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Mock Tracers
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Mock Tracers
Senior Editor: Lori Meek Schuldt
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Merlin Wessels, MSW, LCSW, ACSW; Joyce Whitten, MSN, RN; Gina Zimmerman

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ii
 Table of Contents

Introduction ........................................................................................1

How to Conduct a Mock Tracer ..........................................................5

Section 1: Tracer Scenarios for Hospital and

Critical Access Hospital ..................................................................15
Scenario 1-1. Individual Tracer: Large Urban Hospital ..................................................................17
Scenario 1-2. System Tracer: Midsize Community Hospital ..........................................................20
Scenario 1-3. System Tracer: Critical Access Hospital ..................................................................22
Scenario 1-4. System Tracer: Large Teaching Hospital ................................................................24
Scenario 1-5. System Tracer: Children’s Hospital ........................................................................26
Scenario 1-6. System Tracer: Anticoagulation Clinic at a Large Urban Hospital ............................28
Scenario 1-7. System Tracer: Midsize Community Hospital ..........................................................31
Scenario 1-8. Program-Specific Tracer: Large Hospital ................................................................34
Scenario 1-9. Program-Specific Tracer: Midsize Suburban Hospital ..............................................35
Scenario 1-10. Program-Specific Tracer: Suburban Hospital with Laboratory ................................37

Section 2: Tracer Scenarios for Ambulatory Care and

Office-Based Surgery........................................................................43
Scenario 2-1. Individual Tracer: Ambulatory Surgery Center ........................................................45
Scenario 2-2. Individual Tracer: Office-Based Surgery Practice ....................................................47
Scenario 2-3. System Tracer: Ambulatory Surgery Center ............................................................48
Scenario 2-4. System Tracer: Office-Based Surgery Practice ........................................................50
Scenario 2-5. System Tracer: Urgent Care Center ........................................................................51
Scenario 2-6. System Tracer: Community Health Center ..............................................................53
Scenario 2-7. System Tracer: Family Practice Primary Care Facility ..............................................54
Scenario 2-8. Program-Specific Tracer: Ambulatory Care Organization ........................................56

Section 3: Tracer Scenarios for Behavioral Health Care ..................61

Scenario 3-1. Individual Tracer: 24-Hour Therapeutic School ........................................................63
Scenario 3-2. System Tracer: Community Mental Health Center ....................................................64
Scenario 3-3. System Tracer: Residential Treatment Center ........................................................66
Scenario 3-4. System Tracer: Community Mental Health Center ....................................................67
Scenario 3-5. Program-Specific Tracer: Continuity of Foster/Therapeutic Foster Care....................70
Scenario 3-6. Program-Specific Tracer: Youth Group Home ..........................................................71
Scenario 3-7. Program-Specific Tracer: 24-Hour Adult Mental Health Setting ................................73
Scenario 3-8. Program-Specific Tracer: Residential Drug and Alcohol Treatment Program ............74

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Section 4: Tracer Scenarios for Home Care......................................79

Scenario 4-1. Individual Tracer: Home Health Agency ..................................................................81
Scenario 4-2. Individual Tracer: Home-Based Hospice Agency ......................................................83
Scenario 4-3. System Tracer: Home Care Program with On-Site Pharmacy ..................................85
Scenario 4-4. System Tracer: Hospital-Affiliated Home Health Agency ..........................................87
Scenario 4-5. System Tracer: Home Health Agency with Pharmacy Dispensing Services ..............89
Scenario 4-6. Program-Specific Tracer: Home Medical Equipment Organization ............................91
Scenario 4-7. Program-Specific Tracer: Medicare-Certified Home Health Program ........................93
Scenario 4-8. Program-Specific Tracer: Home Health Agency ......................................................95

Section 5: Tracer Scenarios for Long Term Care ..............................99

Scenario 5-1. Individual Tracer: Small Nursing Facility ..............................................................101
Scenario 5-2. System Tracer: Large Nursing Facility ..................................................................102
Scenario 5-3. System Tracer: Midsize Nursing Facility with Subacute Care Unit ..........................104
Scenario 5-4. System Tracer: Long-Stay Nursing Facility ............................................................105
Scenario 5-5. Program-Specific Tracer: Small Nursing Facility with Rehabilitative Care ..............107
Scenario 5-6. Program-Specific Tracer: Large Nursing Facility ....................................................109

Section 6: Tracer Scenarios for Laboratory ....................................115

Scenario 6-1. Individual Tracer: Laboratory in Large Teaching Hospital ......................................117
Scenario 6-2. Individual Tracer: Laboratory in Rural Hospital ......................................................118
Scenario 6-3. Individual Tracer: Laboratory in Nursing Facility ....................................................120
Scenario 6-4. Individual Tracer: Laboratory in Community Hospital ............................................122
Scenario 6-5. Individual Tracer: Laboratory in Critical Access Hospital ........................................124

Section 7: Tracer Scenarios for Environment of Care ....................129

Scenario 7-1. System Tracer: Security ......................................................................................131
Scenario 7-2. System Tracer: Utility Systems ............................................................................132
Scenario 7-3. System Tracer: Environmental Safety ..................................................................134
Scenario 7-4. System Tracer: Fire Safety ..................................................................................136
Scenario 7-5. System Tracer: Interim Life Safety Measures ........................................................137
Scenario 7-6. System Tracer: Hazardous Materials and Waste ....................................................139
Scenario 7-7. System Tracer: Medical Equipment ......................................................................140
Scenario 7-8. System Tracer: Sterilizer Maintenance ..................................................................141

Section 8: Tracer Scenarios for International ................................147

Scenario 8-1. Individual Tracer: Large Hospital ..........................................................................149
Scenario 8-2. Individual Tracer: Nursing Home ..........................................................................151
Scenario 8-3. Individual Tracer: Ambulatory Care Center ............................................................152
Scenario 8-4. System Tracer: Midsize Hospital ..........................................................................154
Scenario 8-5. System Tracer: Primary Health Center ..................................................................156
Scenario 8-6. System Tracer: Private Hospital ............................................................................157
Scenario 8-7. System Tracer: Primary Care Facility in Hospital ..................................................159

Appendix A: Priority Focus Areas ..................................................163

Appendix B: Mock Tracer Worksheet Form ....................................167
Appendix C: Comprehensive Organization Assessment Form ......171
Index ..............................................................................................175

iv
 Introduction
Tracer methodology is an integral part of the on-site accredita-
tion survey process used by The Joint Commission and Joint
Commission International (JCI). Surveyors use tracers to eval-
uate the care of an individual or to evaluate a specific care
process as part of a larger system. A surveyor reviews an indi-
vidual’s record and follows the specific care processes the indi-
vidual experienced by observing and talking with staff
members in areas where the individual received care. This
methodology provides the surveyor with an opportunity to as-
sess the organization’s systems for providing care and services
and its compliance with accreditation requirements. This
book, part of a series that focuses on familiarizing health care
staff with tracer methodology, can help an organization learn
to conduct simulated—or mock—tracers that mimic actual
tracers. The mock tracer is conducted by someone in the or-
ganization who performs the role of an actual surveyor.
Benefits of Understanding Tracers
Health care organizations that educate staff about tracers will
have a better understanding of the overall survey process, espe-
cially since an on-site surveyor can typically devote up to 60%
of his or her time conducting tracers. In addition, an organiza-
tion that understands tracers can use mock tracers as a tool to
assess its compliance with standards and make improvements
before a surveyor arrives. For example, if an organization wants
to analyze how well a specific aspect of a system on a specific
unit functions—such as the security in the neonatal intensive
care unit of a hospital—it can conduct a mock tracer of that
system. Although its purpose would be to learn more about
how systems function in that particular unit, a mock tracer
would also provide important information that could identify
broader issues for improvement.
Types of Tracers
Surveyors currently conduct three types of tracers:
• Individual: An individual tracer follows the actual experi-
ence of an individual who received care, treatment, or ser-
vices in a health care organization (that is, a patient, a
resident, or an individual served). To select individuals to
trace in U.S. health care organizations, surveyors take into
account an organization’s clinical/service groups (CSGs)
and its top priority focus areas (PFAs) identified through
the Joint Commission’s Priority Focus Process. The CSGs
categorize care recipients and selected services into distinct
populations for which data can be collected. PFAs are
processes, systems, or structures in a health care organiza-
tion that significantly impact safety and/or the quality of
care provided (see Appendix A). The organization’s specific
CSGs and PFAs inform the choice of what types of areas,
units, services, departments, programs, or homes to visit
initially to conduct an individual tracer; the CSGs, in turn,
help the surveyor select an individual to trace. Although in-
formation from the Priority Focus Process may help survey-
ors select the first individuals and areas to trace, a surveyor
may trace the experience of additional care recipients based
on the initial findings during the on-site survey.
• System based: A surveyor may use a system-based tracer to
analyze a high-risk process or system across an entire
organization to evaluate how and how well that system
functions. Currently, there are three topics explored during
the on-site survey using the system tracer approach: med-
ication management, infection control, and data manage-
ment. To analyze a medication management or infection
control system, a surveyor can follow an individual’s actual
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care experience through the organization and assess how
well that particular system functioned related to that indi-
vidual’s care. But to analyze a data management system, the
surveyor conducts a group meeting session and focuses on
assessing an organization’s use of data in improving safety
and quality of care. The goal of a data management system
tracer is to learn about an organization’s performance im-
provement process, including the organization, control, and
use of data. There is no individual care recipient to follow;
however, data from performance improvement are used and
evaluated during the course of individual tracers through-
out a survey.
• Program specific: A surveyor may use a program-specific
tracer to analyze the unique characteristics and relevant is-
sues of a specific type of organization. The goal of this type
of tracer is to identify safety concerns in different levels
and types of care. For example, a patient flow tracer is a
program-specific tracer used in hospitals, whereas a conti-
nuity of care tracer is a program-specific tracer used in an
ambulatory care organization.
A survey may also include an environment of care (EC)
tracer. Like a system tracer, this type of tracer examines orga-
nizational systems and processes—in this case, systems related
to the physical environment.
Second Generation Tracers
During any type of tracer, a surveyor may see something in-
volving a high-risk area that requires a more in-depth look. At
that point, the surveyor may decide to conduct a second gen-
eration tracer, which is a deep and detailed exploration of a
particular area, process, or subject. These types of tracers are a
natural evolution of the existing tracer process.
The following are high-risk topics in hospitals and critical ac-
cess hospitals that surveyors might explore in more detail using
a second generation tracer approach: cleaning, disinfection,
and sterilization (CDS); patient flow across care continuum;
contracted services; diagnostic imaging; and ongoing profes-
sional practice evaluation (OPPE)/focused professional prac-
tice evaluation (FPPE).
Tracers Used Internationally
Tracer methodology is being used to assess health care orga-
nizations beyond the United States. Health care organiza-
tions that undergo JCI accreditation also experience tracer
methodology when surveyors visit their facilities. The con-
2
cept is essentially the same for both domestic and interna-
tional organizations; however, there are slight differences.
Whereas U.S. surveyors use such elements as PFAs and CSGs
to select care recipients to trace, these criteria do not apply to
international surveys. JCI surveyors use information pro-
vided in the organization’s accreditation survey application to
select tracer subjects from an active care recipient list. Sub-
jects typically selected are those who have received multiple
or complex services because they, most likely, have had more
contact with various departments of the organization, pro-
viding a greater opportunity for the surveyor to assess how
systems work in the organization. Furthermore, program-
specific tracers are done as part of “undetermined survey ac-
tivity” appropriate to an organization, as defined in the JCI
Survey Process Guide. Also, international organizations refer
to the EC tracers as “facility management and safety” tracers
and to data management system tracers as “improvement in
quality and patient safety” tracers.
Conducting Mock Tracers
The best way to understand all types of tracers is through prac-
tice—that is, through conducting mock tracers. This involves
developing some basic skills, such as learning how to ask good
questions. An actual tracer is not performed by one person in
isolation. It involves talking with multiple staff members and,
in the case of individual tracers and some system tracers, the
care recipient and even family members (if possible) to learn
details about an individual’s health care experience or how a
particular system functions in an organization. All important
details about the individual’s care or the system’s function can
be explored by asking simple questions in succession. And how
a question is asked is particularly important. A surveyor poses
questions in a manner that encourages the staff member or
care recipient to share as much information as possible. Obser-
vation of the surroundings or attention to how a respondent
answers one question can lead to other related issues and can
trigger additional questions.
Skills in analysis and organization are also involved, particu-
larly in planning a mock tracer, and of course, analysis is nec-
essary to evaluate and prioritize the results of a mock tracer.
Similar skills are involved in the reporting of the results and in
the follow-up on any consequent plans for improvement based
on the results. Often, an organization will institute a mock
tracer program that will train participants for optimum out-
comes to these practice tracers. The benefits that result from
mock tracers support and enhance the continuation of such
teams.

How to Use This Book
More Mock Tracers is designed to help staff members in all
health care settings better understand how the different types of
tracers work and how to conduct mock tracers:
• “How to Conduct a Mock Tracer” follows this Introduc-
tion. It provides step-by-step instruction on performing a
mock tracer.
• Each section of this workbook includes example tracers,
called scenarios, that are specific to a type of health care set-
ting (such as home care and behavioral health care).
• Each scenario is preceded by a list of the PFAs that emerge
during the scenario. For scenarios in an international set-
ting, this summary also explains the criteria for the tracer
subject selection. Then, a narrative describes how a surveyor
might analyze a particular system or use an individual’s
record as a road map through the organization.
• Sample tracer questions follow each scenario. They show
the types of questions a surveyor might ask staff members
or other individuals for the specific scenario. These ques-
tions are keyed to the narrative to show how and when they
might occur during the scenario.
• Each section also includes an example of a tracer worksheet
that utilizes the sample tracer questions from one scenario
and shows how the worksheet might be completed during
mock tracer activities.
• Appendixes describe the PFAs and provide forms that are
helpful in developing a mock tracer program.
Introduction
Terms Used in This Book
This publication is divided into sections that are health care
setting–specific, so each section will use terminology appropri-
ate for its setting. For example, patient will be used for hospi-
tal, ambulatory care, and home care settings; individual will be
used for behavioral care settings; and resident will be used for
long term care settings. The term health care in this workbook
refers to all types of care, treatment, or services provided
within the spectrum of the health care field, including physi-
cal, medical, and behavioral health care.
Acknowledgments
Joint Commission Resources (JCR) is grateful to the multiple re-
viewers and content experts for their feedback to ensure that the
overall content about tracers is accurate and relevant to the nu-
merous health care settings. A special thank you is extended to
Virginia Maripolsky, MSW, RN, Assistant CEO, Nursing Af-
fairs, Bangkok Hospital, Bangkok, Thailand; Judith Moomjian,
RN, MPA, CPHQ, FACHE, Consultant for JCR and Joint
Commission International; David Sladewski, LSCS, MS, CHSP,
CPM, Surveyor and Life Safety Code® Specialist, The Joint Com-
mission; Joyce Whitten, RN, MSN, Surveyor, Home Care Ac-
creditation Program, The Joint Commission; and Aneita Paiano,
MBS, MT(ASCP), Surveyor, Laboratory Program, The Joint
Commission. We also extend our gratitude to writer Ladan
Cockshut for her dedication and diligence in writing this book.
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4
How to Conduct a Mock Tracer
The main activity during a Joint Commission
or Joint Commission International (JCI) survey
of any type of health care organization is the
tracer (see the sidebar “Tracers at a Glance,” at
right). A mock tracer is a practice tracer meant
to simulate an actual tracer. During a mock
tracer, one or more people may play the role of
a surveyor. Some organizations develop teams of
such “surveyors” and repeatedly conduct mock
tracers as part of an ongoing mock tracer pro-
gram.
Mock tracers are done for several reasons:
• To evaluate the effectiveness of an organiza-
tion’s policies and procedures
• To engage staff in looking for opportunities
to improve processes
• To be certain the organization has addressed
compliance issues and is ready for survey at
any time
What follows is a 10-step primer for how to
conduct a mock tracer. It addresses the process
in four phases:
• Planning and preparing for the mock tracer
• Conducting and evaluating the mock tracer
• Analyzing and reporting the results of the
mock tracer
• Applying the results of the mock tracer
Each step within these phases includes sug-
gested approaches and activities. You might
want to use the “Mock Tracer Checklist and
Timeline” on page 7 to guide you through the
phases. The primer also explains how to use the
scenarios, sample worksheets, and appendixes in
this workbook to conduct mock tracers. Note
that the primer can be modified to suit any
health care organization.
Tracers at a Glance
Duration: A Joint Commission individual tracer (see
“Individual tracers” on page 6) is scheduled to take 60 to
90 minutes but may take several hours. During a typical
three-day survey, a surveyor or survey team may
complete several tracers; during a single-day survey, it
may be possible to complete only one or two tracers.
Tracers constitute about 60% of the survey.
Survey team: A typical Joint Commission survey team
includes one or more surveyors with expertise in the
organization’s accreditation program. For domestic (not
international) hospitals and critical access hospitals, a
Life Safety Code®* Specialist is also part of the team. A
team leader is assigned for any survey with more than
one surveyor. A surveyor typically conducts a tracer on
his or her own and later meets up with the rest of the
team to discuss findings.
Tracer activity: During tracer activity, surveyors evaluate
the following:
• Compliance with Joint Commission standards and
National Patient Safety Goals and, JCI for
international organizations, JCI standards and
International Patient Safety Goals
• Consistent adherence to organization policy and
consistent implementation of procedures
• Communication within and between
departments/programs/services
• Staff competency for assignments and workload
capacity
• The physical environment as it relates to the safety of
care recipients, visitors, and staff
(continued)
* Life Safety Code is a registered trademark of the National Fire
Protection Association, Quincy, MA.
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Tracers at a Glance (continued)
Range of observation: During a tracer, the surveyor(s)
may visit (and revisit) any department/program/service
or area of the organization related to the care of the
individual served or to the functioning of a system.
Individual tracers: Individual (patient) tracer activity
usually includes observing care, treatment, or services
and associated processes; reviewing open or closed
medical records related to the care recipient’s care,
treatment, or services and other processes, as well as
examining other documents; and interviewing staff as
well as care recipients and their families. An individual
tracer follows (traces) one care recipient throughout his
or her care in the organization.
System tracers: A system tracer relates to a high-risk
system or the processes that make up that system in an
organization. Currently, three topics are explored during
the on-site survey using the system tracer approach:
medication management, infection control, and data
management. The data management system tracer is
the only tracer that is routinely scheduled to occur on
regular surveys for most organizations; it may include
evaluation of data for medication management and
infection control, as well. Other system tracers take
place based on the duration of the on-site survey; the
type of care, treatment, or services provided by the
organization; and the organization’s accreditation
history. Lab accreditation programs do not have system
tracers. JCI In international organizations, data system
tracers are called “improvement in quality and patient
safety” tracers and are not individual based.
Program-specific tracers: These are tracers that
focus on topics pertinent to a particular accreditation
program and the associated care, treatment, or service
processes. These processes are explored through the
experience of a care recipient who has needed or may
have a future need for the organization’s care,
treatment, or services. Examples include patient flow in
a hospital or suicide prevention at a residential
program. Lab accreditation programs do not have
program-specific tracers.
6
Environment of care tracers: Although the environment
of care (EC) tracer is not one of the defined Joint
Commission system tracers, it is similar to those types of
tracers. Like system tracers, EC tracers examine
organization systems and processes—in this case,
systems related to the physical environment, emergency
management, and life safety. Also, like system tracers, an
EC tracer is often triggered by something observed
during an individual tracer, as surveyors notice
environmental-, emergency management–, and life
safety–based risks associated with a care recipient and
the staff providing care, treatment, or services to that
person. A surveyor may also be assigned to do an EC
tracer as part of a comprehensive survey process.
Note that EC tracers are performed only in facility-based
accreditation programs and do not apply to community-
based programs and services, such as those provided by
some behavioral health care accreditation programs.
JCI For international organizations, EC is referred to as
“facility management and safety.”
Second generation tracers: A surveyor may see
something during a tracer involving select high-risk areas
that requires a more in-depth look. At that point, the
surveyor may decide to conduct a second generation
tracer, which is a deep and detailed exploration of a
particular area, process, or subject.
Planning and Preparing for the
Mock Tracer
Step 1: Establish a Schedule for the Mock
Tracer
Careful planning is necessary for any successful activity, in-
cluding a mock tracer. Consider the following when establish-
ing a schedule for mock tracers in your organization:
• Schedule by phase: Allow adequate time for each phase of a
mock tracer. The focus of each phase outlined in this
primer is shown in the checklist “Mock Tracer Checklist
and Timeline” (see page 7) with suggested time frames,
some of which may overlap. Suggested approaches and ac-
tivities for each phase comprise the remainder of this
primer.

✔ Mock Tracer Checklist and Timeline
✔ Planning and Preparing for the Mock Tracer
Step 1: Establish a Schedule for the Mock Tracer
Step 2: Determine the Scope of the Mock Tracer
Step 3: Choose Those Playing the Roles of Surveyors
Step 4: Train Those Playing the Roles of Surveyors
✔ Conducting and Evaluating the Mock Tracer
Step 5: Assign the Mock Tracer
Step 6: Conduct the Mock Tracer
Step 7: Debrief About the Mock Tracer Process
✔ Analyzing and Reporting the Results of the Mock Tracer
Step 8: Organize and Analyze the Results of the Mock Tracer
Step 9: Report the Results of the Mock Tracer
✔ Applying the Results of the Mock Tracer
Step 10: Develop and Implement Improvement Plans
Note: To follow up on findings and sustain the gains, periodically repeat mock tracers on the same subjects.
• Make it part of your regular PI program: Make mock
tracers part of your ongoing performance improvement (PI)
program. Schedule mock tracers for different depart-
ments/programs/services several times a year.
• Share the plan with everyone: Let everyone in your orga-
nization know about the mock tracers being planned. No
set dates need to be given if the mock tracers are to be
unannounced, but communication about planned and on-
going mock tracers is necessary for recruitment of those
who will play the roles of surveyors and for cooperation
from all departments/programs/services.
• Understand the Joint Commission survey agenda: A
mock tracer typically simulates only the tracer portion of a
survey, which constitutes the foundation of the survey. By
understanding the survey activities, however, those who are
How to Conduct a Mock Tracer
Month 1
Month 1
Month 1
Months 1 and 2
Month 2
Month 3
Month 3
Month 4
Month 4
Months 5–7
playing the roles of surveyors can better simulate tracers to
help your organization prepare for a survey. Joint Commis-
sion surveys follow a tight agenda. Check the Survey Activ-
ity Guide (SAG) for your accreditation program(s). The
guide outlines what happens in each survey activity. All ac-
creditation program SAGs are posted on the Web site for
The Joint Commission. They are also available on your
Joint Commission Connect™ extranet site if yours is an ac-
credited health care organization or an organization seeking
Joint Commission accreditation. JCI International organi-
zations should consult the International Survey Process
Guide (SPG), which is sent to applicants seeking interna-
tional accreditation and is also available to order on the JCI
Web site.
• Relate it to the date of the last survey: Joint Commission
surveys are typically conducted on a regular, triennial basis.
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For most accredited organizations, the survey will occur
within 18 to 36 months after an organization’s last survey, al-
though laboratory surveys and certification program reviews
are on a two-year cycle. With the exception of critical access
hospitals and office-based surgery practices, organizations ac-
credited by The Joint Commission must conduct Periodic
Performance Reviews (PPRs) between full surveys. The PPR
is a management tool that helps the organization incorporate
Joint Commission standards as part of routine operations
and ongoing quality improvement efforts, supporting a con-
tinuous accreditation process. A mock tracer can help by giv-
ing the organization more insight into compliance issues.
Conducting the mock tracer before a survey date allows time
to address compliance issues prior to the PPR deadline; con-
ducting a mock tracer shortly after the last survey is helpful
for assessing compliance with problems highlighted in that
recent survey. Note that the PPR is not applicable to the
Medicare/Medicaid certification–based long term care ac-
creditation program. JCI For international organizations, the
survey will occur within 45 days before or after the accredita-
tion expiration date. International certification programs are
on a three-year review cycle. Also, although international or-
ganizations are not required to complete PPRs, JCI recom-
mends that organizations do a self-assessment of compliance
between surveys. (International certification programs have a
required intra-cycle review process.)
Step 2: Determine the Scope of the Mock
Tracer
Assess your organization to determine where to focus atten-
tion. By listing problems and issues in your organization,
the scope of the mock tracer—whether comprehensive or
limited—will become clear. One or more of the following
approaches may be used to determine a mock tracer’s scope:
• Imitate the Priority Focus Process: The Priority Focus
Process (PFP) provides a summary of the top clinical/service
groups (CSGs) and priority focus areas (PFAs) for an organi-
zation. The CSGs categorize care recipients and/or services
into distinct populations for which data can be collected.
The PFAs are processes, systems, or structures in a health
care organization that significantly impact safety and/or the
quality of care provided (see Appendix A). The PFP is acces-
sible on the Joint Commission Connect site for domestic or-
ganizations and provides organizations with the same
information that surveyors have when they conduct on-site
evaluations. Address all or some of the areas generated in
that report. JCI International organizations do not have
PFPs; however, it may be helpful and important to look at
your last survey results and target areas of greatest concern.
8
• Reflect your organization: Start with your organization’s
mission, scope of care, range of treatment or services, and
population(s) served. Choose representative tracers that
support and define your organization. You might want to
use an assessment tool, such as the Comprehensive Orig-
inization Assessment, to gather this data. (See Appendix C).
• Target the top compliance issues: Review the Joint Commis-
sion’s top 10 standards compliance issues, published regularly
in The Joint Commission Perspectives® (available for subscrip-
tion and provided free to all accredited organizations). Also
check any issues highlighted in Sentinel Event Alerts, which
are available on the Joint Commission Web site, at
http://www.jointcommission.org/sentinel_event.aspx. Address
compliance issues that are also problem prone in your organi-
zation. Be especially mindful to note if any of these top com-
pliance issues have been noted in current or past PPRs. JCI
International organizations can request top compliance issues
from this address: JCIAccreditation@jcrinc.com.
• Review what is new: Address any new Joint Commission
or JCI standards that relate to your organization. New stan-
dards and requirements are highlighted in the binder ver-
sion (although not in the spiral-bound book version) of the
most recent update of the Comprehensive Accreditation
Manual for your program. Also focus on any new equip-
ment or new programs or services in your organization.
Consider mock tracers that will allow opportunities to eval-
uate newly implemented or controversial or problematic or-
ganization policies and procedures and how consistently
they are being followed.
• Start with the subject: Look at typical tracers from any
past surveys and choose several common or relevant exam-
ples for the types of tracers defined in the Introduction to
this workbook. Or, if your organization has never had a sur-
vey, consider the guidelines described in the sidebar
“Choosing Tracer Subjects” on pages 9–10.
• Cover the highs and lows: Focus on high-volume/high-risk
and low-volume/high-risk areas and activities. Ask ques-
tions about demographics for those areas or activities to
help determine whether care, treatment, or services are tar-
geted to a particular age group or diagnostic/condition cate-
gory. Then pick corresponding tracer subjects.
• Target time-sensitive tasks: Look at time-sensitive tasks,
such frequency of staff performance evaluations, critical re-
sult reporting, and the signing, dating, and timing of physi-

cian orders, including whether they are present and com-
plete. These are often challenging compliance areas.
• Examine vulnerable population(s): Review the risks in serv-
ing particularly vulnerable, fragile, or unstable populations in
your organization. Select tracer subjects (care recipients, sys-
tems, or processes) that might reveal possible failing out-
comes. Address related processes of care, treatment, or services
that are investigational, new, or otherwise especially risky.
Step 3: Choose Those Playing the Roles of
Surveyors
If your goal is to conduct more than one mock tracer, either
concurrently or sequentially, you will want to develop a mock
tracer team. Careful selection of those playing the roles of sur-
veyors is critical. A general guide for a mock tracer team is to
follow the number and configuration of your last Joint Com-
mission or JCI survey team (see the sidebar “Tracers at a
Glance” on pages 5–6). However, you might want to involve
more people or have multiple mock tracer teams; try to allow as
many people as possible to be exposed to the tracer process and
to learn more about the surveyors’ angle on the process. If your
organization has not had a survey yet, aim for five to eight team
members, or select one team member for each department/pro-
gram/service in your organization plus one for each type of sys-
tem tracer and one for the EC. Consider the following when
choosing those who will play the roles of surveyors:
• Include administrators: Administrators, managers, and
other leadership should be not only supportive of mock trac-
ers but also involved. Include at least one administrator or
manager on the team. Include executive-level leaders in the
early stages to provide input and model team leadership.
Also, staff may need time off from their regular duties to
participate in various phases of a mock tracer, so team mem-
bers should be sure to get the approval of their managers.
• Select quality-focused communicators: Sharp, focused pro-
fessionals with excellent communication skills are needed to
play the roles of surveyors. Recruit people who are obser-
vant, detail oriented, and committed to quality and profes-
sionalism. Those playing the roles of surveyors should be
articulate, polite, personable, and able to write clearly and
succinctly. They should be comfortable talking to frontline
staff, administrators, and care recipients and families.
• Draw from committees: Often the best choices for those who
will play the roles of surveyors have already been identified
and serve on various committees in your organization. Draw
from committee members to find top-notch candidates.
How to Conduct a Mock Tracer
Choosing Tracer Subjects
Individual tracers: For individual mock tracers, adopt
the way actual surveyors choose care recipients. In
U.S. health care organizations, select them based on
criteria such as (1) whether they are from the top
CSGs in the PFP; (2) whether their experience of
care, treatment, or services allows the surveyor to
access as many areas of the organization as possible;
(3) whether they qualify under the criteria for any
accreditation program–specific tracer topic areas; or
(4) whether they move between and receive care,
treatment, or services in multiple programs, sites, or
levels of care within your organization. Also, consider
tracing care recipients who have been recently
admitted or who are due for discharge. JCI In
international organizations, use information provided
in your organization’s accreditation survey application
to select tracer care recipients from an active list that
shows who has received multiple or complex services.
System tracers: Care recipients selected for tracing a
system typically reflect those who present
opportunities to explore both the routine processes
and potential challenges to the system. For example,
to evaluate medication management systems, select
care recipients who have complex medication
regimens, who are receiving high-alert medications, or
who have had an adverse drug reaction. To evaluate
infection control, select someone who is isolated or
who is under contact precautions due to an existing
infection or compromised immunity. These same care
recipients could be the subjects for data management
system tracers, as each might be included in
performance measurement activities such as infection
control surveillance or adverse drug-reaction
monitoring data. JCI In international organizations,
data system tracers are called “improvement in quality
and patient safety” tracers and are not individual
based.
Program-specific tracers: The focus for these
tracers may include programs such as foster care,
patient flow, continuity of care, fall reduction, and
suicide prevention. For example, to evaluate a
(continued)
9
More Mock Tracers
Choosing Tracer Subjects (continued)
falls reduction program in a long term care facility, you
would select a resident identified as being at risk for
falls to trace components of the program, such as care
recipient education, risk assessment, and falls data.
Environment of care tracers: Subjects for an EC
mock tracer may include systems and processes for
safety, security, hazardous materials and waste, fire
safety, utilities, and medical equipment. For example,
an EC mock tracer might examine the security in the
neonatal intensive care unit, the safety of hazardous
materials that enter through the loading dock, or the
installation of and maintenance for new medical
equipment. Be sure also to include emergency
management and life safety issues as topics for mock
JCI
tracers. In international organizations, EC is
referred to as “facility management and safety.”
Second generation tracers: Subjects for second
generation tracers grow naturally out of tracers
involving high-risk areas because this type of tracer is
a deeper and more detailed exploration of the tracer
subject. Areas subject to second generation tracers
include cleaning, disinfection, and sterilization (CDS);
patient flow across care continuum; contracted
services; diagnostic imaging; and ongoing
professional practice evaluation (OPPE)/focused
professional practice evaluation (FPPE).
• Don’t forget physicians: Because they are a critical part of
any health care organization, physicians should be involved
in mock tracers—and not always just as interview subjects.
Recruit physicians to perform the roles of surveyors. This
angle of participation will not only allow them to apply
their expertise and experience but will also allow them to
add to that expertise and experience.
• Draft from HR, IM, and other departments or services:
Those playing the roles of surveyors may also be drafted
from among the staff and managers of nonclinical depart-
ments, including human resources (HR) and information
management (IM). Housekeeping and maintenance staff
are often valuable as “surveyors” for their unique perspec-
tive of daily operations.
10
Step 4: Train Those Playing the Roles of
Surveyors
All staff trained to portray surveyors need to have both an
overview and more detailed knowledge of tracers as part of
their training. Even those who have been through a survey
need training to play the role of a surveyor. Those who will be
acting as surveyors should do the following as part of their
training:
• Get an overview: Take some time to learn the basics of
tracers. The Introduction to this workbook provides a good
overview. As a next step, read the Survey Activity Guide for
your program, which is posted on the Web site for The
Joint Commission and on Joint Commission Connect. The
guide explains what surveyors do in each part of the differ-
ent types of tracers. JCI The JCI Survey Process Guides are
provided to international organizations applying for accred-
itation and are also for sale on the JCI Web site.
• Learn the standards: Challenging as it may be, it is essential
that those who are playing surveyors become familiar with
current Joint Commission requirements related to the tar-
geted tracer. They must gain a solid understanding of the re-
lated standards, National Patient Safety Goals, and
Accreditation Participation Requirements. To learn about
changes and updates to Joint Commission standards and how
to interpret and apply them, they should read the monthly
newsletter Joint Commission Perspectives (available for subscrip-
tion and provided free to all domestic accredited organiza-
tions). Be particularly careful to give those who are playing
surveyors sufficient time to learn the standards for the depart-
ment or area in which they will conduct a mock tracer. At
least one month is advised (see the sidebar “Mock Tracer
Checklist and Timeline” on page 7). JCI International organi-
zations should be familiar with JCI standards and Interna-
tional Patient Safety Goals, as outlined in the current relevant
JCI accreditation manual. Updates, tips, and more are pro-
vided free via the online periodical JCInsight.
• Welcome experience: Staff and leaders who have been
through a tracer can be valuable resources. Invite them to
speak to the tracer team about their experiences with tracers
and with surveys in general.
• Examine closed medical records: Closed medical records
are an excellent practice tool for individual tracers and indi-
vidual-based system tracers. Examine closed (but recent)
records and then brainstorm the types of observations, doc-
ument review, and questions that a surveyor might use to
trace the subject of the record.

• Study mock tracer scenarios: Tracer scenarios, like those
in this workbook, will help familiarize team members
with the general flow of a tracer as well as the specific and
unique nature of most tracers. The questions that follow
each tracer scenario in this workbook can be used to pop-
ulate a form for a mock tracer on a similar subject in your
organization (see Appendix B). The sample tracer work-
sheet at the end of each section in this workbook pro-
vides a model for how someone playing the role of a
surveyor might complete a worksheet based on such ques-
tions. JCI Note that scenarios with international content
appear in the final section of the workbook, but issues
addressed in scenarios for domestic settings may be trans-
ferable to international settings.
• Practice interviewing: Since a large part of a tracer is spent
in conversation, people who are filling the roles of surveyors
should practice interviewing each other. Although these
people should already be good communicators, a review of
common interview techniques may be helpful (see the side-
bar “Interviewing Techniques” at right).
Conducting and Evaluating the
Mock Tracer
Step 5: Assign the Mock Tracer
A mock tracer team may have one member play the roles of
surveyor in a specific mock tracer, or the team members may
take turns playing the role during the tracer. With repeated
mock tracers, every team member should have the opportu-
nity to play a surveyor. Consider these options when assign-
ing role-playing surveyors to mock tracers:
• Match the expert to the subject: Match a “surveyor”
who is an expert in a department/program/service to a
mock tracer for a similar department/program/service—
but for objectivity, do not assign them to the same
specific department/program/service in which they work.
• Mismatch the expert to the subject: Match a “surveyor”
to a department/program/service that is new to him or
her. This may enhance the objective perspective. Of
course, that person will have to prepare in advance to
become familiar with the requirements for that new
department/program/service.
• Pair up or monitor: Pair “surveyors” so they can learn
from and support each other, or allow one “surveyor” to
follow and monitor the other for additional experience.
How to Conduct a Mock Tracer
Interviewing Techniques
• Take your time. Speak slowly and carefully.
• To help set the interview subject at ease, try
mirroring: Adjust your volume, tone, and pace to
match those of the person to whom you are
speaking. (If the subject is nervous or defensive,
however, use a quiet and calm approach to
encourage that person to match your example.)
• Use “I” statements (“I think,” “I see”) to avoid
appearing to challenge or blame the interview
subject.
• Ask open-ended questions (to avoid “yes/no”
answers).
• Pause before responding to a subject’s answer to
wait for more information.
• Listen attentively, gesturing to show you
understand.
• Listen actively, restating the subject’s words as
necessary for clarification.
• Manage your reactions to difficult situations and
avoid using a confrontational tone, even if your
subject sets such a tone. Take a deep breath and
wait at least three seconds before responding.
• Always thank your interview subject for his or her
time and information.
One of those in the pair might be the mock tracer team
leader.
Step 6: Conduct the Mock Tracer
All departments/programs/services in your organization should
already have been notified about the possibility of staff con-
ducting mock tracers. Unless mock tracers are announced,
however, there is no need to notify interview subjects when the
tracer is scheduled to occur. During the mock tracer, team
members should do the following:
• Collect data: Like real surveyors, those playing the roles
of surveyors must collect data that help to establish
whether your organization is in compliance with applica-
ble accreditation requirements. They should do this by
taking notes on their observations, conversations, and re-
view of documents. Notes may be entered on an elec-
tronic form (using a laptop computer) or on a paper
form.
11
More Mock Tracers
• Be methodical and detail oriented: To help establish
and simulate an actual tracer, those portraying surveyors
should strive to be as methodical and detail oriented as
actual surveyors. The following techniques may be useful:
◦ Map a route through the mock tracer, showing who
will be interviewed in each area. It is helpful to inter-
view the person who actually performed the function
targeted by the tracer, but any person who performs
the same function can be interviewed.
◦ Identify who will be interviewed in each area, using
specific names (if staffing schedules are available) or
general staff titles. For example, if you have singled
out a particular care recipient to trace, identify which
staff members cared for that care recipient. Of course,
this may not be possible to do because staff to be in-
terviewed may depend on what is found in the tar-
geted area, where the care recipient travels within the
organization, and what procedures are performed.
◦ Note the approximate amount of time to be spent in
each department/program/service. That will help keep
the tracer on schedule. Notwithstanding any tentative
scheduling of the tracer, however, you may uncover
unexpected findings that will necessitate either spend-
ing more time in a particular location or going to loca-
tions that were unforeseen at the time the tracer
started. Flexibility is a key attribute of a good surveyor
doing tracers.
◦ Take notes on a form, worksheet, or chart developed
by the team for the purpose of the mock tracer. (The
mock tracer worksheet form in Appendix B can be
used for this purpose.)
◦ Surveyors are directed to be observant about EC is-
sues. Some EC issues may be photographed for the
record, provided that no care recipients are included in
the photos.
• Share the purpose: Whenever possible, remind tracer in-
terview subjects of the purpose of tracers and mock trac-
ers: to learn how well a process or system is functioning
(not to punish a particular staff member or department/
program/service).
• Maintain focus: Keep the process on track and continually
make connections to the broader issues affecting care recipi-
ent safety and delivery of care, treatment, or services.
12
• Be flexible and productive: If a person playing the role
of a surveyor arrives in an area and has to wait for a par-
ticular interview subject, that time can be filled produc-
tively by interviewing other staff and making relevant
observations and notes. If more than one mock tracer is
scheduled for the same day—as in a real survey—“survey-
ors” may cross paths in an area. One “surveyor” should
leave and return at a later time.
• Address tracer problems: Be prepared to identify and
address any problems with the mock tracer process en-
countered during the mock tracer, including practical
arrangements (such as the logistics of finding appropri-
ate staff ), department/program/service cooperation,
team dynamics, and staying on schedule. Decide in ad-
vance whether to address such problems in an ad hoc
fashion (as they are encountered) or as part of a debrief-
ing after the mock tracer to prepare for subsequent mock
tracers.
Step 7: Debrief About the Mock Tracer
Process
After each mock tracer, and particularly after the first few,
meet as a team as soon as possible to evaluate and document
how it went. (Note: This debriefing session should focus on
the mock tracer process, not what the mock tracer revealed
about your organization’s problems or issues. That will be
done in Step 8: “Organize and Analyze the Results of the
Mock Tracer”; see page 13.) You may choose to use one of
the following approaches:
• Hold an open forum: An open forum should allow all
team members to discuss anything about the tracer, such
as methods, logistics, and conflict resolution. For a
broader perspective, invite interview subjects from the
mock tracer to participate.
• Let each member present: In a direct, focused approach,
team members can present their feedback to the rest of
the team, one at a time. Each person playing the role of a
surveyor can be given a set amount of time to present,
with questions to follow at the end of each presentation.
• Fill out a feedback form: Team members and mock
tracer participants can complete a feedback form in
which they record their impressions of the mock tracer
and suggestions for improvement of the process. These
can be vetted and then discussed at the next team meet-
ing to plan for the next mock tracer.

