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JCI Tracer Methodology

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Transcript of JCI Tracer Methodology

JCI Tracer Methodology

2 TYPES OF TRACERS
Patient Tracers
allow hospital staff members to get a patient's perspective of the care provided.
System Tracer
TRACER survey process....
Although our process has just started, it is still in its early stage and much training for our hospital staff is still necessary.....
You can learn more in 8 hours of tracing than in 20 hours of chart review...
MOCK TRACERS
It is highly recommended that hospitals conduct mock tracers.
WHO is JCI ?
Joint Commission International (JCI) was founded in the late 1990s to survey hospitals outside of the United States.
Theresa Gay Dimacali-Calingo BSAR, RN,MAN, PhD.C
Why do we need to conduct a
TRACER ?
In healthcare, a tracer can follow a
patient
from admission to discharge, or can follow a care
regimen within one unit
.
System Tracers
allow staff members and administrators to see how well a unit, department or entire facility is doing.
MMU
Safety
Infection
Control
PATIENT
SAFETY
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
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.
During
individual- based system tracers,
the surveyors assess how well the system processes have been implemented into patient care practices.
Step 1
Step 2
Step 3
Step 4
Step 5
You and your Role !
5 Focus Areas...
1. PATIENT SAFETY
COMMUNICATION
CREDENTIALED PRACTITIONERS
STAFFING
MEDICATION MANAGEMENT AND USE
DONT WAIT FOR JCI TO LOOK AT FOCUS
AREAS FOR US :
Use the following questions to help guide our selection :
Has our hospital been cited for issues in a given area?
Key to success
While we prepare, ask ourselves the following questions ?
1. Does our organization embrace survey preparations as a continuous process ?
2. Have we obtained leadership Support?
4. Do we know our organization's level of compliance?

5.Do we assist leadership with the development and implementation of corrective action plans?
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.
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 .......
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....
Advance certification
JCI SERVICES
Hospitals
Ambulatory healthcare
Behavioral healthcare
Critical Access Hospital
Disease Specific Care
Home care
Health Care Staffing Service
Laboratory Services
Long term care
Nursing care center
Office based Surgery
Date of Implementation April 1, 2014
JCI 5th EDITION
Consists of four sections
Section 1
: APR
Accreditation participation requirements
Section 2
: Patient centered standards

JCI 5th EDITION
3. PFR (Patient and Family Rights)
4. AOP (Assessment Of Patients)
5. COP (Care Of Patients) ambulatory
6. ASC (Anesthesia and Surgical Care)
7. MMU (Medication Management and Use)
8. PFE (Patient and Family Education)
2. ACC (Access to care and continuity of care)
Section 3
: Health care organization management standards
JCI 5th EDITION
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
12.FMS (Facility Management and Safety)
JCI 5th EDITION
13.Staff qualification and education SQE
14.Management of Information MOI
Section 4
: academic medical center hospitals standards
15.Medical profession education MPE
16.Human subjects research Programs HRP
JCI 5th edition of the Hospital Standards contains
285 Standards
1160 Measurable Elements
Typical the survey team consists of a physician, nurse, and administrator
An evaluation that follows or
TRACES
the hospital
experiences of specific patients.
Surveys conduct a complete system analysis on integration and coordination of care processes
Patient tracer
Allows a surveyor to assess an organization’s systems and processes by :
JCI Tracer Methodology
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

WHAT IS TRACER METHODOLOGY ?
Surveyors
review
in-patient
census
SELECT
Currently
In-house
patients
review
patient
charts

identify patient
care areas the
patient visited
identify diff
tests, treatment
& services
patient recieved
attempt to locate
staff members
who treated the
patient
AVAILABLE
UNAVAILABLE
interview staff
member who
treated the
selected patients
interview other
staff who normally
treat this kind of
patient
determine how
staff members
do their jobs and
service patients
May request hospital
policies, staff records
additional charts of
similar patients
Surveyors
move into the
next patient
care area
KEY :
Patient Selection
Staff Interview in Care Area
Post-interview
JCI TRACER PROCESS
TRACER METHODOLOGY
TRACER METHODOLOGY
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.
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.
How do JCI go about the
TRACING PROCESS
If comparable hospital in our area, have recently been surveyed......What tracers did the surveyors conduct at those facilities ?
What are the JCI's hot topics
for survey ?
3. Do we encourage the use of standards and regulations as part of our organization's everyday
operational plan ?
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 ?
Key to success
Key to success
THANK YOU
nurse.education@burjeel.com
If so then we should select that area.
Prezi.com
JCI Tracer Methodology
by : Theresa Gay Calingo, BSAR, RN, MAN, PhD.C
JCI, which is also not-for- profit, currently accredits facilities in Asia, Europe, the Middle East, and South America.
1. IPSG
INSIDE THE JCI SURVEY AND BEYOND STANDARDS
WHAT IS THE VALUE OF A JCI ACCREDITATION
high alert medications
look alike sound alike medication
concentrated electrolytes
appropriate staffing ratio, Nsg competencies per area of specialty.....
What are the JCI's hot topics
for survey ?
A patient with pain
A patient in restraints or seclusion
A patient in isolation
A patient being discharged
A patient with high risks for fall
Pertinent information we need to know to prepare for the re-accreditation....
How do you prevent falls?
Explain the consent process whe the patient does not speak english.
How do you deal with a critical lab results?
What would you do is an active shooter was
in your area?
Pertinent information we need to know to prepare for the re-accreditation....
How will you evacuate an obese patient from the 6th floor in case of fire ?
A patient on conscious sedation
What is your patient discharge process ?
What is your role in patient safety ?
How is care coordinated with other disciplines?
What is a sentinel event / Near Miss ?
What is the role of the staff in the survey
during a TRACER ?
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.
Assume they will want to talk to you,
so have confidence in yourself.... remember
you provide awesome care, so let them see
it !
Prepare yourself to answer their questions.
Consider the following recommendations :
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 polite and smile - do not let the questions make you feel defensive or angry.

Be honest - if you dont know the answer, do not make one up.
Be specific, provide examples for an answer and refer to policies or procedures whenever possible.
Be enthusiastic about what you do.
How do you report incidences ? OVR ?
Compilation of JCI SURVEY question and answers ,email us at
JCI Approach and Philosophy to
the On Site Survey
A survey is not intended to be punitive,
a "
got YOU
" exercise or an inspection.
Tracer Methodology is a process of
identifying imperfections, flaws or broken system, so that we can improve our services......
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