The surveyor would note whether any of the “do not use” abbreviations related to medications are used and talk with the hospitalist about this issue. How are healthcare-acquired infections addressed?

The patient tracer process takes surveyors across a wide variety of departments and involves practitioners and other caregivers in the accreditation process, asking them to describe how they carried out their work. Instead of asking the hospitalist about particular standards, surveyors explain the purpose of the tracer and engage in an educational as well as an evaluative process. This approach moves the on-site survey away from high-level conferences with administrators about policies and procedures to focused discussions with those actually delivering care. The idea is to create an atmosphere that allows for an open exchange of information and ideas between surveyors and the hospitalist and other staff.

These discussions with hospitalists, other staff, and patients—combined with review of clinical charts and the observations of surveyors—make for a dynamic survey process that provides a complete picture of an organization’s processes and services. In other words, the tracers allow surveyors to “see” care or services through the eyes of patients and staff and then analyze the systems for providing that care, treatment, or services.

As surveyors use the tracer methodology to determine standards of compliance as they relate to care delivered to individual patients, they also assess organizational systems by conducting patient-system tracers. The concept behind the patient-system tracers methodology, which focuses on high-risk processes across an organization, is to test the strength of the chain of operations and processes. By examining a set of components that work together toward a common goal, the surveyor can evaluate its level of efficiency and the ways in which an organization’s systems function. This approach addresses the interrelationships of the many elements that go into delivering safe, high-quality care and translates standards compliance issues into potential organization-wide vulnerabilities.

The system tracers provide a forum for discussion of important topics related to the safety and quality of care at the organization level. Surveyors use the system tracers to understand organization findings and to facilitate an exchange of educational information on key topics such as data use for infection control and medication management.

While some of the patient system tracer activities consist of formal interviews, an interactive session, which involves a surveyor and relevant staff members, is an important component of the process. Discussions in this interactive session with the hospitalist and other staff include:

  • The flow of the processes, including identification and management of risk points, integration of key activities, and communication among staff/units involved in the process;
  • Strengths in the processes and possible actions to be taken in areas needing improvement;
  • Issues requiring further exploration in other survey activities; and
  • A baseline assessment of standards compliance.

PPR and the Hospitalist

Beyond the onsite survey, JCAHO’s accreditation process is designed to help organizations maintain continuous compliance with the standards and use them as a daily management tool for improving patient care and safety. This represents a paradigm shift for the hospitalist, who may be more accustomed to organizations ramping up before an on-site survey. This frenzy of activity prior to an on-site survey did not meet the goals of JCAHO accreditation in that it drew physicians and staff away from providing care and managing performance improvement over time.

The PPR is a new form of evaluation conducted by the organization to assess its level of compliance with standards. This comprehensive, self-directed review provides the framework for continuous standards compliance and focuses on the critical systems and processes that affect patient care and safety. By conducting the PPR annually, organizations can self-evaluate their compliance with all Accreditation Participation Requirements, Standards and Evidence of Performance; develop plans of action to address any identified opportunities for improvement; and implement those plans to improve care.

JCAHO requires that physicians at accredited hospitals be involved in the self-assessment component of the PPR and in developing plans of action. Each hospital must make its own determinations about how involved hospitalists and other physicians are with the PPR. JCAHO recognizes that hospitalists have limited time for performance improvement activities, but believes that their participation is crucial because of their commitment to providing care that results in positive outcomes for patients and reduces risk.

Patient Tracer Methodology and PPR in 2006

As part of changes to the accreditation process, JCAHO will shift from scheduled to unannounced on-site surveys. The transition to unannounced surveys began this year:

  • To enhance the credibility of the accreditation process by ensuring that surveyors observe organization performance under normal circumstances;
  • To help healthcare organizations focus on providing safe, high quality care at all times, and not just when preparing for survey;
  • To reduce the unnecessary costs that healthcare organizations incur to prepare for survey; and
  • To address public concerns that JCAHO receive an accurate reflection of the quality and safety of care.

The new accreditation process supports this transition by considering the information generated by the PPR. Organizations will be able to update the PPR, available on each organization’s extranet site, annually to support continuous performance improvement efforts.

JCAHO conducted pilot testing of the unannounced survey process in volunteer organizations during 2004 and 2005, giving its staff insight into real-life issues and concerns at accreditation organizations. JCAHO also worked closely with its various advisory groups, accredited organizations and other stakeholder groups to gain their input and smooth the transition to unannounced surveys.


The participation of the hospitalist in the JCAHO accreditation process is dependent upon common interests in improving healthcare quality and safety. JCAHO accreditation can be used to help the hospitalist and healthcare organizations meet their goals and responsibilities to individual patients. Accreditation activities can help to focus physician involvement in patient safety and other important areas, thus bringing increased relevance to the accreditation process.

In conclusion, the importance of the hospitalist to the JCAHO accreditation process on a continuous basis, not just during the on-site survey, is crucial. TH

Dr. Jacott was appointed a special advisor for professional relations to the Joint Commission in January 2002. As special advisor for professional relations, Dr. Jacott serves as the Joint Commission’s liaison to SHM.

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