Analyzing and Reporting the
Results of the Mock Tracer
Step 8: Organize and Analyze the Results of
the Mock Tracer
Conducting a mock tracer is not enough; the information
gained from it must be organized and analyzed. The prob-
lems and issues revealed in the mock tracer must be re-
viewed, ranked, and prioritized. You might want to use one
or more of the following suggested methods to do this:
• File the forms: If the mock tracer team used forms—
either electronic or paper (such as the form in Appendix
B), those can be categorized for review. The forms might
be categorized by types of problems/issues or by depart-
ment/program/service.
• Preview the data: Those who played the roles of survey-
ors should be the first to review the data (notes) they col-
lected during the mock tracer. They should check for and
correct errors in the recording of information and high-
light what they consider to be issues of special concern.
• Rank and prioritize the problems: The team, led by the
team leader, must carefully evaluate all of the team’s data.
Critical issues or trends can be identified and then ranked
by severity/urgency with regard to threats to life or safety,
standards noncompliance, and violations of other poli-
cies. Prioritizing is the next step and will require consid-
erations such as the following:
◦ What is the threat to health or safety? What is the de-
gree of threat posed by the problem—immediate, pos-
sible, or remote?
◦ What is the compliance level? Is the problem com-
pletely out of compliance? That is, does the problem
relate to a standard that always requires full compli-
ance (that is, Category A standards) or one for which
you may be scored partially compliant or insufficiently
compliant (that is, Category C standards)?
◦ What resources are required? How much staff time
and resources will likely be needed to correct the prob-
lem? Depending on the threat to health or safety and
compliance level, there may be a time limit imposed
on how soon the problem must be corrected (for ex-
ample, immediately or within 45 or 60 days).
How to Conduct a Mock Tracer
Step 9: Report the Results of the Mock Tracer
An organization’s reaction to a mock tracer will depend largely
on the results of the mock tracer, including how—and how
well—the results are reported. In all reports, it is important to
avoid having the tracer appear punitive or like an inspection,
so do not include staff names or other identifying information.
Following are several ways to report results effectively:
• Publish a formal report: Compile all documents and care-
fully edit them. Determine which documents most clearly
summarize the issues. Submit a copy of the report to the
appropriate leadership.
• Present as a panel: Invite leadership to a panel presenta-
tion in which team members present the results of the
tracer—by department/program/service or by other
arrangement (for example, problems with staffing, infection
control, handoff communication, or transitions in care,
treatment, or services).
• Call a conference: Set up an internal conference event in
which you present the results. They could be presented on
paper, delivered by speakers from a podium, and/or deliv-
ered using audiovisual formats. Invite leadership and every-
one who participated in the mock tracer. Keep the
conference brief (no more than two hours), being consider-
ate of attendees’ time. Make the content easier to digest by
color-coding the level of priority and using other keys to
signal the types of problems and their severity. Open up the
conference to feedback with breakout brainstorming ses-
sions on how to address the problems.
• Post for feedback: Post the results on a secure organization in-
tranet and ask for feedback and suggestions from participants
and others in your organization. A bulletin board in the
lunchroom works, too. After a week, remove the report and
incorporate any new information to present to leadership.
• Report in a timely way: One goal of a mock tracer is survey
preparedness via standards compliance, so addressing prob-
lems before a survey is vital. All reports should therefore be
made within one month after completion of a mock tracer
to allow plenty of time to correct compliance problems.
• Accentuate the positive: Remember to pass on positive
feedback that comes to light during the mock tracer and
data analysis. To encourage continued success as well as fu-
ture positive interactions with the mock tracer process, re-
ward or acknowledge departments and individuals that
participate or are especially cooperative and responsive.
13
More Mock Tracers
Applying the Results of the Mock
Tracer
Step 10: Develop and Implement
Improvement Plans
Your reports should indicate which problems must be ad-
dressed immediately and which can wait, which require
minimal effort to correct and which require extensive effort.
Employ one or more of the following improvement plan ap-
proaches to help address corrective actions:
• Hand off to managers: Hand off any easily addressed
corrective actions that are particular to one department/
program/service to the relevant managers. Inform them
of your estimates of time and resources necessary to ad-
dress the problem. Offer to work with them on more
complex corrective actions. Offer to repeat mock tracers
to confirm findings.
• Work with PI: Most of what will need to be done will re-
quire integration into your organization’s PI program. Fol-
low the required approach in addressing corrective actions.
• Check your compliance measures: Be sure to check
which elements of performance (EPs) for a Joint Com-
mission standard require a Measure of Success (MOS).
These are marked with an . At least one measure
demonstrating the effectiveness of recommended changes
should be included in the Plans of Action addressing
compliance for those EPs with an , and it must be in-
cluded if the findings will be integrated into a PPR. JCI
There is no MOS for JCI standards. Standards are Fully
14
Met, Partially Met, Not Met, or Not Applicable. JCI re-
quests that a Strategic Improvement Plan (SIP) be devel-
oped by the organization for any Not Met standard(s)/
measurable element(s) and/or International Patient Safety
Goal(s) cited in the survey report when the organization
meets the conditions for accreditation. International or-
ganizations do not complete PPRs. (See the discussion of
PPRs in “Relate It to the Date of the Last Survey,” under
“Step 1: Establish a Schedule for the Mock Tracer,” on
pages 7–8.)
• Share the plans: Make sure the entire organization is
aware of the corrective actions proposed as a result of the
mock tracer. Cooperation and support during future
mock tracers depend on awareness of their value and
follow-through. Activities and results can be shared in
internal newsletters or staff meetings.
• Monitor the plans: The mock tracer team is not responsi-
ble for completing all the corrective actions, but it is re-
sponsible for working toward that goal by monitoring any
plans based on findings from the mock tracer. Give dead-
lines to heads of departments/programs/services and others
involved in corrective actions (in accordance with any PI
policies). Check regularly on progress and make reports to
leadership and the PI program on progress and cooperation.
• Prepare for the next round: After a few mock tracers,
most organizations discover the exponential value of such
exercises. They then develop a mock tracer program that
allows for periodic mock tracers, sometimes with several
running at one time.
 SECTION 1

Tracer Scenarios for

HOSPITAL AND
CRITICAL ACCESS HOSPITAL

NOTE: No Two Tracers Are the Same

Please keep in mind that each tracer is unique. There is no
way to know all of the questions that might be asked or
documents that might be reviewed during a tracer—nor
what all the responses to the questions and documents
might be. The possibilities are limitless, depending on the
tracer topic and the organization's circumstances. These
tracer scenarios and sample questions are provided as an
educational or training tool for organization staff; they are
not scripts for real or mock tracers.

15
More Mock Tracers

Section Elements
This section includes sample tracers—called scenarios—relevant to hospitals and critical access hospitals. Individual, system,
and program-specific tracers are represented. The section is organized as follows:

Scenarios: Each scenario presents what might happen when a

surveyor conducts a specific type of tracer. The scenarios are
presented in an engaging narrative format in which the reader
“follows” the surveyor through the tracer scenario. Within the
narrative are bracketed numbers that correspond to numbered
sample tracer questions following the tracer.

Sample Tracer Questions: After each scenario narrative is a list

of sample questions a surveyor might ask during that scenario.
These questions can be used to develop and conduct mock tracers
in your organization on topics similar to those covered in the
scenario.

Sample Tracer Worksheet: At the end of the section is a sample

worksheet that shows how the sample tracer questions for one
select scenario in the section might be used in a worksheet format.
The example shows how the worksheet might be completed as
part of a tracer for that scenario. A blank form of the worksheet is
available in Appendix B.

16

INDIVIDUAL
Tracer Scenario
SCENARIO 1-1.
Large Urban Hospital
Summary
In the following scenario, a surveyor traces how an organiza-
tion treated a patient needing hip repair surgery following a
fall. Within the tracer, the surveyor explores issues relating to
these priority focus areas:
• Assessment & Care/Services
• Communication
• Patient Safety
• Physical Environment
Scenario
This tracer was conducted in a 400-bed hospital in an urban
area. The surveyor selected a 72-year-old female patient admit-
ted to the hospital five days earlier through the emergency de-
partment due to a fall that resulted in a suspected hip fracture
and subsequent hip repair surgery.
(Bracketed numbers correlate to Sample Tracer Questions on pages
18–20.)
Talking with the Nurse in the Emergency Depart-
ment. The surveyor first visited the emergency department to
talk with the nurse. She met with the nurse and asked him to
describe what happens when a patient arrives in the emergency
department. [1] The nurse said that this patient arrived during
his shift several days before and remembered her. He recalled
that the patient arrived with her husband and was unable to
walk. He also recalled that one leg was shorter than the other
and was internally rotated. The surveyor asked the nurse how
staff documented an initial assessment and an order for a hip
x-ray in the patient medical record. The surveyor then asked
the nurse to describe the emergency department’s process to
assess patients and interact with the patient and family. [2–6]
The nurse explained that the emergency department followed
a process to conduct a rapid assessment to intervene in cases of
falls-related arrivals in the department.
Speaking with the Radiology Technician. Because the
patient had been transported to radiology for an x-ray, the sur-
Section 1: Hospital and Critical Access Hospital
veyor then visited the radiology department to ask the radiol-
ogy technician to describe how staff members there respond to
x-ray orders and accommodate a patient with a hip-related in-
jury. [7–8] The technician explained that they receive a phone
call with the order in advance of the patient being transported
to the radiology department, which helps radiology staff mem-
bers prepare for the x-ray. He then showed the surveyor how
hip x-rays are conducted. The surveyor asked him to explain
how he prepared this tracer patient for the x-ray and how he
educated her on what to expect during the process. The sur-
veyor then asked how the x-ray results are communicated back
to the emergency department. [9–12] The technician re-
sponded that he first positively identified the patient before
proceeding with the x-ray. The surveyor was able to verify doc-
umentation for the correct process in the patient’s record.
Conferring with Medical/Surgical Nursing Staff. It
was determined that the patient had a hip fracture, and a deci-
sion was made to admit the patient for hip repair surgery. The
surveyor then visited the medical/surgical unit where the pa-
tient was recovering following surgery that had been performed
two days earlier. She talked with the medical/surgical nursing
staff members who were responsible for this patient’s care, in-
cluding how they assessed her pain and risk for falls, collected
data on her medication use, and educated her and her family
about her surgery and postsurgical care, including falls preven-
tion strategies. [13–18] The surveyor then asked a floor nurse
to explain their process for assessing the patient’s skin for pres-
sure ulcers because the patient was still unable to ambulate
without assistance. [19] The nurse explained that she had not
been on shift when the patient first arrived on the unit, but, ac-
cording to notes in the medical record, the patient complained
about significant pain based on her response to the hospital’s
pain scale. As a result, nurses conducted regular assessments
and reassessments to help manage her pain. The surveyor asked
how this process was being handled postsurgically, and the
nurse noted that although the patient seemed a bit more com-
fortable, they had continued their assessments. [20]
The surveyor then talked with the unit’s nursing manager to ask
her about the discharge planning process and what had been
identified so far for this patient. The nursing manager explained
that the discharge planning had begun when this patient was first
admitted to the medical/surgical unit. The attending physician
had already ordered admission to a subacute rehabilitation facil-
ity for the patient upon her discharge, and the social worker was
working with the family to identify an appropriate facility. The
surveyor then asked how the patient and family were being edu-
cated and prepared for discharge. [21–22] The nursing manager
17
More Mock Tracers
said the social worker had met with the family earlier that day to
discuss the plans and answer any questions regarding discharge
from the hospital.
Observing the Physical Therapist. The surveyor received
permission from the patient to observe her physical therapy ses-
sion and to talk with her after she was done. The surveyor first
asked the therapist how physical therapy had been ordered for
this patient and how he was involved in discharge planning.
[23–25] The physical therapist explained that this was the pa-
tient’s second day of therapy and that the order was received in
the department one day earlier. In addition, the physical therapist
had been involved in discharge planning meetings for this pa-
tient. The surveyor observed the physical therapist practicing
hand hygiene before working with this patient and noticed that
he was responsive to any questions the patient had about her
care. The surveyor later asked the therapist what kind of training
and education he received regarding falls risk and patient safety
issues and whether he was aware of the hospital’s policies and as-
sessment processes. He said he attended quarterly training meet-
ings arranged for his department in addition to a safety
orientation he received when he began working at the hospital 10
months earlier. [26–28]
Talking with the Patient. Following the therapy session,
the surveyor asked the patient about her presurgical care and her
postsurgical care, including her understanding of medications,
pain management, and staff hand hygiene. The surveyor also
asked the patient whether she was familiar with the site marking
process and about the informed consent. [29–33] The patient
expressed overall satisfaction about staff and said she had been
well cared for, although earlier that day she had to wait longer
than expected for a nurse to help her to the bathroom. She added
that at first she was confused because the same nurse kept com-
ing into her patient room to “identify” her, but a nurse educator
explained it was part of their process to ensure they were provid-
ing care for the right patient. The patient said she was glad for
the extra safety. She said that her right hip had been marked by
the surgeon and that he explained why he was marking it. She
also said that the procedure was fully explained to her and her
husband, as well as the risks for surgery at the time she signed the
consent for surgery. The surveyor also asked if she had been given
any information regarding anesthesia and informed consent, to
which the patient replied that she had.
Visiting with Operating Room and Surgical Unit
Staff. The surveyor then visited the operating room and spoke
with staff members about their processes for presurgical patient
education and patient preparation. [34–36] The surgical nurse
18
explained that all patients were given prophylactic antibiotics
shortly before surgery. Staff also provided education to the pa-
tient on what to expect during surgery and also reviewed the
consent process with her, her husband, and her daughter, all of
whom were with her at the time of presurgery preparation. The
nurse showed the surveyor where this information was docu-
mented in the electronic medical record and the medication as-
sessment form that the attending anesthesiologist completed.
The surveyor then asked the nurse to show her where patients
are taken for postsurgical recovery and what process they follow
to assess and monitor a patient before being moved back to the
medical/surgical unit. She also asked about the process to assess
for pain postsurgically and how any orders from the surgeon
are documented and handled. [37–38]
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the following topics: electronic medical
records, staff qualification and training, and patient identifica-
tion process.
Scenario 1-1.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 1-1. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Nurse in Emergency Department:
[1] What happens when a patient arrives in the
emergency department? What special response
does it entail?
[2] What kinds of assessments do you perform?
[3] How do you educate and inform the patient and
family about what will happen regarding a patient’s
care?
[4] How do you interface with the radiology department
when an x-ray is needed?
[5] How do you assess, respond to, and monitor for
pain for emergency department patients?
[6] What is your triage process? How do you care for a
patient who might have emergent needs?
 Section 1: Hospital and Critical Access Hospital
Radiology Technician:
[7] How do you receive x-ray orders from the
emergency department?
[8] How do you prepare for the x-ray? How is a patient
transported and accommodated in radiology?
[9] What kind of patient education do you provide?
[10] How are test results communicated back to the
emergency department?
[11] How do you identify the patient to ensure that you
are performing the ordered test on the correct
patient?
[12] How do you place a patient who might be in pain?
Or might be confused?
Medical/Surgical Nursing Staff:
[13] How do you receive patients from the emergency
department? What kind of information do you
receive? How is this information communicated to
you? How do you know what must be set up in the
patient’s room prior to transfer?
[14] What kinds of assessments do you conduct when a
patient arrives on the medical/surgical unit? Who
conducts these assessments?
[15] How do you document medication use?
[16] How do you assess for pain? What kind of
monitoring and reassessment do you perform?
[17] Have you assessed the patient for falls risk? Do you
conduct ongoing falls risk assessments? What
interventions have you put in place to reduce the
patient’s risk of falling? Have you provided
education to the patient and family regarding falls
prevention?
[18] What kind of postsurgical care have you been
providing? What wound care is required?
[19] Did you assess the patient for skin and pressure
ulcer risk?
[20] What kind of pain management have you been
providing for the patient? How do you assess for
pain management in an ongoing manner?
[21] Have you performed discharge planning for the
patient?
[22] Who is involved in ensuring safe placement and
discharge to a rehabilitation facility? Are staff
members educating the patient and family about
discharge to the subacute facility?
Physical Therapist:
[23] What is the process for the physical therapy
department to receive orders for a patient? How is
physical therapy staff informed about a patient’s
plan of care? How do you coordinate the plan of
care with the floor? How do you also communicate
with the nursing and medical staff regarding
recommendations and treatment plans?
[24] What are you doing for this patient? How is this care
documented?
[25] What kind of role do you play in the patient’s
discharge planning? Are you included in the
interdisciplinary patient care team meetings?
[26] What training and orientation have you received
regarding hand hygiene? Can you tell me what is
required?
[27] What training and orientation have you received
related to falls risk and patient safety?
[28] What do you do if the patient appears be in
distress? To whom do you report it?
Patient:
[29] How would you describe your experience as a
patient in this hospital?
[30] How well do you understand the care that you have
been provided, such as medications and pain
management? What do you do if you have a
question about your care?
[31] How have you been educated about your care,
including presurgery and postsurgery? Who has
provided you with this information?
[32] Do you understand why you have been determined
to be a falls risk? Do you understand what you
should do if you need to get up; for example, to use
the bathroom? Have staff members been
responsive to your needs?
[33] Can you tell me about the informed consent forms
that you signed for surgery and for anesthesia? Who
provided you with that information, and who was
present when you signed your consents? Do you
remember if you were told about the procedure, the
risks, the benefits, and the alternatives?
(continued)
19
More Mock Tracers

provement director, the quality improvement specialist, a physi-

Scenario 1-1. cian member of the committee, and a nursing staff member.
Sample Tracer Questions
(Bracketed numbers correlate to Sample Tracer Questions on pages
(continued) 21–22.)

Operating Room and Surgical Care Unit
Staff:
[34] How do you prepare patients for surgery? What kind
of process do you follow?
[35] What is your process for ensuring that the informed
consent was properly obtained?
[36] Do you use a preoperative checklist, and does it
include documentation regarding the patient’s
informed consent?
[37] Please tell me about the postsurgical recovery
process. What kinds of assessments do you
perform? How often? What criteria are used to
safely discharge the patient from recovery
(postanesthesia care unit), and who makes the
discharge decision?
[38] How do you receive and implement orders from the
surgeon and the anesthesiologist? How are those
orders documented?
Talking with the Performance Improvement
Committee. The surveyor asked the committee members to
describe their current performance improvement efforts relat-
ing to a high-risk process, along with their overall approach to
planning for and collecting data and then managing and ana-
lyzing it. [1–4] The quality improvement director responded
that they provided ongoing training and education for staff on
issues related to quality improvement and used a unit- and
department-level approach to collecting and submitting data
on core measures and other related high-risk priority projects.
The surveyor indicated that during an earlier tracer he had
noted an inconsistent approach to how staff documented and
responded to pain for the tracer patient. The director said that
one high-risk improvement project the performance improve-
ment committee was currently undertaking related to pain
management. [5–9]

The physician team member mentioned that a review of both

patient satisfaction data and closed medical records over the
prior six months indicated that the response to patients’ pain
was not handled in a consistent manner. This finding

SYSTEM prompted the committee to launch an improvement project

aimed at ensuring a consistent assessment process and response
to pain throughout the hospital. The surveyor asked the team
Tracer Scenarios to describe the nature of the performance improvement proj-
ect. [10–12] The team explained that the aim of the project
SCENARIO 1-2. was to ensure a consistent pain assessment process and re-
Midsize Community Hospital sponse to pain screening, in which a patient response of pain
score of 2 or higher (using the appropriate pain scoring tools)
Summary would result in a more comprehensive pain assessment. The
In the following scenario, a surveyor traces how an organiza- director added that the project’s goal was to ensure that the
tion uses data. Within the tracer, the surveyor explores issues hospital’s preset minimum pain score would always result in a
relating to these priority focus areas: comprehensive pain assessment. The physician said a pilot test
• Information Management in one of the hospital’s medical/surgical units showed a higher
• Communication than acceptable rate of inconsistency in response to certain
• Quality Improvement Expertise/Activities pain scores. The nurse explained that the team used a failure
• Medication Management mode and effects analysis approach to ascertain the gaps in the
process and discovered that staff members did not consistently
Scenario use the appropriate pain measurement tools or consistently
The surveyor began this system tracer in a 125-bed community apply these tools (such as VAS, Wong-Baker, pediatric pain
hospital with a group discussion involving members of the per- tools, and so on) and that they were unclear about the pain
formance improvement committee, including the quality im- score that would warrant a further assessment. [13–14] By

20
 Section 1: Hospital and Critical Access Hospital
combining information through the staff education newsletter
with an in-service training, the team put in place a docu-
mented process aimed at ensuring a more consistent approach
to pain assessment and management.
The surveyor asked about the status of the pilot test and what
the outcomes were so far. [15] The director said monitoring to
date showed that there had been some improvement in the use
of the appropriate tools, though further monitoring needed to
take place. The team was planning to implement the improve-
ment strategy throughout the hospital and monitor for im-
provement. The surveyor asked the team members how they
were collecting data and reporting results. [16–17] The sur-
veyor then asked what steps the team members integrated into
ongoing staff education and training regarding pain manage-
ment and interventions, including non-medication-related
changes. [18] The nurse explained that they included training
for clinical staff on the use of appropriate pain measurement
tools as well as on alternative pain interventions to the use of
medications, such as repositioning the patient or providing a
quieter environment.
The surveyor asked the committee members whether they in-
cluded patient and family education in the project. If so, how
was this education being provided, and how was it docu-
mented? The surveyor then asked the director to explain what
the next steps were for the project. [19–22] The director ex-
plained that they were planning to continue close monitoring
of the project and continue their interventional work with
staff.
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the following topics: data collection,
pain management, and patient education.
Scenario 1-2.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 1-2. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Performance Improvement Committee:
[1] Please describe some examples of your current
performance improvement work.
[2] How does your performance improvement
committee function? How often do you meet? What
kind of representation do you have from across the
hospital?
[3] What is your approach to planning for, collecting,
monitoring, and analyzing data in the hospital?
[4] What kind of ongoing training and education do you
provide to staff?
[5] How do you identify high-risk processes, and how
do you set priorities for monitoring and
improvement?
[6] What do you do if you discover inconsistencies in a
patient’s documentation?
[7] What kinds of high-risk processes have you
analyzed?
[8] How did you become aware of a need for a
performance improvement project related to a high-
risk process?
[9] What efforts are you undertaking regarding pain
management? Have you made improvements? How
do you know?
[10] How did you design the improvement process? Why
did you choose this high-risk process?
[11] How did you involve staff members in this
improvement project? How were they informed about
it? How were medical staff involved in the project?
[12] How have you involved staff in contributing
feedback as you planned the project?
[13] How have you educated staff on the improvement
project? Have you used any additional methods to
educate or train staff?
[14] You indicated that you used failure mode and effects
analysis (FMEA). Would you please explain how this
was done, and can you show me the documentation
of this process?
[15] What is the current state of the improvement
project? How are you monitoring for improvements?
[16] What data collection process are you using? How
are you reporting your results and to whom?
[17] How have you informed staff about the additional
pilot testing and monitoring and of the results of your
initial pilot test?
(continued)
21
More Mock Tracers
Scenario 1-2.
Sample Tracer Questions
(continued)
[18] How do you inform staff of alternatives to
medication-related pain management interventions?
How is this information documented? How do you
implement best practices?
[19] What steps are you taking to continue monitoring
the project? How are you providing interventions for
staff?
[20] Have you educated patients and family about the
pain management process? How is this education
done?
[21] Have you engaged patients and their family in the
improvement project? How is this engagement
accomplished?
[22] How have patients and their families responded to
the improvement project?
SCENARIO 1-3.
Critical Access Hospital
Summary
In the following scenario, a surveyor traces how an organiza-
tion uses data. Within the tracer, the surveyor explores issues
relating to these priority focus areas:
• Quality Improvement Expertise/Activities
• Information Management
• Infection Control
• Communication
Scenario
The surveyor began this data use system tracer in a 15-bed
critical access hospital by meeting with the performance im-
provement team, which consisted of an attending physician,
the nursing manager, and the hospital’s performance improve-
ment specialist.
(Bracketed numbers correlate to Sample Tracer Questions on pages
23–24.)
Overview with the Performance Improvement
Specialist. The surveyor asked the performance improvement
specialist to describe the critical access hospital’s general data
22
collection, monitoring, analysis, and data use practices and how
the performance improvement team reported data to hospital
leadership and staff. [1–4] The performance improvement spe-
cialist explained that the team collected data from multiple hos-
pital processes, including infection control, medication
management, lengths of stay, and admissions and transfers. The
specialist added that she used database software to help collect
and aggregate the data and to generate reports. [5–6] The sur-
veyor asked the specialist, who was a registered nurse, to explain
what kind of training and ongoing education she received to
carry out her performance improvement–related duties. [7–8]
The specialist explained that being a nurse was a prerequisite for
this job, that she also participates regularly in training workshops
through the state hospital association, and that she was involved
in numerous performance improvement–related discussion net-
works on the Internet. She added that even though the hospital
was in a rural location, with the nearest other hospital approxi-
mately 80 miles away, she had a good collaborative network with
other performance improvement staff in the region who con-
tacted one another regularly for support and information.
Discussing Ongoing Performance Improvement Ac-
tivities with the Performance Improvement Team. The
surveyor asked the performance improvement team to describe a
performance improvement project that was currently under way.
[9–10] The team members presented their hand hygiene im-
provement project. The physician explained that it originated
when the performance improvement team undertook a hand
hygiene compliance monitoring project and noted a higher than
benchmark noncompliance rate with hand hygiene. The sur-
veyor asked them if they identified any patterns or trends and
what specific measures they had put in place to improve the
compliance rate. [11] The performance improvement specialist
explained that they conducted a facility assessment (as part of
their high-risk assessment) and noticed an inadequate number
of hand hygiene dispensers. As a result, one measure they put in
place immediately was to increase the number of dispensers;
they also identified the best placement for the dispensers. They
determined that every patient room would receive a dispenser as
well, and they discussed the best placement of these dispensers
in patient rooms. They used evidence-based literature to assist
them in identifying appropriate locations.
The surveyor asked whether any additional information
emerged from their comprehensive assessment. [12–13] The
team members explained that when they reviewed the hospi-
tal’s policies and procedures relating to infection control, they
discovered that hand hygiene education was not consistently
integrated into the orientation process. As a result, the orienta-
 Section 1: Hospital and Critical Access Hospital
tion process for all new employees was revised to include infor-
mation about the hand hygiene requirements.
Examining Staffing Education and Training on
Data Use with the Performance Improvement Team.
The surveyor then mentioned that during an earlier individual
tracer, she observed a member of housekeeping staff not wash-
ing her hands before entering a patient’s room and then not
washing her hands or using antibacterial gel in the patient’s
presence or when leaving the patient’s room. She asked the
team whether ongoing education regarding practice and
processes was continually enforced with staff beyond the orien-
tation process. [14–16] The nursing manager said that a series
of in-service training programs had been planned to help
housekeeping and other staff members understand the re-
quired process. Not all the staff had received the initial train-
ing or been provided with ongoing in-service education yet,
however, so the team planned to take steps to speed up partici-
pation in and attendance at the training sessions.
Monitoring Progress with the Performance Improve-
ment Team. The surveyor asked the team members to describe
how they were monitoring progress on this initiative, including
whether they were collecting and analyzing ongoing compliance
data. [17–19] She also asked whether they had seen any im-
provements in patterns and trends since they began this project.
The performance improvement specialist noted that hospital
leadership and the board are regularly apprised of progress based
on a monthly hand hygiene compliance observation report. All
hospital staff members are informed about compliance perfor-
mance through the performance improvement team’s monthly
newsletter. Six months into the project, the team members had
noticed a 20% improvement in hand hygiene compliance, but
they were still not quite reaching their benchmarked goal and
could not yet determine whether specific patterns of behavior or
by specific groups of practitioners had been improved. They
planned to continue their work and arrange additional training
activities for staff. The performance improvement specialist said
their aim was to reach their overall goal within the next six
months, and to continue to improve over time.
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the topics of hand hygiene and data use.
The latter topic might include the following:
• Monitoring data for trends and patterns
• Addressing particular identified trends and patterns with
improvement strategies
• Continuing to monitor and compare the data over time
Scenario 1-3.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 1-3. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Performance Improvement Specialist:
[1] How does your performance improvement team
function? How often do you meet? Who else is
involved in quality improvement efforts?
[2] What processes do you have to collect data in your
critical access hospital? Given that your organization
is small, what types of resources (equipment or staff)
do you have available for data collection and
analysis?
[3] How does your team aggregate, monitor, and analyze
the data? What measures do you use? How often do
these processes occur? How is the information shared
with others in your organization and with leadership?
[4] How does leadership stay apprised of your team’s
work?
[5] What kind of electronic support do you have to
support your data use processes?
[6] What is your reporting process? What reports do you
produce? Who receives them?
[7] What kind of training and ongoing education have you
received to support your work on the team or in your
job capacity (as performance improvement staff)?
[8] Do you network or collaborate with any other hospital
or performance improvement group in your region?
How do you stay apprised of current literature or best
practices considering your small staff and remote
location?
Performance Improvement Team:
[9] Would you please describe and share information on
a current performance improvement project under
way at your critical access hospital?
[10] How did you prioritize this project? How do you
prioritize improvement projects?
[11] Would you please describe how you planned for this
project? What measures have you put in place to
monitor improvement? Who is involved?
(continued)
23
More Mock Tracers
Scenario 1-3.
Sample Tracer Questions
(continued)
[12] When you conducted your baseline assessment of
hand hygiene compliance, what did you review or
assess? How did you use the results to make
conclusions?
[13] Are you comparing the results of your improvements
to your baseline data? Are you monitoring over time?
[14] What kind of training and education do you provide to
staff on performance improvement or data use
issues? Who provides the training? How do you stay
current and ensure that the training is appropriate?
[15] In relation to this current performance improvement
project, what kind of training and education have you
provided to staff members to secure their
knowledgeable involvement?
[16] How is this training and education integrated into your
hospital’s new employee orientation program? Is it
provided as ongoing in-service education and as “just-
in-time” training for those individuals involved in
quality improvement projects?
[17] How do you collect and analyze data? How do you
monitor your improvement activities?
[18] What methods do you use to share this information
with staff and to make any ongoing adjustments, if
necessary?
[19] What is your time frame for this project? Will you
continue to monitor for ongoing compliance over
time?
SCENARIO 1-4.
Large Teaching Hospital
Summary
In the following scenario, a surveyor traces how an organiza-
tion addresses infection prevention and control. Within the
tracer, the surveyor explores issues relating to these priority
focus areas:
• Patient Safety
• Information Management
• Infection Control
• Quality Improvement Expertise/Activities
24
Scenario
This tracer took place in a 550-bed teaching hospital. The sur-
veyor began the tracer with representatives of the infection
prevention and control committee, which included the direc-
tor of infection prevention and control, the quality improve-
ment director, two infection control specialists, and two
clinical staff representatives.
(Bracketed numbers correlate to Sample Tracer Questions on pages
25–26.)
Discussing Responsibilities and Structure with the
Infection Prevention and Control Committee. The sur-
veyor asked the infection prevention and control committee
members participating in the tracer to describe the full mem-
bership of the committee, how often they meet, what kinds of
data they collect, how they assess priorities, and how they
monitor and report data. [1–4] The infection prevention and
control director explained that they meet monthly and have
responsibility for infection prevention and control oversight
and planning for the entire hospital. She explained that the in-
fection prevention and control committee also was responsible
for infection prevention and control–related staff training and
education for the hospital. Regarding data collection, the com-
mittee focused on collecting data on and monitoring all criti-
cal infection control issues—including, but not limited to,
hand hygiene, surgical site infections, catheter-associated
urinary tract infections (CAUTIs), and issues related to the
environment of care (such as construction or equipment mon-
itoring and use). She also explained that other members of the
committee included managers or representatives of all vital
departments, including pharmacy, laboratory, housekeeping,
environmental services, and all clinical and clinical support
departments.
Talking with the Committee About Integration of
Infection Prevention and Control Activities. The sur-
veyor then asked the infection prevention and control com-
mittee members how other departments such as pharmacy,
laboratories, and facilities management participated in the in-
fection prevention and control committee meetings. [5–6]
The director explained that because the committee included
representatives from the technology, facilities, and pharmacy
departments, the committee was able to receive input quickly
from other departments when discussing and considering in-
fection prevention and control initiatives. The director added
that she and one infection control staff member also attend
other organizationwide committee meetings to provide an in-
fection control perspective on other initiatives.

Examining a Current Improvement Effort with
the Committee. The surveyor asked the infection preven-
tion and control committee members to present one of the
committee’s current improvement efforts. [7–8] The infec-
tion prevention and control director mentioned the recent
launch of a CAUTI initiative. The committee had noticed
an increase in the number of CAUTIs in postsurgical pa-
tients in certain units in recent months. The team theorized
that the increase was related to poor technique on specific
units where staff had not made any adjustment to ensure
that catheters were checked. The improvement initiative fo-
cuses on encouraging nurses to respond according to set
guidelines, even with less than optimal staffing, by creating
more triggers for nurses and to encourage more communica-
tion between staff and patients with catheters. Because the
hospital had been able to remedy its staffing problem on
those specific units in recent weeks, the director did not
know whether the problem would continue. However, the
team decided to monitor it closely to be sure that all staff on
all units knew the newly introduced contingency process in
case any staffing issues occurred. [9–12]
Discussing Related Individual Tracer Activity and
Surgical Site Infections with the Committee. After in-
dividual activity related to infection control, the surveyor
conducted a group discussion focused on infection control
with the infection prevention and control committee mem-
bers. The surveyor said that earlier that day, she traced a 55-
year-old female patient who had been admitted for cardiac
surgery six days prior and had developed a surgical site in-
fection postsurgically. The surveyor asked the committee
members about their process for educating staff about com-
plying with the National Patient Safety Goal requirements
related to reduction of surgical site infections. [13–14]
The surveyor added that although the patient’s medical
record stated she had been identified at high risk for infec-
tion because of her diabetes, this risk factor was not appro-
priately flagged in her electronic medical record. As a result,
some preoperative measures were not documented properly,
which led to an inconsistent administration of insulin. The
surveyor asked the committee members to delineate the cor-
rect procedure and asked to see the hospital policy and pro-
cedure relating to the preoperative care of diabetic patients.
[15–16] She then asked what the committee would do in
the event of an apparent discrepancy between process and
practice. The director explained that the infection preven-
tion and control department monitors all surgical site infec-
tions regularly and was aware of this patient’s case. The
Section 1: Hospital and Critical Access Hospital
infection control staff ’s analysis indicated that the electronic
medical record had not correctly flagged the patient’s record.
With some searching, staff found that after a recent update
to the electronic medical record software, the program no
longer connected the assessment data correctly to some of
the previously flagged surgical site infection risk data. [17–
19] According to the director, the hospital had already no-
ticed this problem in another instance and was conducting a
thorough analysis of the electronic medical record software.
Meanwhile, the committee had already reported this system
flaw to the technology department and planned to work
closely on assessing whether there were any other software
issues that needed to be addressed.
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the topics of infection control and staff
communication.
Scenario 1-4.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 1-4. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Infection Prevention and Control
Committee:
[1] How does your infection prevention and control
committee function?
[2] How often does your committee meet? What kind of
representation is on it?
[3] What kinds of data do you collect and monitor? How
do you analyze your results and to whom do you
report them?
[4] Do you use evidence-based guidelines to assist in
implementation strategies and requirements?
[5] Is infection prevention and control represented in
other forums at the hospital (such as environmental,
pharmacy, or performance improvement
committees)?
(continued)
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Scenario 1-4.
Sample Tracer Questions
(continued)
[6] What other disciplines or departments are
represented on the infection prevention and control
committee? Why? How are they educated to the
requirements of infection prevention and control?
[7] What kinds of improvement initiatives is the
committee currently implementing? How did you
select these initiatives? How did you prioritize these
initiatives? What types of activities are involved in
each?
[8] How have you educated and trained staff on these
improvement initiatives?
[9] How are you monitoring progress?
[10] How are you reinforcing the project in an ongoing
manner?
[11] How have you reported improvements to date and
to whom? What are your next steps? Will you
monitor for improvement over time?
[12] With relation to the CAUTI improvement efforts,
what kind of staff education and training do you
provide?
[13] What evidence-based practices have you
implemented to reduce surgical site infections?
[14] What kind of staff education and training do you
provide regarding preventing surgical site
infections? How are medical staff educated and
involved in the process?
[15] How do you ensure that staff understand and follow
procedures related to infection prevention and
control?
[16] What is the policy on documenting presurgical
assessment, particularly in relation to preventing
surgical site infections?
[17] What kind of integration is designed into your
electronic medical record software?
[18] What do you do in the event of an error in the
software? What backups do you use?
[19] Are infection prevention and control–related
concerns integrated into your hospital information
management planning?
26
SCENARIO 1-5.
Children’s Hospital
Summary
In the following scenario, a surveyor traces how an organiza-
tion addresses infection prevention and control. Within the
tracer, the surveyor explores issues relating to these priority
focus areas:
• Patient Safety
• Orientation & Training
• Infection Control
• Quality Improvement Expertise/Activities
Scenario
The surveyor conducted this tracer at a 200-bed children’s hos-
pital with members of the infection control committee at the
midpoint of the on-site survey, according to the planned
agenda. After individual tracer activity related to infection
control, the surveyor conducted this group discussion focused
on infection control. The representatives from the infection
control committee at the tracer meeting were the infection
control coordinator, an infection control specialist, the physi-
cian leader, and the hospital performance improvement coor-
dinator.
(Bracketed numbers correlate to Sample Tracer Questions on pages
27–28.)
Talking with the Infection Control Coordinator
About the Committee and Its Plan. At the outset of the
tracer, the surveyor asked the infection control coordinator
to delineate the overall infection control plan for the hospi-
tal, what roles were filled on the committee and in the hos-
pital, and what the identified key areas of focus were for the
infection control committee. [1–4] The infection control
coordinator explained that the primary goal for the hospital
in its infection control plan was to ensure that any infection
risks were identified and that steps to mitigate the risks were
implemented. He also indicated that the hospital annually
reviews the infection control plan and ensures that it ana-
lyzes its collected data surrounding infection prevention and
control in an effective, population-appropriate, guideline-
based manner.
The surveyor then asked the infection control coordinator
what kind of education and training he and his staff received
in relation to infection prevention and control. He also asked
what kind of infection control training and education is pro-

vided to staff in general. [5–7] The coordinator explained that
he and his staff all had clinical backgrounds, had undergone
additional training in relation to infection prevention and con-
trol, were actively involved in national associations related to
infection prevention and control, and attended meetings of
their local chapters of the national association.
The surveyor asked the infection control coordinator to de-
scribe any of the committee’s current infection control mon-
itoring activities, particularly how priorities were established
and how the key infection risks for the environment and
population were determined. [8–10] The infection control
coordinator explained that the committee regularly collects
data on hand hygiene and health care–associated infections.
He noted that the committee focused in particular on surgi-
cal site infections, respiratory-related infections, and MRSA
(methicillin-resistant Staphylococcus aureus) infections, which
were more prominent in the hospital setting. He explained
that the data were aggregated electronically using a combi-
nation of spreadsheets and database software. Reports were
prepared and distributed monthly, in advance of each infec-
tion control committee meeting, and distributed to hospital
leadership and the board of directors. In addition, the infec-
tion control department prepared a monthly newsletter for
staff as a way to reinforce and report on current risks and
initiatives and to provide ongoing information and report-
ing to staff.
Discussing a Potential Influx of Patients with the
Infection Control Committee. The surveyor asked the in-
fection control committee representatives to describe their
plan for a potential influx of infectious patients. [11] The hos-
pital performance improvement coordinator said that they had
devised a plan relating to a large influx of patients and had co-
ordinated with the nearby general hospital to collaborate on an
integrated plan. She added that the infection control commit-
tee had involved local authorities and first responders (emer-
gency and police) in the plan as well. The surveyor asked if
they had ever done a tabletop exercise or a drill of the plan,
[12] and the infection control coordinator explained that they
had conducted a tabletop exercise using the scenario of an in-
flux of H1N1 (“swine flu”) patients as the trigger six months
earlier during one of the infection control committee meetings
before the plan was finalized. The physician leader added that
department heads were involved in the tabletop exercise and
then expected to disseminate information to staff on the plan
in the event that there was an influx of patients. The commit-
tee analyzed and reviewed the effectiveness and response to
this drill.
Section 1: Hospital and Critical Access Hospital
Speaking with the Infection Control Specialist
About Patient and Family Education. The surveyor asked
the infection control specialist to describe how education is
provided to patients and families (particularly parents) in rela-
tion to infection prevention and control. [13] The infection
control specialist explained that the committee had prepared
special educational materials that were given to parents in rela-
tion to hand hygiene and surgical site infections, as well as in-
fection control practices regarding respiratory risks. The
infection control specialist noted that most parents appeared
to be well informed about risks and were often ready to do
whatever they could to support good infection control prac-
tices. The surveyor asked the infection control specialist how
the hospital accommodated the needs of patients and families
who had limited English language skills. [14] The infection
control specialist noted that the hospital uses a translation
service and has also translated some of its educational materials
into the other languages most commonly spoken by patients
and families. She showed the materials to the surveyor.
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the topics of infection control, data use,
and patient education.
Scenario 1-5.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 1-5. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Infection Control Coordinator:
[1] How do you organize and structure your infection
control activities in the hospital?
[2] Would you please show me your infection control
plan and explain how it is developed, reviewed, and
updated?
[3] How do you structure your committee? Who is
represented? How often do you meet?
(continued)
27
More Mock Tracers
Scenario 1-5.
Sample Tracer Questions
(continued)
[4] What focus does the infection control committee
have in the hospital?
[5] What kind of training and experience do your
infection control staff members have?
[6] How do you provide ongoing continuing education
for infection control staff and for other staff in the
hospital?
[7] What other resources are available to you for
professional development?
[8] What current infection control monitoring activities
are you involved in? Which are the key priorities and
why?
[9] How do you aggregate and analyze the data that
you are collecting? Do you make changes and
improvements based on this analysis? Can you
describe the changes?
[10] What process do you follow to communicate results
and information to leadership and staff?
Infection Control Committee:
[11] What is your planned response to a potential influx
of infectious patients?
[12] Have you conducted any drills around a potential
influx of infectious patients? How have you engaged
staff in the process? Have you analyzed the
effectiveness of response to these drills? Have you
made improvements based on this analysis?
Infection Control Specialist:
[13] What kind of education do you provide to patients
and families in relation to infection control? Do you
document this education, and, if so, where and how
is it documented?
[14] How do you accommodate the cultural and linguistic
needs of patients and families?
28
SCENARIO 1-6.
Anticoagulation Clinic at a
Large Urban Hospital
Summary
In the following scenario, a surveyor traces how an organiza-
tion manages medications—in particular, anticoagulants.
Within the tracer, the surveyor explores issues relating to these
priority focus areas:
• Patient Safety
• Medication Management
• Information Management
• Quality Improvement Expertise/Activities
Scenario
This tracer was conducted as a group discussion with staff at
the anticoagulation clinic on the second day of an on-site sur-
vey at a 350-bed urban hospital. The group assembled in-
cluded the clinic’s pharmacy director of anticoagulation
services, the hospital’s quality improvement director, the hospi-
tal’s chief pharmacy officer, the clinic’s nursing manager, and
the clinic’s physician director.
(Bracketed numbers correlate to Sample Tracer Questions on page
30.)
Collecting Background Information on the Antico-
agulation Clinic from the Clinic’s Pharmacy Director.
The surveyor began the tracer by reviewing its documentation
related to medication management and then focused in on
anticoagulation-related issues. The surveyor asked the clinic’s
pharmacy director to describe the organization’s overall ap-
proach to anticoagulation therapy and patient safety issues.
[1–2] The pharmacy director explained that the clinic had
been launched two years earlier as an attempt to consolidate
anticoagulation therapy being handled in the hospital with the
aim of consistency and close monitoring to ensure patient
safety, noting that they were following the specific Joint Com-
mission requirements of the National Patient Safety Goal
(NPSG) regarding anticoagulant therapy, NPSG.03.05.01.
The surveyor asked the pharmacy director to share more infor-
mation about the origination of the clinic. [3–5] The phar-
macy director explained that data collected by the hospital’s
medication safety committee three years earlier indicated a rise
in the number of reported adverse medication errors relating
to anticoagulation therapy. Subsequent analysis, he explained,

uncovered issues of patient noncompliance, complex dosing,
and poor monitoring contributing to these adverse events. The
outcome of the analysis and planning process resulted in the
decision to establish an anticoagulation clinic and to assure full
compliance with the NPSG requirements and evidence-based
guidelines for the management of anticoagulation therapy.
Talking with the Clinic’s Nursing Manager About
Safe Anticoagulation Therapy. The surveyor asked the
clinic’s nursing manager what process the clinic used to help
ensure the safety practice of anticoagulation therapy. [6–7]
The nursing manager indicated that patient education and
orientation was a central part of their process as a clinic,
providing education and orientation to patients who were in
the hospital and also to new patients receiving an anti-
coagulant and to patients referred to the clinic for ongoing
monitoring. The surveyor asked the nursing manager to
share some examples of education provided to patients. [8]
The nursing manager explained that when a patient is first
referred to the clinic, whether as an admitted hospital pa-
tient or as an outpatient, the nursing manager or another of
the nurse education specialists arranges a time to conduct a
detailed orientation with the patient. They also had
brochures that were customized and presented to each pa-
tient as part of this orientation program.
The surveyor then asked what kinds of challenges they en-
countered with patients. [9] The nursing manager responded
that when the clinic first opened, despite their comprehen-
sive patient orientation upon admission to the clinic, they
were still tracking inconsistent patient compliance with diet
and continued to have trouble getting patients to remember
to disclose any new medications. As a result, the clinic staff
wrote a new process to reinforce these issues during each visit
when an outpatient comes in to have the International Nor-
malized Ratio (INR) conducted and documented. Clinic
staff members also presented an ongoing medication record
that they asked patients to carry with them at all times and
have updated if any changes were made by any other physi-
cians providing care and treatment to them. The nursing
manager said that she and the other nurse education special-
ists forward information along to the patient’s referring
physician relating to poor compliance or follow-up monitor-
ing and ask for ongoing follow-up and communication. The
surveyor asked how the response had been with this added
reinforced follow-up. [10] The nursing manager replied that
they had seen a 10% increase in INRs within therapeutic
ranges among patients and a decrease in anticoagulation-
related readmissions to the hospital.
Section 1: Hospital and Critical Access Hospital
Speaking with the Hospital’s Quality Improvement
Director About Data Collection and Documentation
Practices. The surveyor asked the hospital’s quality improve-
ment director to describe what kinds of data the clinic collects
and how the clinic’s activity is documented. [11] The quality
improvement director explained that the clinic used an elec-
tronic medical record with software to track and document
INR levels along with related information. The quality im-
provement director noted that the clinic collects and submits
data on missed appointments, patient education and training,
INRs, ongoing communication with primary care physicians,
and hospital readmissions based on high or low INRs. She
added that the clinic also correlates poor patient compliance
with referring physicians so they can send a monthly report to
physicians.
Soliciting Physician Response from the Clinic’s
Physician Director. The surveyor asked the clinic’s physician
director what the response rate had been from physicians in re-
lation to these reports and whether the reports had helped im-
prove INR consistency. [12–13] The physician director noted
that physicians had generally responded well to receiving these
reports and that they are prescribing and monitoring far more
consistently now than before the clinic was established.
Discussing Equipment Use and Handling with the
Hospital’s Chief Pharmacy Officer. The surveyor asked
the hospital’s chief pharmacy officer what the approach was to
administer warfarin to patients. [14] The chief pharmacy offi-
cer explained the patient education process and the role that
pharmacy played in regulating the warfarin dosage. The chief
pharmacy officer explained that the INR was measured by a
point-of-care device and that the laboratory reviewed the qual-
ity control results to ensure that the quality control was done
each day of use and was within the acceptable range. The labo-
ratory also ensured that the staff members using the point-of-
care device were trained and had a competency assessment at
least annually, using at least two methods. The chief pharmacy
officer explained that they had a choice to use a quiz, observa-
tion, monitoring quality control, or running an unknown
sample to assess competency, but they had chosen a quiz and
observation because the process was relatively new and they
wanted to address some common concerns with the quiz. The
chief pharmacy officer noted that the warfarin clinic had really
been a cooperative approach between the laboratory and the
pharmacy to ensure patient safety.
The surveyor then asked the chief pharmacy officer what
the approach was to administer heparin intravenously to
29
More Mock Tracers
patients in the hospital. [15] The chief pharmacy officer ex-
plained that the hospital uses programmable pumps when
administering heparin intravenously to patients and that they
are continuously monitored for quality control. The chief phar-
macy officer then explained that they used a weight-based
heparin protocol and that the laboratory provided guidelines to
ensure that their therapeutic range for heparin correlated with
the PTT (partial thromboplastin time) levels when there was a
lot number change for PTT. [16]
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the topics of anticoagulation therapy
and patient compliance. The surveyor might also suggest,
based on the work the hospital had been doing through its
clinic, that the organization submit its experience to The Joint
Commission’s Leading Practice Library.
Scenario 1-6.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 1-6. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Clinic’s Pharmacy Director:
[1] What is your approach to medication management
as it relates to high-risk processes such as
anticoagulation therapy?
[2] What is your hospital’s policy on safe
anticoagulation therapy? Who has oversight over
the development and updating of policies and
procedures relating to anticoagulation? What
resources have you used in the development of
these policies?
[3] Please describe the origin of your anticoagulation
clinic. What led you to establish it? Do you believe
you have had a positive impact on the care of these
patients? How did the community physicians
respond to the establishment of your clinic? Do they
support and complement your care and treatment?
30
[4] Please describe the initial implementation of the
clinic. How did you involve and inform staff,
including medical staff? What kind of training or
education did you receive relating to this new
project?
[5] How do you analyze your data and plan for
improvement?
Clinic’s Nursing Manager:
[6] What steps do you follow to practice safe
anticoagulation therapy?
[7] Please explain how you educate and orient patients
and their families. What measures do you take to
monitor and to ensure compliance?
[8] Will you please show me some examples of
documented patient education?
[9] What kinds of issues require reinforcement among
patients? What measures do you implement to
ensure compliance? What midstream adjustments
have you had to make to your process?
[10] How have you engaged physicians in this process?
What has their response been?
Hospital’s Quality Improvement Director:
[11] What kinds of data do you collect at the clinic? How
do you document care and treatment?
Clinic’s Physician Director:
[12] How do you keep the referring physicians informed
about patients who are not compliant? Do you ask
them to assist you with compliance?
[13] Have you identified any correlation between
improved consistency in physician prescribing and
more stable INRs among patients? Can you show
me the data?
Hospital’s Chief Pharmacy Officer:
[14] How do you administer warfarin to inpatients?
[15] How do you administer heparin to inpatients?
[16] Please describe the kind of equipment you use and
how you monitor it. What safety measures are in
place to ensure safe administration and dosing?
How do you ensure that your INR and PTT results
are accurate?

