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CE Article: The evolution of mock survey tracers*

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Learning objectives: After reading this article, you will be able to

  1. Describe how to break down a tracer tool to address each chapter of the standards
  2. Discuss incorporating National Patient Safety Goals into a tracer tool
  3. Describe best practices for how frequently a tracer tool should be reexamined and updated
  4. Discuss how to create mock survey teams and break down duties among team members

Facilities that went through a Joint Commission (formerly JCAHO) survey in 2005 were fortunate to be part of the last year of announced surveys. Back then, 2008 probably seemed decades away. My, how quickly time flies. Welcome to the new year and-for many facilities-welcome to unannounced surveys.

The concept of developing a tracer tool is not a new one. But creating the sort of tool that can respond and evolve with standards changes, and with the facility, is a matter of constant practice, review, and vigilance, says Margaret Martello, RN, director of risk management and regulatory affairs at Mount Auburn Hospital in Cambridge, MA.

"We first started using this in January of this year, but started developing it at the end of 2006," says Martello. "We had asked ourselves, 'How are we going to make our own assessment and measure where we are, what areas we need to work on?' Finally we asked, 'Why don't we mimic what The Joint Commission [surveyors do] when they come to survey?'"

What Mount Auburn needed, Martello says, was a way to make assessments about where the facility was in terms of continuous readiness on a continuous basis-and it needed to put an objective tool in front of the people making this assessment.

"Most people are doing some kind of tracer activity. It makes sense," says Martello.

Make sure to also follow these tips when preparing for a survey at your facility:


Mount Auburn uses 10 three-person teams, primarily made of up of steering committee members, that survey different areas each month.

The teams contain a clinician, an administrator, and someone representing environment of care (EOC), who then divvy up the tasks with an eye toward each others' strengths. For example, the clinical person may focus on medical records. At some organizations, CEOs also go on tracers. Click here to read about one in Mississippi.

Ten locations are surveyed each month-interventional radiology, cardiology, labor and delivery, and the neonatal ICU were all recently surveyed concurrently, for example-and the hospital sends various teams to survey different units to provide additional, varied perspectives.

"This is probably the most aggressive we've been with it," says Gayla Jackson, RN, BSN, a nurse manager at Mount Auburn Hospital. "We've had [mock surveys] in the past but never to this degree."


"Monthly, we come up with a top-five set of issues uncovered through the tracer," says Martello.

Quarterly, she presents the top 10 issues to hospital leadership, along with action plans for how these issues will be addressed.

"You do see a lot of familiar things, but the list does change," says Martello. Issues with hand hygiene, linen carts, and ceiling tiles are perennial trouble spots, as is the case in most facilities, but the tracer tool will also turn up areas that may need a new or renewed focus for the facility.

Change happens on the unit floor, but the initiative for change needs to come from the source, says Jackson.

Providing these updates "can help focus on a particular problem to see certain components where we can target our energy," Martello says.

For example, empty hand gel sanitizer dispensers in the emergency department is an easily fixable issue and explains why there might be a downturn in handwashing compliance.

The results of the mock survey are sent back to the appropriate unit director for any unit-specific issues, whereas other issues, such as medication refrigerator settings, are addressed hospitalwide.

Tip: The tracer tool should contain some measurable component from each chapter of the standards as well as measure compliance with the National Patient Safety Goals (NPSG). But "keep it simple," says Martello. "You can't measure everything. Take key items out of the chapters to focus on." For some more information on the 2008 NPSGs, click here:


"We've definitely added things as standards were changed and added, but we've learned along the way," says Martello. "We often ask, 'Are we sure this is really what we want to measure?'"

You do not want to alter the tool from month to month, she says, but as what you want to know in terms of data tracking evolves, make sure the tracer tool evolves with you.

Tip: Refine the tool at least twice a year, both in terms of standards changes and goals by The Joint Commission as well as your facility's own internal goals.

As the tool develops, so do the training materials for those charged with providing accurate surveys.

"We've developed a reference guide for team members," says Martello. "Not everyone is knowledgeable in all areas. When you send someone out there without the right knowledge, [he or she] can't ask the right questions."

Tip: "You want to be clear what you're measuring for sure," says Martello. "You don't want to gather all [these] data and not know what to do with [them]." Martello advises piloting, piloting, and piloting again, in quick succession. Also, keep consistent track of the latest version of your tracer tool.

"Our challenge has been making sure teams use the right tool-just like old forms, sometimes an older version of the tool will pop up after it's been updated," she says.

Keep in mind even the most knowledgeable team members may need time to adjust and perfect their use of the tracer tool.

"If you're not used to the form, you're not 100% sure. It takes a while to get used to it," says Jackson.

Be ready to provide education for your internal surveyors, and also know their strengths and weaknesses to get the most out of the mock survey.

"We were working on a survey of the GI unit and had someone from information technology on the survey team. He was at a loss when it came to the chart, so that was left to the nursing representative," says Jackson. "The IT representative focused on [environment of care] components: food and drink present where it should not be . . . points that a nonnurse can spot."

For more information on how tracers can help your organization, click here:

Adapted from Briefings on The Joint Commission, November 2007, HCPro. Inc.


1. "Preparing for a Hospital Survey"

2. "Mississippi hospital CEO goes on mock tracers"

3. "Facts about 2008 NPSGs"

4. "Tracer Methodology and Your Organization: Why Tracers Are an Integral Part of Your Organization's Assessment, Improvement, and On-site Survey"

Click here to take your quiz and receive free CE credits.