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JCI Tracer Methodology
by : Theresa Gay Calingo, BSAR, RN, MAN, PhD.C
It is useless to want to re-do the work that we may have done negligently.
It's best to appreciate and do things well from the beginning....
THANK YOU
Compilation of JCI SURVEY question and answers ,email us at
nurse.education@burjeel.com
Tracer methodology is also used to
assess key systems such as data use, infection control and medication management.
Information regarding each system is obtained during discussion with a group of selected staff.
Key to success
4. Do we know our organization's level of compliance?
5 Focus Areas...
5.Do we assist leadership with the development and implementation of corrective action plans?
CREDENTIALED PRACTITIONERS
Key to success
6.Have we developed accreditation-readiness
team or committee that meets on a regular basis to discuss compliance issues, new standard developments or survey- process changes ?
COMMUNICATION
appropriate staffing ratio, Nsg competencies per area of specialty.....
MEDICATION MANAGEMENT AND USE
- high alert medications
- look alike sound alike medication
- concentrated electrolytes
INSIDE THE JCI SURVEY AND BEYOND STANDARDS
JCI 5th edition of the Hospital Standards contains
285 Standards
1160 Measurable Elements
JCI 5th EDITION
Date of Implementation April 1, 2014
Consists of four sections
Section 1 : APR
Accreditation participation requirements
JCI SERVICES
Section 2 : Patient centered standards
Hospitals
1. IPSG
Laboratory Services
Advance certification
2. ACC (Access to care and continuity of care)
Home care
Nursing care center
Ambulatory healthcare
Office based Surgery
Critical Access Hospital
Long term care
Disease Specific Care
Behavioral healthcare
Health Care Staffing Service
WHO is JCI ?
Joint Commission International (JCI) was founded in the late 1990s to survey hospitals outside of the United States.
JCI, which is also not-for- profit, currently accredits facilities in Asia, Europe, the Middle East, and South America.
JCI 5th EDITION
3. PFR (Patient and Family Rights)
4. AOP (Assessment Of Patients)
5. COP (Care Of Patients) ambulatory
JCI 5th EDITION
6. ASC (Anesthesia and Surgical Care)
12.FMS (Facility Management and Safety)
7. MMU (Medication Management and Use)
13.Staff qualification and education SQE
8. PFE (Patient and Family Education)
14.Management of Information MOI
Section 4 : academic medical center hospitals standards
JCI 5th EDITION
15.Medical profession education MPE
Section 3 : Health care organization management standards
16.Human subjects research Programs HRP
9. QPS (Quality improvement and Patient Safety)
10. PCI (Prevention and Control of Infections) laboratory
11. GLD (Governance, Leadership and Direction) for hospitals and academic medical institutions
2 TYPES OF TRACERS
System Tracer
WHAT IS THE VALUE OF A JCI ACCREDITATION
Patient Tracers allow hospital staff members to get a patient's perspective of the care provided.
System Tracers allow staff members and administrators to see how well a unit, department or entire facility is doing.
JCI Tracer Methodology
WHAT IS TRACER METHODOLOGY ?
Patient tracer Allows a surveyor to assess an organization’s systems and processes by :
Following the treatment path an individual patient has taken in the hospital, or
Following a process in the hospital from a beginning to an endpoint
TRACER survey process....
How do JCI go about the
TRACING PROCESS
Typical the survey team consists of a physician, nurse, and administrator
TRACER survey process....
Surveyors are able to evaluate how
well the hospital's processes and departments work with each other.
Surveyors interview physicians and staff involved in each patient's care
as well as the patients themselves when possible.
An evaluation that follows or TRACES the hospital
experiences of specific patients.
Why do we need to conduct a
TRACER ?
Surveys conduct a complete system analysis on integration and coordination of care processes
- In healthcare, a tracer can follow a patient from admission to discharge, or can follow a care regimen within one unit.
TRACER METHODOLOGY
identify diff
tests, treatment
& services
patient recieved
SELECT
Currently
In-house
patients
Surveyors
review
in-patient
census
identify patient
care areas the
patient visited
review
patient
charts
attempt to locate
staff members
who treated the
patient
JCI TRACER PROCESS
Is an effective evaluation method that is used to assess a healthcare organization's performance of care and the services provided as viewed or experienced by the patient.
UNAVAILABLE
AVAILABLE
KEY :
Patient Selection
Staff Interview in Care Area
Post-interview
interview staff
member who
treated the
selected patients
interview other
staff who normally
treat this kind of
patient
Surveyors
move into the
next patient
care area
determine how
staff members
do their jobs and
service patients
May request hospital
policies, staff records
additional charts of
similar patients
TRACER METHODOLOGY
What are the JCI's hot topics
for survey ?
A patient with pain
A patient in restraints or seclusion
A patient in isolation
Pertinent information we need to know to prepare for the re-accreditation....
A patient being discharged
A patient with high risks for fall
How do you prevent falls?
A patient on conscious sedation
Explain the consent process whe the patient does not speak english.
How do you deal with a critical lab results?
Key to success
What would you do is an active shooter was
in your area?
DONT WAIT FOR JCI TO LOOK AT FOCUS
AREAS FOR US :
You can learn more in 8 hours of tracing than in 20 hours of chart review...
While we prepare, ask ourselves the following questions ?
Use the following questions to help guide our selection :
1. Does our organization embrace survey preparations as a continuous process ?
2. Have we obtained leadership Support?
- Has our hospital been cited for issues in a given area?
Key to success
3. Do we encourage the use of standards and regulations as part of our organization's everyday
operational plan ?
- If so then we should select that area.
MOCK TRACERS
Pertinent information we need to know to prepare for the re-accreditation....
If comparable hospital in our area, have recently been surveyed......What tracers did the surveyors conduct at those facilities ?
How will you evacuate an obese patient from the 6th floor in case of fire ?
What is your patient discharge process ?
What is your role in patient safety ?
What are the JCI's hot topics
for survey ?
How is care coordinated with other disciplines?
What is a sentinel event / Near Miss ?
How do you report incidences ? OVR ?
It is highly recommended that hospitals conduct mock tracers.
Tracers that simulate a JCI visit ( Feb 22 and 23, 2016 ) to assess our level of compliance before the surveyors arrive and throughout the year, using a tracer-patient selection worksheet.
Although our process has just started, it is still in its early stage and much training for our hospital staff is still necessary.....
JCI Tracer Methodology
Theresa Gay Dimacali-Calingo BSAR, RN,MAN, PhD.C
TRACER METHODOLOGY
Tracer methodology requires surveyors to select active patients and trace their care through departments or services of the hospital
Surveyors are looking for how well we perform our roles in caring for patients.
They can determine how well a hospital has implemented its policies and procedures
Consider the following recommendations :
Answer their question directly (keep your answers short and sweet) and ask the surveyor to repeat or rephrase the question if you did not understand it.
Be honest - if you dont know the answer, do not make one up.
Be polite and smile - do not let the questions make you feel defensive or angry.
Be specific, provide examples for an answer and refer to policies or procedures whenever possible.
Be enthusiastic about what you do.
JCI ACCREDITATION
We just dont tell the surveyors how we do it, we also have to show the documents to prove how it was done
Now is the time to understand what you need to do to accommodate tracers .......
What is the role of the staff in the survey
during a TRACER ?
JCI Approach and Philosophy to
the On Site Survey
As surveyors move around the hospital
they will speak with the staff members who have been involved in the tracer patient's care , treatment and services.
A survey is not intended to be punitive,
a "got YOU" exercise or an inspection.
Assume they will want to talk to you,
so have confidence in yourself.... remember
you provide awesome care, so let them see
it !
Tracer Methodology is a process of
identifying imperfections, flaws or broken system, so that we can improve our services......
Prepare yourself to answer their questions.
During individual- based system tracers, the surveyors assess how well the system processes have been implemented into patient care practices.