SCENARIO 1-7.
Midsize Community Hospital
Summary
In the following scenario, a surveyor traces how an organiza-
tion manages medications. Within the tracer, the surveyor ex-
plores issues related to the following priority focus areas:
• Medication Management
• Orientation & Training
• Patient Safety
• Equipment Use
• Quality Improvement Expertise/Activities
Scenario
This tracer was conducted at a 180-bed community hospi-
tal. The surveyor asked about ordering/prescribing proce-
dures and about pharmacy protocols for dispensing
medications. She asked to see reports of adverse drug events
and near misses, or close calls. For this medication manage-
ment tracer she selected a near-miss report involving 4-year-
old boy. During the course of this tracer, issues raised
concerning contracted services necessitated additional tracer
activity. Thus, this scenario is an example of a second gener-
ation tracer, which takes an in-depth look at a high-risk
topic (see Introduction, page 2).
(Bracketed numbers correlate to Sample Tracer Questions on pages
32–33.)
Talking with the Pharmacist. The surveyor first talked
with the pharmacist in following up on the pediatric patient
near miss. [1–2] The pharmacist explained that the patient
was prescribed a wrong dose of vancomycin because of a
switch in dosing weight from kilograms to pounds. [3] The
pharmacist explained that he had ultimately caught the error
when he reviewed the order. [4]
The surveyor then asked the pharmacist whom he had notified
about the error. [5–6] The pharmacist said he had notified the
pharmacy director, but he did not know whether the director
had informed the hospital. The pharmacist, who had begun
work at the pharmacy just a few weeks prior, explained that he
worked for a national company contracted by the hospital to
provide medications and pharmaceutical services. Because he
had caught the mistake before the medication was given to the
patient, he felt there was no harm done and that it would not
matter if it took a month or so to report the error. At that mo-
ment, the surveyor realized that she would need to take an in-
Section 1: Hospital and Critical Access Hospital
depth look at the hospital’s contracted services as soon as she
finished the medication management tracer.
The pharmacist and the surveyor then discussed ways the
pharmacy worked to ensure safe medication management
practices. The pharmacist said that the hospital had a bar-code
medication verification process, but this process would not
have caught the near-miss dosing error they had been dis-
cussing. [7–8] The surveyor and the pharmacist also discussed
the pharmacy’s role in the hospital’s medication management
process, including its procedures in drawing up patient-
specific doses.
Questioning the Pediatric Ward Nurse. The surveyor
then proceeded to the pediatric unit to trace another patient
who had also suffered an adverse drug event involving van-
comycin. In this case, she explored the medication manage-
ment process regarding the care of a child with a ureteral
stricture. The child had developed hypertension as a result of
collateral kidney damage. A review of the medical record
showed that the patient was taking antihypertensive medica-
tions, including captopril, spironolactone, and furosemide.
The boy was also placed on vancomycin therapy as a result of a
cellulitis culture that had revealed methicillin-resistant Staphy-
lococcus aureus (MRSA).
The surveyor asked the child’s nurse to explain how patients
should be weighed to determine appropriate dosage. The nurse
said that all patient weights must be recorded in kilograms.
The surveyor then asked the nurse to show her the medica-
tions the patient had received, and together they reviewed the
medication administration record and discussed prescriptions
policies and preparing doses. [9–11] The surveyor next asked
to see syringes and found patient-specific doses as well as bar-
code labeling that was not attached to the doses. [12] The
nurse said the children’s syringes were so small that properly
wrapping the bar-code label so that the scanner could read it
was difficult and created problems. She said that bar codes
often failed for that reason. [13–14]
Returning to the Pharmacist. The surveyor returned to
the pharmacist to follow up on the issues prompted by the
MRSA diagnosis in the second pediatric patient. She asked the
pharmacist if the organization had an antimicrobial steward-
ship program. [15] The pharmacist said that he served as a key
member of the hospital’s multidisciplinary antimicrobial stew-
ardship team, which had developed practice guidelines and
pathways along with education programs. Other antimicrobial
stewardship team members included an infection control
31
More Mock Tracers
professional, a microbiologist, an infectious diseases physician,
a representative from information management, a nursing
leader, the hospital’s epidemiologist, and an administrative
leader. The pharmacist added that the team worked closely
with the hospital’s pharmacy and therapeutics committee. The
surveyor asked the pharmacist what training he had received
that qualified him to serve on the antimicrobial stewardship
team. [16] The pharmacist described his professional creden-
tials and said that the hospital had provided additional train-
ing when he had joined the team.
The surveyor asked if the antimicrobial stewardship team
monitored vancomycin use. [17] The pharmacist replied that
the organization did track use of this antibiotic, using guide-
lines from the Healthcare Infection Control Practices Advisory
Committee of the U.S. Centers for Disease Control and Pre-
vention. The surveyor completed the discussion with the phar-
macist by asking which health care–associated infections the
organization tracked and how the organization used the infor-
mation it obtained to determine formulary restrictions. [18]
Concluding with the Medical Director. The surveyor
concluded the medication management tracer by meeting with
the hospital medical director. She asked how the hospital veri-
fied competency. [19] The medical director replied that nurses
and other hospital staff undergo a competency assessment
upon hire and then annually thereafter. These assessments are
documented in the personnel record, the director added, and
showed the surveyor the record for the pediatric ward nurse
with whom she had spoken. The surveyor confirmed that the
nurse’s competency had been assessed, verified, and docu-
mented. The medical director explained that for pharmacists,
verification of competency was the responsibility of the phar-
macy, as provided for in the contractual agreement between
the hospital and the pharmacy.
Talking with the Pharmacy Director. Turning her at-
tention to the issue of the contracted services between the na-
tional company and the hospital, the surveyor wanted to first
talk to the pharmacy director, whom she was able to reach by
phone. Interested in the depth of the director’s involvement
with the pharmacy and the hospital, she asked about his rela-
tionship with both and how often he was actually on the
premises. [20] The director explained that he traveled among a
large number of hospitals and other health care organizations
in the area for which his company provided services. He was at
this particular hospital about once a month. He answered ad-
ditional questions from the surveyor about his participation on
this facility’s various committees, [21] the methods and fre-
32
quency of communication with the hospital, [22] and the
orientation pharmacy staff received from the hospital. [23]
Conferring with the Chief Operating Officer. Fi-
nally, the surveyor met with the hospital’s chief operating offi-
cer, who managed the pharmacy contract. She asked to see a
copy of the contract, [24] which she examined before they
talked. She then asked extensive questions regarding the hospi-
tal’s relationship with the company providing its pharmacy
services. [25–26] The officer responded with information
about the organization’s need for pharmacy services and the
complete history of its affiliation with the national company.
Their discussion eventually turned to performance expecta-
tions and the methods and frequency of evaluations regarding
this performance. [27–28] The surveyor also asked about any
other contracted services agreements the hospital had and re-
quested reviews of each contract.
Moving Forward. Based on the medication management
tracer, the surveyor may discuss the following in the Daily
Briefing: performing a root cause analysis on dosing near
misses in order to understand risk points in weight-based dos-
ing processes; conducting a failure mode and effects analysis or
using process improvement tools to examine the potential for
errors associated with pediatric syringes and bar-code labeling
and scanning; and staying focused on antimicrobial steward-
ship as an integral component of infection control efforts.
Based on the further examination of contracted pharmacy
services, the surveyor might discuss the hospital’s overall con-
tract process.
Scenario 1-7.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 1-7. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Pharmacist:
[1] Is there a pediatric formulary? If so, are prescribers
aware of the medications on this list?
 Section 1: Hospital and Critical Access Hospital
[2] How is the review of prescriptions conducted? What
policies guide practice?
[3] What is the pharmacist’s role in reviewing
vancomycin therapy as a retrospective process and
regarding real-time monitoring of current patient
therapy?
[4] What happened after this near miss was identified?
Has a root cause analysis been performed?
[5] Have the prescriber and the nurse been informed of
the findings following an evaluation and analysis of
the near miss?
[6] What happens with medication error data? Have
you seen any changes when a medication error is
identified?
[7] Are bar-code bypasses tracked? Explain how.
[8] How are bypasses analyzed?
Pediatric Ward Nurse:
[9] How are medications provided for pediatric
patients? Who prepares them?
[10] How are medications prescribed? What policies are
in place related to prescribing?
[11] What medications are parts of floor stock? If you
need to prepare a dose of medication, what is the
process for doing so?
[12] Do you review the medication label to see whether it
includes the required information?
[13] How does the bar-code process work? How do you
use it for stat medications or for partial doses from
vials or containers that are pulled from floor stock?
[14] How are medication errors reported? What
procedure does the organization follow if an error is
caught before it reaches the patient? Have you ever
reported an error or a near miss?
Pharmacist:
[15] Does the organization have an antimicrobial
stewardship program? If not, how do you ensure
that antimicrobial agents are used properly? If so,
what are the antimicrobial stewardship activities?
Describe the process and its outcomes.
[16] What training have you received that qualifies you to
serve on the antimicrobial stewardship team?
[17] Does the antimicrobial stewardship team track the
use of vancomycin? How does it use that
information?
[18] Does the organization track methicillin-resistant
Staphylococcus aureus (MRSA) incidence? What
other health care–associated infections does it
track? How is information about health care–
associated infection rates used in the antimicrobial
stewardship program?
Medical Director:
[19] How does the hospital verify competency? How
often is competency assessed? How is verification
of competency documented?
Pharmacy Director:
[20] What is your role as pharmacy director? What are
your responsibilities? How frequently are you on-site
at the hospital pharmacy?
[21] Are you part of the hospital’s pharmaceutical and
therapeutics committee? Are you a member of any
other committees at this hospital?
[22] What reports do you routinely submit to the
hospital? How frequently are these reports
submitted?
[23] What orientation do your company’s employees
receive from the hospital?
Chief Operating Officer:
[24] Please show me a copy of the contract. How is the
contract managed?
[25] How would you describe your hospital’s relationship
with the contract company?
[26] What is the role of hospital leadership in relation to
contracted services?
[27] What performance criteria for contracted staff are
set in advance? How do you monitor performance?
How frequently is performance evaluated? When
was the last time performance was evaluated?
[28] What contractual provisions are made for medical
staff oversight? When was the last review by
medical staff?
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PROGRAM-
SPECIFIC
Tracer Scenarios
SCENARIO 1-8.
Large Hospital
Summary
In the following scenario, a surveyor traces how an organiza-
tion manages patient flow. Within the tracer, the surveyor ex-
plores issues relating to these priority focus areas:
• Communication
• Staffing
• Patient Safety
Scenario
This patient flow tracer was conducted in a 230-bed hospital.
During individual tracers earlier in the on-site survey, the sur-
veyor had noticed a few issues of concern related to patient
flow, namely, the emergency department (ED) waiting room
was overflowing and a number of patients had been held for
long durations in the ED, waiting for a hospital bed. The sur-
veyor further observed, while visiting the postanesthesia care
unit (PACU), a patient waiting to be moved to the intensive
care unit (ICU) while staff prepared an ICU bed. The surveyor
conducted the patient flow tracer with staff and leadership
from quality improvement, the ED, and the PACU, in addi-
tion to staff from the hospital’s patient safety committee. The
discussion also included the hospital’s “bed czar,” a new role
filled by one of the hospital’s discharge nurse specialists. This
scenario is an example of a second generation tracer, which
takes an in-depth look at a high-risk topic (see Introduction,
page 2).
(Bracketed numbers correlate to Sample Tracer Questions on page
35.)
Talking with the Quality Improvement Director.
The surveyor began the discussion by asking the quality im-
provement director to describe the hospital’s process to man-
age patient flow in the hospital. [1] The quality improvement
director explained that the hospital had been collecting data
on patient flow, including information on ED admits, wait
times in the emergency department, and wait times for beds
(particularly those from the PACU or ED to the ICU or a
medical/surgical unit). [2] The quality improvement director
34
explained that an analysis on wait time data indicated a 12%
increase in wait time in the emergency department over the
previous year’s data. [3] This increase in wait time had resulted
in an increase in the number of delays for patients being trans-
ferred from the emergency department to beds, she noted.
The surveyor asked what kinds of improvement efforts the
hospital had put in place to address these delays in patient
flow. [4] The quality improvement director explained that the
hospital had formed a team consisting of leadership from the
hospital and representatives from the ED, PACU, and medical
staff to implement a process to reduce patient backflow—that
is, congestion in one area that causes delays in another area.
He noted that the improvement effort had been introduced
several months earlier. The team found that one reason for an
upsurge in patients in the ED was the closure, nine months
earlier, of an urgent care center in the neighboring community.
The team had also noted that patient upsurge tended to occur
in the early evening.
Speaking with the Emergency Department Director.
The surveyor asked the ED director how the hospital was ad-
dressing the upsurge in patients. [5] The ED director stated
that hospital leadership had been considering opening an ur-
gent care center to address the gap in services. He added that
the hospital had revisited the staff schedule to ensure better
overlap of staffing in the early evening hours, which had
helped mitigate the problem somewhat.
Talking with the Bed Czar. The surveyor asked the bed
czar what kinds of improvement processes the hospital had in
place to mitigate patient backflow. [6] The bed czar explained
that she had been implementing new processes to better track
bed availability and to communicate anticipated issues to key
departments in the hospital earlier in the process—particularly
working with ICU staff to help move patients who were ready
to step down to medical/surgical units in a timely manner.
The surveyor asked the bed czar what kind of training and
support she was providing to staff in her new role. [7] She
described how she had been working in conjunction with
key hospital leaders to ensure that her new responsibility
was clearly communicated to staff, and she indicated that
she had been leading in-service training for hospital staff
members to help orient them to the new role and communi-
cation strategy. She noted that the team was placing particu-
lar focus on ensuring that the discharge process begins in a
timely and consistent manner to help move the patient
through care more efficiently.

Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the following topics: data use, perfor-
mance improvement, and staff training and competency.
Scenario 1-8.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 1-8. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Quality Improvement Director:
[1] Please describe your process to oversee and
manage patient flow in your hospital. Who has
oversight and management responsibility? How do
they interface with the departments in the hospital?
[2] What kinds of data do you collect in relation to
patient flow?
[3] How are these data analyzed and communicated?
[4] What kinds of improvement efforts has the hospital
put in place to address delays in patient flow?
Emergency Department Director:
[5] What kinds of communication processes do you
have in place to help the hospital address an
upsurge in patients?
Bed Czar:
[6] What kind of improvement process do you have in
place to mitigate patient backflow? How has this
process been implemented in the hospital?
[7] What kind of training and support are you providing
to staff in the improvement process? How are you
tracking progress and communicating results?
Section 1: Hospital and Critical Access Hospital
SCENARIO 1-9.
Midsize Suburban Hospital
Summary
In the following scenario, a surveyor traces how an organiza-
tion addresses suicide prevention. Within the tracer, the sur-
veyor explores issues relating to these priority focus areas:
• Patient Safety
• Assessment & Care/Services
• Rights & Ethics
• Equipment Use
Scenario
During a data use system tracer at a 94-bed suburban hospital,
the surveyor learned of an unsuccessful suicide attempt by a
70-year-old male patient on a medical/surgical unit. Because
the attempt took place two weeks earlier and the patient had
already been discharged from the hospital, the surveyor opted
to conduct a closed record suicide prevention program-specific
tracer.
(Bracketed numbers correlate to Sample Tracer Questions on pages
36–37.)
Meeting with Staff to Learn About the Incident. To
start the tracer, the surveyor asked to meet with the patient
safety officer, the nursing manager of the unit where the sui-
cide attempt occurred, the quality improvement director, and
the clinical social worker. She first reviewed the medical record
with the staff by asking them what had transpired and how the
staff had been able to intervene to prevent a suicide. Because
the hospital had also performed a root cause analysis after this
close call, or near miss, was identified, the group was able to
delineate the specific events that led to the incident and what
the hospital had learned. [1–3] The nursing manager ex-
plained that the patient had been admitted several days earlier
due to a fall in the home resulting from dehydration, nausea,
and exhaustion. On assessment, the patient had disclosed that
he had recently been diagnosed with a recurrence of cancer,
which had been in remission for the previous decade. The pa-
tient was admitted to help stabilize his condition.
Staff noticed no family or visitors to the hospital and asked the
patient if he had any involved relatives or next of kin. The
nursing manager said the patient explained that his wife had
passed away three months earlier and his children (now adults
with families of their own) lived in a different region of the
country. [4–5] The patient had shown no overt signs of
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suicidal ideation according to the standard guidelines that
most staff on the medical/surgical units had been trained to
recognize, and so there had been no suicide risk assessment
conducted or additional interventions implemented. The pa-
tient was placed in a private room with a private bathroom.
According to the nursing manager, the patient had rigged a
noose from his belt and planned to hang himself from a rail in
the hospital’s bathroom. He was attempting to attach the belt
to a railing in the bathroom when the nurse entered his room
to check his status and assess his pain, thus interrupting him.
When the surveyor asked what intervention the nurse put in
place after she discovered the patient, the nursing manager
mentioned that the nurse quickly approached the patient, re-
moved the belt, and helped the patient return to his bed. [6]
She stayed with the patient and then quickly pushed the assis-
tance button for additional staff to enter the room and help.
When the patient was stabilized, the medical/surgical unit
manager contacted the psychiatric unit for assistance. A suicide
risk assessment was conducted at that time. The surveyor then
asked what response the unit provided to support the patient.
[7] The nursing manager explained that although the unit staff
members were less experienced with suicidal patients, they
knew to remain in the patient’s presence and to ensure that his
medical needs were addressed. The unit manager explained
that she was the responder who performed the suicide risk as-
sessment with the patient, during which she learned that cer-
tain key risk factors—a compromised social network and ill
health—were not documented by staff in the emergency de-
partment and medical/surgical unit and could have con-
tributed to the patient’s suicidal ideation. The staff, based on
guidance from behavioral health clinical staff, took measures
to secure the patient’s room, removing any objects or items
that could be used in another attempt, and implementing one-
on-one monitoring. After his condition improved, the patient
was discharged first to the behavioral health unit for additional
assessment, care, and counseling. After he was emotionally sta-
bilized, he was transferred to a subacute rehabilitation facility.
Discussing with Staff Future Response to Suicide
Prevention in Nonpsychiatric Settings. The surveyor
asked the group members to describe what they learned from
conducting their own root cause analysis and, particularly,
what measures they had put in place for additional interven-
tions in nonpsychiatric settings. [8–9] The patient safety offi-
cer referred to a Sentinel Event Alert that had been recently
issued by The Joint Commission in relation to suicide preven-
tion in the emergency department and medical/surgical units,
noting that the information in it was useful in helping to
36
guide their improved process. She said the patient safety com-
mittee had decided to designate this as a high-priority project
and was in the process of revisiting the entire suicide preven-
tion plan, with particular assistance and input from clinical
psychiatric staff. The surveyor asked what other plans were in
place to aid with planning and implementation. [10–12] The
quality improvement director explained that the committee
was also planning a facilities tour to determine whether there
were any environmental factors in the emergency department
and on the medical/surgical units that could potentially con-
tribute to successful suicide attempts.
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the topic of suicide prevention, includ-
ing the possible suggestion to consult the Leading Practice
Library.
Scenario 1-9.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 1-9. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Staff:
[1] When do you conduct suicide risk assessments?
How are such assessments documented? What do
you do when potential risk factors are identified?
[2] Could you describe this high-risk event that
triggered additional improvement efforts? Can you
explain what transpired when this patient attempted
suicide on a medical/surgical unit? How were staff
members able to prevent this potential suicide?
What was done to assure that the patient remained
safe for the remainder of his hospitalization?
[3] Did you conduct a root cause analysis? What did
you learn from this analysis?
[4] Did you ascertain the role or presence of family or
significant others for this patient?
[5] Before this event, what training had emergency
department and medical/surgical staff received in
relation to suicide risk assessment and prevention?

[6] What training and education have your staff
received in relation to intervening in an attempted
suicide? What changes or improvements have you
made as a result of your root cause analysis?
[7] How did the staff member enlist additional support?
What would the appropriate response be without
compromising the safety of the patient or of other
patients on the unit?
[8] What did you learn from conducting a root cause
analysis? What factors contributed to the failure of
staff to identify this patient as a suicide risk?
[9] What types of resources and materials have you
used in planning improvements relating to suicide
risk assessment and prevention?
[10] Who is involved in this planned improvement
project? What will you do to help implement and
monitor improvements?
[11] How will you educate and train staff in
nonpsychiatric settings such as the emergency
department or medical/surgical units?
[12] What environmental factors have you identified that
could increase the risk of successful suicide
attempts on these units?
SCENARIO 1-10.
Suburban Hospital with Laboratory
Summary
In the following scenario, a surveyor traces how an organiza-
tion integrates laboratory functions into a hospital environ-
ment. Within the tracer, the surveyor explores issues relating
to these priority focus areas:
• Assessment & Care/Services
• Communication
• Information Management
• Organizational Structure
• Quality Improvement Expertise/Activities
Scenario
This program-specific laboratory integration tracer was con-
ducted at a 78-bed suburban hospital. The staff members with
whom the surveyor met included the hospital’s laboratory di-
rector, a laboratory technician, the quality improvement direc-
tor, the patient safety coordinator, and the emergency
department director.
Section 1: Hospital and Critical Access Hospital
(Bracketed numbers correlate to Sample Tracer Questions on page
38.)
Visiting with the Tracer Team Members at the
Hospital Laboratory. The surveyor began the tracer at
the laboratory, where she met with the laboratory director
and one of the laboratory technicians. The quality im-
provement director and the patient safety coordinator were
there as well. She first asked the laboratory director to de-
lineate the laboratory’s process to receive stat test orders
and specimens and to communicate stat test results. [1]
The laboratory director explained that the laboratory re-
ceives and enters all orders and then documents test results
in its laboratory information system (LIS), but because the
hospital was still in the process of implementing an inte-
grated electronic system throughout the organization, the
laboratory used a combination of paper and electronic
methods to document and track the tests and communi-
cate results. The surveyor asked the laboratory director to
show her an example of how the laboratory maintains its
documentation. [2]
The surveyor then asked the laboratory director to describe
how laboratory documentation had been integrated into the
hospital and its activities. [3–6] The laboratory director re-
sponded that due to the current transition in the hospital
from paper and electronic to an all-electronic approach, the
laboratory’s integration had been aided by the attempt to
systematize the organizationwide process to improve the
communication of test results. The director explained that
recent data on the timeliness of reporting test results and the
subsequent process flow study had allowed the hospital to
identify bottlenecks and inefficiencies in the process. The
process improvement team consisting of laboratory and
emergency department staff members had found some gaps
in communication between the emergency department and
the laboratory and was planning to identify and implement
improvements to eliminate inconsistent communication of
stat orders and results.
The surveyor asked the laboratory director to elaborate, and
she explained that inconsistent reporting occurred in rela-
tion to how stat tests were identified as they came into the
laboratory. [7] The laboratory director explained that a cur-
rent improvement project was already being addressed by
the process improvement team and more effective commu-
nication between the laboratory and the rest of the hospital
was a key feature of the new electronic medical record being
implemented.
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More Mock Tracers
Meeting with the Emergency Department Direc-
tor. The surveyor then visited the emergency department to
ask department staff members how they communicate with
the laboratory when there is a stat test order that requires
their action. [8] She approached the emergency department
director and asked her about the department’s policy on de-
fined stat test results. [9] The emergency department direc-
tor explained that staff prepared an electronic order that did
not cross over to the LIS, so the order had to be delivered to
the laboratory with the specimens or e-mailed to the labora-
tory. The results also did not cross over from the LIS to the
hospital system and had to be faxed to the emergency de-
partment. They had experienced problems, she explained,
because the systems were not yet fully integrated and some
e-mailed orders and faxed results did not get sent or com-
municated in a timely manner. There were also transcription
errors with the orders. This communication lag could result
in a delay in getting the results and the emergency depart-
ment having to follow up directly with the laboratory to
check on the results.
When the surveyor mentioned the process improvement ef-
fort to better integrate the communication between the lab-
oratory and the emergency department by way of the
electronic medical record, the emergency department direc-
tor also stated that she was involved with the process im-
provement team and had spent a great deal of time so far
working with the laboratory director on this plan. The sur-
veyor asked when this effort would be introduced, and the
emergency department director mentioned that the entire
system was being rolled out in approximately three months.
When asked what the staff members were doing in the in-
terim to reduce the incidence of delay in the reporting of
stat test results, the emergency department director ex-
plained that they had already decided to use an additional
system of a follow-up phone call as the stat test order was
making its way to the laboratory. [10] In addition, the labo-
ratory was supposed to e-mail the emergency department
back to acknowledge receipt of the order and work within
their set time frames to report results to the physician.
Moving Forward. Based on the tracer, the surveyor
may discuss areas of improvement in the Daily Briefing. The
discussion might address the topics of communicating stat
test results and testing the effectiveness of electronic
systems.
38
Scenario 1-10.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 1-10. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Tracer Team:
[1] What is your process to receive stat tests and to
report stat test results? How do the orders come into
the lab? How do you ensure that all orders, even
orders that are added on after you receive the
specimens, are completed? Do you acknowledge
them? How do you report test results?
[2] Please show me an example of your documentation.
Who is responsible for this documentation?
[3] How has laboratory documentation been integrated
into the hospital’s documentation? Do you have
integrated participation in planning committees and
other ongoing activities?
[4] What kind of system do you use to communicate
test results with the areas of the hospital that order
the tests?
[5] How do orders come into the laboratory? Is there
any variation between departments? Must all orders
be written? If there are verbal orders, how are they
validated?
[6] What gaps in communication exist between the
laboratory and other hospital departments? How are
you working to reduce those gaps?
[7] Are you measuring data, and are teams that are
involved in the process working to improve the
process? Have you seen any positive results?
Emergency Department Director:
[8] How do you communicate a stat test order to the
laboratory? What follow-up do you need to do?
What is the process to deliver the sample to the
laboratory? How do you receive stat test results
from the laboratory?
[9] What improvement process are you utilizing to
improve the communication process?
[10] What are you doing in the interim to reduce the gap?
 Section 1: Hospital and Critical Access Hospital

Sample Tracer Worksheet: Scenario 1-6.

The worksheet below is an example of how organizations can A correct answer is an appropriate answer that meets the re-
use the sample tracer questions for Scenario 1-6 in a worksheet quirements of the organization and other governing bodies.
format during a mock tracer. The bracketed numbers before An incorrect answer should always include recommendations
each question correlate to questions described in the scenario. for follow-up.

Tracer Team Member(s): Terry Clark Data Record(s):

Subjects Interviewed: Yusuf Hamid, Suzanne Unit(s) or Department(s): anticoagulation clinic
Durand, Sofia Garcia, Jordan Lewis, Aja Vijaya
Tracer Topic or Care Recipient: anticoagulation
safety

Interview Subject: Clinic’s Pharmacy Director

Questions Correct Incorrect Follow-Up Comments or

Answer Answer Needed Notes
[1] What is your approach to ✓ Staff answered
medication management as it appropriately.
relates to high-risk processes
such as anticoagulation therapy?

[2] What is your hospital’s policy ✓ May need additional Staff did not know the
on safe anticoagulation staff training. policy.
therapy? Who has oversight
over the development and
updating of policies and
procedures relating to
anticoagulation? What
resources have you used in the
development of these policies?

[3] Please describe the origin of ✓ Staff members were aware

your anticoagulation clinic. What of the work done to open the
led you to establish it? Do you clinic.
believe you have had a positive
impact on the care of these
patients? How did the
community physicians respond
to the establishment of your
clinic? Do they support and
complement your care and
treatment?

(continued)

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Interview Subject: Clinic’s Pharmacy Director (continued)

Questions Correct Incorrect Follow-Up Comments or

Answer Answer Needed Notes
[4] Please describe the initial ✓
implementation of the clinic.
How did you involve and inform
staff, including medical staff?
What kind of training or
education did you receive
relating to this new project?

[5] How do you analyze your ✓ May need more Thorough information
data and plan for improvement? emphasis on follow-up provided on the process and
on data use. good examples of methods
used.

Interview Subject: Clinic’s Nursing Manager

Questions Correct Incorrect Follow-Up Comments or

Answer Answer Needed Notes
[6] What steps do you follow to ✓ Review orientation and New staff members seemed
practice safe anticoagulation training for new staff. unaware of hospital’s
therapy? anticoagulation therapy
practice.
[7] Please explain how you ✓
educate and orient patients and
their families. What measures
do you take to monitor and to
ensure compliance?

[8] Will you please show me ✓ Good example by

some examples of documented pharmacist.
patient education?

[9] What kinds of issues require ✓

reinforcement among patients?
What measures do you
implement to ensure
compliance? What midstream
adjustments have you had to
make to your process?

[10] How have you engaged ✓ Review how to follow up. Staff members seemed
physicians in this process? unaware of the role of
What has their response been? physicians aside from
prescribing.

40
 Section 1: Hospital and Critical Access Hospital

Interview Subject: Hospital’s Quality Improvement Director

Questions Correct Incorrect Follow-Up Comments or

Answer Answer Needed Notes
[11] What kinds of data do you ✓
collect at the clinic? How do you
document care and treatment?

Interview Subject: Clinic’s Physician Director

Questions Correct Incorrect Follow-Up Comments or

Answer Answer Needed Notes
[12] How do you keep the ✓ Work with clinic on No clear process to keep
referring physicians informed process design. physicians informed.
about patients who are not
compliant? Do you ask them to
assist you with compliance?

[13] Have you identified any ✓ Work with clinic on No consistent data use
correlation between improved data use practices. practices.
consistency in physician
prescribing and more stable
INRs among patients? Can you
show me the data?

Interview Subject: Hospital’s Chief Pharmacy Officer

Questions Correct Incorrect Follow-Up Comments or

Answer Answer Needed Notes
[14] How do you administer ✓
warfarin to inpatients?

[15] How do you administer ✓

heparin to inpatients?

[16] Please describe the kind of ✓

equipment you use and how you
monitor it. What safety
measures are in place to ensure
safe administration and dosing?
How do you ensure that your
INR and PTT results are
accurate?

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42
 SECTION 2

Tracer Scenarios for

AMBULATORY CARE
AND OFFICE-BASED SURGERY

NOTE: No Two Tracers Are the Same

Please keep in mind that each tracer is unique. There is no
way to know all of the questions that might be asked or
documents that might be reviewed during a tracer—nor
what all the responses to the questions and documents
might be. The possibilities are limitless, depending on the
tracer topic and the organization's circumstances. These
tracer scenarios and sample questions are provided as an
educational or training tool for organization staff; they are
not scripts for real or mock tracers.

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Section Elements
This section includes sample tracers—called scenarios—relevant to ambulatory care and office-based surgery. Individual,
system, and program-specific tracers are represented. The section is organized as follows:

Scenarios: Each scenario presents what might happen when a

surveyor conducts a specific type of tracer. The scenarios are
presented in an engaging narrative format in which the reader
“follows” the surveyor through the tracer scenario. Within the
narrative are bracketed numbers that correspond to numbered
sample tracer questions following the tracer.

Sample Tracer Questions: After each scenario narrative is a list

of sample questions a surveyor might ask during that scenario.
These questions can be used to develop and conduct mock tracers
in your organization on topics similar to those covered in the
scenario.

Sample Tracer Worksheet: At the end of the section is a sample

worksheet that shows how the sample tracer questions for one
select scenario in the section might be used in a worksheet format.
The example shows how the worksheet might be completed as
part of a tracer for that scenario. A blank form of the worksheet is
available in Appendix B.

44
 Section 2: Ambulatory Care and Office-Based Surgery
INDIVIDUAL
Tracer Scenarios
SCENARIO 2-1.
Ambulatory Surgery Center
Summary
In the following scenario, a surveyor traces an organization’s
process for ophthalmologic surgery. Within the tracer, the sur-
veyor explores issues relating to these priority focus areas:
• Assessment & Care/Services
• Infection Control
• Orientation & Training
• Patient Safety
Scenario
A surveyor conducted this individual patient tracer in an am-
bulatory surgical center that provided a variety of surgical ser-
vices, including ophthalmologic surgery. The surveyor selected
a 63-year-old female patient who had undergone cataract sur-
gery the day before.
(Bracketed numbers correlate to Sample Tracer Questions on pages
46–47.)
Visiting with Registration Staff. The surveyor began
her tracer in the reception/check-in/registration area by asking
the registration staff members what process they follow when a
new patient comes to the center for surgery. She also asked
what kinds of consent, education, and information are shared
with the patient. [1–3] The receptionist in the registration area
explained that the center contacts patients in advance of their
surgery to go over any questions they might have and instructs
them to bring in some documents they will receive in the mail
in advance of their surgery.
The surveyor asked to see how the registration staff docu-
mented this advance contact, and the receptionist showed
her the electronic medical record (EMR) and where it was
documented in the medical record. She also asked the recep-
tionist what steps are taken to ensure privacy for patients
when they are checking in. [4] The receptionist showed the
surveyor the sitting area in front of the check-in computer
desk, which was set a short distance away from the waiting
room and provided a quieter spot for the receptionist to
check in the patient. The surveyor then asked the reception-
ist what kind of orientation she received to do her job and
what ongoing training was provided. [5] The receptionist re-
sponded that because the ambulatory surgical center’s EMR
software was recently installed, all reception staff members
had undergone several in-service training sessions to learn
how to use it. The receptionist added that she attended bi-
monthly staff meetings at which she received in-service
training relating to patient safety and anything else the cen-
ter’s quality improvement specialist wanted staff to know.
Meeting with the Nurse in the Ophthalmology
Service. The surveyor then visited the ophthalmology service,
where the tracer patient had undergone surgery. She first met
with the nurse to ask how the service receives and assesses sur-
gical patients. [6] The nurse indicated that the patient had
come for a presurgical assessment a week earlier. The surveyor
asked to see the assessment form and for the nurse to indicate
what kind of documentation was included for the patient. [7]
The nurse showed the surveyor the physical assessment and
medication forms as well as the surgical informed consent
form.
The surveyor then checked the EMR to verify inclusion of the
documentation. Because the patient had been designated as di-
abetic, the surveyor asked the nurse to describe what kind of, if
any, additional assessments or documentation would need to
be collected for the patient. [8] The nurse said that the pa-
tient’s diabetes was flagged for anesthesia services’ attention,
and the patient had to undergo an additional blood screening
prior to surgery. The surveyor verified the orders and docu-
mentation on the EMR.
The surveyor then asked about what presurgical education was
provided to the patient, and the nurse showed the educational
material and the education checklist that the nurse completes
and asks the patient to sign in acknowledgement of receiving
the information. [9] The surveyor also asked the nurse to de-
scribe what kinds of competencies and ongoing training she
received for her job. [10]
Talking with the Anesthesiologist. The surveyor then
met with the surgical center’s anesthesiologist to discuss pre-
operative surgical preparation, including his understanding
of the Universal Protocol for Preventing Wrong Site, Wrong
Procedure, Wrong Person SurgeryTM and when it is con-
ducted, the presedation assessment, and the sedation con-
sent form. The surveyor also asked what the process was to
mark the site and who did it. [11–13] The anesthesiologist
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explained that he was very familiar with the Universal Proto-
col and that the entire team followed the Universal Protocol
after the patient had been prepped and before she under-
went sedation. While he did his presedation check, the anes-
thesiologist explained, he also had the patient verify the
correct eye for the procedure and complete the sedation
consent form. The surgeon, he explained, would usually
mark the site after the correct site was verified, though
sometimes the anesthesiologist had done it if the surgeon
was unavailable. These steps were documented on the
presurgical checklist, which the surveyor was able to verify
in the EMR.
Speaking with the Surgical Nurse. The surveyor
then visited the postsurgery recovery area where the patients
recover before being discharged. She met with one of the
surgical nurses there to ask her about her postsurgical assess-
ment process and in what kind of discharge planning she is
involved. [14–15] The surveyor noted that several patients
were recovering in the area, with family or companions sit-
ting in chairs near the patients’ beds. The nurse explained
that patients recover here with family or other designated
companions at the bedside until the surgeon comes to check
on them, and they are discharged after they have been pro-
vided with education and have fully recovered from sedation
or anesthesia. She explained that she conducts regular assess-
ments of patients by checking on their postsedation condi-
tion and their pain. She also explained her involvement in
discharge planning and education, which is provided to the
patients and family members throughout their stay in
recovery.
The surveyor asked what specific education is included and
what patient follow-up the surgical center undertakes.
[16–17] The nurse said that staff members provide educa-
tion to patients on preventing surgical site infections, post-
surgical care instructions, and contact information in case
they have any questions. The nurse added that the surgical
center does a phone follow-up 24 to 48 hours after the sur-
gery to see how the patient is recovering, and the surgeon
also schedules an office visit to follow up with the patient
and check on recovery.
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the topic of site marking and its docu-
mentation.
46
Scenario 2-1.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 2-1. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Registration Staff:
[1] What is your registration or check-in process?
[2] How do you document the registration? What
education and/or information do you provide to
patients upon check-in?
[3] What consent forms or education about informed
consent is shared?
[4] How do you ensure that the patient is able to
complete the registration process with as much
privacy as possible? What provision do you have in
the event that the patient requires additional
privacy?
[5] What kind of orientation and training do you receive
to do your job?
Ophthalmology Nurse:
[6] How are new patients checked into the service? Do
you perform any presurgical assessments of
patients? If so, what are they?
[7] What kind of documentation do you complete for a
surgical patient?
[8] If the patient presents with any high-risk factors,
such as diabetes, what additional assessments or
documentation, if any, do you perform?
[9] What kind of education do you provide to patients in
relation to the surgery, risk factors, and any
postsurgical care? Do you have any documentation
to accompany this process?
[10] What kinds of competency assessments and
ongoing training have you received in relation to
your job?
Anesthesiologist:
[11] What kind of education and process do you follow in
relation to the Universal Protocol? What is the
surgical center’s process?
 Section 2: Ambulatory Care and Office-Based Surgery
[12] Please describe your presedation or preanesthesia
assessment. Who performs this assessment?
[13] What is your sedation and operative consent
process? Can you show me the form you use?
Surgical Nurse:
[14] What type of postsurgical assessment do you
perform?
[15] What is your discharge planning process?
[16] What postoperative information, education, and
material do you provide to the patient?
[17] How do you follow up with surgical patients?
SCENARIO 2-2.
Office-Based Surgery Practice
Summary
In the following scenario, a surveyor traces how an office-
based surgery practice manages a patient’s return to surgery.
Within the tracer, the surveyor explores issues relating to these
priority focus areas:
• Assessment & Care/Services
• Communication
• Infection Control
• Patient Safety
Scenario
This tracer was conducted in an office-based surgery practice
that performed oral surgery. The surveyor selected a 31-year-
old female patient who was about to undergo a second surgery
to remove a displaced root from an extraction that took place
three months earlier. The surveyor began the tracer by review-
ing the record. He subsequently spoke with the oral surgeon,
the office manager, the nursing manager, and the patient.
(Bracketed numbers correlate to Sample Tracer Questions on page
48.)
Speaking with the Oral Surgeon. The surveyor asked the
oral surgeon to explain the unexpected outcome of the initial
procedure. [1] The surgeon explained that the patient had un-
dergone an extraction to remove a severely decayed upper molar,
but during the procedure, one root of the tooth was displaced
into the patient’s maxillary sinus. This issue was identified by the
surgeon after the tooth had been removed, and the surgeon com-
municated to the patient what the next steps should be.
The surveyor asked the surgeon to describe how he followed
up with the patient and what kinds of risks he communicated
in advance of this surgery. [2–4] The surgeon responded that
in advance of any surgery relating to upper molar extractions,
he does explain the risk of sinus exposure or perforation to pa-
tients, which he did and which was documented in the file.
After the surgeon saw the root on the x-ray, he explained to
the patient the options and prescribed antibiotics and decon-
gestants to help mitigate the chance of a sinus infection that
the patient might develop. The evening after surgery he also
phoned the patient at home to follow up on the options and
to check on her pain and answer any questions.
The surveyor then asked what the subsequent care and surgical
treatment was for the patient. [5] The surgeon explained that
the patient was scheduled for a sinus surgery within approxi-
mately four weeks after the original surgery. The aim was to
initially resolve any infection and then remove the root that
was displaced into the sinus.
The surveyor asked how the patient responded to the need for
additional surgery and how the surgeon’s decision to disclose
the risks and options had affected her. [6] The surgeon replied
that although the patient was anxious about an additional sur-
gical procedure, she appeared to understand the need and was
also eager to resolve the situation.
Talking with the Office Manager. The surveyor then
spoke with the office manager about the process of admission
and follow-up, particularly in the case of a patient who re-
quires subsequent surgery. [7] The office manager explained
that after the need for an additional surgery was determined,
the patient was scheduled, following the same presurgical
process and assessment that was done for the initial surgery.
Conferring with the Nursing Manager. The surveyor
then asked the nursing manager what kind of assessment and
patient education was provided. [8] The nursing manager said
that the staff provided the same consent forms and education
materials, along with additional instructions on postdischarge
recovery.
Speaking with the Patient. The surveyor then asked
permission to speak with the patient, who was about to un-
dergo the surgery. He asked the patient what her experience
had been and how she believed the surgeon had handled her
situation in relation to the unexpected outcome. He also
wanted to know if the patient thought she had had all of her
questions answered. [9–10] The patient responded that she
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had been satisfied with the way that the surgeon disclosed the
unexpected outcome to her and had been regularly updating
her; she also said that she was able to get responses to her ques-
tions. She added that the practice provided good pain manage-
ment. The surveyor asked the patient whether she remembered
having the risks of this type of surgery disclosed to her, to
which the patient said yes. [11]
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the topics of informed consent and pa-
tient education.
Scenario 2-2.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 2-2. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Oral Surgeon:
[1] Would you please explain the case of an
unexpected outcome in a surgery that resulted in
another surgery?
[2] What kinds of risks related to this type of surgery did
you communicate to the patient?
[3] What process do you have to answer any patient
questions?
[4] When there is an unanticipated outcome, how do
you communicate it?
[5] What type of follow-up do you do for this type of
situation?
[6] How has the patient responded to the unexpected
outcome? What is your process for communicating
with the patient?
Office Manager:
[7] What is your process of admission and presurgical
evaluation process?
Nursing Manager:
[8] What kind of education do you provide to the patient
regarding home care and infection prevention?
48
Patient:
[9] Have your questions regarding this unanticipated
outcome been answered to your satisfaction?
[10] Have you felt well informed on the situation
throughout the process?
[11] Did you recall having all of the risks relating to the
original surgery disclosed? How about with this
surgery?
SYSTEM
Tracer Scenarios
SCENARIO 2-3.
Ambulatory Surgery Center
Summary
In the following scenario, a surveyor traces how an organiza-
tion uses data. Within the tracer, the surveyor explores issues
relating to these priority focus areas:
• Information Management
• Orientation & Training
• Patient Safety
• Quality Improvement Expertise/Activities
Scenario
This tracer was conducted in a general ambulatory surgery
center that included orthopedic surgery services, eye surgery,
and general surgery. The surveyor conducted this tracer as a
group discussion to explore the surgery center’s data use prac-
tices. He met with the medical director, the quality improve-
ment specialist, the center’s pharmacy consultant, and a nurse
who was a staff representative to the performance improve-
ment committee.
(Bracketed numbers correlate to Sample Tracer Questions on pages
49–50.)
Overview of Data Use Practices with the Medical
Director. The surveyor began the discussion by asking the
medical director who had responsibility for quality improve-
ment activity and what oversight was provided at the surgery
center. [1–4] The medical director explained that the center
had one specialist on staff who had responsibility for quality
 Section 2: Ambulatory Care and Office-Based Surgery
improvement and patient safety and that there was a perform-
ance improvement committee that met periodically to provide
oversight and planning input into data use management and
improvement initiatives. The director added that the ambula-
tory surgery center had expanded over the past year when it
added eye surgery to its services, so the center’s leadership was
considering expanding the staff.
Talking with the Quality Improvement Specialist.
The surveyor asked the quality improvement specialist what
kind of training she received for her job, whether competency
was assessed, and what methods she was trained to use in rela-
tion to data collection and analysis. [5–9] The specialist ex-
plained that she was hired into this role three years earlier and
had had previous work experience in a quality improvement
role at another ambulatory care organization. She added that
she had been using basic spreadsheet software to enter data
and used it to manually analyze and monitor the results, a task
that had become increasingly challenging considering the in-
crease in the amount of data she now had to handle. She noted
that the center leadership had recently decided to invest in
custom-designed software to help facilitate a more efficient
electronic analysis and aggregation of data.
The surveyor asked what the plan was to install the software and
train staff on its use and what interim contingency measures the
center was putting in place in the event that the software had
technical problems. [10–11] The quality improvement specialist
indicated that the software company had involved her in beta
testing the software and that it was having a number of training
sessions both before and after the software went live. The team
hoped that this testing would help ensure a smoother transition
to using the software and making use of the data.
Discussing a Performance Initiative with the Tracer
Team. The surveyor asked the group to describe any recent im-
provement initiatives that the surgery center had implemented
based on its data use activities. [12] The quality improvement
specialist mentioned an ongoing improvement effort to improve
the labeling of medications for use during surgeries. The surveyor
wanted to explore the origination of the initiative, the process of
design, who was involved in the project, and what data practices
were currently in place to monitor improvement and track re-
sults. [13–17] According to the pharmacy consultant, it was dis-
covered a year earlier that there had been some inconsistent
handling and storage of medications for surgery. Although the
surgery center had not experienced an adverse medication event,
it had noted a number of close calls, or near misses, related to
staff members placing certain similarly named drugs in too close
proximity. The staff nurse added that as a result of staff reporting
close calls and the performance improvement team noticing a
trend of several close calls being reported over a three-month pe-
riod, the surgery center opted to prioritize this issue as an im-
provement project. The surveyor asked to review the data
collected and the results of analysis of data leading to the per-
formance improvement activities. The surveyor also asked the
tracer team about the methodology for ongoing monitoring and
data collection, frequency of collection, population and sample
size, and threshold for improvement.
The performance improvement team first conducted a risk as-
sessment and a focused tour of the operating suite and re-
viewed the most commonly identified medications involved in
these close calls. They noticed that certain medications were
being stored in the wrong bins and that the labeling of the
medications was not distinctive enough. The team immedi-
ately instituted a number of changes to the physical environ-
ment that helped the operating room staff better visually and
physically differentiate between the medications. The phar-
macy consultant also held a series of in-services with staff to
explain the changes in the operating room. The team now does
periodic walking tours of the surgical suite to check on the
medication location and labeling. A monthly tracking of close-
call or adverse medication event reports has shown a signifi-
cant drop in such events since the changes were implemented.
The performance improvement team planned to continue
monitoring progress for the next few months. The surveyor
asked the tracer team to identify the threshold for improve-
ment after monitoring the monthly collection of data.
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the topics of data use, data analysis,
sample size and threshold for improvement, staff education,
and medication labeling and storage.
Scenario 2-3.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 2-3. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
(continued)
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Scenario 2-3.
Sample Tracer Questions
(continued)
Medical Director:
[1] How do you structure your data use activities?
[2] Who has responsibility for data use management?
Who has oversight?
[3] What reporting processes do you follow?
[4] In the event of organization expansion, what planning
processes does leadership have in place related to
data management?
Quality Improvement Specialist:
[5] What kind of training and education are provided for
staff responsible for data management? How do you
structure staff responsibility?
[6] How do you track data? What do you collect? How is
it aggregated and analyzed?
[7] How do you input data?
[8] How do you manage data?
[9] How often do you update and review the data?
[10] If you are using a software tool, what contingency
plan do you have in place in the event of a problem
with the software?
[11] How do you plan for implementation of a new
software process and determine the most appropriate
software and training for your organization? What
proactive performance activities did you utilize prior to
implementation? What contingency plan do you have
in place in the event of a problem with the software
during the transition or after its implementation?
Tracer Team:
[12] What improvement initiatives are you currently
involved in?
[13] How did you prioritize this initiative? What data led
you to launch the improvement project?
[14] Who has been involved in designing and
implementing this improvement project?
[15] What improvements did you put in place?
[16] How did you familiarize staff members with this
change? How did you secure their engagement in the
effort?
[17] How are you maintaining the improvements from the
initiative and monitoring its results?
50
SCENARIO 2-4.
Office-Based Surgery Practice
Summary
In the following scenario, a surveyor traces how an organiza-
tion uses data. Within the tracer, the surveyor explores issues
relating to these priority focus areas:
• Communication
• Organizational Structure
• Orientation & Training
• Quality Improvement Expertise/Activities
Scenario
The surveyor conducted this tracer in an office-based surgery
practice that performed gastrointestinal procedures. The sur-
veyor met with the practice’s owner/surgeon and nursing man-
ager who also had responsibility for quality improvement in
the practice.
(Bracketed numbers correlate to Sample Tracer Questions on page
51.)
Discussing Data Use with the Surgeon and the
Nursing Manager. The surveyor asked the surgeon and the
nursing manager to describe their method of data collection
for the practice and how they analyze and utilize the data.
[1–4] The nursing manager said that she had primary respon-
sibility for collecting data on certain key areas such as post-
surgical follow-up, sedation and anesthesia, patient education,
and infection rates; she added that the practice selects certain
data collection and analysis approaches based on the emer-
gence of certain trends, such as an increase in certain types of
procedures, and based on the type of data needed.
The nursing manager explained that she uses spreadsheet and
database software to enter the data on a regular basis and then
focuses on aggregating and analyzing the data, with the support
of other leadership during monthly leadership meetings. The
surveyor asked what the practice does with the data it analyzes.
[5–6] The nursing manager pointed out a recent example in
which the practice had tracked an inconsistency in postopera-
tive follow-up calls. When the nursing manager analyzed the
data, she discovered that due to a recent change in staffing du-
ties, the responsibility for making patient phone calls was not
being consistently handled—certain staff members mistakenly
believed that other staff members were responsible for follow-
ing up. The practice held an in-service with staff to reinforce
roles and responsibilities and recirculated the revised procedure
 Section 2: Ambulatory Care and Office-Based Surgery

for staff. The surveyor asked what the outcome of the interven-
tion had been. [7] The nursing manager noted that within a Surgeon and Nursing Manager:
month, there was a significant improvement in follow-up calls, [1]
with a 100% follow-up rate as compared to an 80% follow-up
[2]
rate the month before the intervention.
[3]
Asking About Staff Training and Education. The [4]
surveyor asked the team what type of education and training
on data use management is provided to staff members with
[5]
quality improvement responsibility. [8–9] The surgeon said
that several years earlier, the role of the surgery practice’s nurs- [6]
ing manager was expanded to include data use and analysis. As
a result, the practice provided additional training and support
to the nursing manager so she could assume this new element [7]
of her role. The nursing manager said that in addition to at-
tending ongoing training, she was a member of a national as-
sociation focused on performance improvement and used the
association’s Web site and online training seminars to enhance [8]
her knowledge as she could.
What is your data use process?
What types of data do you collect?
What is your method to collect and analyze data?
Who has responsibility for data collection in your
organization?
What do you do with your data?
Will you please give an example of a performance
improvement activity you undertook based on data
analysis?
How did you monitor and track the outcome of this
performance improvement activity? What was the
outcome?
What type of education and training do you provide
for staff with responsibility for data use and
management?

Discussing Data Collection on Frequent Procedures.
The surveyor asked the surgeon to name one of the practice’s
frequent procedures, to which the surgeon replied incisional
hernia repair surgery. [10] The surveyor asked the team mem-
bers to give an example of data they have selected to collect to
study in relation to surgery. [11–12] The nursing manager ex-
plained that the practice had noticed a higher than expected
number of patients having been referred to the practice for in-
cisional hernia repair surgeries. The surveyor asked if the prac-
tice was reporting or acting on these data, and the nursing
manager replied that the practice did communicate incisional
hernia repair surgery rates to surgeons. [13–14]
[9] What continuing education or resources do you
have access to that will support your development in
this area?
[10] What are some frequent procedures performed by
your organization?
[11] What data do you collect in relation to them? What
type of analysis have you performed?
[12] What type of outcome has an analysis of these data
provided?
[13] Will you act on these data? If so, what kind of follow-
up will you undertake?

Moving Forward. Based on the tracer, the surveyor may [14] How do you share these data?
discuss areas of improvement in the Daily Briefing. The discus-
sion might address the topics of data use and staff education.

SCENARIO 2-5.
Scenario 2-4. Urgent Care Center
Sample Tracer Questions
Summary
The bracketed numbers before each question correlate to In the following scenario, a surveyor traces how an organiza-
questions, observations, and data review described in the
tion addresses infection prevention and control. Within the
sample tracer for Scenario 2-4. You can use the tracer
tracer, the surveyor explores issues relating to these priority
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the focus areas:
end of this section). The information gained by conducting • Assessment & Care/Services
a mock tracer can help to highlight a good practice and/or • Infection Control
determine issues that may require further follow-up. • Patient Safety
• Physical Environment

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Scenario
This tracer was conducted in a busy urgent care center, located
in a low-income neighborhood in a large East Coast city. The
surveyor conducted this system tracer with the urgent care cen-
ter’s medical director and the nursing manager who also had
oversight responsibility for the center’s infection control plan.
(Bracketed numbers correlate to Sample Tracer Questions on page
53.)
Tracing Infection Control Practices with the Med-
ical Director and the Nursing Manager. The surveyor
first asked the medical director and the nursing manager to ex-
plain what kinds of infection control–related data they collect
and analyze in an ongoing manner. She also asked what their
infection risk assessment was and whether that assessment in-
fluenced their data collection. [1–4] The nursing manager said
that in general they track vaccinations and staff exposure, hand
hygiene surveillance data, infectious patients, and safe disposal
of sharps. She continued that she analyzes the data for negative
trends, for example, if the previous month’s hand hygiene sur-
veillance data showed a lower compliance rate than the bench-
mark or the month preceding.
The surveyor asked who receives the infection control–related
data reports and at what frequency. [5] The nursing manager
responded that she produces a report each quarter and it circu-
lates to the center’s leadership.
Talking About Training. The surveyor then asked the
nursing manager to explain her professional training and expe-
rience with infection control, and she replied that she had
been in this role for several years but had no prior specific ex-
perience beyond what all nurses are expected to know. [6] She
had received on-the-job training and attended local chapter
meetings and courses offered by the national association con-
cerning infection control.
Monitoring the Physical Environment. During an
earlier individual tracer, the surveyor had observed a number
of issues that she wanted to raise during the discussion. For in-
stance, when she went to the rest room, she noticed that the
wastebasket was overflowing. She asked whether there was any
staff member designated to monitor the physical environment
for potential infection control issues. [7–8] The nursing man-
ager indicated that although it was her overall responsibility,
she had not had time to do a thorough check on the facility
because her other duties took up too much time. Housekeep-
ing did have responsibility for cleanup, but housekeeping staff
52
members came to the facility only in the evenings. The sur-
veyor recommended that the nursing manager and leadership
discuss enlisting additional staff to help monitor the physical
environment; one possibility, the surveyor noted, was using a
premade checklist to help staff members easily identify and
quickly address any potential issues. The surveyor also sug-
gested reconsidering when to have housekeeping staff mem-
bers come in; having them arrive during the day could be an
effective way to engage more staff into mitigating any poten-
tial infection control issues. [9]
Separating Healthy and Sick Patients. In addition,
the surveyor had observed that the waiting area in the center
did not have any designated sitting areas for sick versus healthy
patients, and the medical director acknowledged the fact that
the waiting area did not have any physical separation between
healthy and sick patients and said the center would consider a
way to use signage or a superficial physical barrier to designate
the areas more effectively. [10]
Discussing Disinfecting Toys. The surveyor asked the
nursing manager how often the staff members cleaned the toys
in the waiting area and whether they were aware that there
were some soft toys in the toy box. The nursing manager said
she was unaware of any soft toys, which were against the cen-
ter’s policy. She did say that the center’s policy was to clean the
toys on a regular basis. The surveyor questioned the schedule
for “regular” and documentation that the cleaning had been
performed. She asked what products are used for disinfection
of toys in general and when a patient has been identified as
posing a high risk of infection. [11]
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the topic of infection control, particu-
larly as it relates to the physical environment.
Scenario 2-5.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 2-5. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
 Section 2: Ambulatory Care and Office-Based Surgery
Medical Director and Nursing Manager:
[1] What are your infection control practices in the
center?
[2] Who is responsible for the infection control plan?
How often do you review it?
[3] What kinds of data do you collect relating to
infection control?
[4] What method do you use to analyze the data?
[5] Who receives infection control–related reports? How
often are these reports generated? What is in the
reports?
[6] What kind of training and experience does the staff
member responsible for infection control have?
What kind of ongoing training does this person
receive? How does he or she gain access to
resources?
[7] How often do you tour your physical environment for
infection control–related issues?
[8] How do you report and evaluate an infection
control–related improvement?
[9] How well trained are housekeeping staff members
on infection control practices? How do you
communicate center procedure to them?
[10] What kind of process do you have to separate
potentially infectious patients? How are they
segregated?
[11] How often do you clean the toys in the waiting
room? How is this cleaning documented? What
products are used for disinfection of toys in general
and when a patient has been identified as posing a
high risk of infection?
SCENARIO 2-6.
Community Health Center
Summary
In the following scenario, a surveyor traces how an organiza-
tion controls infection. Within the tracer, the surveyor ex-
plores issues relating to these priority focus areas:
• Communication
• Infection Control
• Orientation & Training
• Patient Safety
Scenario
The surveyor conducted this infection control system tracer in
a community-based primary health care center. A physician at
this center acted as the facility’s director of infection preven-
tion and control. A nurse with prior experience as an infection
control coordinator in a community hospital also worked on
the staff and comanaged the infection prevention and control
program at this facility with the physician director of infection
control.
(Bracketed numbers correlate to Sample Tracer Questions on page
54.)
Overview of Infection Control Activities with the
Physician and the Nurse. The surveyor met with the physi-
cian and the nurse who together managed the center’s infec-
tion control program. [1] In response to his question regarding
the structure of the center’s infection control program, they ex-
plained that there was no infection control committee but that
they communicated necessary information regarding infection
control needs and activities to other physicians and staff in the
primary health care center and collected data as needed.
Exploring Program and Roles. The surveyor asked the
physician and the nurse to explain the focus of the infection
control program infection risk assessment and to each describe
their roles in coordinating and managing the infection control
program. [2–3] The nurse responded that she had coordinated
the infection control program at a small hospital before joining
the staff of this center and that she had training and certifica-
tion in infection control. The physician stated that he was a
specialist in internal medicine, not epidemiology. However, he
added, he had previous training and experience in infection
control and was currently a member of an infection control
committee at a community-based hospital. The nurse and the
physician said that they met once a week to discuss potential
infection control risks, and the nurse said she collected data on
known infectious disease risks and outbreaks. They also identi-
fied preventive infection control activities to implement at the
health center. [4–7]
Identifying Infection Control Risks and Data
Analysis. The surveyor asked the two professionals to identify
the greatest infection control issues that they currently consid-
ered risks to the population served by the health center. She
also asked them to identify any indicators or studies in which
they currently collected data. [8–9] They explained that they
monitored for hand hygiene and that this was a main focus for
the prevention of the spread of infection. They also focused on
53
More Mock Tracers
potential exposures via accidental sharps injuries and handling
potentially infectious body fluids. The surveyor asked whether
they were able to perform data analysis and studies for identi-
fied challenges. [10–12] They said that they used national
guidelines and information to direct the focus of their activi-
ties and provided periodic education programs for staff.
The surveyor asked the physician and the nurse if they had
data and analysis regarding staff compliance with hand hy-
giene requirements. She also asked them how they measured
compliance and whether they believed that their measurement
and intervention strategies were effective. [13]
Speaking with Staff in Patient Areas. After the formal
meeting and review, the surveyor visited some of the patient
care areas to observe infection control activities and to inter-
view staff members regarding their knowledge of risks and re-
quired prevention activities. [14–15] She also asked staff
members how they protected staff, patients, and others from
potential exposures to patients and family members who come
to the facility with fever and potentially contagious respiratory
or other diseases. [16–17]
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the topics of staff education and hand
hygiene.
Scenario 2-6.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 2-6. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Physician and Nurse:
[1] How do you structure responsibility for infection
control in your organization?
[2] What is the focus of your infection control program?
[3] What roles do you fulfill?
[4] What background do you bring to your infection
control work?
54
[5] How often do you meet relating to infection control
issues?
[6] What process do you use for data management?
[7] How do you select preventive infection control
activities?
[8] What have you identified as your greatest infection
risks?
[9] What indicators or studies do you use to identify
data to collect?
[10] What data analysis do you perform? What methods
do you use?
[11] Do you use any guidelines or studies to help
structure your work?
[12] What kind of education and training do you provide
to staff?
[13] How do you measure staff compliance with hand
hygiene? How effective are your intervention
strategies and measurement? Are you following the
guidelines from the U.S. Centers for Disease Control
and Prevention or the World Health Organization?
Staff:
[14] What kinds of infection control practices are you
taught about?
[15] Can you tell me what the center’s hand hygiene
policy is?
[16] How do you protect yourself and others from potential
exposure to infectious patients and family members?
[17] What do you do when you suspect that a patient or
family member at the center has an infectious
condition?
SCENARIO 2-7.
Family Practice Primary Care Facility
Summary
In the following scenario, a surveyor traces how an organiza-
tion manages medications. Within the tracer, the surveyor ex-
plores issues relating to these priority focus areas:
• Communication
• Infection Control
• Orientation & Training
• Patient Safety
 Section 2: Ambulatory Care and Office-Based Surgery
Scenario
The surveyor conducted this medication management
system tracer at a family practice primary care center. He
asked the nursing coordinator and a physician involved in
oversight of medication management to participate in the
discussion.
(Bracketed numbers correlate to Sample Tracer Questions on
page 56.)
Overview of Medication Management Practices
with the Physician and the Nursing Coordinator. The
surveyor asked the nursing coordinator and the physician to
explain the medication management process in the center.
[1–2] The surveyor also asked them to indicate the high-risk
areas they had identified in their medication management
process. [3] They said that poor patient compliance was the
most common and most serious risk. When the surveyor
asked whether they had collected any data on this issue, they
said it was impossible to monitor but that physicians were in
full agreement that it is a serious problem. The nursing co-
ordinator added that the common practice of giving patients
sample medications without written instructions from the
pharmacist may make the problem worse.
The surveyor then asked the nursing coordinator and the
physician what background they had and what training they
received to handle medication management oversight. [4–6]
The nursing coordinator mentioned that she had not had
much training, and she said her role was regarded as more of
an administrative oversight duty, while the physicians took
most of the responsibility for clinical oversight of the pro-
gram. The physician said that the practice leadership met
periodically to discuss medication management issues.
Discussing High-Alert Medication Practices with
the Nursing Coordinator. The surveyor asked the nursing
coordinator how the center had determined which were the
high-alert medications and look-alike/sound-alike medica-
tions and how these medications were stored and labeled.
[7–10] The nursing coordinator said the pairs had been se-
lected and were reviewed at least annually and that they
were labeled and identified in the storage room. The sur-
veyor added that when he conducted individual patient trac-
ers, he also observed medication storage in the emergency
cart outside the medication storage room. He asked the
nursing coordinator whether the support staff members were
generally aware of the identified high-alert medications or
which look-alike/sound-alike pairs of medications had been
selected. The nursing coordinator said that the emergency
medications were to be used only in serious patient emer-
gencies and, in these situations, the staff simply had to ad-
minister what the physician ordered. Otherwise, these
medications were all supposed to be stored in the medica-
tion storage room only. Therefore, no education on this
topic had been given to the staff.
The surveyor asked to visit the medication storage room in
the facility. [11] The high-alert sample medications were
clearly identified with colored labels. There was also green
fluorescent labeling on the shelves, and there were boxes for
look-alike/sound-alike medications. The nursing coordina-
tor said that special labeling was done only in the medica-
tion storage room, and only the nursing and medical staff
had access to the room. When the surveyor checked the
storage boxes, he noticed that some of them actually con-
tained other medications that were not identified on the
boxes. [12] The nursing coordinator said that she wanted to
get another storage system but was informed that the budget
did not allow such an expenditure.
Talking with the Nurse in the Vaccination
Administration Area. The surveyor also observed the vac-
cination administration area. [13–15] He saw that boxes of
vaccines were stored in a refrigerator that had a thermometer
inside. The surveyor asked how the center ensured that the
temperature in the refrigerator maintained the manufac-
turer’s recommended temperature during off-hours and on
days that the center was closed. He asked how staff members
know what the temperature was when they come in at the
beginning of the day or the day after the center was closed.
As he peered inside the refrigerator, the surveyor noticed
bottles of drinking water. The nurse in charge of vaccina-
tions said she knew that policy required food items to be
stored separately from medication storage areas, but she be-
lieved that water was not food, and there was only the one
refrigerator. The surveyor observed boxes of injection nee-
dles stored directly on the floor. [16] The nurse said that she
knew this location was not acceptable, but the center needed
more space and more shelves.
Moving Forward. Based on the tracer, the surveyor
may discuss areas of improvement in the Daily Briefing. The
discussion might address the topics of medication storage
and the scheduling of team meetings about medication
management.
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More Mock Tracers
Scenario 2-7.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 2-7. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Physician and Nursing Coordinator:
[1] What is your medication management process?
[2] Who has responsibility for medication management?
[3] What are the high-risk areas you have identified in
your medication management process? How have
you identified them?
[4] What kind of background and training have you
received to help you perform duties related to
medication management oversight?
[5] Do you receive any ongoing training and access to
resources?
[6] How often does the organization arrange time to
discuss medication management issues?
Nursing Coordinator:
[7] What are the high-alert medications and look-alike/
sound-alike medications you keep in the center?
[8] Where are they stored? Where are they labeled?
How do you ensure that the storage area is secure
and that the correct temperature is maintained in the
medication refrigerator? What are your processes to
protect medications in the case of loss of electricity?
What do you do if the medication refrigerator
temperature was not maintained?
[9] What training and information do you share with
staff about these types of medications?
[10] What do you do in the event of a medication error?
Do you have a culture of safety that promotes
reporting of medication errors?
[11] Please show me where you store medications. What
is your process for their safe storage? What
labeling, if any, do you use?
[12] How do you make sure that medications are not
placed in the wrong locations? How do you monitor
for proper placement?
56
Nurse:
[13] Where do you administer vaccinations?
[14] Where do you store the vaccines?
[15] What is the practice’s policy on safely storing vaccines?
What else is allowed in the refrigerators?
[16] Where do you store your supplies? What do you do
if you do not have enough space to store all of your
supplies?
PROGRAM-
SPECIFIC
Tracer Scenario
SCENARIO 2-8.
Ambulatory Care Organization
Summary
In the following scenario, a surveyor traces how an organiza-
tion maintains continuity of care. Within the tracer, the sur-
veyor explores issues relating to these priority focus areas:
• Assessment & Care/Services
• Communication
• Organizational Structure
• Patient Safety
Scenario
This tracer took place in a large ambulatory care organization.
The surveyor selected a 68-year-old male patient who had
been coming to this facility for the past five years. The patient
had been generally healthy but over the past three months had
come in multiple times with complaints of general malaise,
weight loss, and difficulty sleeping. He had also complained of
shortness of breath and was last seen in the facility approxi-
mately one week prior.
On the morning of the survey, the patient arrived at the orga-
nization experiencing discomfort while breathing. After check-
ing in at the registration desk and then waiting in the waiting
room for his turn to be seen, he was then called into the exam-
ination room by the nurse. The nurse set him up in the room.
The physician who had been seeing him over the past few vis-
its then examined the patient and found him to be in moder-
ate respiratory distress. The physician had planned to take a
chest x-ray that day and to potentially request referral to a
 Section 2: Ambulatory Care and Office-Based Surgery
pulmonologist if the patient’s condition did not improve; but
based on the patient’s presenting condition at the time of this
visit, he decided instead to immediately transfer him to a
nearby hospital emergency department via emergency vehicle.
When the surveyor started this tracer activity, the patient had
already been picked up from the ambulatory care organization
by the ambulance and was en route to the hospital.
(Bracketed numbers correlate to Sample Tracer Questions on pages
57–58.)
Discussing the Case with the Physician. The sur-
veyor met with the physician and asked him to give him a
summary of the care of the patient and to review the pa-
tient’s medical record with him. [1] The physician explained
that he had been doing blood work on the patient during
the prior visit and that he had planned on doing a chest x-
ray at this visit and requesting a pulmonology consultation
if the symptoms did not improve. He said that he suspected
chronic obstructive pulmonary disease, but he first wanted
to rule out lung cancer. The patient had been smoking one
to two packs of cigarettes each day for many years. [2] The
surveyor reviewed the progress notes and assessment infor-
mation in the patient record. The physician said that he did
not send a transfer note with the patient to the hospital. [3]
Instead, he gave a verbal report to the ambulance personnel.
He said that he also had privileges in the hospital where the
patient was being transported and would provide additional
information to the hospital upon request. The surveyor
asked if the patient’s current medication list was forwarded
to the emergency department. The physician said he did not
think that was necessary because he was going to the hospi-
tal and could provide the information in person when he
arrived. [4–6]
Interviewing the Nurse. The surveyor spoke to the
nurse and asked her whether any education had been provided
to the patient. [7–8] She said that in the past he had been
given a brochure on smoking cessation but that no one on
staff had actually met with him to review the information in
the brochure. She was sure the physician had advised him to
quit smoking. There was no documented evidence in the pa-
tient’s record of such a discussion or that the brochure had
been given to the patient.
Speaking to the Registration Clerk. The surveyor met
with the registration clerk and asked her if the patient had told
her when he arrived of his discomfort in breathing or if she
noticed whether he was having difficulty breathing. [9–10]
The surveyor asked her if it was a policy to register patients
and to get them seen more quickly if they appeared to be in
any kind of distress. She said that she did not notice that he
was in distress and that he sat in the waiting room with his
sons until it was his turn to be seen. The surveyor asked the
registration clerk if she had any training or education in recog-
nizing a patient in respiratory distress. [11] She said that she
had gone through the standard orientation for her position
when she began her job. The surveyor asked the registration
clerk how long the patient waited to be seen. [12] She said she
did not recall. Looking at the log, it appeared that he waited
about 30 minutes before being called into the examination
room by the nurse.
Prior to meeting with the physician, the surveyor observed
him talking to the patient’s sons, who were still in the wait-
ing room, about the patient’s condition and transfer to the
hospital. Many other patients and families were present in
the area.
Talking with the Family Members. Because the pa-
tient’s sons were still at the ambulatory care organization, the
surveyor asked if he could talk with them in private. They
agreed and met with him in a small private office area.
[13–14] They told him that they were very happy with the
care their father had received at this facility and that they
trusted the doctor who was caring for him. They said that they
had reviewed the educational brochure about not smoking
with their father but that he did not seem to pay any attention
to the information.
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the topics of patient triage, education,
and wait times.
Scenario 2-8.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 2-8. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
(continued)
57
More Mock Tracers
Scenario 2-8.
Sample Tracer Questions
(continued)
Physician:
[1] Please describe the care of this patient. How
responsive was the patient to the care? What kind of
tests and additional referrals did you order?
[2] What do you document on the patient record?
[3] How did you refer the patient to the hospital? What
information have you communicated to the hospital?
How was this information communicated?
[4] What is your process regarding transferring a
patient to a higher level of care? What is to be
communicated to the next provider of care? What is
your process and policy on calling 911–EMS
(emergency medical services) system and/or a
private ambulance?
[5] What is your organization’s emergency response?
Do you have training in resuscitation? What
emergency equipment and training are available?
Are the emergency equipment, medications, and
supplies secure and not expired?
[6] Do you honor advance directives?
58
Nurse:
[7] What kind of education have you provided to the
patient?
[8] Where would this education be documented in the
record?
Registration Clerk:
[9] What happens when a patient arrives at the
organization?
[10] What do you do if you notice the patient is showing
signs of illness or distress?
[11] What training or education have you had in
recognizing signs of illness or distress?
[12] How long did this patient wait to be seen? What is
your policy for delays in wait time? What do you do
if you do not think the patient can wait?
Family Members:
[13] What is your experience of care at the organization?
[14] Has your relative responded to any educational
material provided?
 Section 2: Ambulatory Care and Office-Based Surgery

Sample Tracer Worksheet: Scenario 2-5.

The worksheet below is an example of how organizations can A correct answer is an appropriate answer that meets the re-
use the sample tracer questions for Scenario 2-5 in a worksheet quirements of the organization and other governing bodies.
format during a mock tracer. The bracketed numbers before An incorrect answer should always include recommendations
each question correlate to questions described in the scenario. for follow-up.

Tracer Team Member(s): Lydia Grammarri Data Record(s):

Subjects Interviewed: Joseph Barnes, Heather Unit(s) or Department(s): urgent care center
Henrikson
Tracer Topic or Care Recipient: infection control

Interview Subject: Medical Director and Nursing Manager

Questions Correct Incorrect Follow-Up Comments or

Answer Answer Needed Notes
[1] What are your infection ✓ Staff answered
control practices in the center? appropriately.

[2] Who is responsible for the ✓ Need more frequent Not reviewed since plan
infection control plan? How review. was drafted.
often do you review it?

[3] What kinds of data do you ✓ Good evidence of

collect relating to infection knowledge.
control?

[4] What method do you use to ✓ May need more Good examples of methods
analyze the data? emphasis on follow-up used.
on data use.
[5] Who receives infection ✓
control–related reports? How
often are these reports
generated? What is in the
reports?

[6] What kind of training and ✓ More training may need Inconsistent answers.
experience does the staff to be provided.
member responsible for
infection control have? What
kind of ongoing training does
this person receive? How does
he or she gain access to
resources?

(continued)
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Interview Subject: Medical Director and Nursing Manager (continued)

Questions Correct Incorrect Follow-Up Comments or

Answer Answer Needed Notes
[7] How often do you tour your ✓
physical environment for
infection control–related issues?

[8] How do you report and ✓ IC staff members need to No clear evidence of
evaluate an infection control– clarify reporting reporting process.
related improvement? process.
[9] How well trained are ✓ Schedule additional No orientation for new
housekeeping staff members on trainings. housekeeping staff on IC
infection control practices? How practices.
do you communicate center
procedure to them?

[10] What kind of process do ✓ Need to determine a way No physical separation of

you have to separate potentially to segregate potentially sick patients from healthy
infectious patients? How are infectious patients. ones in waiting room.
they segregated?

[11] How often do you clean the ✓ IC staff members need to Nursing manager unaware
toys in the waiting room? How is pay closer attention to that toy box contained soft
this cleaning documented? appropriate selection, toys, which are against
What products are used for cleaning, and center’s policy. Said toys
disinfection of toys in general disinfection of toys. cleaned on “regular” basis
and when a patient has been but not specific how often.
identified as posing a high risk
of infection?

60

Tracer Scenarios for
BEHAVIORAL HEALTH CARE
NOTE: No Two Tracers Are the Same
Please keep in mind that each tracer is unique. There is no
way to know all of the questions that might be asked or
documents that might be reviewed during a tracer—nor
what all the responses to the questions and documents
might be. The possibilities are limitless, depending on the
SECTION 3
tracer topic and the organization's circumstances. These
tracer scenarios and sample questions are provided as an
educational or training tool for organization staff; they are
not scripts for real or mock tracers.
61
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Section Elements
This section includes sample tracers—called scenarios—relevant to behavioral health care. Individual, system, and program-
specific tracers are represented. The section is organized as follows:

Scenarios: Each scenario presents what might happen when a

surveyor conducts a specific type of tracer. The scenarios are
presented in an engaging narrative format in which the reader
“follows” the surveyor through the tracer scenario. Within the
narrative are bracketed numbers that correspond to numbered
sample tracer questions following the tracer.

Sample Tracer Questions: After each scenario narrative is a list

of sample questions a surveyor might ask during that scenario.
These questions can be used to develop and conduct mock tracers
in your organization on topics similar to those covered in the
scenario.

Sample Tracer Worksheet: At the end of the section is a sample

worksheet that shows how the sample tracer questions for one
select scenario in the section might be used in a worksheet format.
The example shows how the worksheet might be completed as
part of a tracer for that scenario. A blank form of the worksheet is
available in Appendix B.

62

INDIVIDUAL
Tracer Scenario
SCENARIO 3-1.
24-Hour Therapeutic School
Summary
In the following scenario, a surveyor traces how an organiza-
tion works with a young individual in a 24-hour therapeutic
school. Within the tracer, the surveyor explores issues relating
to these priority focus areas:
• Screening, Assessment & Care, Treatment, and Services
• Communication
• Medication Management
• Orientation & Training
• Individual Served Safety
Scenario
This tracer was conducted in a 24-hour therapeutic boarding
school that provided education and care, treatment, and ser-
vices to a youth-aged population. The surveyor chose to trace a
14-year-old male. He had been diagnosed with attention
deficit hyperactivity disorder (ADHD) and had arrived at the
school several months earlier. He received individual and
group therapy and was participating in the school’s life skills
activities and extracurricular activities. When the surveyor re-
viewed the youth’s clinical record, she learned that he had re-
cently been acting out physically and sexually toward staff and
other youth in the facility.
(Bracketed numbers correlate to Sample Tracer Questions on page
64.)
Talking with the Therapist and Social Workers. The
surveyor began the tracer with the therapist and social workers,
asking them what kinds of assessments are performed for a
new youth on arrival and what kind of interdisciplinary work
goes into the treatment plan for the youth. [1–2] The thera-
pist explained that a comprehensive assessment for this youth
was completed upon arrival and then the therapist met with
the family and the treatment planning team to draft the
youth’s plan of care. In the case of this individual, because of
his ADHD diagnosis, he also had a medication assessment and
treatment plan integrated in his care planning. In addition, be-
cause one of the primary reasons for his being admitted to the
Section 3: Behavioral Health Care
therapeutic boarding school was a history of violent behavior
and self-harm, additional risk assessments were conducted.
The surveyor asked how the youth and his parents were in-
volved in the care planning process. [3–5] The therapist ex-
plained that he met with the youth and reviewed the plan with
him. The therapist had him sign an agreement to abide by the
principles of the school and to follow the plan of care, which
included individual and group therapy sessions, participation
in daily “chores” in his residential suite at the school, and at-
tendance at classes. Health care staff would administer his
medication to him and monitor his response to the medica-
tion. The youth was encouraged to participate in offered ex-
tracurricular activities, and the social worker followed up to
assess how well the youth was assimilating into the social at-
mosphere of the school.
The surveyor asked how the youth had adapted to the plan of
care and whether any issues had arisen since admission. [6–8]
The therapist said that because the youth had a history of act-
ing out violently, the school had identified activities intended
to help him address his anger constructively. According to the
therapist, the youth at first had been engaged in the plan of
care and had not been showing any inappropriate behavior,
but recently he had been acting out violently toward staff and
other male youth. In addition, he had made disruptive, sexu-
ally explicit comments toward one of his female classmates
during a school activity.
The surveyor asked what the staff had done in response to these
behaviors. [9] The therapist responded that when the youth
began to act out in defiance of the plan of care, and early inter-
ventions did not work, school staff members escalated the re-
sponse—according to the plan of care—to remove privileges,
such as interactions with specific peers and being put in more
one-on-one therapy. The therapist added that the staff had
processes in place to therapeutically and positively respond to
both the youth and those around him at the time of an out-
burst. The surveyor asked if this was a generally accepted
process for similar cases of youth acting out. [10] The therapist
explained that the general process is individualized for each
youth, but the principle is based on ensuring the safety and se-
curity of the youth, staff, and other individuals living at the
school. The therapist then explained that a further exploration
indicated that the violent behavior coincided with the youth’s
first on-site visit with his parents, so the staff ’s current priority
was working with him to help resolve the issues that were trig-
gering the behavior. The surveyor reviewed the youth’s record
and found all of this documented in the care plan.
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Speaking with the Nurse.The surveyor then went to visit

the health office to speak with the nurse who was responsible for [3]
administering the youth’s medication. She asked the nurse how
she monitored the youth and his medication use; she also asked [4]
the nurse to explain how she documented medication adminis-
tration. [11–12] After the nurse described these processes, the
surveyor asked if there had been any instances of violent behavior [5]
toward her or her fellow staff members. The nurse said there had
been no instances that she knew of. The surveyor asked if she [6]
knew what to do in the event that a youth acts out violently.
[13–14] The nurse said she had been through some training and [7]
knew to call for help. The nurse added that she ensured that
other staff members were on hand during times of the day when [8]
medications were being administered.
How do you involve the youth and parents in the
process? What do you communicate and when?
How do you update and modify the plan of care,
treatment, and services? Who monitors it? How is
this documented?
How are teachers involved?
How has the youth adapted to the treatment plan?
Have you had to make any adjustments?
If there has been any inappropriate behavior, what
has the response been?
What kind of training and experience prepares staff
to intervene when there is a violent outburst?

The surveyor concluded her tracer by returning to the adminis-
trative offices to review the personnel files of the therapist, the so-
cial worker, and the nurse to verify their competencies and
licensure.
[9] What is the response to such behavior? How does
this impact the treatment plan, if at all?
[10] What process is followed for aggressive behavior in
youth?

Nurse:
Moving Forward. Based on the tracer, the surveyor may
[11] How do you monitor medication use for youth?
discuss areas of improvement in the Daily Briefing. The discus-
sion might include some questions such as the following: [12] How do you document administration of
• Are your interventions effective with this youth? medications?
• How do you evaluate effectiveness? [13] If a youth acts out inappropriately, such as violently,
• How do you measure effectiveness? what is your response?
• How do you improve the outcome of his treatment?
[14] What training have you received in responding to
such situations?
Scenario 3-1.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 3-1. You can use the tracer SYSTEM
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the Tracer Scenarios
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or SCENARIO 3-2.
determine issues that may require further follow-up.
Community Mental Health Center
Therapist and Social Workers:
Summary
[1] What kinds of assessments do you perform for a In the following scenario, a surveyor traces how an organiza-
new youth on arrival at the school?
tion uses data. Within the tracer, the surveyor explores issues
[2] What kind of interdisciplinary work do you undertake relating to these priority focus areas:
when planning treatment for a youth? Who is • Screening, Assessment & Care, Treatment, and Services
involved? How is this documented? • Communication
• Information Management
• Quality Improvement Expertise/Activities

64

Scenario
This data use system tracer was conducted in a community men-
tal health center located in an urban setting. In it the surveyor ex-
plored the center’s data collection and analysis methods along
with any current improvement projects under way.
(Bracketed numbers correlate to Sample Tracer Questions on pages
65–66.)
Talking with Staff About Data Use Activities. The sur-
veyor began the tracer by asking staff members involved in the
center’s quality improvement activities to meet with him to dis-
cuss their data management efforts. The center’s clinical director,
psychologist, and social worker joined the surveyor in the discus-
sion. The surveyor asked the group members to describe their
general approach to data use management and how the center
structured it into staff duties and overall planning work. [1–3]
The center’s director explained that she had primary responsibil-
ity for the performance improvement work and plan and that she
met with a team of representative staff periodically to discuss data
and plan any needed improvements, though they did not have a
specific performance improvement team.
The surveyor asked how they organized themselves when they
wanted to implement an improvement at the center. [4–5] The
director explained that she forms a small team consisting of her-
self and relevant staff members to help plan and implement the
improvement. This ad hoc team, she explained, tended to dis-
band after the improvement had been implemented. She did not
see the point of having an added administrative structure when
they were already very busy.
Focusing on an Improvement Initiative with the
Tracer Team. The surveyor asked the group members to ex-
plain one current improvement project they had under way.
[6–8] The social worker explained that they had been unhappy
with their successful job placement rate for the individuals they
serve. Evidently, although they had had success finding referrals
for jobs, the individuals served were not being successfully placed
in the jobs. The center had aggregated its data from its referral
numbers, its documented successful placements, and its numbers
of referrals per individual until a successful job placement was se-
cured. An analysis of the data indicated that the center had not
been consistently following up with individuals, and the individ-
uals were not reporting their failed job placements or simply not
returning to the center.
The surveyor asked what kind of follow-up or communication
process was followed before the improvement initiative and what
Section 3: Behavioral Health Care
they implemented. [9–10] The psychologist explained that the
staff worked with each individual on job placements and fol-
lowed up on each subsequent visit. What they realized was that
the process was not formalized enough, with no contract being
signed and no consistent outreach to the individuals. The team
devised an approach that placed more emphasis on outreach as
early as possible in the process and recommended that more
follow-up be put in place. The team also designed and imple-
mented a new contract that the individual and the representative
of the center signed to formalize the job placement process.
The surveyor asked the tracer team members what preliminary
results were telling them. [11] The social worker said that with
more consistent lines of communication and the formality of a
signed contract, the center appeared to be seeing some improve-
ment with successful job placements. The director said she was
collecting the data and was noticing a positive trend toward im-
proved compliance.
The surveyor asked the team members what access they might
have to resources and training to aid them with data use manage-
ment. [12–13] The director mentioned that she had previous ex-
perience as a quality improvement specialist in a psychiatric
hospital and had brought that experience to the center. In addi-
tion, staff members had participated in a number of training ses-
sions offered through their state association.
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The surveyor
might ask team members whether they have data charts that dis-
play the progress of the plan over time. He might ask the social
worker the following questions:
• What is meant by “more consistent”?
• How is that measured?
• Is it displayed as a graph?
Scenario 3-2.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 3-2. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
(continued)
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• Communication
Scenario 3-2. • Infection Control
Sample Tracer Questions • Physical Environment
• Rights & Ethics
(continued)
Scenario
Staff: This infection control system tracer was conducted in a resi-
[1] Please describe the data use management process
dential program for young adults located in a small city. The
that you use. What kinds of methods for data
surveyor asked to meet with the staff members who have input
collection and analysis do you follow?
into and responsibility for the infection control program,
[2] What staff members are involved in data use which included the nursing manager, one of the social workers
management?
on staff, and the director of the residential program.
[3] Who has responsibility for data management and
who has input into it? (Bracketed numbers correlate to Sample Tracer Questions on page
[4] How do you plan for improvements or analyze risks 67.)
in your setting?
[5] Who is involved in your improvement planning? Overview of Infection Control Practices with the
Director. The surveyor began this tracer by speaking with the
Tracer Team: director of the individuals who had input into and oversight
[6] What current improvement projects do you have responsibility for the infection control program. The surveyor
under way? Please choose one to discuss. asked him to describe who was primarily responsible for infec-
[7] What triggered this improvement initiative? What tion control and which staff performed other functions for the
data analysis did you do to lead you to prioritize this program. [1–3] The director said that although he had input
initiative? into and oversight responsibility for infection control, the
[8] Who was involved in the initiative? nursing manager carried out the actual task of monitoring and
analyzing data relating to infection control. He added that the
[9] How did this process work before the implemented
residential program managed infection control through its
initiatives? Please describe what changed as a
result of the implementation.
overall performance improvement committee, which included
administrative, counseling, and health staff. [4–5] He noted
[10] How did you implement the changes? What kind of
that the committee handled infection control issues on an
accompanying education did you provide?
as-needed basis, but, in general, the nursing manager produced
[11] What are you learning so far? How do you plan to reports relating to infection control once every quarter.
track and monitor results? What reporting process
will you follow?
Discussing Data Analysis and Interventional
[12] What training do you have to perform data use Practices with the Nursing Manager. The surveyor
management duties? asked the nursing manager how she handled the data and
[13] What access do you have to resources and what methods she used to analyze it. [6–7] The nursing
training? manager said that she collected data on an ongoing basis
using spreadsheet software and then generated reports once a
quarter. The surveyor asked what kinds of data the residential
program collects and how they are used. The surveyor also
SCENARIO 3-3. asked about education provided to infection control practices
Residential Treatment Center staff as well as individuals in the program. [8–10] The nurs-
ing manager explained that due to its nature, the facility did
Summary not have many infection control–related issues or risks with
In the following scenario, a surveyor traces how an organiza- which to contend. The primary issues of concern were hand
tion implements its infection control system. Within the hygiene compliance, cleanliness in the environment, and
tracer, the surveyor explores issues relating to these priority food hygiene. Much of the facility’s education and training
focus areas: involved ensuring that staff and individuals in the program

66

understood the importance of good hand hygiene and main-
taining a clean environment.
Focusing on an Infection Control Improvement
Project with the Tracer Team. The surveyor asked the team
members whether they had launched any infection control–
related improvement projects lately. [11–12] The director
mentioned a recent spate of incidents in which individuals had
been hoarding food in their rooms, causing an increase in pests
in the residential areas. The nursing manager explained that
when individuals enter the program, they are oriented about
specific rules and residence expectations, which include a rule
against hoarding certain foods in their private rooms. The
team decided to launch an initiative to reeducate individuals
on the hoarding of inappropriate food in their rooms and to
work with housekeeping on improving cleaning in the residen-
tial areas.
The surveyor asked what the response to the initiative had
been. [13–16] The director explained that the facility had
used pest control services to get the previous problem under
control. With increased cleaning efforts and enlisting individu-
als’ diligent compliance with food storage rules, there had been
no recurrence of pests in the facility.
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The sur-
veyor might ask questions such as the following:
• Has the facility had any problems with bedbugs, ticks, or
lice?
• How do you keep showers clean to prevent athlete’s foot
and other fungus problems?
• How do you inspect and/or treat clothing brought in from
outside the facility?
Scenario 3-3.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 3-3. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
Summary
determine issues that may require further follow-up.
In the following scenario, a surveyor traces how an organiza-
tion manages medications. Within the tracer, the surveyor ex-
plores issues relating to these priority focus areas:
Section 3: Behavioral Health Care
Director:
[1] Who is primarily responsible for the infection control
program? What staff members are also involved?
[2] Do you convene a committee to address infection
control? If so, how often does it meet?
[3] What is the scope of your infection control program?
[4] Who is responsible for collecting and analyzing data?
[5] When do you assess infection control risks?
Nursing Manager:
[6] What methods do you use for data collection and
data analysis?
[7] What do you do with the data that you collect?
[8] What kinds of data do you collect? What specific
infection control areas do you focus on?
[9] How do you ensure that your approach to data
collection and analysis meets the infection control
needs of your program?
[10] What is your approach to educating staff and
individuals served about infection control?
Tracer Team:
[11] What current infection control performance
improvement projects are you currently
undertaking?
[12] Please describe an infection control–related
improvement project that you have recently
implemented.
[13] How did you become aware of the problem? What
analysis did you form in relation to it?
[14] Who was involved in planning the improvement?
[15] How did you educate staff and individuals served
about the new initiative?
[16] How have you been monitoring the response? Do
you have any results so far? What are you doing
with these data?
SCENARIO 3-4.
Community Mental Health Center
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• Screening, Assessment & Care, Treatment, and Services
• Individual Served Safety
• Medication Management
• Orientation & Training
• Staffing
Scenario
This data use system tracer was conducted in a community
mental health center. The surveyor asked to meet with the staff
responsible for medication management so she could explore
the organization’s medication management practices and any
data- or improvement-related activity. The community mental
health center was large, serving an urban population and in-
cluding psychiatry and counseling among other services.
(Bracketed numbers correlate to Sample Tracer Questions on page
69.)
Medication Management Review with Staff. The
surveyor began the tracer with staff involved in medication
management–related activity, including the center’s quality im-
provement specialist, counselor, and psychiatrist. She first
asked those assembled to describe what types of medication
management processes and practices existed in the center and
what particular risks and areas of concern the center addressed.
She also asked the group to describe staff members’ responsi-
bility and involvement in overseeing and analyzing the med-
ication management process. [1–2] The quality improvement
specialist explained that he had the primary responsibility for
oversight and management of the medication management
process as part of the overall quality improvement process for
the center. The surveyor asked what kind of medication-
related assessment was performed by the center as part of the
overall assessment. [3–4] The counselor mentioned that each
individual received a medication assessment and that current
medication information is integrated into the individual’s clin-
ical record.
Discussing Data with the Quality Improvement
Specialist. The surveyor then asked the staff members to
describe what data collection and analysis they performed
in relation to medication management. [5–6] The quality im-
provement specialist responded that the center collected data
on medication use, adverse medication events, and close calls,
or near misses. He added that medication compliance was an
important area of focus for the center because the individuals
served required a specialized medication regimen and the cen-
ter needed to ensure that all medications for all individuals (in-
cluding medications they might receive under medical care)
68
were tracked and monitored. Primary responsibility for collect-
ing, entering, and analyzing data rested with the quality im-
provement specialist.
Talking with the Counselor. The surveyor asked what
kinds of interventions and education the center provides to in-
dividuals related to medication and safe medication practices.
[7] The counselor answered that the center provides education
both at the center and online through the center’s Web site.
The counselor explained that part of the center’s mission is to
ensure that during each visit in which medications were moni-
tored and discussed, education was provided and reinforced.
The quality improvement specialist added that although ad-
ministration of medicines was rare in the center, the center
does maintain a small supply of sample medications and other
medications to assist individuals unable to acquire medications
elsewhere.
Following Up with the Quality Improvement
Specialist. The surveyor then asked the quality improvement
specialist how he becomes aware of reported medication safety
issues and how he educates staff on them. [8–9] The quality
improvement specialist explained that he regularly checks the
major professional, state, and federal agencies for medication
safety updates and shares this information with staff. He added
that during periodic staff training sessions, he sets aside time
to discuss any safety issues, including medication safety con-
cerns that have come up at the center (such as poor compli-
ance or adverse medication events).
Speaking with the Psychiatrist. The surveyor asked the
psychiatrist to describe the nature of psychiatric services of-
fered through the center. [10] The psychiatrist explained that
he was at the center only once a week and his primary role was
to see individuals needing psychiatric services and those with
prescription medications. The surveyor asked about the con-
sent process and how the psychiatrist discloses risks and bene-
fits. [11] The psychiatrist noted that due to the therapeutic
nature of the care the center provides, the individual would
also be undergoing extensive therapy and education in correla-
tion with his or her medication and would have been well in-
formed of the risks and benefits.
The surveyor asked to see a clinical record for an individual
currently receiving antidepressants. [12] The record she re-
viewed showed that the individual had received a medication
assessment and had been receiving antidepressants for the pre-
vious six months. Notes in the record indicated continued ed-
ucation and response from the individual. The surveyor also

noted an individual care plan that included ongoing individual
therapy and group work in conjunction with antidepressants.
The surveyor asked what the center does in the event that in-
dividuals are not compliant with their medication regimen.
[13–14] The psychiatrist noted that the center’s policy is to
counsel and help the individual address the reason for non-
compliance, as needed. He added that the multidisciplinary
care team meets to review cases and adjusts the individual’s
care plan as warranted.
Staffing and Competency Review with the Director.
As a final step in the tracer, the surveyor asked the director of
the center to show her the credentialing and licensure records
for the psychiatrist and the counselor. The surveyor saw up-to-
date licensure for both in these records. [15]
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might include the topic of self-administration of med-
ications. The surveyor also might ask questions such as the
following:
• What is your process to ensure that your sample medica-
tions are not expired?
• Do you give injectables? If so, where are they stored? Are
they refrigerated? If so, how do you ensure the proper tem-
perature range for the refrigerator?
Scenario 3-4.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 3-4. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Staff:
[1] Who has oversight responsibility for your
medication management process? Who else has
input?
[2] Please describe your safe medication
management practices. What are particular areas
of concern and risk you address with the
individuals you serve?
Section 3: Behavioral Health Care
[3] How do you assess an individual’s medication
use? Where is this information documented?
[4] In relation to medication management, do you
have any special medications you need to have on
hand? How do you ensure their safe handling and
storage?
Quality Improvement Specialist:
[5] What data management practices do you employ
in relation to medication management?
[6] What types of data do you collect and analyze?
Who has responsibility for collecting them? How
do you use these data?
Counselor:
[7] What kinds of education and interventions do you
provide to individuals? How do you reinforce
education?
Quality Improvement Specialist:
[8] How do you stay apprised of any new or
developing medication safety issues? How is this
information reported to staff?
[9] What kind of education and training is provided to
staff in relation to medication management?
Psychiatrist:
[10] Please describe the nature of care you provide.
How often is it provided? What type of staffing is
involved?
[11] What is the consent process? How are individuals
informed about risks and benefits?
[12] Please show me the clinical record of an individual
receiving medication. Where do you document
treatment and care planning? Show me the signed
consent forms.
[13] What do you do in the event that the individual is
not compliant with his or her medication regimen?
[14] How often do you review and update a care plan
for an individual receiving this type of care?
Director:
[15] What is the credentialing and licensure process for
your clinical staff? Please show me your files.
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PROGRAM-
SPECIFIC
Tracer Scenarios
SCENARIO 3-5.
Continuity of Foster/Therapeutic
Foster Care
Summary
In the following scenario, a surveyor traces how an organiza-
tion maintains continuity of foster/therapeutic foster care.
Within the tracer, the surveyor explores issues relating to these
priority focus areas:
• Screening, Assessment & Care, Treatment, and Services
• Organizational Structure
• Orientation & Training
• Rights & Ethics
• Staffing
Scenario
This tracer took place in a child welfare agency. Earlier in the
survey, the surveyor had learned that two fostered children had
just been moved to a new foster home for the third time in 10
months. The agency was currently investigating the situation.
The surveyor opted to conduct a continuity of foster/thera-
peutic foster care program-specific tracer. The surveyor asked
to meet with the agency director and foster care staff about
their foster care placement process.
(Bracketed numbers correlate to Sample Tracer Questions on page
71.)
Overview of the Foster Placement Process with the
Director and the Case Worker. The surveyor selected the
record of one of the children who had been placed in multiple
foster homes to trace with the staff. She met with the agency
director and a foster care case worker. She began the discussion
by asking the director how the agency matches a child to a fos-
ter home and what care planning is involved. [1–3] The direc-
tor explained that the agency has criteria that it uses to match
a child with a foster home/family. The agency also uses a
multidisciplinary care planning approach to match the child
appropriately to the foster care home. The surveyor asked how
often each child’s case plan is reviewed. [4] The director men-
tioned that the agency aims to review each case plan every six
70
months, and this review was often done in conjunction with
local and state authority reviews for each child.
The surveyor asked the director what the agency’s initial re-
view of these two cases indicated about any gaps in the
agency’s process. [5–6] The foster care case worker explained
that one of the children was 10 years old and spoke a different
language than the foster parents, which had made it more dif-
ficult to bridge the gap between the child and family. The sur-
veyor asked what, if any, culturally competent interventions
were built into the case planning process. [7] The director ex-
plained that the plan does address cultural and language differ-
ences, but in this case the standard process was not working.
Agency staff members were planning to take a closer look to
see if their process needed modification or if it just required a
more individualized approach to identify specific triggers that
could result in a new placement.
Examining the Data with the Director. The surveyor
asked what types of data the agency was collecting and analysis
it was conducting to determine the causes for these replace-
ments. [8] The director said that agency staff members were
planning to conduct a series of interviews with children and
foster home parents, along with conducting a failure mode and
effects analysis on the agency’s overall process. They also had
data from previous placements and interviews with foster
home parents and children that they were factoring into the
review. The director added that they were planning to reassess
their placement criteria list and determine whether it was still
appropriate. The surveyor asked the director how often they
review the criteria list. [9] The director replied that it is re-
viewed once a year, but agency leadership was considering
whether to revisit that review policy.
Discussing Training and Development for Place-
ments with the Director. The surveyor asked the director
what kinds of training the agency provides to its foster care case
workers to help them with their professional development. [10]
The director said that frequent in-service training is offered on
topics such as interviewing foster home parents and children,
tending to special emotional needs of children, adhering to
standards and regulation, and mitigating stresses from the job.
The director said the agency was considering including more
training about cultural competency. The surveyor also asked
what kinds of skills training and development were provided to
foster home parents. [11] The director replied that foster home
parents are required to take parenting courses, learn interven-
tional methods to deal with special emotional needs of chil-
dren, and develop good communication skills.

Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might include questions such as the following:
• What is the process for foster home parents to report con-
cerns to the staff regarding the child or youth?
• How are the foster parents involved in care planning?
• If respite is needed, what is the process for parents to follow?
Scenario 3-5.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 3-5. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Director and Case Worker:
[1] Please describe your process to match children to
foster homes. What care planning is involved in the
process? Do you use a multidisciplinary approach?
If so, please describe it.
[2] What criteria do you use to match a child to a
family?
[3] What kinds of assessments do you conduct for new
children? What special assessments do you conduct
and when are those warranted?
[4] How often do you review the case plan for a child?
[5] How do you review the cases of children undergoing
multiple placements?
[6] What initial findings are there?
[7] How do you factor cultural competency into your
case plan for children? Have you assessed its
effectiveness?
Director:
[8] What types of data and analysis do you employ to
study trends?
[9] How often do you review your placement criteria? If
you want to make any adjustments, what is your
process to do so?
[10] What kinds of training does the agency provide to its
staff? What specialized training do foster care case
workers receive?
[11] What kinds of skills training and development do
you provide to foster home parents?
Section 3: Behavioral Health Care
SCENARIO 3-6.
Youth Group Home
Summary
In the following scenario, a surveyor traces how a youth group
home manages an elopement program. Within the tracer, the
surveyor explores issues relating to these priority focus areas:
• Screening, Assessment & Care, Treatment, and Services
• Individual Served Safety
• Orientation & Training
• Physical Environment
• Staffing
Scenario
This tracer was conducted at a children and youth group home
located in an urban setting. The surveyor had conducted an in-
dividual tracer earlier in the day during which she learned that
a 15-year-old female youth had attempted to elope from the
home the previous week. Although the home manager was able
to intervene to avert a successful elopement, this youth had at-
tempted several elopements over the previous month. The sur-
veyor decided to conduct a program-specific elopement tracer
to explore how the home managed its elopement risks and what
interventions it had in place to avert elopements.
(Bracketed numbers correlate to Sample Tracer Questions on page
72.)
Talking with the Home Manager. The surveyor met
with the home manager and asked him to provide an overview
of how the home deals with potential elopements, identifying
youth at risk, and environmental and other interventions the
home has built into its process. He also asked how the home
trains and utilizes staff to reduce both elopement attempts and
successful elopements. [1–6] The manager explained that with
its young population, the home is always at risk for elope-
ments, so assessing individuals on arrival in the home is a top
priority. Staff members looked at causal factors (whether a
youth has a boyfriend or girlfriend, for example) and previous
behavior (if available) when assessing a youth for elopement
risk. They also make sure the youth understands the rules re-
lating to residence and the consequences relating to attempted
or successful elopement. He added that staff members are pro-
vided with training and education on elopement risk and in-
terventions during orientation and in an ongoing manner.
The surveyor asked what staff members do if they assess a
youth as being at risk for elopement. [7–8] The home
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manager explained that the home notes the risk in the youth’s
case plan and then uses a combination of interventions, in-
cluding checking on the youth more frequently and ensuring
that the youth’s room is not located near a part of the home
from which the youth could more easily elope. He also de-
scribed the home’s general features (including security alarms)
and mentioned that doors are locked after a certain time, and
several staff members check areas in the home overnight.
The surveyor then reviewed the youth’s record and asked the
home manager to describe the nature of the attempted elope-
ments. [9] The youth apparently had a new boyfriend and was
attempting to elope to spend time with him. Before the new
relationship, the manager had not noticed any significant
elopement problems with the youth because her social circle
consisted primarily of others in the home. Because the home’s
current interventions did not appear to be working, the sur-
veyor asked what additional response the home was planning.
[10–11] The manager noted that the latest elopement attempt
was late in the evening, around the time the swing shift staff
leaves and the “graveyard” shift begins. He opted to change the
staffing schedule to allow for more overlap and monitoring in
the home in the evening hours to see if that would help. Also,
he discovered that the youth had figured out a way to disable
the alarm for a short period, so the home was planning to in-
vest in a more effective system immediately.
Interviewing the Individual Served. The surveyor
received permission to speak with the youth. He asked her
to explain if she understood the rules on unauthorized de-
parture from the home during off-hours. [12] She answered
that she did understand and the manager had explained it to
her, but she said she thought she was being treated unfairly.
She only wanted to see her boyfriend. When the surveyor
asked if the youth had been informed about the importance
of ensuring her safety, she said she did understand that but
knew how to take care of herself. [13] She added that she
did like the home, however, and would try to do better. She
mentioned that the home manager had offered to allow her
boyfriend to come to the home after school so the two of
them could do homework together, which the youth
thought would be OK. She did not want to leave the home
or have to face more serious consequences, she said, so she
would try not to break the rules.
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The sur-
veyor might ask to see a copy of the work order or purchase
agreement for the new or upgraded alarm system. Topics the
72
surveyor might discuss include the home’s visitation policies
and staff training on elopements.
Scenario 3-6.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 3-6. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Home Manager:
[1] What is your elopement prevention or reduction
plan?
[2] How do you address elopement risk in the home?
[3] What elopement risk assessments do you conduct
for children and youth coming into the home? How
do you identify a child or youth at risk?
[4] What kind of training do you provide for staff relating
to elopement risks?
[5] What interventions do you have in place to reduce
elopements?
[6] What role does staff play in identifying elopement
risk and intervening?
[7] What response do you put in place for a child or
youth identified as being an elopement risk?
[8] What behavioral and environmental interventions do
you put in place regarding elopement risk?
[9] What was the nature of the youth’s elopement
attempt? What were the causal factors?
[10] What has your response been?
[11] What interventions have you put in place? Have you
had to make any changes to staffing or the physical
environment?
Individual Served:
[12] Do you understand what the home’s rules are on
unauthorized departures? When was this explained
to you?
[13] Do you understand why you are not allowed to leave
the home after a certain hour in the evening? When
was this explained to you?

SCENARIO 3-7.
24-Hour Adult Mental Health Setting
Summary
In the following scenario, a surveyor traces how an organiza-
tion conducts a suicide prevention program. Within the tracer,
the surveyor explores issues relating to these priority focus
areas:
• Screening, Assessment & Care, Treatment, and Services
• Communication
• Individual Served Safety
• Physical Environment
• Rights & Ethics
Scenario
The surveyor wanted to explore how the adult mental health
program addressed suicide risks through an individual served
who had attempted suicide since being admitted to the mental
health program six weeks earlier. The surveyor chose a 32-year-
old woman who was being treated for severe depression and
drug abuse and was admitted to the program for treatment
after a suicide attempt. The surveyor conducted a discussion
with the program’s director, social worker, and psychologist.
She also invited the facilities manager to participate.
(Bracketed numbers correlate to Sample Tracer Questions on page
74.)
Talking with the Director. The surveyor asked the di-
rector to describe the program’s process to prevent suicide. [1]
The director explained that there can be a high risk of suicide
in the environment among some of the individuals, so the pro-
gram placed great emphasis on its suicide prevention efforts.
The process involves an initial suicide risk assessment when
the individual enters the program and also regular reassess-
ments for suicide risk, regardless of whether the initial assess-
ment placed the individual at suicide risk. [2–4] In the case of
an individual designated as a suicide risk, the director said, the
program puts a number of measures in place aimed at prevent-
ing that individual from attempting suicide. These measures
include more regular checks, one-on-one therapy, ensuring
that the space is safe, and activities geared toward removing
opportunities for extensive isolation. The surveyor asked what
kinds of suicide interventions staff members are trained to
make. [5] The director said that staff members are trained to
observe changes in individuals that may signal suicide risk, as
well as how to direct activity away from anything that might
facilitate a suicide attempt.
Section 3: Behavioral Health Care
The surveyor then asked what kind of data collection and
analysis work staff members do in relation to suicide preven-
tion. [6] The director said that they collect data on in-
creased suicide risks based on assessment and track suicide
attempts. They use the assessment data, she added, to deter-
mine what causal factors contribute to suicide risks.
Speaking with the Facilities Manager. The surveyor
asked the facilities manager what the program has done
to better secure the environment against suicide risk. [7]
The facilities manager mentioned that the facility had re-
moved physical elements that could make it easier for indi-
viduals to attempt suicide, such as hooks in walls and bars
inside showers and closets, and replaced them with safer
alternatives.
Talking with the Psychologist. The surveyor then
asked to review the individual’s treatment plan, asking the
psychologist to describe the plan of care and assessments.
[8] The psychologist explained that the individual had been
admitted to the program six weeks earlier for severe depres-
sion, suicidal ideation, and alcohol abuse. The individual, a
32-year-old mother of two who had recently separated from
her husband and had been living with her parents, had at-
tempted suicide before being admitted to the program. Ac-
cording to her record and assessment, she had been receiving
treatment for depression at a local community mental health
center prior to admission but had been having trouble with
compliance and had gradually begun to show signs of suici-
dal ideation. When she attempted suicide, she was admitted
to the hospital and, after being stabilized, was transferred to
the inpatient psychiatric unit for a short duration. Soon
thereafter she was discharged into the 24-hour program.
Following Up with the Director. The surveyor asked
the program director what kind of information the program
receives from the hospital regarding a new individual com-
ing to the program. [9] The director explained that the hos-
pital, the individual, and the family had all been involved in
the decision that the individual could benefit from some
time in the program. At the time of referral, a preadmission
assessment is conducted along with referring information
from the hospital.
Moving Forward. Based on the tracer, the surveyor
may discuss areas of improvement in the Daily Briefing. The
discussion might address the topic of environmental risk as-
sessment, in particular, assessment for suicide risk.
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Scenario 3-7.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 3-7. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Director:
[1] Can you describe your process to prevent suicide
among the individuals you serve?
[2] What types of assessments do you conduct? When
do you reassess an individual?
[3] Can you show me an example of your assessment?
What do you do with this information?
[4] What kinds of interventions do you employ for
individuals at risk for suicide?
[5] What type of training do staff members have in
relation to intervening in the cases of individuals at
risk for suicide? How do they know when to
intervene?
[6] What kind of data collection and analysis do you
perform in relation to suicide risk among your
population? What methods do you use?
Facilities Manager:
[7] What kinds of environmental interventions have you
put in place? How do you secure the environment to
mitigate suicide risk?
Psychologist:
[8] What is your plan of care and assessment for an
individual designated as a suicide risk?
Director:
[9] What kind of referral or discharge information do
you receive for a new individual?
74
SCENARIO 3-8.
Residential Drug and Alcohol
Treatment Program
Summary
In the following scenario, a surveyor traces how an organiza-
tion addresses the issue of violence, including management
and prevention efforts. Within the tracer, the surveyor explores
issues relating to these priority focus areas:
• Screening, Assessment & Care, Treatment, and Services
• Individual Served Safety
• Orientation & Training
• Physical Environment
Scenario
The surveyor conducted a violence program-specific tracer in a
residential drug and alcohol treatment program. The data use
system tracer identified a recent increase in violent behavior by
a small number of individuals served in the program. The sur-
veyor opted to conduct a program-specific violence tracer to
explore the program’s systems and processes to manage violent
behavior. He began his tracer by holding a discussion with
program staff and then concluded it by tracing an individual
who had recently been exhibiting violent behavior.
(Bracketed numbers correlate to Sample Tracer Questions on pages
75–76.)
Meeting with Nursing Staff and the Clinical
Director. The surveyor first met with a member of the nurs-
ing staff and the clinical director. He asked them to describe
what process was in place to address violent behavior occurring
in the program. [1–3] The clinical director explained that be-
cause violent behavior did happen from time to time, the pro-
gram had written a comprehensive plan, and staff members
had undergone extensive training both during their orienta-
tions and in an ongoing manner on how to defuse potentially
violent behavior and how to minimize injury to themselves
and others. As an example, the director mentioned the use of a
panic button in group therapy.
The surveyor asked how well the interventions and prevention
processes had been working. [4–5] The director responded
that in general the individuals were responsive to the interven-
tions, but staff members had found—through an analysis of
their incident reporting data—that certain areas of the pro-
gram were more vulnerable to individuals exhibiting violent

behavior, namely, during group sessions. The surveyor asked if
the staff members could give an example of an intervention
strategy the program had designed to anticipate and better
mitigate violence in these areas. [6] The clinical director ex-
plained that they had changed the dynamics of certain group
sessions after they found that some individuals were triggering
others’ violent behavior. Staff members also learned that in one
of the group session rooms, tables were not properly secured to
the ground, which had allowed one of the group session par-
ticipants who had an angry outburst to lift and throw a table,
thereby injuring one of the other participants. Following the
incident, the program better secured the tables.
Talking with the Nurse. The surveyor asked the nurse
to describe the training she has received on responding to vio-
lent behavior. [7–8] The nurse explained that she had under-
gone training and orientation relating to violence and how to
call for help in the event that her own safety was compro-
mised. The surveyor asked what kinds of responses the pro-
gram uses when an individual acts out violently. [9–10] The
nurse referred to the program’s “code team,” which was called
into action by staff through use of a panic button, a verbal
warning, or the telephone.
Discussing Assessment with the Clinical Director.
The surveyor asked the staff what kind of assessment was con-
ducted for individuals at risk for violent behavior. [11] The
clinical director explained that the individuals are all assessed
on admission to the program and in an ongoing manner for
potential violent behavior through a series of qualitative ques-
tions and indicators. The surveyor asked to see an example of
the assessment. The surveyor also asked what, if any, interven-
tion takes place after the multidisciplinary team determines
that the individual is at risk for violent behavior. [12] The
clinical director said that the team’s response would depend on
the causal stimuli for violent behavior. In the case of external
triggers such as a reaction to comments from others in a group
setting, the team might focus on more individual sessions until
the individual was better able to respond constructively in a
group session.
Finally, the surveyor asked to review the clinical record of an
individual who had recently exhibited a series of violent out-
bursts. The record indicated that the individual had not been
designated as being at risk for violent behavior on admission to
the program but had begun to exhibit more violent behavior
during group sessions. The surveyor noted that when the care
plan was modified to provide more individual sessions, the in-
dividual’s behavior had changed, he had not experienced any
Section 3: Behavioral Health Care
violent outbursts since the modification to his treatment plan,
and the team was reassessing his reintegration into group
sessions. [13]
Meeting with the Individual Served. The individual
had just completed a therapy session, so the surveyor secured
permission to speak with him. The surveyor first asked how
the individual’s experience of care had been in the program.
[14] The individual said in general he was fine with it and the
staff had been nice. The surveyor asked if the individual had
been aware of his behavior in group session being potentially
dangerous to himself, the counselor, and other participants.
He also asked if the individual was aware of how his behavior
had been perceived by others around him. [15] The individual
responded that he had been disappointed in his own reactions
during the group sessions, but he was “just having a hard time
with the way people were saying things.” He commented that
even so, he liked the group sessions and was hoping to rejoin
them after the counselor helped him figure out why he got so
angry so easily and helped him learn how to respond more
constructively.
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address such topics as staff education, assess-
ment, and treatment planning documentation.
Scenario 3-8.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 3-8. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Nursing Staff and Clinical Director:
[1] What is your process to deal with violent behavior?
[2] Please describe your process to manage violence
among individuals in the program. How often do you
review and update your process?
[3] What accompanying staff education is included with
the plan?
(continued)
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Scenario 3-8. Clinical Director:

Sample Tracer Questions [11] What kind of assessment do you conduct for
individuals at risk for violent behavior?
(continued)
[12] Please show me your assessment for a new
[4] How do you monitor the effectiveness of your individual. How do you assess for violent behavior?
interventions? What is your response when an individual is
[5] What type of data analysis do you conduct? designated at risk for this type of behavior?

[6] Can you give an example of an intervention you [13] For an individual who has shown violent behavior in
have employed that has effectively prevented the program, how does the individual’s treatment
violence? What was the staff and individual plan reflect a response to this behavior? Please
response to this intervention? show me an example.

Nurse: Individual Served:

[7] Can you describe the type of training you have
received in relation to preventing violence?
[8] How were you oriented to the program’s process
during your orientation?
[9] What types of responses do you employ when faced
with a violent or potentially violent outburst?
[10] How do you enlist the assistance of the response
team?
[14] How has your experience of care been in the
program?
[15] Have you been aware of the perception of your
behavior in the group sessions? What do you think
about the response from program staff to the
incidents?

76
 Section 3: Behavioral Health Care

Sample Tracer Worksheet: Scenario 3-1.

The worksheet below is an example of how organizations can A correct answer is an appropriate answer that meets the re-
use the sample tracer questions for Scenario 3-1 in a worksheet quirements of the organization and other governing bodies.
format during a mock tracer. The bracketed numbers before An incorrect answer should always include recommendations
each question correlate to questions described in the scenario. for follow-up.

Tracer Team Member(s): Fiona Alberto
Subjects Interviewed: Mina Khadem, Mary
McDougall, Michael Hennington
Tracer Topic or Care Recipient: care plan and
interventions for violent youth
Data Record(s): youth’s medical record and care
plans; personnel files of therapist, social worker, and
nurse
Unit(s) or Department(s): therapeutic school

Interview Subject: Therapist and Social Workers

Questions Correct Incorrect Follow-Up Comments or

Answer Answer Needed Notes
[1] What kinds of assessments ✓
do you perform for a new youth
on arrival at the school?

[2] What kind of interdisciplinary ✓ Reinforce process. Good knowledge on

work do you undertake when interdisciplinary; staff did
planning treatment for a youth? not know about
Who is involved? How is this documentation
documented? responsibility.
[3] How do you involve the ✓ Good staff suggestion for
youth and parents in the electronic information.
process? What do you
communicate and when?

[4] How do you update and ✓ Excellent documentation

modify the plan of care, example on clinical record.
treatment, and services? Who
monitors it? How is this
documented?

[5] How are teachers involved? ✓

[6] How has the youth adapted ✓
to the treatment plan? Have you
had to make any adjustments?

[7] If there has been any ✓ School staff support

inappropriate behavior, what excellent; good
has the response been? understanding.
(continued)
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Interview Subject: Therapist and Social Workers (continued)

Questions Correct Incorrect Follow-Up Comments or

Answer Answer Needed Notes
[8] What kind of training and ✓ Reinforce No record of staff training
experience prepares staff to documentation. on violence in the record.
intervene when there is a violent
outburst?

[9] What is the response to such ✓ Orientation needs New staff unsure about
behavior? How does this impact reviewing. Review how to response.
the treatment plan, if at all? follow up.
[10] What process is followed ✓
for aggressive behavior in
youth?

Interview Subject: Nurse

Questions Correct Incorrect Follow-Up Comments or

Answer Answer Needed Notes
[11] How do you monitor ✓
medication use for youth?

[12] How do you document ✓ Need to review No clear process or evidence

administration of medications? documentation process of documentation.
with staff.

[13] If a youth acts out ✓ Need to review data use No consistent data use
inappropriately, such as practices with staff. practices.
violently, what is your response?

[14] What training have you ✓

received in responding to such
situations?

78

Tracer Scenarios for
HOME CARE
NOTE: No Two Tracers Are the Same
Please keep in mind that each tracer is unique. There is no
way to know all of the questions that might be asked or
documents that might be reviewed during a tracer—nor
what all the responses to the questions and documents
might be. The possibilities are limitless, depending on the
SECTION 4
tracer topic and the organization's circumstances. These
tracer scenarios and sample questions are provided as an
educational or training tool for organization staff; they are
not scripts for real or mock tracers.
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Section Elements
This section includes sample tracers—called scenarios—relevant to home care. Individual, system, and program-specific tracers
are represented. The section is organized as follows:

Scenarios: Each scenario presents what might happen when a

surveyor conducts a specific type of tracer. The scenarios are
presented in an engaging narrative format in which the reader
“follows” the surveyor through the tracer scenario. Within the
narrative are bracketed numbers that correspond to numbered
sample tracer questions following the tracer.

Sample Tracer Questions: After each scenario narrative is a list

of sample questions a surveyor might ask during that scenario.
These questions can be used to develop and conduct mock tracers
in your organization on topics similar to those covered in the
scenario.

Sample Tracer Worksheet: At the end of the section is a sample

worksheet that shows how the sample tracer questions for one
select scenario in the section might be used in a worksheet format.
The example shows how the worksheet might be completed as
part of a tracer for that scenario. A blank form of the worksheet is
available in Appendix B.

80

INDIVIDUAL
Tracer Scenarios
SCENARIO 4-1.
Home Health Agency
Summary
In the following scenario, a surveyor traces how an organiza-
tion cares for an infant in need of respiratory care. Within the
tracer, the surveyor explores issues relating to these priority
focus areas:
• Assessment & Care/Services
• Patient Safety
• Communication
• Orientation & Training
Scenario
A surveyor conducted this individual patient tracer in a home
health agency that provided care, treatment, and services to
adult and pediatric patients within a 50-mile radius. The pa-
tient chosen for the tracer was a prematurely born 9-week-old
infant who was admitted to home care two weeks earlier and
who required ongoing personal care and support, nursing care,
and respiratory care.
The surveyor selected the patient to trace at the agency’s main
office and reviewed the patient’s medical record. She learned
that the patient weighed four pounds at birth and now needed
full-time care at home. The agency agreed to provide care 10
hours a day, four days a week, because both parents worked
full-time. The care plan showed that the patient was receiving
supplemental oxygen and the continuous use of an apnea
monitor. A licensed practical nurse (LPN) was scheduled for
four 10-hour shifts. The parents provided care when the
agency was not there. A registered nurse (RN) conducted a su-
pervisory visit with the LPN at the home every two weeks.
(Bracketed numbers correlate to Sample Tracer Questions on pages
82–83.)
Traveling to the Home with the Nursing Manager.
After the nursing manager secured permission from the pa-
tient’s mother to visit the infant, the surveyor traveled with the
agency’s nursing manager to meet the LPN at the home. On
the way, the surveyor asked the nursing manager to describe
Section 4: Home Care
the purpose of the RN’s supervisory visits. [1] The nursing
manager described the agency’s policy to perform these visits
every two weeks to consistently monitor how well the LPN
was following the patient’s care plan, how well the LPN docu-
mented any changes in the patient’s status, and how well the
parents and the LPN were working together. Next the surveyor
asked the nursing manager to describe the agency’s initial as-
sessment process for pediatric patients and the competency re-
quired of nurses working with infants. [2–4] The nursing
manager explained that, according to agency policy, an RN
conducted an initial nursing assessment on the day of the pa-
tient’s admission to determine the patient’s status and confirm
that the nursing services ordered by the physician would likely
meet the needs of the infant and parents. The staff also coordi-
nated with a home medical equipment organization to ensure
timely delivery and setup of the equipment. The surveyor then
talked with the nursing manager about how the LPN was ori-
ented to the equipment and asked what the LPN’s responsibil-
ities were related to the equipment. [5–7]
Meeting the LPN. On arrival at the home, the surveyor
entered and met the LPN, who was busy caring for the infant.
The LPN said she worked approximately 10 hours a day with
the infant because of the parents’ overlapping work schedules.
The surveyor received permission from the LPN to observe her
providing care. After watching her for a little while, the sur-
veyor asked the LPN to tell her about the goals that had been
set for the patient’s care and describe how the patient’s care
plan would help meet those goals. The surveyor asked the
LPN how she reported any changes in the infant’s status, if
any. [8–9] The LPN pointed to the home medical record as
her source for the plan of care and described how policy re-
quires her to contact the physician and then the main office to
report if any changes occur in addition to making notes in the
on-site record. The surveyor asked the LPN to describe an ex-
ample of how she handled a change in the infant’s condition.
[10] The LPN said one week earlier the infant had a low-grade
fever, so she contacted the physician, who ordered a small dose
of over-the-counter medicine. The LPN then contacted the
home health agency office, spoke with the RN pediatric super-
visor, and included a note in the infant’s record. The surveyor
asked the LPN to explain what she meant by “low-grade”
fever. [11]
The surveyor then mentioned to the LPN that she was told
that oxygen was delivered and set up in the home at the same
time that home care had commenced. The LPN confirmed
that was true. The surveyor asked the LPN to demonstrate
how the oxygen concentrator and the apnea monitor worked
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and what her role was with the equipment. [12] When the
surveyor and the LPN went to look at the concentrator, the
LPN and surveyor noticed that the concentrator filters were
unclean. The surveyor then asked the LPN what training and
education she received regarding the filters. [13] The LPN said
she learned how to check the concentrator and how to change
the tubing. She also explained the apnea monitor. The sur-
veyor then asked the LPN what other kinds of specialized
training she had received for pediatric care. [14] The LPN ex-
plained she had additional pediatric training for home care,
medication safety, and pain assessment.
Meeting with the Parent. Since it was nearing the end
of the LPN’s workday and the mother had arrived home from
work, the surveyor then talked with the mother about her ex-
perience with the home health agency. [15] The surveyor
asked the mother to describe the orientation and education she
and her husband received from the agency, particularly in rela-
tion to home safety and reporting any concerns about their in-
fant’s health during off-hours when the LPN was not present.
[16–17] The mother explained that they had been very happy
with the quality of care the agency provided so far. The mother
added that the LPN always updated her when she came home
and always answered any questions she had. If the mother was
confused about something, she said the LPN remained in the
home to make sure she received the clarification she needed.
The surveyor asked the mother to show her how she checked
the oxygen concentrator and apnea monitor. Then she asked
the mother to recall the last time the monitor alarmed and de-
scribe what actions she took to ensure that the baby was OK.
[18] She also asked if the mother knew how to report a prob-
lem with the machines. [19] The mother explained that she
received training from the home medical equipment company
that delivered and set up the equipment, which, she added, was
reinforced by the RN during the first few days the equipment
was used. The mother said she felt quite comfortable working
with the equipment. She then pointed to a packet of materials
the RN provided on the first day of care. The packet included
an after-hours phone number for the home care agency as well
as contact information for the home medical equipment com-
pany in case an additional delivery of oxygen needed to be
made beyond the regular schedule. The mother expressed an
overall satisfaction with the quality of care that her infant re-
ceived so far and was extremely glad to have the support so she
and her husband could continue to work.
Returning to the Agency Office for Follow-up with
the Nursing Manager. Upon return to the office, the sur-
veyor asked to review the personnel file of the LPN to verify
82
competencies and training, particularly in relation to pediatric
care. [20] The nursing manager explained the agency’s process
for initial and ongoing staff training as well as how managers
consistently monitor work performance and competencies.
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the topic of staff competencies with re-
spect to the provision of pediatric care.
Scenario 4-1.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 4-1. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Nursing Manager:
[1] Please describe the process you use to perform
supervisory visits of licensed practical nurses
(LPNs). Who is qualified to conduct these
supervisory visits? How do you determine that the
staff members who are qualified are competent in
their performance of these supervisory visits?
[2] What is your process for assessing a new patient?
[3] How do you document the assessment?
[4] What assessments should be performed for this
patient? Does your organization perform any
specialized types of assessment for specific
populations, such as pediatric patients? Who is
responsible for assessing the parent’s ability to
safely monitor the infant using the equipment
provided when the nurse is not there?
[5] What processes does your organization use to
coordinate with another organization that might be
delivering equipment or other supplies to the home?
How is the LPN trained to monitor the equipment?
What is the LPN’s role related to the equipment?
[6] What kind of training and orientation is provided to
LPNs providing pediatric care in the home? Are
additional competencies required for nurses who care
for patients with oxygen concentrators or apnea
monitors? How does your organization assess the
competency of nurses who provide this type of care?

[7] What competencies does the agency require of
LPNs who take care of pediatric cases? Can you
show me where this is documented in the personnel
record?
Licensed Practical Nurse (LPN):
[8] Can you tell me about the plan of care for this
patient? What kinds of patient activities are you
required to do in order to implement this plan of
care?
[9] What is the process you follow when your patient’s
status changes?
[10] As an example, can you tell me what happened the
last time your patient’s status changed?
[11] Based on your understanding of this patient, what
are the most important nursing concerns for this
patient? How do you assess for these conditions?
[12] Can you demonstrate how the oxygen concentrator
and apnea monitor work? What is your role? How
do you recognize respiratory distress? What
happens when the monitor goes off?
[13] What kind of training have you received on this
equipment? How do you check to see if the
equipment is working properly? What do you do if
the equipment is not working properly? What do you
do if it needs cleaning?
[14] What other specialized training and competency
have you received in relation to assessing pediatric
populations?
Parent:
[15] How do you feel about the quality of care that your
infant has received from the agency so far?
[16] What kind of orientation or training did you receive
from the home health agency? What kind of
information did agency staff share with you?
[17] How do you contact the agency during off-hours?
[18] Can you show me what you do if the alarm on the
apnea monitor goes off?
[19] What tells you that the equipment is operating
properly? What would you do if you thought
something might be wrong with the equipment?
Nursing Manager:
[20] Can you show me where training and competencies
related to pediatric care are documented in the
personnel file?
Section 4: Home Care
SCENARIO 4-2.
Home-Based Hospice Agency
Summary
In the following scenario, a surveyor traces how an organiza-
tion provides end-of-life care. Within the tracer, the surveyor
explores issues relating to these priority focus areas:
• Assessment & Care/Services
• Communication
• Medication Management
• Physical Environment
Scenario
This individual tracer was conducted in a home-based hos-
pice agency. The surveyor selected the record of an 81-year-
old male patient who was receiving end-of-life hospice care
for end-stage lung cancer. The patient was living in the
home of his daughter and her family. The patient had been
in the care of the hospice for three weeks and was receiving
end-of-life support with particular attention to pain manage-
ment, including narcotics via an infusion pump. The patient
and family were also receiving pastoral care and emotional
support.
(Bracketed numbers correlate to Sample Tracer Questions on pages
84–85.)
Reviewing the Record with the Nursing Manager.
The surveyor asked the nursing manager to review the record
with her so she could identify where the assessment, care
planning, and interdisciplinary coordination of care were
documented. [1] The surveyor also reviewed how the referral
for the patient had been received and what type of communi-
cation and documentation was included in relation to the
referral. [2–3]
The surveyor then asked the nursing manager to explain the
agency’s process to plan the interdisciplinary care for a new
hospice patient. [4] The nursing manager explained that the
agency’s policy was for nursing, the medical director, pastoral
care, and social work to convene after the initial patient assess-
ment to draft the care plan for the patient. She added that the
team met regularly to review the record and care plan and did
periodically adjust a patient’s care plan. The surveyor then
arranged to meet the nurse at the patient’s home, where the
nurse would be conducting her assessment. The nursing man-
ager had also secured permission from the patient and family
for the surveyor to visit.
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Visiting the Nurse in the Home. When the surveyor
arrived at the home, the nurse was there to meet her outside
the home. They first discussed the care plan for the patient
and what kinds of ongoing assessment and care the nurse pro-
vided during her visits. [5–6] The nurse explained that she had
met with the patient and his daughter when the patient was
referred to the agency by his physician. During her visits, she
conducts a comprehensive assessment of all systems, with par-
ticular attention to pain and medication management. The
nurse then began her visit with the patient, where the surveyor
observed her checking the patient’s infusion pump settings,
and then she discussed with the patient and the family how ef-
fectively the current settings were controlling the patient’s
pain. When the alarm to the infusion pump went off, the
nurse proceeded to administer the medication. The surveyor
observed her proficiency in changing the cassette and appro-
priate infection control technique when securing supplies
needed to change the cassette. The surveyor asked the nurse
where the pump had come from and how she determined
whether the pump required replacement. [7] The nurse ex-
plained that the agency contracts with a local pharmacy to mix
the medications and prefill the cassettes as well as provide the
infusion pump. The pharmacy also delivers needed supplies to
the home. She added that she had been trained to use the infu-
sion pump and knew to contact the pharmacy in the event
that the pump required replacement. The surveyor then asked
the nurse to explain how she verifies the correct medication
order to the correct patient and what process she follows to
dispose of narcotics safely. [8–9] The nurse then explained the
process she follows each time, by reviewing the five rights re-
lated to medication administration to the medication order,
which she had already compared to the patient’s medication
label. She shared that she also checked expiration dates. She
added that she had explained this process to the family and pa-
tient early on so they understood why she was doing this. In
addition, the nurse was able to demonstrate safe handling and
disposal protocols for the used medications.
Speaking with the Patient and Family. The surveyor
then spoke with the patient and his daughter, the patient’s pri-
mary caregiver. Because the patient was receiving care from the
nurse, the surveyor spoke primarily with the daughter. The
surveyor asked her to describe their experience with care the
agency was providing and asked whether the agency had an-
swered any questions she had. [10–11] The daughter said that
it had been nice to have her father at home and that the
agency had been a great support during this difficult time. She
added that the nurse visit, along with regular visits from vol-
unteers and the hospice’s chaplain and social worker, had been
84
very helpful to her entire family. The daughter also said that
she had ready access to the hospice and the nurse in case they
needed urgent help, including off-hours contact information.
The surveyor asked what physical symptoms she might see as
her father progressed toward end of life and what kind of emo-
tional support they were receiving or knew was available.
[12–13] The daughter accurately described end-of-life symp-
toms and explained that the hospice team had taken a lot of
time to explain what to expect and had frequently offered sup-
port and information.
Meeting with the Social Worker and the Chaplain.
The surveyor then returned to the hospice agency and met with
the social worker and the chaplain. She asked them to describe
what kind of ongoing care they were providing for this patient
and what bereavement support would be given. [14–18] After
admission, the chaplain explained that when the hospice team
had written a plan of care and after the family had expressed a
wish for spiritual care, he had arranged a visit almost immedi-
ately. The social worker explained that she had been working
with the family on securing additional volunteer resources. The
surveyor asked the staff members to describe what kind of ori-
entation and training they received in the hospice agency to
help them do their jobs effectively. [19] The staff members ex-
plained that they had both undergone orientations and that the
hospice agency provided regular, bimonthly in-service trainings
that they were required to attend. The surveyor was able to ver-
ify this training by checking their personnel records.
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the following topics:
• Organization’s assessment of its own performance
• Patient and family education
• Medication management
• Documentation
Scenario 4-2.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 4-2. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.

Nursing Manager:
[1] How do you coordinate and document the
assessment of a new hospice patient? What
processes do you have in place to ensure timely
assessment and documentation?
[2] How do you receive a new referral? How is this
referral documented?
[3] What role does the referring physician have on the
team? How do you communicate with the referring
physician?
[4] What kind of care planning is involved with new
patients? Please describe your interdisciplinary
team planning process. How often does the
interdisciplinary team meet? Where are its activities
documented?
Nurse:
[5] Please describe the initial assessment that you
conducted for this patient. What kind of ongoing
assessment do you conduct for patients, particularly
in relation to pain management and symptom
management? What happens when the patient
cannot respond to your questions about pain?
[6] What processes does the team use to manage the
patient’s medications? Does your organization use
any analgesic or medication management algorithm
as part of your care planning?
[7] If you use equipment, such as an infusion pump,
how do you maintain the equipment? How are the
supplies delivered to the patient? Who checks
whether there are expiration dates? What do you do
in the event of a problem with the equipment?
[8] How do you verify that the correct medications are
being administered to the correct patient? How do
you check expiration dates?
[9] What is your process for the safe disposal of
medications?
Patient and Family:
[10] What has your experience of care been with the
agency?
[11] What have you done if you have had questions?
How do you get responses to your questions?
[12] What kind of education have you received about
what to expect at the end of life?
[13] If you are receiving any pastoral care, what has the
experience been? Do you believe your needs have
been addressed?
Section 4: Home Care
Social Worker and Chaplain:
[14] How do you assess the needs of the patient and
family? What risk factors do you consider when
assessing for the potential for a complicated grief
reaction?
[15] What kind of involvement have you had in the care
planning for this patient? How is this involvement
documented?
[16] What is your role in the interdisciplinary process?
[17] What is the current plan to support survivors after
the patient dies? Is this what is done for all patients,
or does every patient’s family have its own plan?
[18] Please describe the ongoing care you are providing.
How do you evaluate the effectiveness of the care
you provide to the patient and family?
[19] What kind of orientation and training have you
received to do your job at this agency? What
ongoing education do you receive?
SYSTEM
Tracer Scenarios
SCENARIO 4-3.
Home Care Program with
On-Site Pharmacy
Summary
In the following scenario, a surveyor traces how an organiza-
tion manages data. Within the tracer, the surveyor explores is-
sues relating to these priority focus areas:
• Communication
• Leadership
• Information Management
• Medication Management
• Quality Improvement Expertise/Activities
Scenario
This data use system tracer was conducted in a midsize
home care program with an on-site pharmacy. The program
provided home health, personal care and support, and
home-based pharmaceutical care, including infusion pumps
and respiratory therapy. The surveyor was scheduled for four
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days, and on the second day the surveyor chose to explore
the home care program’s general use of data, paying particu-
lar attention to any recent projects related to performance
improvement. The surveyor asked the staff involved in data
use practices to meet with him to discuss the organization’s
general approach to data use. The home care program ad-
ministrator, the nursing manager, and the pharmacist met
with the surveyor.
(Bracketed numbers correlate to Sample Tracer Questions on page
87.)
Talking with the Home Care Program Adminis-
trator. The surveyor asked the home care program adminis-
trator who had primary responsibility for data collection
and analysis. [1–2] He also asked what types of data they
collect and from the data they collect how they decide when
analysis and performance improvement are required. [3–4]
The administrator explained that the program regularly col-
lected data for OASIS (Outcome and Assessment Informa-
tion Set), chart audits, falls and fall injuries, medication
errors and adverse drug reactions, and incident reports. The
administrator added that all staff members were responsible
for the collection of data and that leadership is responsible
for data aggregation and analysis.
Speaking with the Nursing Manager. The surveyor
asked the nursing manager what kinds of methods are used
for aggregation and analysis of data, to which the nursing
manager replied that she used spreadsheet software to input
data and that OASIS data were already aggregated when
the agency reviewed them. Analysis of OASIS is done
quarterly. [5]
The surveyor asked the nursing manager to share an example
of a performance improvement initiative the home care pro-
gram had put in place based on its analysis of the data. [6] The
nursing manager explained that two years earlier she had no-
ticed from analyzing the program’s incident reports that the
program was experiencing a high rate of injury from falls
among its patients. A subsequent failure mode and effects
analysis indicated that the program was providing inconsistent
interventions to help prevent falls and decrease injuries from
falls. The surveyor then asked the nursing manager to describe
changes that were made to the interventions and how the pro-
gram has monitored for results. [7] The nursing manager ex-
plained that they formed a team represented by staff and
leadership to design an improvement assessing and reassessing
a patient at risk for falls as well as a “safe house” checklist that
86
a nurse would complete with the patient and family during the
first visit. The nursing manager added that staff members have
noted a significant reduction in the number of injuries from
falls and the severity of the injuries when the patient did fall
since launching this improvement. Although injuries de-
creased, there did seem to be an increase in the number of
falls. The team hypothesized that this increase resulted from
staff and patients being more aware of when and how to report
falls.
Talking with the Pharmacist. The surveyor asked the
group members to describe a particular current improve-
ment effort that the program was undertaking. [8–9] The
pharmacist explained that they were currently undertaking
an effort to improve the communication and reporting of
medication errors and adverse drug reactions. The reason for
the initiative was that during a six-month period there had
been no medication errors or adverse drug reactions re-
ported. For the next six months the pharmacist kept a
record of the calls that came to him from staff and physi-
cians that would warrant a report to be filed. Then, staff ed-
ucation related to those events and when to file reports was
provided. The pharmacist went on to say that staff members
indicated that they were confused about when these reports
were to be completed; they thought they were to be done
only when staff members were responsible for the event.
Leadership, on an ongoing basis, reinforced that reports
were not punitive and encouraged writing the reports based
on the team’s defined criteria. As a result, analysis included
looking for trends in events in order to prevent errors in the
future. A trend was noticed in caregiver error in administer-
ing IV medications. An education worksheet was developed
for staff and caregivers, which resulted in a decrease of er-
rors. [10–13] Finally, the surveyor asked how leadership pri-
oritized what performance improvement projects would be
initiated. The pharmacist replied that such decisions were
based on the mission and vision of the organization.
Moving Forward. Based on the tracer, the surveyor
may discuss areas of improvement in the Daily Briefing. The
discussion might address the topic of factoring into an orga-
nization’s performance improvement cycle an evaluation of
whether data still needed to be collected and how, if war-
ranted, the organization would reduce, alter, or halt its col-
lection methods. The discussion might also include the
topic of proactive improvement activities, such as using fail-
ure mode and effects analysis to explore failures in the or-
ganization and to help in prioritizing improvement planning
work.

Scenario 4-3.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 4-3. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Home Care Program Administrator:
[1] Who has primary responsibility for data collection
and analysis?
[2] What is your approach to data use in the
organization?
[3] What types of data do you collect? What is your
process to collect, aggregate, analyze, and monitor
data?
[4] What are your performance improvement goals
relating to data collection?
Nursing Manager:
[5] What kinds of data collection methods do you use?
[6] Please provide an example of when data analysis
helped in prioritizing performance improvement
efforts.
[7] How did you design your improvement, implement it,
and then monitor for results?
Pharmacist:
[8] What current performance improvement efforts is
your agency involved in?
[9] How did you determine this area was a priority for
improvement?
[10] What process did you follow to design and
implement your improvement process?
[11] How did you educate staff on the new process?
[12] What procedures or processes did you change to
help facilitate this improvement?
[13] How have you monitored results so far? Are you
making any modifications to your process?
Section 4: Home Care
SCENARIO 4-4.
Hospital-Affiliated Home Health Agency
Summary
In the following scenario, a surveyor traces how an organiza-
tion handles infection prevention and control, including re-
lated data use. Within the tracer, the surveyor explores issues
relating to these priority focus areas:
• Communication
• Infection Control
• Information Management
• Quality Improvement Expertise/Activities
Scenario
This infection control system tracer was conducted in a
large, hospital-affiliated home care agency that provided
home health, personal care and support, home medical
equipment, and hospice care to patients in an urban setting.
The surveyor wanted to explore the home care agency’s gen-
eral approach to infection prevention and control practices
and review any data used for improvement efforts related to
this area. She also wanted to look at staffing roles and re-
sponsibilities, along with competencies, for infection pre-
vention and control. The home care agency director, the
agency’s nursing manager, the home care infection control
specialist, and the hospital’s infection prevention and con-
trol director participated in the discussion.
(Bracketed numbers correlate to Sample Tracer Questions on pages
88–89.)
Discussing Infection Control Practices with the
Tracer Team. First the surveyor asked the staff members gath-
ered if they could describe their infection prevention and con-
trol program and their prioritized risks from their geographic
location and population served; the results of the agency-
reported infections; and the results of their surveillance. [1–2]
The home care infection control specialist explained that their
infection prevention and control program is under the umbrella
of the hospital’s program. The home care agency did prioritize
its risk by reviewing issues specific to its setting, she said. For
example, the agency’s prioritized risk consisted of addressing
catheter-associated urinary tract infections (CAUTIs) and im-
proving hand hygiene compliance. The infection control spe-
cialist said goals were developed for these two risks, and
ongoing monitoring was being done, the results of which are
reported to the Hospital Quality Team and from there to the
Professional Advisory Committee and the Governing Board.
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The surveyor asked the hospital infection prevention and con-
trol director how the home care agency is integrated into the
hospital’s planning efforts in relation to infection control. [3]
The infection prevention and control director explained that
the home care agency’s infection control specialist was a mem-
ber of the hospitalwide infection control committee and that
she and the nursing manager were responsible for evaluating
and analyzing the data from the agency-specific infection pre-
vention and control activities and from the results of audits.
The surveyor then asked the director who was accountable to
ensure valid analysis of home care infection control data. [4]
The director explained that the agency analysis was reported to
the hospital infection control committee, which in turn pro-
vided guidance and direction. The agency infection control
specialist said that every time a patient was placed on an an-
tibiotic, this was reported by the staff to the infection control
specialist. The infection control specialist and the director re-
viewed the data quarterly or more frequently as needed to de-
termine trends. This information was forwarded to the
infection control committee then to the quality committee.
Examining a High-Risk Infection Control Example
with the Home Care Infection Control Specialist. The
surveyor then asked the home care infection control specialist
to provide an example of how this information fed into the de-
velopment of prioritized risk. [5] The specialist explained that
the home care agency had identified catheter-associated uri-
nary tract infections as a high-risk area for the agency. The sur-
veyor asked the specialist to delineate the nature of the
agency’s strategy to address CAUTIs. [6] She responded that
the agency reviewed each record of a patient with a urinary
tract infection in detail and that the agency had been conduct-
ing a series of in-service trainings with home care staff—with
particular attention focused on educating patients and care-
givers on catheter care and urinary tract infection prevention
strategies. The specialist added that they were working with
community physicians to ensure consistency in obtaining uri-
nalysis and cultures as needed for the appropriate antibiotic
use.
Reviewing Records with the Tracer Team. During the
previous day of the on-site survey, the surveyor had identified
and visited a patient with a catheter-associated urinary tract in-
fection. She asked the group to review the patient’s record with
her and discuss the infection control–related practices that
were observed during the tracer. [7] The surveyor noted that
the patient was admitted into the home care agency from the
community. The patient, who was seeing a urologist and had a
Foley catheter inserted in the urologist’s office, was referred to
88
home care due to repeated CAUTIs. The home care agency
visited the patient every three weeks to change the catheter
and bag and to check for any signs of infection. During the
visit, the surveyor observed that the nurse changed the catheter
and bag and checked the patient’s status but did not provide
any education to the patient.
Back at the office, the surveyor reviewed the record and noted
the dates the patient was placed on antibiotics and traced that
information to the infection control log. The agency did fol-
low through with the process the staff had explained to the
surveyor. The surveyor asked the group members how patient
education was incorporated into their visits specific to prevent-
ing CAUTIs. [8] The nursing manager responded that nurses
are expected to educate patients each visit based on the nurse’s
assessment, but over time, the more the nurse visits the pa-
tient, the less emphasis there may be on education. The sur-
veyor noted that in the case of the patient she traced the day
before, although the nurse performed appropriate infection
control with good hand hygiene while changing the catheter
and bag, the patient seemed confused about the process the
nurse was following and what the patient’s role was in prevent-
ing infections. [9–10]
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the idea of the organization working
with the infection control committee to ensure that all meth-
ods to reduce the occurrence of urinary tract infections are in
place, including meeting with medical staff urologists to deter-
mine whether catheter use is truly necessary for patients. The
surveyor might also address the idea of the home care agency
examining its data collection and analysis approach to
catheter-associated urinary tract infections. In addition, the
surveyor might address the topic of patient education.
Scenario 4-4.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 4-4. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.

Tracer Team:
[1] Please describe your agency’s infection control
practices. How are they structured? Who is
responsible?
[2] What issues do you focus on in the agency? Who is
responsible for monitoring them? What roles and
functions relating to infection control do you have?
[3] How do you integrate your infection control work into the
broader work of your affiliated hospital or larger health
system? How do you ensure that your perspective is “at
the table”? Is there a separate infection control
committee within the home health agency?
[4] What levels of responsibility and accountability exist
for infection control analysis in your organization?
Home Care Infection Control Specialist:
[5] What high-risk process have you opted to focus on?
Why was this process selected?
[6] What is the nature of your agency’s strategy to
address this particular infection control risk?
Tracer Team:
[7] What types of infection control–related practices are
performed in the home, particularly in relation to
catheter-associated urinary tract infections and other
related infection control risks?
[8] What type of education do you provide to patients?
[9] How do you verify that patients understand the
process? How are you making sure staff members
are able to perform this activity?
[10] What is the agency compliance with hand hygiene?
How do you measure compliance? Has compliance
improved?
SCENARIO 4-5.
Home Health Agency with
Pharmacy Dispensing Services
Summary
In the following scenario, a surveyor traces how an organiza-
tion manages medications. Within the tracer, the surveyor ex-
plores issues relating to these priority focus areas:
• Communication
• Medication Management
• Orientation & Training
• Patient Safety
Section 4: Home Care
Scenario
This tracer was conducted in a midsize home health agency
with on-site pharmacy dispensing services where the surveyor
looked at the agency’s overall medication management
processes through a medication management system tracer. He
also focused on issues related to the safe handling of medica-
tion and labeling and storage. He spoke with the agency’s
pharmacist, one of the pharmacy technicians, the home care
director, and the nursing manager.
(Bracketed numbers correlate to Sample Tracer Questions on pages
90–91.)
Reviewing the Medication Management System
with the Pharmacist. The surveyor asked the staff members
to provide an overview of their medication management sys-
tem and processes. He also asked to review any policies, proce-
dures, and guidelines used related to information about the
agency’s medication management system. [1–2] The pharma-
cist explained that she had primary oversight responsibility for
medication management in the agency and that the majority
of the medication-related activity resided in the pharmacy.
[3–5] She also explained that the agency had a medication
management committee that met periodically to look at data
related to medication management and plan for any needed
improvements. The surveyor asked the pharmacist to delineate
how the agency tracks medications from procurement, selec-
tion, storing, dispensing, and through to monitoring. [6] The
pharmacist explained that she uses an electronic software sys-
tem that allows the pharmacy to enter medications and then
dispense the medication into patient-specific prescriptions,
which would be either mailed to the patient or picked up by
the patient or family at the “pick-up window.” The surveyor
reviewed the system with the pharmacist.
Discussing Tracking with the Nursing Manager. The
surveyor then asked the nursing manager how the agency
tracks specific issues, such as having an accurate medication
list, dispensing errors, and confidentiality issues related to
pharmacist counseling. [7] The nursing manager explained
that for patients admitted to home health, the nursing staff
conducts a medication assessment and reconciliation on ad-
mission and then documents it in the patient’s medical record.
This documentation is also shared with the pharmacy, she
continued, to facilitate effective communication during transi-
tions of care between home care and the pharmacy.
Talking about Reporting Systems with the Director.
The surveyor asked the home care director to share what kind
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of reporting system was in place for reporting errors, near
misses, and adverse drug events. [8] The director explained
that the agency used an incident reporting system to report
any close calls or adverse drug events. The surveyor asked the
staff to give an example of a recent close call or adverse event
and what the agency did to respond to it. [9–10] The director
described a recent report of a close call involving a patient who
did not immediately disclose to the nurse that she was taking a
new medication that caused a harmful interaction with an-
other documented preexisting medication. The director ex-
plained that this close call caused the agency to strengthen its
process to ask patients at the outset of every visit if they were
taking any new medications.
Touring the Pharmacy with the Pharmacist and
Pharmacy Technician. Prior to touring the pharmacy, the
surveyor asked for a list of the hazardous medications the
pharmacy had on its shelves. The surveyor then began a tour
of the pharmacy, where he wanted to review the handling,
storage, and labeling of medications. [11–12] The pharmacist
and pharmacy technician were able to demonstrate the correct
handling of medications, and the surveyor observed the correct
labeling and storage of high-alert medications. The surveyor
asked who had access to the pharmacy, and the pharmacist was
able to identify a limited list of staff members who had access
to the room. [13] The surveyor then asked the pharmacy tech-
nician to explain how he handled and prepared high-alert
medications such as oral chemotherapy agents. [14] The tech-
nician explained that he underwent a specific training and
competency assessment when he started working at the agency,
and he knew the correct procedure was to wear gloves and use
appropriate hand hygiene procedures when handling the prod-
uct. The surveyor also asked the pharmacist what the process
was to dispose of medications; the pharmacist explained that
the agency followed state and federal guidelines. [15] The sur-
veyor was able to verify proper disposal during the tour. The
surveyor asked to see how the pharmacy staff dispensed con-
trolled substances and was impressed with how well staff mem-
bers knew and followed regulatory guidelines.
The surveyor concluded the tracer by reviewing the personnel
files of the pharmacist and pharmacy technician to verify their
licensure and competencies.
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the topic of the agency reviewing the
frequency at which it reviewed and updated its medications list
and what methods it used to share any ongoing changes, par-
90
ticularly in relation to high-alert and look-alike/sound-alike
medications. The surveyor might also discuss the idea of the
agency relying on readily accessible guidelines, such as those
from the National Institute for Occupational Safety and
Health, to provide helpful information to staff on how to han-
dle hazardous medications.
Scenario 4-5.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 4-5. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Pharmacist:
[1] Would you please describe your medication
management systems and processes?
[2] What documentation and monitoring systems do
you have in place for tracking medications?
[3] What kind of oversight exists for medication
management?
[4] Who is primarily responsible for medication
management?
[5] If you have a committee or team dedicated to
medication management, what staff members are
involved?
[6] What process or method do you use to track
medications from procurement through monitoring?
Nursing Manager:
[7] How do you plan for specific medication issues,
such as having an accurate and current list of
medications?
Director:
[8] What kind of reporting system do you have in place
for reporting errors, close calls, and adverse
medication events? Who is responsible for tracking
them?
[9] What kinds of adverse events or close calls do you
track?
[10] What has your response been to an example of a
situation where there was a close call or adverse
event?

Pharmacist and Pharmacy Technician:
[11] Please show me where you store all medications in
the pharmacy. What is your process for handling
medications that may look alike or sound alike?
[12] How do you ensure that all medications are correctly
labeled or stored?
[13] Who has access to the pharmacy? How do you
secure its access?
[14] How do you handle high-alert medications such as
oral chemotherapy agents?
[15] What is your process for disposing of medications?
PROGRAM-
SPECIFIC
Tracer Scenarios
SCENARIO 4-6.
Home Medical Equipment Organization
Summary
In the following scenario, a surveyor traces how an organiza-
tion handles and processes equipment and supplies. Within
the tracer, the surveyor explores issues relating to these priority
focus areas:
• Assessment & Care/Services
• Equipment Use
• Physical Environment
• Rights & Ethics
Scenario
A surveyor conducted this tracer in a suburban home medical
equipment (HME) organization, where he explored the orga-
nization’s systems to safely handle and process equipment and
supplies. He examined the storage and handling processes at
the HME organization and the delivery and setup processes at
a patient’s home. The tracer began in the facility and con-
cluded in a patient’s home.
(Bracketed numbers correlate to Sample Tracer Questions on pages
92–93.)
Overview of the Facility with the Director and
Equipment Manager. The surveyor began his tracer in the
Section 4: Home Care
HME facility, where he asked the director and the equipment
manager to speak with him about the facility. He first asked
them to tell him where the equipment was stored. He also
asked them to explain the HME organization’s process to
safely store, label, and handle equipment. [1–3] The equip-
ment manager explained that he and the equipment techni-
cians had primary responsibility for maintaining and securing
equipment, which included oxygen tanks among other equip-
ment. The surveyor asked the equipment manager if there was
a special process to ensure that oxygen was stored safely in the
HME facility as well as what type of safety guidelines were in
place for drivers to secure the oxygen tanks during transport
and delivery and for other technicians during repair or mainte-
nance of the equipment. [4–5] The HME director explained
that the organization followed manufacturer’s guidelines relat-
ing to the safe handling of equipment and that all staff had
undergone competency training to ensure safety. The surveyor
asked to see the personnel record of one of the delivery staff
members to ensure that he had taken part in training and
competency evaluation in relation to safely handling and deliv-
ering oxygen. [6]
The surveyor then asked to be shown where the equipment
staff kept maintenance logs for the oxygen and other equip-
ment. [7] The equipment manager showed the surveyor the
equipment maintenance log, which the surveyor then verified
against a selected oxygen tank. The surveyor asked the HME
director what kind of education delivery technicians provide to
patients receiving oxygen equipment. [8] He explained that all
delivery technicians are trained to provide education and train-
ing for patients not only on the correct operation of the con-
centrators but also on the safe handling of the oxygen to
prevent an adverse event such as a home fire. He showed the
surveyor the education materials that delivery technicians pres-
ent to the patients when they deliver the equipment. [9] The
surveyor asked what the process is for patients to contact the
HME organization during off-hours if they have any equip-
ment-related issues. [10] The HME director explained that
patients are given contact instructions when the equipment is
first delivered to the home.
Accompanying the Delivery Technician. The surveyor
asked to accompany a delivery technician on a home visit re-
lating to oxygen delivery or maintenance. The HME organiza-
tion had a maintenance visit scheduled for a patient receiving
oxygen. After the HME organization secured the permission
of the patient, the surveyor accompanied the delivery techni-
cian to the patient’s home. The tracer patient was a 52-year-
old man receiving oxygen to help treat his chronic obstructive
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pulmonary disease. He was also receiving home health care for
knee surgery, resulting from injuries sustained during an on-
the-job injury. The surveyor asked the delivery technician what
he typically does during a maintenance visit. [11] The techni-
cian explained that he first speaks to the patient to see how he
is doing and if he has had any problems with the equipment
since his last visit. He added that in addition to performing his
customary maintenance on the equipment, he would also
check the location of the oxygen and do a brief environmental
assessment to ensure that there were no fire safety hazards in
the home. The technician also used the oxygen analyzer to
check O2 percentages and liter flow.
The surveyor noted in his review of the patient’s record that
the patient had been flagged as a smoker. The surveyor asked
the technician what kind of smoking cessation and safety ad-
vice staff members provide to patients at risk for smoking
while using oxygen. [12–13] The technician explained that he
was not there at the initial visit when the equipment was deliv-
ered, but in a case like this one he would provide additional
information about fire safety. He added that during follow-up
visits, he would check with the patient to see if the patient had
any questions about his oxygen and check to see whether the
patient was being compliant.
After the surveyor and technician arrived in the home, the sur-
veyor observed the technician interacting with the patient. The
technician did a thorough job reassessing the patient while con-
ducting his maintenance on the tank; the surveyor also noted
the technician appropriately documenting his visit. During the
visit, the patient’s wife—who was at home with the patient,
being his primary caregiver—mentioned that they had had a
question about the oxygen but had been unsure about whether
to call the office. The technician reminded the couple about the
contact information provided on the equipment and education
materials provided and encouraged them to call at any time if
they had questions or concerns about the equipment.
Speaking with the Patient and Family. The surveyor
then spoke briefly with the patient and his wife, asking them
about their experience of receiving equipment and care from
the HME organization. [14] The patient expressed satisfac-
tion, although he complained about the smoking restrictions
placed on him, explaining that he knew of other friends or
family smoking with oxygen and nothing having happened.
When asked by the surveyor, the patient explained that he was
aware of the means to file a complaint with the organization,
but he realized this was not really a complaint, just a difficulty
with which he had to cope. [15]
92
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the topics of maintenance of equip-
ment—including how such maintenance is performed,
particularly in relation to home visits—and the value of the or-
ganization’s smoking cessation materials.
Scenario 4-6.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 4-6. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Director and Equipment Manager:
[1] Where do you store and manage your equipment?
[2] What is your process to safely store, label, and
handle equipment?
[3] Who is primarily responsible for equipment in the
organization?
[4] What type of safety guidelines and process do you
follow for specific equipment, such as oxygen?
[5] How do you instruct and train all staff involved in
handling oxygen in its safe handling, use, and
delivery? How is this documented?
[6] Would you please show me a personnel record for a
staff member who has undergone competency
training in relation to oxygen?
[7] Where do you keep maintenance logs for your
equipment?
[8] What education do your delivery technicians provide
to patients receiving special equipment such as
oxygen?
[9] What kind of patient education and training
materials do you provide in relation to this
equipment?
[10] How do you instruct patients to contact you during
off-hours?
Delivery Technician:
[11] What kind of assessment and interaction takes
place during a maintenance visit in the home?

[12] What kind of smoking cessation education do you
give to patients who are identified smokers? How do
you reassess their compliance or noncompliance
during follow-up visits?
[13] What kind of documentation do you complete during
maintenance visits?
Patient and Family:
[14] What has your experience been with this home
medical equipment organization? Have you been
able to get help with answers to your concerns or
questions?
[15] Do you know how to file a complaint about care in
the organization?
SCENARIO 4-7.
Medicare-Certified Home Health Program
Summary
In the following scenario, a surveyor traces how a Medicare-
certified home health agency addresses hospital readmissions.
Within the tracer, the surveyor explores issues relating to these
priority focus areas:
• Assessment & Care/Services
• Communication
• Patient Safety
• Quality Improvement Expertise/Activities
Scenario
This tracer was conducted in a Medicare-certified home health
agency where the surveyor explored issues related to hospital
readmission rates based on data discussed during the data use
system tracer in which the surveyor noticed a high number of
hospital readmissions during the previous year. She began the
tracer by leading a discussion with staff about the agency’s
processes to reduce hospital readmission rates and then con-
ducted a tracer for a patient who had been readmitted to the
hospital. She met with the clinical nursing supervisor, one of
the visiting nurses, and the agency administrator during the
discussion.
(Bracketed numbers correlate to Sample Tracer Questions on page
94.)
Discussing Hospital Readmissions with the Tracer
Team. The surveyor asked the agency administrator, the clini-
cal nursing supervisor, and the nurse to outline their approach
Section 4: Home Care
to reducing the incidence of hospital readmissions; she also
asked them to describe any data they have been collecting in
relation to hospital readmission rates. [1–2] The administrator
explained that their process for care planning included a com-
prehensive approach to assessment, communication, educa-
tion, and coordination of care. Because the agency provided
personal care and support services, the nursing supervisor
added, the agency was reinforcing its education of its home
health aides to ensure that they could spot any potential issues
that might create conditions for rehospitalization. [3–4] The
surveyor asked to see any documentation relating to additional
training or competency for home health aides, which the nurs-
ing supervisor (who was also the quality improvement special-
ist) was able to present to the surveyor. [5]
The surveyor asked how the agency interacted with local hos-
pitals—from which many patients were discharged into their
care—to gain better information on patients at discharge and
to communicate any identified issues, such as potential med-
ication errors, pressure ulcers, urinary tract infections, or con-
gestive heart failure. [6] The agency administrator said that
because the agency was not directly affiliated with a hospital,
this was an issue that the agency was attempting to improve,
and, in fact, agency staff members had recently been able to
participate in a number of area meetings between area home
care organizations and the hospitals to discuss ways to reduce
readmissions. The surveyor also wanted to know what kind of
education and ongoing communication is provided to patients
and their families about issues that could escalate to hospital
readmission and how to prevent them. [7] The nurse ex-
plained that she shares information with patients during her
first visit to the home and in an ongoing manner during home
visits, something she noted she tracked on the education
checklist that was included in every patient’s medical record.
Tracing the Patient with the Tracer Team. The sur-
veyor selected a record of a 72-year-old female patient who
had been discharged from the hospital into the home care
agency for postsurgery recovery and care. Within three weeks
of discharge from the hospital, the patient had to be readmit-
ted to the hospital to rule out an infection and manage pain
secondary to a stage III pressure ulcer on the ankle. The record
indicated that the patient was partially immobile from the sur-
gery but also had poor mobility preceding the surgery due to
obesity and complications relating to diabetes. [8]
The surveyor asked the staff members to describe their wound
and skin assessment process for a patient such as the one being
traced. [9–11] The nursing supervisor explained that all patients
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More Mock Tracers
undergo a skin and wound assessment on entry into care, and
the agency contracts with a wound care specialist who works
on an as-needed basis specifically with patients who require
wound care. A review of the patient’s record indicated that al-
though an initial wound care assessment had been conducted
for the patient and the wound was stage II on admission, a
consult for the wound care specialist had not been set up. The
agency administrator said although she did not know why a
referral for a wound care specialist was not made, the person
who investigates the reason probably would focus on the com-
munication at transitions of care and care planning. It was
hoped that what was learned from the investigation would en-
sure that there were no other similar outcomes. [12] The
agency, she added, had made wound care a priority, high-risk
focus area for improvement planning purposes. One plan was
to use the wound care specialist in a more regular way in an
assessment capacity for patients identified at higher risk for
pressure ulcers.
The surveyor then observed that the medical record noted that
the patient had been provided with educational material about
pressure ulcers and that the educational checklist also indi-
cated ongoing education. She then asked the nurse to explain
how agency staff members verify that a patient understands
the education. [13] The nurse responded that she often uses
practical examples and follow-up questions to verify that a pa-
tient has understood the information she has given.
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the following topics:
• The organization’s assessment plan, particularly in relation to
identifying risks for pressure ulcers and hospital readmission
• Communication and coordination of care, in particular the
importance of clear lines of communication and coordina-
tion between hospitals and home care
Scenario 4-7.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 4-7. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
94
Tracer Team:
[1] Please describe your approach to handling hospital
readmissions. Who is involved? What are you doing
to reduce their incidence?
[2] What data have you been collecting relating to
hospital readmission rates?
[3] What specific education and training do you provide
to support staff? How and when do you provide
education? How do you verify competency?
[4] Are there any other ways you have engaged staff in
helping reduce hospital readmission rates? If so,
what are they?
[5] What documentation do you have regarding training
and education for staff in relation to reducing
hospital readmission rates? Will you please show it
to me?
[6] What kind of interaction do you have with local
hospitals and/or long term care facilities to better
communicate issues that may result in hospital
readmissions? How effective is this interaction?
[7] What kind of patient education and training do you
provide regarding risk factors that can lead to
hospital readmissions?
[8] Will you please show me a record of a patient who
had to be readmitted to the hospital from home
care?
[9] What is your process to assess skin and wounds for
potential pressure ulcers or other complications?
[10] How do you communicate any issues? What type of
escalation do you normally plan for?
[11] What role does a wound care specialist play in your
assessment and care planning process?
[12] Please explain how you mitigate any potential
issues during transitions of care and if an issue
requires immediate response. How do you factor
such issues into your process?
[13] How do you verify that a patient has understood the
patient education you have provided? What type of
follow-up do you provide?

SCENARIO 4-8.
Home Health Agency
Summary
In the following scenario, a surveyor traces how a home health
agency addresses the issue of patient falls. Within the tracer, the
surveyor explores issues relating to these priority focus areas:
• Assessment & Care/Services
• Communication
• Equipment Use
• Patient Safety
• Physical Environment
Scenario
The surveyor conducted this tracer in a midsize home health
agency that provided care primarily to geriatric patients. The
surveyor wanted to explore the agency’s falls risk reduction
program and explore any issues that might lead to an increased
risk of falls among patients. The tracer began with a group dis-
cussion involving the agency’s director, nursing supervisor, and
physical therapist, and it concluded with a home visit where
the surveyor wanted to see how the agency had assessed and
intervened with a patient designated as being at risk for falls.
(Bracketed numbers correlate to Sample Tracer Questions on page
96.)
Overview of Falls Risk Reduction Program with the
Tracer Team. The surveyor began the discussion by asking
the staff members what their process was to evaluate patients
for falls risk, including what actions they might take when a
patient is designated a falls risk and what types of reassess-
ments they conduct for at-risk patients. [1–4] The director ex-
plained that because the majority of the agency’s patient
population was elderly, they had decided to integrate a more
comprehensive falls risk assessment for all of their patients, in-
cluding looking at the in-home environment, medication
usage, current medical condition and recovery, and preexisting
conditions. As a result, she added, they had been able to inter-
vene earlier and had seen a reduction in the number of re-
ported falls.
The surveyor then asked the director what types of data the
agency collected in relation to falls risk and what it does
with that information. [5–7] The nursing supervisor, who
was also the agency’s improvement specialist, noted that the
agency collected and submitted data on witnessed and un-
witnessed falls. Those data, she explained, had actually
Section 4: Home Care
helped the agency improve its falls risk reduction program
because the data had indicated that some falls were occur-
ring among patients that the agency had previously desig-
nated as not being a falls risk.
The surveyor asked the staff members to provide examples
of ways that staff intervene and promote falls risk reduction
when in the home. [8–9] The nursing supervisor explained
that all staff members who visit the home, including physi-
cal therapists, home health aides, and nursing staff, take
time during each visit to work with patients on falls risk is-
sues, including ensuring that the physical environment is
safe and educating the patient and family about safe behav-
iors that will help prevent falls. The surveyor then verified
where this education was documented in the patient’s
record.
The surveyor asked the physical therapist what types of in-
terventions and education he provides to patients during
physical therapy home visits in relation to falls and falls risk.
[10–11] The physical therapist noted that the important
factor is for patients to disclose whether they have had a fall
and to understand the importance of moving (or not mov-
ing) safely. The surveyor asked the physical therapist what
he does in the event of a patient fall while in the home. [12]
The physical therapist explained that the first priority is to
ensure the patient’s safety and well-being and then to con-
tact the agency and emergency services if necessary. The next
priority, he explained, would be to report the incident to the
agency, document the incident, and then take whatever
measures are necessary to ensure that the patient and home
environment are safe.
Talking with the Physical Therapist. After request-
ing and receiving permission, the surveyor traveled with the
physical therapist to visit an 82-year-old female patient who
was at the home of her son and daughter-in-law while recu-
perating from hip replacement surgery. She was receiving
postsurgical care, bathing and other personal care assistance,
and physical therapy/mobility exercises from the home
health agency. The patient’s record indicated that on entry
to home care, the agency had assessed and indicated the pa-
tient was at risk for a fall. The surveyor observed appropriate
interventions in the home, including the removal of slip
rugs and other loose objects and the relocation of the pa-
tient from her second-floor bedroom to the ground-level
guest bedroom. [13–15] She also observed that the physical
therapist conducted a reassessment for falls risk at the begin-
ning of his visit with the patient.
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More Mock Tracers
Speaking with the Family Caregiver. While the
physical therapist was working with the patient, the sur-
veyor spoke with the patient’s daughter-in-law, who was also
functioning as the patient’s primary caregiver. She asked her
how her experience of care had been with the home health
agency, to which the daughter-in-law responded they were
satisfied with care and that it had been very effective so far.
[16] The surveyor also asked what type of education and
support they had received in relation to changing the home
environment to prevent her mother-in-law having a fall.
[17] The daughter-in-law explained that it had been quite
complicated to change things around, but they understood
the reason for it. One challenge, she added, was making sure
her children did not leave toys or other items on the floor to
present an additional hazard.
After the surveyor returned to the office, she reviewed
the contract the agency had with the physical therapy
company. She also reviewed the physical therapist’s file for
competencies.
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the following topics:
• Sharing best practices with national associations or agencies
for use in training efforts
• Techniques such as root cause analysis to discover the
reasons for a patient fall, which can help with planning and
future prevention activities
Scenario 4-8.
Sample Tracer Questions
The bracketed numbers before each question correlate
to questions, observations, and data review described in
the sample tracer for Scenario 4-8. You can use the
tracer worksheet form in Appendix B to develop a mock
tracer (see an example of a completed tracer worksheet
at the end of this section). The information gained by
conducting a mock tracer can help to highlight a good
practice and/or determine issues that may require
further follow-up.
Tracer Team:
[1] Please describe your falls risk reduction program.
[2] How do you assess patients for falls risk?
96
[3] What actions do you take when a patient is
designated a falls risk?
[4] What ongoing fall assessments and
reassessments do you conduct?
[5] What types of data do you collect in relation to
falls risk? How do you use these data?
[6] What external reporting requirements relating to
falls risk do you meet?
[7] How have the data assisted you with your
agency’s improvement efforts?
[8] How are staff members trained to intervene and
respond to falls risks?
[9] What specific interventions will staff carry out to
reduce falls? How are these actions documented?
[10] When physical therapy staff members visit the
home, what types of falls risk reduction activities
do they carry out?
[11] What education do you provide to patients? How
are patients and families educated about home
environment hazards?
[12] What is your response in the event of a patient
fall? How is this response documented?
Physical Therapist:
[13] How do you assess the home environment for falls
risk?
[14] What falls risk interventions have you put in place
in the home environment?
[15] How do you reassess the patient on returning
home visits?
Family Caregiver:
[16] What has your experience of care been with the
home health agency?
[17] How have you been educated about falls risk? Do
you understand why the home health staff
members have asked you to make changes in the
home environment? Do you understand what
would constitute a falls risk?
 Section 4: Home Care

Sample Tracer Worksheet: Scenario 4-7.

The worksheet below is an example of how organizations can A correct answer is an appropriate answer that meets the re-
use the sample tracer questions for Scenario 4-7 in a worksheet quirements of the organization and other governing bodies.
format during a mock tracer. The bracketed numbers before An incorrect answer should always include recommendations
each question correlate to questions described in the scenario. for follow-up.

Tracer Team Member(s): Jan Bock Data Record(s): wound—hospital readmit

Subjects Interviewed: Samantha van Buuren, Unit(s) or Department(s):
Maria Martinez, Lashawna Henderson
Tracer Topic or Care Recipient: hospital
readmission

Interview Subject: Tracer Team

Questions Correct Incorrect Follow-Up Comments or

Answer Answer Needed Notes
[1] Please describe your ✓ Staff answered
approach to handling hospital appropriately.
readmissions. Who is involved?
What are you doing to reduce
their incidence?

[2] What data have you been
collecting relating to hospital
readmission rates?
[3] What specific education and
training do you provide to
support staff? How and when do
you provide education? How do
you verify competency?
✓ May need additional Inconsistent under-
staff training. standing of available data
and collected data.
✓ Staff members were aware
of the education and able to
demonstrate evidence in the
documentation.

[4] Are there any other ways you ✓

have engaged staff in helping
reduce hospital readmission
rates? If so, what are they?

[5] What documentation do you ✓

have regarding training and
education for staff in relation to
reducing hospital readmission
rates? Will you please show it to
me?
(continued)

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Interview Subject: Tracer Team (continued)

Questions Correct Incorrect Follow-Up Comments or

Answer Answer Needed Notes
[6] What kind of interaction do ✓ Identified as an issue by
you have with local hospitals the agency staff. New
and/or long term care facilities project under way.
to better communicate issues
that may result in hospital
readmissions? How effective is
this interaction?

[7] What kind of patient ✓ Good demonstration of

education and training do you available educational
provide regarding risk factors material.
that can lead to hospital
readmissions?

[8] Will you please show me a ✓

record of a patient who had to
be readmitted to the hospital
from home care?

[9] What is your process to ✓ May need reinforcement Staff demonstrated

assess skin and wounds for or a review of the current inconsistent approach,
potential pressure ulcers or process. particularly in this traced
other complications? record.
[10] How do you communicate ✓
any issues? What type of
escalation do you normally plan
for?

[11] What role does a wound
care specialist play in your
assessment and care planning
process?
[12] Please explain how you
mitigate any potential issues
during transitions of care and if
an issue requires immediate
response. How do you factor
such issues into your process?
✓ Review how to follow up. This process is inconsistent.
Staff not clear on when a
wound care specialist should
be utilized.
✓ Same as above. Unclear
process and
underutilization of wound
care specialist.

[13] How do you verify that a ✓ Good examples provided.

patient has understood the
patient education you have
provided? What type of follow-
up do you provide?

98

Tracer Scenarios for
LONG TERM CARE
NOTE: No Two Tracers Are the Same
Please keep in mind that each tracer is unique. There is no
way to know all of the questions that might be asked or
documents that might be reviewed during a tracer—nor
what all the responses to the questions and documents
might be. The possibilities are limitless, depending on the
SECTION 5
tracer topic and the organization's circumstances. These
tracer scenarios and sample questions are provided as an
educational or training tool for organization staff; they are
not scripts for real or mock tracers.
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Section Elements
This section includes sample tracers—called scenarios—relevant to long term care. Individual, system, and program-specific
tracers are represented. The section is organized as follows:

Scenarios: Each scenario presents what might happen when a

surveyor conducts a specific type of tracer. The scenarios are
presented in an engaging narrative format in which the reader
“follows” the surveyor through the tracer scenario. Within the
narrative are bracketed numbers that correspond to numbered
sample tracer questions following the tracer.

Sample Tracer Questions: After each scenario narrative is a list

of sample questions a surveyor might ask during that scenario.
These questions can be used to develop and conduct mock tracers
in your organization on topics similar to those covered in the
scenario.

Sample Tracer Worksheet: At the end of the section is a sample

worksheet that shows how the sample tracer questions for one
select scenario in the section might be used in a worksheet format.
The example shows how the worksheet might be completed as
part of a tracer for that scenario. A blank form of the worksheet is
available in Appendix B.

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INDIVIDUAL
Tracer Scenario
SCENARIO 5-1.
Small Nursing Facility
Summary
In the following scenario, a surveyor traces how a small nurs-
ing facility handles a close call, or near miss, regarding a fall.
Within the tracer, the surveyor explores issues relating to these
priority focus areas:
• Assessment & Care/Services
• Communication
• Orientation & Training
• Physical Environment
• Staffing
Scenario
A surveyor conducted this tracer in a 14-bed nursing facility in
a suburban area. The facility provides both short-term rehabili-
tation care and long term care. The surveyor selected a 53-
year-old male resident who was in short-term rehabilitation
following a total knee replacement surgery. The medical record
indicated he had nearly fallen two days earlier.
(Bracketed numbers correlate to Sample Tracer Questions on page
102.)
Speaking with Nursing Staff. The surveyor began her
tracer with the nursing staff, asking the nurse what the general
care process is for residents admitted for short-term rehabilita-
tion. [1–2] The nurse indicated that the resident arrives at the
facility with specific orders from the physician. In this case, the
resident required palliative care and mobility exercises with
physical therapy. The surveyor asked what kind of ongoing as-
sessments she provides as part of the palliative care. [3–4] The
nurse responded that pain management and medication man-
agement were the primary concerns, as well as wound care.
She also added that the resident was receiving daily physical
therapy.
The surveyor noted that the resident was designated as a
falls risk due to the nature of his admission and that he had
a recently documented close call, or near miss. [5] The
nurse responded that the resident had attempted to walk to
Section 5: Long Term Care
the toilet in his room without waiting for assistance; the fall
was averted only because a staff member had been walking
past the resident’s room and was able to intervene and assist
the resident. The surveyor asked the nurse what kind of in-
terventions the nursing facility had put in place to prevent
any further close calls or actual falls. [6–7] The nurse ex-
plained that after a resident has been designated as a falls
risk, a large star is put on his or her record to help prompt
greater mindfulness by staff. In the case of this resident, the
nurse noted that due to the resident’s general good health
preceding his admission to the hospital for knee surgery and
subsequent discharge to short-term rehabilitation, along
with his desire to “get better” faster, the nursing staff needed
to provide more regular checks on the resident, in particular
to ensure that he had assistance going to the bathroom. The
nurse added that staff members had also spent time educat-
ing and working with the resident on the importance of al-
lowing staff to assist him with ambulating. [8]
Meeting with the Resident. The surveyor then visited
the resident’s room to discuss his experience of care in the
nursing facility. [9–11] The resident said that he had been
generally happy with the quality of care and was eager to
improve so he could go home. He was satisfied with the
pace of physical therapy and said his pain was being man-
aged appropriately. The surveyor asked what kind of educa-
tion and information was provided to him before being
discharged into the nursing facility. [12] The resident re-
sponded that due to the nature of his surgery, the physician
wanted to discharge him into rehabilitation until he was
more mobile. He noted that he understood the nature of the
care plan and that the nursing facility staff had explained it
to him well.
The surveyor asked the resident if he understood he had been
designated a falls risk. [13] The resident acknowledged that he
knew and said he understood why, but he said he believed the
constant checks on him were unnecessary. He said he had
agreed to be more patient in the future and had not moved
without assistance since the close call three days earlier. The
surveyor asked what kind of educational materials had been
provided to him, to which the resident responded that he had
received materials on pain management and falls, as well as in-
formation on discharge from the nursing facility. [14]
Moving Forward. Based on the tracer, the surveyor
may discuss areas of improvement in the Daily Briefing. The
discussion might address the topic of reducing the risk of
falls.
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Scenario 5-1.
Sample Tracer Questions SYSTEM
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
Tracer Scenarios
sample tracer for Scenario 5-1. You can use the tracer
worksheet form in Appendix B to develop a mock tracer SCENARIO 5-2.
(see an example of a completed tracer worksheet at the end
of this section). The information gained by conducting a mock Large Nursing Facility
tracer can help to highlight a good practice or determine
issues that may require further follow-up. Summary
In the following scenario, a surveyor traces how an organiza-
Nursing Staff: tion manages data use. Within the tracer, the surveyor explores
[1] What is your process to care for short-term issues relating to these priority focus areas:
rehabilitation residents?
• Assessment & Care/Services
[2] How do you receive your orders for care, treatment, • Communication
and services? How are these orders documented? • Orientation & Training
[3] What kind of ongoing assessments do you provide for • Physical Environment
a rehabilitation resident? • Staffing
[4] How do you assess for pain? When do you reassess?
[5] How do you assess for falls risk? What else can trigger Scenario
a falls risk designation? This data use tracer was conducted by a surveyor in a 200-bed
[6] If a resident is designated as a falls risk, what nursing facility located in an urban setting. The surveyor
interventions do you provide? wanted to explore how the facility approached data and how it
[7] How do you follow up on this intervention? What used data in improvement efforts, paying particular attention
modifications do you make with regard to particular to the facility’s data relating to dementia screening and assess-
issues a resident may face? ment practices. The tracer took place during a meeting that in-
[8] What kind of education do you provide to residents cluded the facility administrator, the nursing director, and the
about falls risk and falls prevention? improvement specialist.

Resident: (Bracketed numbers correlate to Sample Tracer Questions on pages

[9] What has your experience been with care at the
103–104.)
nursing facility?
[10] What type of care has been provided? Has this been
explained to you by staff?
Discussing Data Use Practices with the Facility Ad-
ministrator. The surveyor asked the facility administrator to
[11] Have you been assessed for pain? How often does
describe the method of data use and collection for the nursing
staff do this assessment? Is your pain being managed
well? facility. [1–4] The facility administrator said that the nursing fa-
cility focused its data collection efforts on areas such as pressure
[12] Please tell me about your experience with discharge
planning while you were in the hospital before being ulcers, screening and assessments, and infection rates. In addi-
admitted to the nursing facility. Did you have enough tion, he said that the facility selected certain data collection and
information? Did you have the ability to have your analysis approaches based on the emergence of certain trends;
questions answered? for example, a rise in certain types of infections such as MRSA
[13] You have been designated as a falls risk by the nursing (methicillin-resistant Staphylococcus aureus). He added that the
facility. Do you understand what that means? Do you responsibility for data analysis rested with the improvement spe-
understand why the staff has put certain interventions
cialist, although the facility did have a performance improve-
in place?
ment committee that met periodically to deal with oversight.
[14] What kind of education have you received while in the
nursing facility? Do you have any questions that you
have not had answered? Discussing Data Analysis with the Improvement
Specialist. The surveyor asked the improvement specialist to

102

describe how the facility analyzes and utilizes the data. The im-
provement specialist explained that she uses spreadsheet and
database software for data entry and then focuses on aggregat-
ing and analyzing the data, with the help and support of the
performance improvement committee. The surveyor asked
what the facility does with the data analysis. [5–6] The im-
provement specialist mentioned a recent incident in which a
resident was erroneously diagnosed as having dementia. The
resident had actually been disoriented and confused due to the
effects of medication, and the documentation stated that the
resident had dementia, even though the record had no indica-
tion of a screening, assessment, or diagnosis of dementia. As a
result, the resident was being treated for dementia while still
showing the adverse effects of medication. When the facility
did a record review, the lack of a dementia screening or assess-
ment was identified, and then when the resident was properly
assessed for dementia, it was correctly identified that she was
in fact suffering from the adverse side effects of medication.
Discussing Intervention Outcome with the Nursing
Director. The surveyor asked what the outcome of the inter-
vention had been. [7] The nursing director responded that the
committee performed a failure mode and effects analysis and
discovered that the triggers for resident assessment were not as
clearly defined as they should have been. The facility refined
its process and reeducated staff. Now the medication and de-
mentia screenings happened concurrently, and staff members
were advised to verify a change in treatment by reviewing the
care plan in the medical record for clear documentation of it.
Talking with the Nursing Director and the Im-
provement Specialist About Staff Education. The sur-
veyor asked the staff what type of data use training and
education had been provided to the performance improvement
staff. [8–9] The nursing director said that the facility had es-
tablished a performance improvement specialist role three
years earlier and recruited into the position a staff nurse who
had a background and experience in data analysis. The im-
provement specialist said that in addition to being able to at-
tend an occasional training workshop hosted by the state
association, she belonged to a national association focused on
performance improvement and went to its Web site and ac-
cessed online training seminars to enhance her knowledge
whenever she could.
Discussing Current Performance Improvement Ef-
forts with the Tracer Team. The surveyor asked the staff
members to share one current improvement project based on
the data use practices that they had under way. [10] The facil-
Section 5: Long Term Care
ity, the nursing director explained, was currently focused on
improving resident and family education due to recent data
from resident satisfaction reviews that indicated residents were
unhappy with the quality of education and communication
they received from the facility.
The surveyor asked the staff members what kind of interven-
tion the facility had planned, how they had implemented it,
and what results they were monitoring so far. [11] The im-
provement specialist responded that the committee had been
pilot testing some new educational materials and had planned
a number of additional follow-up outreach phone calls for the
family members of residents to help reinforce information and
answer any questions.
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the topics of resident assessment and
data use.
Scenario 5-2.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 5-2. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Facility Administrator:
[1] What is your process to manage data at the facility?
[2] Please describe your methods to collect and input
data. How do you analyze your data? Can you
describe your methods to use and monitor the data?
What reporting processes do you follow?
[3] Are there any particular areas of focus in your data
collection approach?
[4] Who has responsibility for managing the data? Is
there a committee that has any oversight for
performance improvement?
Improvement Specialist:
[5] What do you do with your data?
(continued)
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meet with the nursing director and the facility’s infection control
Scenario 5-2. specialist.
Sample Tracer Questions
(Bracketed numbers correlate to Sample Tracer Questions on page
(continued) 105.)
[6] Can you point to an example of a time when you
used your data in a specific improvement effort? Discussing Infection Control Practices with the Nurs-
ing Director and the Infection Control Specialist. The sur-
Nursing Director: veyor asked the nursing director and the infection control
[7] What outcome have you observed based on the specialist to first explain what kind of infection control plan they
intervention that you planned? had in place and to share what related data the facility collects
and analyzes. [1–2] The nursing director said that they track
Nursing Director and Improvement hand hygiene surveillance data, flu vaccinations, catheter-
Specialist: associated urinary tract infections, and pressure ulcer–associated
[8] What type of education and training have you infections. The nursing director added that the facility analyzes
provided to staff responsible for quality data for negative trends, such as a rise in pressure ulcer cases
improvement?
among residents. The surveyor asked what sort of oversight the
[9] What additional resources do you have access to? facility had in place in relation to infection prevention and con-
trol practices. [3–4] The infection control specialist replied that
Tracer Team: the facility had an infection control team that meets quarterly to
[10] What are some current performance improvement
go over data and planning efforts. The surveyor asked who re-
efforts your facility is undertaking? Please select
ceives the infection control–related data reports and at what fre-
one to outline and describe.
quency. [5] The nursing director responded that she produces a
[11] What kind of improvement did you plan? How did report once each quarter and it circulates to the infection control
you implement and monitor results? What reporting
team and the rest of the facility’s leadership.
process do you have in place?

Talking with the Nursing Director About Staff Train-

ing and Education. The surveyor then asked the nursing di-
rector to explain how she had come to be in this position and
SCENARIO 5-3. what formal training she had in relation to infection prevention
Midsize Nursing Facility with and control. [6–7] The nursing director said that she had been
in this role for about two years but had no prior specific experi-
Subacute Care Unit ence as a nursing director aside from her experience as a regis-
tered nurse. She said that she had received on-the-job training
Summary and had attended courses through the national association con-
In the following scenario, a surveyor traces how an organiza- cerning infection control.
tion handles infection prevention and control. Within the
tracer, the surveyor explores issues relating to these priority Reviewing Current Prevention Practices with the
focus areas: Nursing Director. The surveyor asked the nursing director to
• Assessment & Care/Services discuss the facility’s current infection prevention and control
• Communication practices. [8–9] The nursing director said that during an infec-
• Infection Control tion control team meeting the previous year, she had reported an
• Organizational Structure increase in the number of pressure ulcers and subsequent infec-
tions, which had also resulted in an increase in hospital readmis-
Scenario sions. The team opted to launch an improvement project focused
This infection control system tracer was conducted in a 92-bed on reducing the number of pressure ulcers and pressure ulcer–
nursing facility that included a subacute care unit. The surveyor related infections. Through a failure mode and effects analysis,
wanted to explore the facility’s infection control plan and any the team discovered that skin risk assessments were being con-
specific infection prevention and control activities. She asked to ducted in an inconsistent manner, that stage I and stage II ulcers

104
 Section 5: Long Term Care

were not being reported in a timely manner, and that there were
no wound care specialists on staff. Nursing Director and Infection Control
Specialist:
The surveyor asked what type of intervention the team designed [1]
and implemented. [10] The nursing director responded that the
facility opted to provide more education for staff on identifying [2]
and reporting pressure ulcers and on conducting consistent skin
[3]
assessments. The facility also decided to contract in a wound care
specialist not only to help conduct wound care but also to train
and monitor staff activities in relation to skin assessment and [4]
wound care. The specialist also reviewed and modified the facil-
ity’s pressure ulcer staging, wound care, and skin assessment
protocols. [5]
The surveyor asked what kind of response the facility had tracked
since implementing the improvement. [11] The nursing director Nursing Director:
explained that she had been tracking the number of reported [6]
pressure ulcers since the launch of the intervention and the rate
had decreased, along with related infections, though it was still
slightly above the goal rate. In addition, the team was conducting [7]
periodic infection control tracers to see how well staff members
understand the newly revised protocols and process. Although
some staff members still needed help conducting consistent skin [8]
assessments, the wound care specialist was working with the facil-
ity and mentoring staff. The nursing director added that she be-
[9]
lieved the facility was close to achieving its goal rate. [12]
What kind of infection prevention plan does the
facility have in place?
What kinds of data do you collect and analyze?
Who is responsible for collecting and tracking the
data?
What sort of oversight does your organization put in
place relating to infection control? What kind of
monitoring do you have in place?
Who creates and receives infection control–related
reporting? How often are reports generated?
What kind of background and training do the
infection prevention and control staff members
have?
What ongoing training and resources do the
infection prevention and control staff members have
access to?
What current infection prevention and control
practices are in place?
What data analysis led you to choose to undertake
this improvement project?

Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The discus-
sion might address the topic of staff training and education as
well as the topic of infection control as it relates to the following
issues:
• Hand hygiene
• Catheter-associated urinary tract infections
• Pressure ulcer–associated infections, including skin assessment
and wound care
[10] How did you design your improvement project?
What are the core elements of the improvement
project? Please describe how you implemented the
improvement and how you have been monitoring for
results.
[11] What kind of response have you seen to the
initiative?
[12] What are your next steps?

Scenario 5-3. SCENARIO 5-4.

Sample Tracer Questions Long-Stay Nursing Facility
The bracketed numbers before each question correlate to Summary
questions, observations, and data review described in the In the following scenario, a surveyor traces how an organiza-
sample tracer for Scenario 5-3. You can use the tracer
tion manages medications. Within the tracer, the surveyor ex-
worksheet form in Appendix B to develop a mock tracer
plores issues relating to these priority focus areas:
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
• Communication
a mock tracer can help to highlight a good practice and/or • Medication Management
determine issues that may require further follow-up. • Organizational Structure
• Staffing

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Scenario
The surveyor conducted this tracer in a 110-bed nursing facil-
ity that served a predominantly long-stay population. The sur-
veyor wanted to explore the facility’s medication management
system and processes. The surveyor met with the facility’s con-
sulting clinical pharmacist, the nursing director, and the med-
ical director.
(Bracketed numbers correlate to Sample Tracer Questions on pages
106–107.)
Discussing Medication Management Practices with
the Medical Director. The surveyor asked the medical direc-
tor to explain the facility’s medication management process.
The surveyor also asked what the process was to collect, aggre-
gate, analyze, and track data relating to medication manage-
ment. [1–3] The medical director said that he had oversight
responsibility for the medication management processes and
that he worked with the pharmacist on reviewing residents’
medication regimen. In addition, the facility had a medication
management team consisting of facility leadership that addressed
periodic issues relating to medication management.
Talking About High-Alert Medication Practices
with the Tracer Team. The surveyor asked the team mem-
bers to explain what high-risk areas they had identified in their
medication management process. [4] The pharmacist said that
the facility tracked International Normalized Ratios for anti-
coagulants, adverse drug events, and pain management
through appropriate medication management. The nursing di-
rector replied that the safe management of multiple medica-
tion regimens for residents was the biggest concern. The
surveyor asked whether the facility had been tracking any data
related to this issue. [5–6] The consulting clinical pharmacist
explained that a failure mode and effects analysis indicated
that the vast majority of adverse medication events occurred
among residents on multiple medications.
The surveyor asked the team members to describe the nature
of their intervention to improve the safety of multiple med-
ication regimens. [7–8] The pharmacist responded that the
facility conducted regular monthly reviews of any resident
on multiple medications and had been working to reduce
the number of medications administered—when possible,
by employing therapeutic, nonmedication measures. In ad-
dition, the team members had opted to provide additional
training to staff on particular medication-related side effects
so that they could alert staff about any potential adverse
medication events.
106
The surveyor asked the team to discuss the non-medication-
related therapeutic interventions that the facility was using with
residents. [9] The nursing director said that the dietitian and the
physical therapist had been involved in the planning to suggest
and implement alternative treatments when trying to reduce a
resident’s complex medication regimen. The medical director of-
fered the examples of interventions such as changing the resi-
dent’s position in bed or darkening a room to relieve pain or
discomfort. The surveyor asked how staff had been educated and
trained on implementing nonmedication interventions. [10] The
nursing director said that some staff members were still getting
used to the new approach but that it gradually was becoming
more widely accepted.
The surveyor then asked what kinds of results the team was see-
ing so far in its effort to effectively cope with complex medica-
tion regimens. [11] The pharmacist said that in general the data
indicated a reduced rate of adverse medication errors, and the
team had successfully and safely reduced the number of complex
medications among a number of residents so far.
Touring the Facility with the Pharmacist. The surveyor
then proceeded to tour the facility to observe the medication
storage area. The high-alert medications were identified with
clearly distinguishable labels. The surveyor asked the pharmacist
who had access to the storage room. [12] The pharmacist replied
that he, the medical and nursing leadership, and the nursing staff
had access to the locked room. The surveyor then asked to see
the medication storage cart, which was properly secured and
locked. [13] The surveyor also visited the vaccine storage area.
[14] He observed that the vaccines were correctly stored in a re-
frigerator and were appropriately dated and labeled.
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The discus-
sion might address the topic of medication management.
Scenario 5-4.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 5-4. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.

Medical Director:
[1] What is the facility’s medication management
process?
[2] What process do you have to collect, aggregate,
analyze, and track data relating to medication
management?
[3] Who has oversight responsibility for the
medication management process?
Tracer Team:
[4] What high-risk areas have you identified and do
you track in your medication management
process?
[5] What is your biggest concern? How are you
tracking it?
[6] What analysis tools have you used to identify
major areas of concern in medication
management?
[7] Please describe the nature of your analysis. What
type of interventions have you implemented? How
are you tracking results?
[8] What education and training have you provided to
staff in relation to this intervention?
[9] What kinds of nonmedication therapeutic
interventions do you utilize in the facility?
[10] How have you educated staff on these
interventions?
[11] What kinds of results are you seeing in relation to
your interventions?
Pharmacist:
[12] How do you store medications? What is your
process to safely handle them? Who has access
to the storage room?
[13] Please indicate where you keep medication carts.
How do you secure them?
[14] Where do you secure and store vaccines?
Section 5: Long Term Care
PROGRAM-
SPECIFIC
Tracer Scenarios
SCENARIO 5-5.
Small Nursing Facility with
Rehabilitative Care
Summary
In the following scenario, a surveyor traces how an organiza-
tion cares for a resident and addresses the resident’s specific
needs. Within the tracer, the surveyor explores issues relating
to these priority focus areas:
• Assessment & Care/Services
• Communication
• Physical Environment
• Rights & Ethics
Scenario
This tracer took place in an 18-bed nursing facility that provided
both long-term and short-term rehabilitative care. The surveyor
met with staff to review the resident roster and chose to trace a
55-year-old male long term care resident with diabetes. The resi-
dent was morbidly obese and had been diagnosed with type 2
diabetes nine months earlier. According to the resident’s record,
the resident was admitted to the nursing facility for short-term
rehabilitation from foot surgery after being discharged from the
hospital eight weeks earlier. Due to poor progress with rehabili-
tation and wound healing and difficulty getting the medications
and management of the disease under control, the resident had
been moved to long term care in the facility.
(Bracketed numbers correlate to Sample Tracer Questions on pages
108–109.)
Talking with the Resident. Prior to coming to the facil-
ity, the resident had lived alone. The surveyor asked permis-
sion to meet with the resident and discuss his experiences in
the organization, to which the resident agreed. [1] The sur-
veyor then met privately with the resident. The resident said
that he was satisfied with the facility and that the nurses and
nurses’ aides provided good care to him, but he was discour-
aged that he had not been able to go home yet. [2] The sur-
veyor asked if he understood why he had not been discharged
from the nursing facility yet. [3–4] The resident replied that
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he did understand and had been trying harder to comply with
the treatment plan. He added that the staff members did not
always explain why some treatment had to happen at certain
times, with which he found difficult to comply. [5]
The surveyor asked the resident to describe his experience of
residing in the facility. [6–8] The resident said that some
nurses and aides were nicer than others because they took time
to explain what was happening. He also added that with his
difficulty moving, he could not always join in activities, so he
was grateful when he had visitors and television available in his
room. He said he had never had a problem with getting help
from staff as long as he was patient.
The surveyor asked him if he knew about the resident council
and if he had ever attended a session. [9–10] The resident re-
sponded that he had not felt mobile enough to attend a meet-
ing yet, but he did receive some reading materials based on
past meetings. He added that the resident representative had
visited him and asked him if he had any complaints or con-
cerns; his only concern so far had been trying to cope with the
loneliness of the prolonged stay and infrequency of visitors.
The surveyor asked if staff had offered to help him go to a
meeting or activity, even with his lack of mobility, and the resi-
dent answered yes. He added that he hoped to attend the next
meeting, if he continued to progress. [11]
The surveyor finally asked the resident about his experience
with food in the facility. [12] The resident said that he under-
stood he was on a strict diabetic diet to help control his disease
but that the quality of the food was not very good. The sur-
veyor asked if he had given any feedback to the facility or re-
ported a concern through the resident council, and the
resident responded that he had not complained because he as-
sumed the food quality was related to the restricted diet.
The surveyor thanked the resident and continued on her sur-
vey, but she checked in with the resident during the course of
the day to observe him receiving physical therapy and point-
of-care testing. [13]
Observing and Conferring with Staff. The surveyor
observed a good rapport between the resident and staff mem-
bers, and care was carried out appropriately. She then checked
the resident’s record to note the documentation by staff, which
was appropriately completed. [14]
The surveyor then met with staff members to discuss their care
for this resident. She asked a nurse what kind of accommoda-
108
tion the facility had to make for the resident, considering his
size. [15–16] The nurse responded that the facility used an ap-
propriately sized walker during physical therapy and a bariatric
wheelchair to help move the resident to activities. The sur-
veyor asked the nurse what kind of training she had received
to accommodate and support obese residents, and the nurse
replied that she had received training during her orientation
but noted that the quality improvement staff also provided pe-
riodic updates and training on new equipment. [17]
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the following topics:
• Resident education
• Staff training and education
Scenario 5-5.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 5-5. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Resident:
[1] What has your care experience been like in the
facility?
[2] Do you have any concerns about your experience of
stay here in the facility?
[3] Do you understand why your stay in the facility has
been prolonged? How was this information
communicated to you?
[4] Have you been able to get your questions answered
about your care?
[5] What do you do if you do not understand the reason
for a particular treatment?
[6] What has the resident experience been like for you
in the facility?
[7] Are there any activities in which you have been able
to participate? Do you have access to television or
other forms of entertainment, if you wish it?
[8] Are you able to receive visitors in your room?

[9] Have you been able to participate in any resident
council meetings? Do you know when they are
taking place?
[10] Have any resident representatives met with you?
Are you aware of the information being shared at
the meetings?
[11] Have staff members been able to help
accommodate you to attend any resident meetings
or activities?
[12] What is your opinion of the food in the facility? Do
you know how to report any concerns, if you have
any?
[13] What kind of care do you receive during the day?
Staff:
[14] How do you document the care or services you are
providing to the resident?
[15] What kind of accommodation do you make for
residents who are of larger size?
[16] What kind of equipment is required?
[17] Do you have any additional training or competency
in order to accommodate the special equipment
needs of larger residents?
SCENARIO 5-6.
Large Nursing Facility
Summary
In the following scenario, a surveyor traces how an organiza-
tion manages staffing to ensure continuity of care for residents.
Within the tracer, the surveyor explores issues relating to these
priority focus areas:
• Communication
• Orientation & Training
• Resident Safety
• Staffing
Scenario
The surveyor conducted a program-specific staffing tracer in a
215-bed nursing facility in an urban setting. She explored the
nursing facility’s process for ensuring staffing in the facility.
She asked to meet with the facility’s administrator, human re-
sources director, and nursing director, along with representa-
tive staff members, including a certified nurse assistant, agency
staff, and nonnursing staff. The meeting aimed to look at data
Section 5: Long Term Care
and practices related to staffing, with specific focus placed on
how the facility ensures continuity of care for residents amid
staffing changes or turnover.
(Bracketed numbers correlate to Sample Tracer Questions on page
110.)
Discussing Staffing Practices with the Tracer Team.
The surveyor asked the administrator to describe the system
the facility had in place to plan for and accommodate any pos-
sible staffing turnover or utilization of contracted staff. [1–2]
The administrator showed the surveyor the staffing plans that
facility leadership had designed to help plan for any possible
staffing needs. The surveyor then asked the staff members to
describe what requirements the facility had to comply with to
meet any predetermined staffing ratios and mix. [3–4] The
human resources director said that their staffing plans
factored in accommodating any requirements, in addition to
critical areas where staffing changes should not be too pro-
nounced in just one unit, to help promote continuity of care
for residents and prevent any unwarranted disruption in care.
The surveyor asked the human resources director what kind of
data collection the facility conducted in relation to staffing.
[5–6] The human resources director responded that the facil-
ity collected and submitted Minimum Data Set outcomes data
and then looked at correlating any negative outcomes to
staffing. The surveyor asked how much staff turnover they had
experienced in the facility. [7] The human resources director
responded that more than a year ago, support staffing had
been particularly difficult, so the facility had contracted with
agency staff to fill needed positions. The contracted staff, the
human resources director explained, worked for lengthier du-
rations, with the aim of ensuring that even contracted staff
knew the residents and could interact with them more easily.
The surveyor asked what kind of orientation and training is
provided to contracted staff. [8] The human resources director
responded that all staff members undergo the same orientation
to the facility, including high-risk processes such as infection
control, falls prevention, and pain management. The surveyor
then asked to review personnel files for contracted staff and
was able to verify suitable orientation and training.
Considering the ethnic diversity of the staff and resident
population, the surveyor asked the director what accommo-
dation had been made for cultural competency and multi-
lingual environments. [9–11] The nursing director said that
the staff members had undergone a number of in-service
trainings to help them discuss and learn about the cultural
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More Mock Tracers

and linguistic diversity among staff and with residents. Since

conducting these trainings, the nursing director said, the fa- Tracer Team:
cility had noticed that residents seemed better integrated [1] What system do you have to monitor and review
into the facility and staff members were more easily interact- your staffing practices?
ing with residents from different cultural or linguistic back- [2] How do you plan for staffing turnover or utilization of
grounds. contracted staff?
[3] Are there any compliance requirements you need to
Speaking with Residents. The surveyor concluded the meet regarding staffing? If so, how do you meet
tracer by visiting resident areas in the facility. She was given those requirements?
permission to speak with a number of residents, and she asked
[4] What staffing plans do you have in place?
them about their experiences of care in the facility and how fa-
miliar and comfortable they felt with the staff. [12–13] The [5] What kinds of data collection practices do you
conduct in relation to staffing?
residents expressed satisfaction with the experience of care, and
one resident added that although she knew the nursing staff [6] What processes do you have in place in relation to
very well, she thought the support staff members did change using contracted staff?
frequently, and they rarely pronounced her name correctly [7] What kind of staffing turnover have you experienced
even though she had been a resident in the facility for several in the facility? Has it been concentrated in a specific
years. area? What planning and response have you put in
place?
Moving Forward. Based on the tracer, the surveyor may [8] What kind of orientation and training do you provide
discuss areas of improvement in the Daily Briefing. The dis- to contracted staff? Where do you document this
cussion might address the topic of contracted staffing. education?
[9] What processes have you put in place to
accommodate the linguistic or cultural differences of
Scenario 5-6. residents and among staff?
Sample Tracer Questions [10] Have you offered any additional skills training for
staff with regard to cultural competency?
The bracketed numbers before each question correlate to
[11] What improvements have you tracked or
questions, observations, and data review described in the
documented as a result of additional training?
sample tracer for Scenario 5-6. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
Residents:
end of this section). The information gained by conducting [12] What have your experiences with staff in the facility
a mock tracer can help to highlight a good practice and/or been?
determine issues that may require further follow-up. [13] Do you feel as though the staff members know you?
Do they know you by name?

110
 Section 5: Long Term Care

Sample Tracer Worksheet: Scenario 5-5.

The worksheet below is an example of how organizations can A correct answer is an appropriate answer that meets the re-
use the sample tracer questions for Scenario 5-5 in a worksheet quirements of the organization and other governing bodies.
format during a mock tracer. The bracketed numbers before An incorrect answer should always include recommendations
each question correlate to questions described in the scenario. for follow-up.

Tracer Team Member(s): Chris Wilson Data Record(s): Minimum Data Set outcomes
Subjects Interviewed: Julio Esperanza, Rhonda data; personnel files
Boule, Jamal Miller Unit(s) or Department(s): large nursing facility
Tracer Topic or Care Recipient: resident care for
resident with diabetes
Interview Subject: Resident

Questions Correct Incorrect Follow-Up Comments or

Answer Answer Needed Notes
[1] What has your care ✓
experience been like in the
facility?

[2] Do you have any concerns ✓

about your experience of stay
here in the facility?

[3] Do you understand why your ✓ Resident showed a good

stay in the facility has been
prolonged? How was this
information communicated to you?
[4] Have you been able to get
your questions answered about
your care?
understanding of the
reason for his stay and
why it had been prolonged.
✓

[5] What do you do if you do not ✓

understand the reason for a
particular treatment?

[6] What has the resident ✓

experience been like for you in
the facility?

[7] Are there any activities in ✓ Good understanding of

which you have been able to what the resident can
participate? Do you have
access.
access to television or other
forms of entertainment, if you
wish it?

(continued)

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Interview Subject: Resident (continued)

Questions Correct Incorrect Follow-Up Comments or

Answer Answer Needed Notes
[8] Are you able to receive ✓ Discuss provision of Resident did not know
visitors in your room? visitor policy to what resources he has
residents. available to receive visitors.

[9] Have you been able to ✓

participate in any resident
council meetings? Do you know
when they are taking place?

[10] Have any resident ✓

representatives met with you?
Are you aware of the
information being shared at the
meetings?

[11] Have staff members been ✓

able to help accommodate you
to attend any resident meetings
or activities?

[12] What is your opinion of the ✓

food in the facility? Do you know
how to report any concerns, if
you have any?

[13] What kind of care do you ✓

receive during the day?

Interview Subject: Staff

Questions Correct Incorrect Follow-Up Comments or

Answer Answer Needed Notes
[14] How do you document the ✓ Staff showed mastery of
care or services you are documentation of resident
providing to the resident? care.
[15] What kind of ✓
accommodation do you make
for residents who are of larger
size?

[16] What kind of equipment is ✓ May need reinforcement Staff demonstrated

required? or a review of the current inconsistent approach,
process. particularly in this traced
record.

112
 Section 5: Long Term Care

Interview Subject: Staff (continued)

Questions Correct Incorrect Follow-Up Comments or

Answer Answer Needed Notes
[17] Do you have any additional ✓ Staff members were
training or competency in order knowledgeable and showed
to accommodate the special evidence of training for
equipment needs of larger residents with special
residents? needs.

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114

Tracer Scenarios for
LABORATORY
NOTE: No Two Tracers Are the Same
Please keep in mind that each tracer is unique. There is no
way to know all of the questions that might be asked or
documents that might be reviewed during a tracer—nor
what all the responses to the questions and documents
might be. The possibilities are limitless, depending on the
SECTION 6
tracer topic and the organization's circumstances. These
tracer scenarios and sample questions are provided as an
educational or training tool for organization staff; they are
not scripts for real or mock tracers.
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Section Elements
This section includes sample tracers—called scenarios—relevant to laboratories. The section is organized as follows:

Scenarios: Each scenario presents what might happen when a

surveyor conducts a specific type of tracer. The scenarios are
presented in an engaging narrative format in which the reader
“follows” the surveyor through the tracer scenario. Within the
narrative are bracketed numbers that correspond to numbered
sample tracer questions following the tracer.

Sample Tracer Questions: After each scenario narrative is a list

of sample questions a surveyor might ask during that scenario.
These questions can be used to develop and conduct mock tracers
in your organization on topics similar to those covered in the
scenario.

Sample Tracer Worksheet: At the end of the section is a sample

worksheet that shows how the sample tracer questions for one
select scenario in the section might be used in a worksheet format.
The example shows how the worksheet might be completed as
part of a tracer for that scenario. A blank form of the worksheet is
available in Appendix B.

116

INDIVIDUAL
Tracer Scenarios
SCENARIO 6-1.
Laboratory in Large Teaching Hospital
Summary
In the following scenario, a surveyor traces an organization’s
point-of-care testing. Within the tracer, the surveyor explores
issues relating to these priority focus areas:
• Analytic Procedures
• Communication
• Infection Control
• Information Management
• Patient Safety
Scenario
This tracer took place in a laboratory in a large teaching
hospital. The surveyor wanted to look at the hospital’s prac-
tice of point-of-care testing. For this tracer, the surveyor
selected a patient who had been admitted to a medical/
surgical unit from the emergency department (ED) based on
results from point-of-care testing. The patient was a 72-
year-old female who was on anticoagulants while recovering
from surgery. When she began to feel unwell and was trans-
ported to the hospital, a point-of-care test indicated that
her International Normalized Ratio (INR) was critically
high. The patient was then admitted for treatment and
stabilization.
(Bracketed numbers correlate to Sample Tracer Questions on page
118.)
Overview of Point-of-Care Practices with the
Tracer Team. The surveyor began her tracer by speaking
with the laboratory director, laboratory staff members, and
the ED director to determine what their point-of-care test-
ing practices and processes were and what oversight the lab-
oratory had. [1–2] The laboratory director indicated that
the laboratory oversaw the process but that the testing was
done by ED staff or wherever the patient was being treated.
The emergency department had determined that its point-
of-care INR testing meter was categorized as a waived
method under Clinical Laboratory Improvement Amend-
ments of 1988 complexity provisions.
Section 6: Laboratory
Visiting with the Emergency Department Director
and the ED Technician. The surveyor then went to the
emergency department and asked the ED director what processes
and procedures exist to ensure accurate and timely results for
point-of-care testing. [3] The ED director explained that the
department had specific processes to follow to expedite stat tests
and to communicate critical results. In this case, staff immedi-
ately ordered the test and performed it as a point-of-care proce-
dure. The surveyor observed the ED technician perform a
point-of-care INR test and reviewed the quality control records.
The surveyor then asked the technician to describe what hap-
pens to stat test results. [4] The ED technician indicated that
she documented in the patient’s medical record that the critical
result was communicated to the physician immediately. [5–6]
Following the Phlebotomist. Because the admitted
patient was due to have an INR test done on the medical/
surgical unit, the surveyor followed a phlebotomist to collect a
blood specimen for testing in the laboratory. The surveyor
asked the phlebotomist how he received orders. [7] He ex-
plained how the order system worked and that he had pre-
prepared labels in his cart that he would attach to the speci-
men after it was drawn.
The phlebotomist greeted the patient and then explained why
he was identifying her before drawing her blood. [8] The phle-
botomist proceeded to identify the patient by asking her name
and date of birth and then compared the information on the
labels to the wristband. Before the phlebotomist began, the pa-
tient jokingly asked if he was going to wash his hands; the
phlebotomist apologized, explaining that he had done it in the
laboratory. [9] He quickly performed hand hygiene again. He
then drew the blood sample, labeled the specimen correctly
using two identifiers in the presence of the patient, and sent
the specimen to the laboratory for processing. [10] The sur-
veyor then went to the laboratory and asked the technologist
what process was used to report a patient’s INR test results
that were processed on the laboratory coagulation analyzer.
[11] The technologist noted that the results were documented
electronically and then followed the laboratory’s guidelines for
identifying and reporting critical results.
Asking the Emergency Department Director About
Training and Competency. The surveyor asked the ED di-
rector what kind of training and competency is given for staff
members who conduct point-of-care tests. [12–13] The ED
director explained that all staff members are required to
demonstrate competency annually by taking a quiz.
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More Mock Tracers

Reviewing Personnel Records with the Laboratory

Director. The surveyor then returned to the laboratory and [8] How do you ensure correct patient identification
before drawing a sample?
asked to review the laboratory technologist’s personnel records
to verify that his competency was assessed annually utilizing all [9] What hand hygiene do you practice before taking a
six methods required for moderately complex testing. [14–15] sample?
She also wanted to verify what kind of training and education [10] How do you label the specimen after it is drawn?
the phlebotomist had received in relation to hand hygiene and [11] How are test results reported back to the unit and
other infection control practices. [16] Although the personnel recorded in the patient’s record?
record indicated that the staff had undergone infection
control–related training, the laboratory director noted that he Emergency Department Director:
would take some time to reinforce the correct procedure. [12] Will you please show me the personnel files of
laboratory staff?
Moving Forward. Based on the tracer, the surveyor may [13] What kind of training and competency do you
discuss areas of improvement in the Daily Briefing. The dis- provide for staff members who conduct point-of-care
cussion might address the following topics: critical results, testing?
hand hygiene, and competency, particularly waived point-of-
care testing competency. Laboratory Director:
[14] What methods do you use to assess competency for
waived testing?
Scenario 6-1. [15] What methods do you use to assess competency for
Sample Tracer Questions moderately complex testing?
[16] What kind of education and training do you provide
The bracketed numbers before each question correlate to for staff in relation to hand hygiene?
questions, observations, and data review described in the
sample tracer for Scenario 6-1. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or SCENARIO 6-2.
determine issues that may require further follow-up. Laboratory in Rural Hospital
Tracer Team: Summary
[1] What processes and procedures do you have in In the following scenario, a surveyor traces how a laboratory
relation to point-of-care testing?
uses an outlying laboratory for additional testing. Within the
[2] What oversight responsibility does the laboratory tracer, the surveyor explores issues relating to these priority
have in relation to point-of-care testing? focus areas:
• Analytic Procedures
Emergency Department Director and
• Communication
ED Technician:
• Information Management
[3] What special procedures exist in relation to the
emergency department?
• Physical Environment

[4] What process exists for stat test results?

Scenario
[5] How are results communicated? How are these This individual tracer was conducted at a rural hospital that had
documented? laboratory services but also used an outlying laboratory for addi-
[6] What process do you follow if the ordering physician tional testing. The hospital laboratory staff consisted of a labora-
is unavailable? tory manager and a laboratory technician, and the nursing staff
conducted additional point-of-care testing. Some tests were con-
Phlebotomist:
ducted on site in the hospital’s laboratory, while others were sent
[7] How do you receive an order for a point-of-care
to an outlying laboratory situated in another hospital approxi-
testing specimen?
mately 45 miles away and part of the same health system.

118

(Bracketed numbers correlate to Sample Tracer Questions on pages
119–120.)
Reviewing Laboratory Practices with the Labora-
tory Manager and the Laboratory Technician. The
surveyor conducted this tracer with the laboratory manager
and the laboratory technician. At the outset of the tracer,
the surveyor reviewed proficiency test results. [1–2] She ob-
served that the testing process was consistently handled and
well documented and that proficiency scores were acceptably
maintained.
The surveyor then asked the manager to lead a tour of the lab-
oratory. [3] She observed that although the laboratory had
enough work space for the limited laboratory work conducted
on site, the staff members also had a lot of personal items in
the work space, including the technician’s backpack with an
opened soft drink bottle and an unopened bag of potato chips
alongside it. She noted that the blood specimen refrigerator
was well secured and verified the temperature. The surveyor
asked the manager to describe the policy relating to food in
the laboratory. [4–5] She explained that the hospital policy
stated that neither food nor other nonessential items should be
stored in the laboratory, but because the staff lounge was cur-
rently being remodeled, staff members did not know where
else to put their personal things. The surveyor suggested bring-
ing a temporary storage box or unit near the entrance to the
laboratory for nonessential personal items.
The surveyor then asked the manager to describe the labora-
tory’s process for sending laboratory testing out in those cases
when it lacked the equipment for specific tests. [6] The man-
ager explained that the laboratory did most of the essential,
frequently requested tests on site but that some tests were con-
ducted by an outlying laboratory. She explained that they used
the larger laboratory in the nearest hospital, which was part of
the same health system. This other laboratory had additional
equipment and the capacity to handle the vast majority of ad-
ditional testing required. The surveyor asked the manager
what kind of communication process existed between her and
the other laboratory and how she was aware of when test re-
sults were ready. [7] The manager explained that the other lab-
oratory posted results on the health system’s extranet site and
that it was set up to alert her laboratory office whenever a re-
sult was available.
Tracing a Patient with the Laboratory Manager
and the Laboratory Technician. The surveyor chose to
trace a patient who had had a blood test for HIV three days
Section 6: Laboratory
earlier. The patient was a 26-year-old woman who had been
brought to the emergency department after she had been as-
saulted. During her assessment and treatment in the emer-
gency department, the physician opted to conduct an
emergency HIV test, which the laboratory had sent to the
other laboratory urgently. The surveyor reviewed the pa-
tient’s file with the manager and the technician. The sur-
veyor asked the technician to describe what he would do if
they had to process any urgently needed tests that had to be
sent off-site. [8–9] The technician responded that the
process is to flag the test sample, order transportation, and
then activate the extranet’s testing alert system (used for all
tests going to the other laboratory) to flag the test as urgent.
The surveyor reviewed the patient’s record—both the paper
record and the electronic record—and noted that the sample
was entered correctly. The record also indicated that the test
result was posted using a numbering code on the extranet
site within six hours.
The surveyor asked the manager how the laboratory was se-
cured to protect the staff, the samples, and the privacy of test
results. [10] The manager responded that the laboratory was
accessible to only herself, the laboratory technician, and hospi-
tal leadership and that as she understood it, the hospital’s com-
puter system was password protected and only those
employees of physicians who needed to know the test result
would have access to the result.
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the following topics: documentation re-
quirements, infection control, transportation and tracking of
specimens, and reporting of test results.
Scenario 6-2.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 6-2. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
(continued)
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Scenario 6-2.
Sample Tracer Questions
(continued)
Laboratory Manager and Laboratory
Technician:
[1] Can you show me your proficiency test results,
attestation forms, and raw data?
[2] Do you rotate the testing among the staff and
perform the proficiency tests as you would a
patient? How do you track them?
[3] Please show me the laboratory. Where do you store
equipment?
[4] What is your policy regarding storage of
nonlaboratory items in the laboratory? What do you
do in the event that break or lunch areas normally
accessible to staff are not currently available?
[5] Will you please show me the temperature logs for
your storage refrigerators?
[6] What is your process in the event that there is a test
that cannot be completed on site?
[7] How do you communicate with the outlying
laboratory? What is the process to transport a
sample and to receive results?
[8] What do you do in the event that you have a test
that needs to go to your outlying laboratory and that
is designated as urgent? What triggers a test to be
handled urgently?
[9] What communication processes do you have in
place for receiving and reporting these critical
results?
[10] How do you ensure the security of the laboratory
and its samples? How do you ensure the privacy of
test results? What process is in place to secure your
electronic records?
120
SCENARIO 6-3.
Laboratory in Nursing Facility
Summary
In the following scenario, a surveyor traces how a laboratory
prepares and provides blood products. Within the tracer, the
surveyor explores issues relating to these priority focus areas:
• Analytic Procedures
• Communication
• Information Management
• Resident Safety
Scenario
The surveyor conducted this tracer in a laboratory located in a
nursing facility; the surveyor had noted that the facility had
provided transfusions for a number of residents. The surveyor
selected a 75-year-old female resident who had received a
transfusion due to severe anemia. The surveyor wanted to look
at the methods by which a resident receives blood products
and how the laboratory stores, handles, and delivers the prod-
uct to the resident.
(Bracketed numbers correlate to Sample Tracer Questions on pages
121–122.)
Overview of the Resident’s Record with the Labora-
tory Director. A review of the resident’s record noted that the
medical director had ordered a unit of packed cells for the resi-
dent because her hemoglobin was 7.1 grams/dL and that the
resident had signed a consent form for the transfusion. The sur-
veyor went to the laboratory to ask the laboratory director how
they received such orders and what their process was to prepare
and provide the blood product to the resident. [1–2] He ex-
plained that after the order came in, the laboratory performed a
type- and cross-match, allowing the nursing staff to administer
the blood to the resident on the same day. The surveyor asked if
any other tests were performed. [3] The director explained that
standard process required staff to perform a thyroid profile, a
chemistry profile, and a complete blood cell count.
Following the Nurse Delivering the Blood Product to
the Resident. The surveyor then traveled to the resident with
the laboratory director to ask the nursing staff about the process
to administer blood products to a resident. [4] The nurse ex-
plained that her first priority was to ensure that the blood prod-
uct was being given to the correct resident, which she said she
verified along with another nurse by checking the patient’s
name, date of birth, and medical record number against the la-

beling on the blood product. She also added that she explained
what she was doing to the resident because she had found in the
past that some residents had become anxious or confused when
the nurse came in and verbally verified a resident’s identity when
the resident was already known to the nurse. The surveyor was
able to verify the correct resident identification process on the
resident’s record. [5–6] She then added that while blood is
being administered to the resident, the nurse checks for any re-
action to the transfusion, which she noted may be indicated by a
rise in body temperature as well as watching for other signs and
symptoms that were listed in their transfusion policy. The sur-
veyor asked what the nurse did to check for a reaction. [7] The
nurse explained that according to the facility’s policy, she
checked the resident’s vital signs during and after administration
and documented the readings before the transfusion, 15 min-
utes after the start of the transfusion, and regularly thereafter ac-
cording to the facility’s policy. In this case, the resident did not
show any change in body temperature or any other noticeable
signs of a reaction, so the nurse also documented that there was
no transfusion reaction. The surveyor was able to verify the doc-
umentation by reviewing the record.
The surveyor then asked the nurse what she would do if there
were a transfusion reaction. [8] The nurse explained that the
first response is to stop the transfusion and to notify the med-
ical director and then to inform the laboratory so that the lab-
oratory could begin a transfusion reaction workup. The
surveyor then asked the nurse what kind of training and ongo-
ing competency she received in relation to handling and ad-
ministering blood products. [9] The nurse explained that she
had attended a safety and training seminar earlier in the year
during which the laboratory director and nursing director had
given some new instruction in relation to a new product that
the facility was using. (The surveyor was later able to verify
this account when he reviewed the nurse’s personnel file.)
Returning to the Laboratory with the Director. The
surveyor then returned to the laboratory to look at the instru-
ment maintenance logs for the laboratory equipment, particu-
larly in relation to blood products. She reviewed the
temperature records and alarm checks for the refrigerator
where the blood products were stored. She also reviewed the
quality control and testing records associated with the units of
blood transfused and the resident. She reviewed all the blood
bank and transfusion procedures and policies. [10–11] She
noted that the laboratory had appropriately documented all
maintenance for the set time period and found the quality
control and testing records complete and correct for the time
period reviewed.
Section 6: Laboratory
The surveyor then reviewed the laboratory’s procedures, qual-
ity control, calibration verification, and correlation records for
other tests that were performed on the resident. The docu-
ments demonstrated that the technical supervisor had reviewed
these documents. [12] The surveyor could not find documen-
tation for the last time results were submitted for interlabora-
tory comparison. The laboratory director explained that the
quality control results were submitted monthly to the instru-
ment vendor and that the documentation had been inadver-
tently lost due to a recent upgrade of software on the
laboratory’s computers. [13] But the director had backed up
the data and was able to retrieve the documentation and report
for the surveyor to review and noted that all data had agreed
with peer data.
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the following topics: blood storage, test-
ing, transfusion safety, and data management.
Scenario 6-3.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 6-3. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Laboratory Director:
[1] How do you receive an order for blood products in
the laboratory?
[2] What process do you follow to prepare and test the
blood product before providing it to the resident?
[3] Do you conduct any additional tests? How are they
documented?
Nurse:
[4] What process do you follow to administer blood to a
resident?
[5] How do you ensure that this is the correct resident?
What resident identification process do you follow?
[6] Do you provide any education to residents as you
are verifying their identity?
(continued)
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artery bypass graft surgery. The tracer explored laboratory

Scenario 6-3.
Sample Tracer Questions
(continued)
[7] What steps do you take while administering blood
products? What process do you follow to check for a
transfusion reaction? How is this process
documented?
[8] What would you do in the event that a resident did
have a transfusion reaction?
[9] What training and competency have you had in
relation to handling and administering blood
products?
Laboratory Director:
[10] What documentation do you have in relation to
instrument maintenance?
[11] What kind of documentation do you maintain for
quality control, calibration, calibration verification,
and correlation?
[12] Will you please show me your quality control
records? How do you review peer data?
[13] What process do you follow to document and report
these quality control records? Where is this
information filed and managed? Is it backed up if
stored electronically?
processes for surgically related testing and perioperative point-
of-care testing.
(Bracketed numbers correlate to Sample Tracer Questions on page
123.)
Looking at Laboratory Practices with the Operat-
ing Room Manager. The selected tracer patient had under-
gone surgery three days earlier. According to the medical
record, the patient had received blood products during surgery.
The record also indicated that the patient had received peri-
operative coagulation testing. The surveyor began her tracer by
looking at the function of laboratory services in the surgical
suite. [1–2] She met with the operating room manager to dis-
cuss what types of perioperative testing happens in the operat-
ing room and what kind of documentation and competency
relating to these tests takes place. [3] The operating room
manager reported that all point-of-care testing processes are
documented and overseen by the laboratory, but an inter-
disciplinary team from each department that performs point-
of-care and waived testing (including the operating room)
meets periodically with the laboratory to ensure consistency
and to foster good practices and open discussion. The manager
added that staff members are monitored for competency annu-
ally using six methods for the moderately complex tests. She
also showed where in the patient’s record the testing, and its
result along with the normal ranges, was documented.

Overview of the Laboratory with the Director. In-

side the laboratory, the surveyor met with the laboratory direc-
SCENARIO 6-4. tor to learn about the laboratory’s processes. [4] She asked the
Laboratory in Community Hospital laboratory director to describe the way that the laboratory in-
teracts with the rest of the hospital, particularly in relation to
Summary point-of-care testing and waived testing. [5] The director ex-
In the following scenario, a surveyor traces a laboratory’s plained that he had oversight responsibility for all laboratory
processes for surgically related testing and perioperative point- processes and did monitor their implementation and ongoing
of-care testing. Within the tracer, the surveyor explores issues function in the hospital.
relating to these priority focus areas:
• Analytic Procedures At the surveyor’s request, the laboratory director then con-
• Communication ducted a tour of the laboratory by looking first at the point-
• Information Management of-care testing records from the cardiovascular operating
• Orientation & Training room. [6] The surveyor also reviewed the activated clotting
• Patient Safety time (ACT) records from the cardiac catheterization labora-
tory. The surveyor found that the equipment maintenance,
Scenario refrigerator temperature checks, and quality control docu-
This individual tracer was conducted in a midsize community mentation were inconsistently handled and not always per-
hospital where the surveyor selected a closed record of a 66- formed according to the organization’s procedure. The tracer
year-old patient who had been in the hospital for coronary patient had been added to the catheterization laboratory

122

schedule at the end of the day. The catherization laboratory
had run the quality control only at 6:00 A.M. that day, but
the patient’s ACT test was performed at 5:00 P.M. More than
eight hours had elapsed since the control was run. [7] The
laboratory director explained that recent staffing turnover in
the cardiac catheterization laboratory and a new process had
led to some inconsistencies in the handling of the documen-
tation, which the main laboratory, the cardiac catheteriza-
tion laboratory, and the interdisciplinary point-of-care team
were working on improving. The personnel competency
records were reviewed in the catheterization laboratory. The
records indicated that competency had been assessed annu-
ally using six methods for the staff members who had been
working there for more than a year. However, two new em-
ployees had undergone initial training for the ACT test, but
the training did not include quality control. Also, the new
employees had not had a competency assessment in six
months for the ACT.
The surveyor then observed that the quality control, mainte-
nance, calibration, and other records for analyzers located in
the main laboratory were appropriate. Correlations per-
formed every six months demonstrated consistency of labo-
ratory results between locations and between equipment.
The surveyor also reviewed the patient’s medical record and
found that the results from the operating room, catheteriza-
tion laboratory, and main laboratory and the respective nor-
mal ranges were documented appropriately. The electronic
and the external liquid controls performed in the cardiovas-
cular operating room were run at the appropriate times and
were within range. [8]
In the blood bank, the surveyor observed that the laboratory
had an appropriate quality system for storing the units and
testing the patient and that the nursing staff had a safe transfu-
sion system. The laboratory technician explained that six
months earlier the blood bank had converted its process to a
completely electronic system, which had not only simplified
and helped systematize its documentation but also had built in
safety checks to help prevent errors. The surveyor reviewed the
implementation document for the blood bank computer sys-
tem. [9] The surveyor noted that quality control and tempera-
ture monitoring and alarm checks were well documented.
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the following topics: interdepartmental
communication, documentation, quality control, and training
and competency.
Section 6: Laboratory
Scenario 6-4.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 6-4. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Operating Room Manager:
[1] Will you please describe the kind of testing
conducted preoperatively?
[2] Who monitors these tests? How are they
documented?
[3] What interaction and communication do you have
with the laboratory in relation to your testing
practices?
Laboratory Director:
[4] How does the laboratory function in the hospital?
What kind of organizational structure is in place?
[5] What kind of oversight responsibility do you have for
the hospitalwide point-of-care testing and waived
testing? What reporting processes are in place?
What kind of monitoring do you conduct?
[6] What processes are in place for your hematology
and chemistry testing?
[7] What routine documentation do you have in place in
the laboratory? How do you monitor it for
completeness? What type of external reporting do
you have in place? What reports do you receive?
[8] What type of quality control do you conduct?
[9] If you have recently migrated from paper
documentation to an electronic system or are
planning to, what training and adjustments did you
have to make? How did you or will you train staff?
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SCENARIO 6-5.
Laboratory in Critical Access Hospital
Summary
In the following scenario, a surveyor traces a laboratory’s
handling of tests, in particular waived testing. Within the
tracer, the surveyor explores issues relating to these priority
focus areas:
• Analytic Procedures
• Information Management
• Orientation & Training
• Staffing
Scenario
A surveyor conducted this tracer in a laboratory at a 14-bed
critical access hospital in a remote northern state. The sur-
veyor wanted to look at the hospital laboratory’s approach to
handling tests, paying particular attention to how it oversaw
waived testing in the critical access hospital. The surveyor
selected a closed record of a 52-year-old female patient who
had been treated for pneumonia in the hospital. Because she
was also diabetic, the surveyor wanted to look at how the
hospital staff checked her glucose levels.
(Bracketed numbers correlate to Sample Tracer Questions on
page 125.)
Reviewing Laboratory Oversight of Waived Testing
with the Director. The surveyor began his tracer by speaking
with the laboratory staff and touring the laboratory. The labo-
ratory was small and had limited testing equipment. The
laboratory director explained that tests that could not be
performed at his laboratory were sent out to an independent
freestanding laboratory 37 miles away. [1] The surveyor asked
the laboratory director what the laboratory’s role was in over-
seeing and conducting any waived testing and where responsi-
bility lay for the development of policies and procedures. [2]
The director explained that the critical access hospital used
waived testing extensively and that he was responsible for over-
seeing the process. He noted that he periodically reviewed the
written policies and procedures and documented such reviews.
He also reviewed the daily quality control performed by the
nursing staff and pulled reports to make sure that all critical
values were communicated to the physician. He followed up
with the nursing manager regarding any outliers and discussed
possible solutions.
124
The surveyor asked the director if he ever spent time ob-
serving waived testing or providing education and training
for staff members who conduct testing. [3–4] The director
responded that he and designated nursing supervisors con-
ducted periodic monitoring of testing and that all staff were
required to complete a training session with waived testing
when starting at the critical access hospital. The director
added that staff members annually showed their compe-
tency to perform waived glucoses by demonstrating two
methods such as attaining an 80% score on a quiz or
through observation, quality control, or testing an un-
known sample. The surveyor then asked to review the per-
sonnel files of representative staff members who conducted
waived testing so he could verify the documentation of
their training and competency.
Talking with the Nurse. The surveyor then began his
tracer of the female patient. He talked with a nurse on the
unit where the patient stayed. He asked the nurse what kind
of waived testing would be performed on this patient, and
the nurse explained that she did regular glucose testing be-
cause the patient was diabetic. [5] The surveyor asked the
nurse to explain what kind of documentation she would in-
clude in the record. [6] The nurse explained that all testing
and results are documented in the patient’s record along
with the normal range for the test. The surveyor was able to
verify this documentation in the record.
The nurse then conducted her waived testing with the pa-
tient. She first greeted the patient and washed her hands.
Then she verified the patient’s identity and explained what
she was going to do. She conducted the test appropriately
and then documented the results into the record. [7]
Speaking with the Patient. Then the surveyor spoke
with the patient. He asked her if she understood why she
was receiving glucose testing and if the nurse explained the
process to her. [8] The patient responded that she under-
stood that she would need regular testing because she was
diabetic.
Moving Forward. Based on the tracer, the surveyor
may discuss areas of improvement in the Daily Briefing. The
discussion might address the following topics: glucose meter
testing, recordkeeping, and communication between
laboratory and nursing staff and between nursing staff and
patients.
 Section 6: Laboratory

Scenario 6-5. [3] What kind of monitoring do you do with regard to

waived testing? How do you verify competency with
Sample Tracer Questions staff?
[4] How is this type of monitoring documented? Where
The bracketed numbers before each question correlate to
do you document competency?
questions, observations, and data review described in the
sample tracer for Scenario 6-5. You can use the tracer Nurse:
worksheet form in Appendix B to develop a mock tracer
[5] What kind of waived testing is performed on
(see an example of a completed tracer worksheet at the
patients? What has been ordered for this particular
end of this section). The information gained by conducting
patient?
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up. [6] How do you document the testing? Where is it
documented? What do you do with a result that is
Laboratory Director: out of the normal range?

[1] What equipment do you use in the laboratory? What [7] How do you ensure that you have correctly identified
kind of testing can you perform? the patient? What sort of education do you provide
to the patient?
[2] What is the laboratory’s role in overseeing and
conducting any waived testing? Who has Patient:
responsibility for the hospital’s policies and [8] Would you please tell me why you are receiving this
procedures? test?

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Sample Tracer Worksheet: Scenario 6-2.

The worksheet below is an example of how organizations can A correct answer is an appropriate answer that meets the re-
use the sample tracer questions for Scenario 6-2 in a worksheet quirements of the organization and other governing bodies.
format during a mock tracer. The bracketed numbers before An incorrect answer should always include recommendations
each question correlate to questions described in the scenario. for follow-up.

Tracer Team Member(s): Pat Franklin Data Record(s): critical result

Subjects Interviewed: Ramesh Patel, Lucia Unit(s) or Department(s): laboratory and
Lancione emergency department
Tracer Topic or Care Recipient: using outlying
laboratory for additional testing

Interview Subject: Laboratory Manager and Laboratory Technician

Questions Correct Incorrect Follow-Up Comments or

Answer Answer Needed Notes
[1] Can you show me your ✓
proficiency test results,
attestation forms, and raw data?

[2] Do you rotate the testing ✓

among the staff and perform the
proficiency tests as you would a
patient? How do you track
them?

[3] Please show me the ✓

laboratory. Where do you store
equipment?

[4] What is your policy regarding ✓ Reinforce food policy. Staff members are not
storage of nonlaboratory items Find better alternative following the policy due to
in the laboratory? What do you for staff to store food. remodeling of the staff
do in the event that break or lounge.
lunch areas normally accessible
to staff are not currently
available?

[5] Will you please show me the ✓

temperature logs for your
storage refrigerators?

[6] What is your process in the ✓ Need to retrain staff on Not all staff members
event that there is a test that correct procedure. interviewed knew the
cannot be completed on site? process.

126
 Section 6: Laboratory

Interview Subject: Laboratory Manager and Laboratory Technician (continued)

Questions Correct Incorrect Follow-Up Comments or

Answer Answer Needed Notes
[7] How do you communicate ✓
with the outlying laboratory?
What is the process to transport
a sample and to receive results?

[8] What do you do in the event ✓

that you have a test that needs
to go to your outlying laboratory
and that is designated as
urgent? What triggers a test to
be handled urgently?

[9] What communication ✓ Review follow-up The online communication

processes do you have in place practice for staff. method was well presented,
for receiving and reporting these but the follow-up in which
critical results? internal staff
communicates results to
the right units was
inconsistent.
[10] How do you ensure the ✓ Security log and review
security of the laboratory and its excellent.
samples? How do you ensure
the privacy of test results? What
process is in place to secure
your electronic records?

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128

Tracer Scenarios for
ENVIRONMENT OF CARE
NOTE: No Two Tracers Are the Same
Please keep in mind that each tracer is unique. There is no
way to know all of the questions that might be asked or
documents that might be reviewed during a tracer—nor
what all the responses to the questions and documents
might be. The possibilities are limitless, depending on the
SECTION 7
tracer topic and the organization's circumstances. These
tracer scenarios and sample questions are provided as an
educational or training tool for organization staff; they are
not scripts for real or mock tracers.
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Section Elements
This section includes sample tracers—called scenarios—relevant to environment of care or facility management and safety
systems. The section is organized as follows:

Scenarios: Each scenario presents what might happen when a

surveyor conducts a specific type of tracer. The scenarios are
presented in an engaging narrative format in which the reader
“follows” the surveyor through the tracer scenario. Within the
narrative are bracketed numbers that correspond to numbered
sample tracer questions following the tracer.

Sample Tracer Questions: After each scenario narrative is a list

of sample questions a surveyor might ask during that scenario.
These questions can be used to develop and conduct mock tracers
in your organization on topics similar to those covered in the
scenario.

Sample Tracer Worksheet: At the end of the section is a sample

worksheet that shows how the sample tracer questions for one
select scenario in the section might be used in a worksheet format.
The example shows how the worksheet might be completed as
part of a tracer for that scenario. A blank form of the worksheet is
available in Appendix B.

130

SYSTEM
Tracer Scenarios
SCENARIO 7-1.
Security
Summary
In the following scenario, a surveyor traces how an organiza-
tion maintains security. Within the tracer, the surveyor ex-
plores issues relating to these priority focus areas:
• Physical Environment
• Equipment Use
• Staffing
• Patient Safety
Scenario
This survey was conducted in a 384-bed hospital in an urban set-
ting. First built in the late 1800s, the hospital had undergone sig-
nificant renovations and expansions over the years, including a
wing added to the hospital about two years earlier. For the tracer,
the surveyor asked the facilities manager, the safety director, and
the security chief to accompany him on a building tour.
(Bracketed numbers correlate to Sample Tracer Questions on page
132.)
Talking with the Security Chief as the Building Tour
Starts. The surveyor began his tour at the main entrance of the
hospital. [1] He asked accompanying staff to show him how
the building is secured during an unwelcome event, such as a
terrorist attack; he asked the security chief how many security
staff members monitor the hospital during the day and
evening, as well as what type of patrolling is conducted around
the grounds. [2–3] The surveyor also asked the security chief
what kind of security staffing was at the hospital. [4] The secu-
rity chief explained that there were three permanent security
staff members at the hospital, himself included, with the re-
maining security staff members on hire through a contracted
agency. The surveyor asked what kind of orientation and train-
ing the contracted security staff members received, particularly
in the event of an unexpected shift change or staffing change.
[5] The security chief said that the significant majority of con-
tracted staff had been working at the hospital for at least six
months and always underwent a hospital orientation and train-
ing at the outset of working at the hospital.
Section 7: Environment of Care
The surveyor then asked to be taken to areas of the hospital
that were designated as a higher security risk, such as the psy-
chiatric and the labor and delivery units. [6] He observed that
there was appropriate security on the entrances to these areas
with access available through an access pad and intercom. The
surveyor asked the security chief what the process is for staff
members to report a lost access card. The chief responded that
staff members are required to report the loss immediately, and
then security verifies the loss, deprograms the access card, and
reprograms a new access card. [7] In the event of repeated
losses by specific staff members, the security chief conducts a
more focused investigation. [8]
Speaking with the Tracer Team as the Tour Contin-
ues. The surveyor asked the staff where the hospital’s genera-
tors were. [9–11] The facilities manager explained that one
generator was in the basement and another was located outside
the hospital, attached to the adjoining building. The surveyor
first asked to be escorted to the basement of the hospital to
view the generator there. When the tracer team arrived at the
generator room, the surveyor observed that there was a sign on
the door stating “Warning: Generator—No Unauthorized Ac-
cess.” The surveyor asked why there was a sign on the door to
indicate where the generator was. [12] The safety director
stated that it had been there for a number of years and was
meant to discourage entrance. The surveyor pointed out that
this sign actually could create increased risk because anyone in-
tending to sabotage the generator would be able to find the
room more easily. The surveyor suggested using a different sys-
tem to identify the room, such as a number or another type of
code. The surveyor asked how the staff ensured that the room
was always locked. [13–14] The security chief explained that
there was restricted access to this room and checking this door
was a part of the security team’s regular walking tour of the
hospital. The surveyor then checked the door and found that
it was locked.
The surveyor then asked to be taken to see the second genera-
tor, which was located outside the building. [15–16] This gen-
erator was attached to the building, and the hospital had
bricked and fenced it in. The surveyor noted that it was appro-
priately secured and unmarked, making it difficult for anyone
to gain access to it.
Finally, the surveyor asked to review facilities-related docu-
mentation on security, asking in particular to look at the most
recent documentation relating to the last maintenance checks
of the generators and the files of contracted security staff
members to verify training and orientation sessions. [17–18]
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Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the following topics: assessment of con-
tract security staff knowledge, evaluation of the environment,
and surveillance of generators.
Scenario 7-1.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and records review described in
the sample tracer for Scenario 7-1. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Security Chief:
[1] Please show me where your major entrances are for
the hospital. How do you monitor entrance and
egress?
[2] In the event of a security problem, such as an attack
or accident, how do you secure the building? What
is your response?
[3] How many security staff members monitor the
hospital during the day and evening? What is your
approach to patrolling the facilities and grounds?
[4] What type of security staffing do you use?
[5] What kind of orientation and training do contracted
security staff members receive? What do you do
when there is an unexpected staff change?
[6] What areas in the hospital are designated as high
security risk? Please take me to tour these areas.
[7] Who has access to these areas? What do you in the
event that a staff member loses an access card or
key?
[8] What do you do if a particular staff member
repeatedly loses an access card?
Tracer Team:
[9] Where are your generators located?
[10] How have you secured your generators?
[11] What risks have you identified with the generators in
relation to an adverse event, such as a terrorist
attack or sabotage?
132
[12] Have you considered the risk implications in how
you identify the generator room?
[13] How do you secure it?
[14] Who has access to the generator? How do you track
access?
[15] Please show me where your exterior generator is
located. How have you secured this generator?
[16] Who has access to the exterior generator?
[17] Please show me your documentation on the
generators. Has any recent maintenance been done
on them?
[18] Please show me your files for your contract security
staff. Where are orientation to the hospital and
training documented in these files?
SCENARIO 7-2.
Utility Systems
Summary
In the following scenario, a surveyor traces how an organiza-
tion examines its utility systems. Within the tracer, the sur-
veyor explores issues relating to these priority focus areas:
• Physical Environment
• Equipment Use
• Orientation & Training
• Patient Safety
Scenario
This tracer was conducted in a 140-bed psychiatric hospital
where the surveyor focused his attention on utility systems
within the hospital. The hospital was located in a multistory
building in an urban setting. He began the tracer with the
safety director and the facilities manager.
(Bracketed numbers correlate to Sample Tracer Questions on pages
133–134.)
Reviewing Utility Systems Documentation with the
Safety Director. The tracer began with the surveyor asking to
review any documentation relating to utility systems, includ-
ing where manuals and training material were located. [1] He
also wanted to know what kind of maintenance and checks
were performed on these systems and what related documenta-
tion the staff could show him. [2] The safety director ex-
plained that during orientation and training, she and the

facilities manager hold a facilities orientation for new clinical
staff during which they include basic information on how the
utility systems function, how to contact facilities staff in the
event of a problem, and what do to in the event of common
problems before facilities staff arrive on the unit to assist.
Talking with the Psychiatric Nurse. The surveyor
then proceeded with his building tour. He started the tour
on one of the units. He approached a member of the clinical
staff, a psychiatric nurse, and asked her if she could tell him
where the sprinklers were on the unit and what she would
do in the event that one of the patients managed to knock
off one of the plates covering the actual sprinkler head. [3]
She was able to indicate where they were located on the unit
and then added that she remembered being trained on how
to address this issue during her orientation several years ear-
lier, but she could not recall what to do. She added that she
would probably ask another staff member to help her figure
it out while one of them contacted the facilities manager.
The surveyor asked her where the unit’s incident report
form was, and the nurse pulled it up on one of the comput-
ers. [4] The surveyor then asked her what she would do if
the computers were down. She pulled out a folder in the
nurse’s station that held a few paper copies of the incident
report form to show him.
Visiting with the Certified Nursing Assistant. The
surveyor then went to visit another unit, where he first ob-
served that the electrical shutoff panels were well secured and
had evidence of an up-to-date maintenance check. [5] The
surveyor approached one of the certified nursing assistants on
the floor and asked him to show him where the shutoff panels
were and also asked what he would do if he needed to shut off
the power. [6] The certified nursing assistant was able to show
the surveyor the shutoff panels and explained the correct pro-
cedure to shut off power. He added that the unit’s priority
would be to contact the facilities manager and safety director.
The surveyor then asked the certified nursing assistant how he
knew this. [7–8] The certified nursing assistant explained that
he had received training during his orientation several months
earlier. He added that before his qualification as a certified
nursing assistant, he had worked in building maintenance at a
nearby hospital. He also said that the nursing manager had
shown him where the basic instructions on the unit’s utilities
were stored in the nurses’ station area.
Checking Utilities Labeling with the Facilities
Manager. The surveyor continued his tour by reviewing
how well utilities throughout the hospital were labeled in
Section 7: Environment of Care
the event of an emergency full or partial shutdown. He
noted that although the utilities in the basement and other
inaccessible areas were well labeled, he did not see as much
consistency on the medical floors. [9] Some electrical shut-
off panels did not have evidence of labeling, and others ap-
peared to be inconsistently labeled. The surveyor asked the
facilities manager how often the utilities were checked for
correct labeling. [10] The facilities manager said they were
checked periodically.
Contingency Planning with the Safety Director and
the Facilities Manager. The surveyor then spoke to the
safety director and the facilities manager about what kind of
contingency planning they had undertaken in the event of a
complete power failure—including the generators—in the fa-
cility. [11] The facilities manager explained that they had writ-
ten plans to respond and had emergency response processes in
place. They had also performed intermittent tests of their
emergency power systems to help maintain them.
The surveyor also asked to see the personnel training record
for the nurse on the first unit he visited. [12] He learned that
she had been hired before the facilities manager and the safety
director had introduced a new training session relating to the
physical environment.
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the following topics: competency of
maintenance staff, additional in-service training for staff mem-
bers who began working at the hospital before the new orien-
tation was introduced, and labeling of newly installed utility
shutoff devices before a construction process is closed out and
the contractor receives final payment.
Scenario 7-2.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 7-2. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
(continued)
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Scenario 7-2.
Sample Tracer Questions
(continued)
Safety Director:
[1] Please show me any documentation you have about
maintenance, inspection, and testing of your utility
systems. Where are the paper manuals located for
these systems? What electronic material do you
have? How is this material made available to staff?
[2] What kinds of tests and checks do you perform on
the utility systems? How often do you perform them?
Psychiatric Nurse:
[3] Please take me to one of your psychiatric units to
help inspect the sprinkler system. Where are the
sprinklers located on this unit? What would you do in
the event that a patient managed to damage a
sprinkler?
[4] Where is the incident report form located? If you
cannot access an electronic version, do you have a
paper version? If so, where is that located?
Certified Nursing Assistant:
[5] Please show me where the electrical shutoff panels
are on this unit. How can I verify whether the
maintenance is up-to-date and there is labeling in
the event of an emergency shutdown?
[6] What would you do in the event that you need to
shut off the power on the unit?
[7] Whom do you contact if you need to do an
emergency shutdown or have a problem with power?
[8] What kind of training and orientation have you
received in relation to utility systems?
Facilities Manager:
[9] How do you label your utilities for full or partial
shutdown?
[10] How often do you check these utilities for correct
labeling?
Safety Director and Facilities Manager:
[11] What emergency planning have you conducted
around power failures and utility system failures?
What testing do you do to help mitigate such
failures?
[12] Will you please show me the personnel training
records?
134
SCENARIO 7-3.
Environmental Safety
Summary
In the following scenario, a surveyor traces how an organiza-
tion examines environmental safety. Within the tracer, the sur-
veyor explores issues relating to these priority focus areas:
• Orientation & Training
• Patient Safety
• Physical Environment
• Staffing
Scenario
This tracer was conducted in a 175-bed suburban community
hospital. Because the hospital was located in the northern
United States and it was winter, the facility was experiencing
inclement weather at the time of the survey. The surveyor
began his tracer by doing a general building tour and opted to
focus on environmental safety issues. The facilities manager,
safety director, and quality improvement director accompanied
him on his tour. He intended to conclude his tracer by having
a group discussion about current improvement efforts relating
to environmental safety.
(Bracketed numbers correlate to Sample Tracer Questions on page
135.)
Observing Environmental Safety in the Hospital
with the Tracer Team. The surveyor observed a member of
the housekeeping staff who was cleaning the floor near one of
the medical/surgical units. The staff member was using “Wet
Floor/Piso Mojado” warning signs near where she was clean-
ing, but the surveyor did not see any arrows to indicate to
which side of the sign the floor was wet. He asked the team ac-
companying him whether the hospital had a process to ensure
that signage of this type was clear. [1–2] The facilities manager
acknowledged that it did, and he was unsure why the house-
keeping staff was still using the incorrect version. The surveyor
asked the safety director what the process was for staff to re-
spond in the event that a patient, staff member, or visitor falls
due to inadequate signage or distraction. [3–4] The safety di-
rector explained that after addressing the individual’s potential
injuries, there was an incident report that staff members were
expected to complete so that she could track any particular en-
vironmental safety trends.
The surveyor then continued his tour near the main entrance
to the hospital, where he observed the use of walk-off mats

and the safe use of gritting salt at the entrance of the building.
He also observed maintenance staff assisting in clearing snow
on walkways and in the parking areas, being careful not to
block doors and other access points with snow. He asked the
team members what their process was to handle inclement
weather and who had primary oversight responsibility. [5–6]
The safety director said that she kept track of state-issued
weather warnings and that she and the environment of care
committee had devised a response plan for extreme weather
conditions such as snow and ice in the winter and tornados in
the summer. In the case of the weather on this day, the safety
director had received a “severe weather” warning the evening
before and had mobilized the response plan, which meant
maintenance staff began treating the entrances, walkways, and
parking lot areas overnight in preparation for the coming
snow, thereby easing access for any patients or visitors coming
to the facility.
Discussing Data Use with the Tracer Team. The
surveyor then met in a conference room with the facilities
manager, quality improvement director, and safety director
to discuss their use of data in relation to environmental
safety. [7–8] The quality improvement director said that she
worked with the safety director on analyzing data that came
through on the incident reports and helped prepare a
monthly report that was presented at the environment of
care committee.
The surveyor asked what kind of special environmental safety
issues have emerged through analysis of these incident re-
ports. [9–10] The safety director mentioned a recent incident
report in which emergency department staff had to intervene
with a patient who became violent while in the emergency de-
partment. The environment of care committee analyzed the
data and noted a rise in violent events in the emergency de-
partment resulting in injuries suffered by staff and other pa-
tients nearby. A root cause analysis indicated that due to some
recent staffing shortages in the emergency department, the
hospital had had to temporarily bring in contract staff, and
their orientation had not included adequate information
about dealing with violence, deescalating behavior, and calling
for help. The environment of care committee launched a per-
formance improvement initiative focused on improving orien-
tation and training for staff in high-risk areas, such as the
emergency department, and providing more comprehensive
information for contracted or temporary staff. [11] The sur-
veyor asked how the team was monitoring results, and the
safety director said it had tracked a decrease in the number of
incident reports relating to violence.
Section 7: Environment of Care
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the following topics:
• Implementation of improvements with frontline staff
• Planning for every type of inclement weather
• Establishment of a process that tracks emergency depart-
ment patients with suicidal ideation
Scenario 7-3.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 7-3. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the end
of this section). The information gained by conducting a mock
tracer can help to highlight a good practice and/or determine
issues that may require further follow-up.
Tracer Team:
[1] What interventions do you put in place to ensure that
your environment is safe when the floor is being
cleaned or there is inclement weather?
[2] How do you ensure that your signage is correct and
safe for patients, staff, and visitors?
[3] What do you do in the event of a fall or injury in relation
to the environment? What kind of response is required?
[4] Who receives incident reports? What is the process to
enter data from the report for the purposes of data use?
[5] When you have inclement weather, what is your
response plan? Who is responsible for tracking and
implementing the plan?
[6] What are the components of the plan? Who has
responsibility for carrying it out?
[7] What types of data do you collect in relation to
environmental safety?
[8] Who is responsible for collecting the data? Who
analyzes the data? What methods do you use for
collection and analysis?
[9] What kinds of environmental safety issues have you
discovered and addressed as a result of your data
collection and aggregation?
[10] Who was responsible for planning and designing the
improvement? How did you implement the
improvement? How are staff members educated about
the improvement?
[11] How are you monitoring results?
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SCENARIO 7-4.
Fire Safety
Summary
In the following scenario, a surveyor traces how an organiza-
tion addresses fire safety. