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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

STAFFING

appropriate staffing ratio, Nsg competencies per area of specialty.....

Step 2

Step 3

Step 4

MEDICATION MANAGEMENT AND USE

  • high alert medications
  • look alike sound alike medication
  • concentrated electrolytes

1. PATIENT SAFETY

Step 1

Step 5

You and your Role !

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

MMU

PATIENT

SAFETY

WHAT IS THE VALUE OF A JCI ACCREDITATION

Safety

Patient Tracers allow hospital staff members to get a patient's perspective of the care provided.

Infection

Control

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.

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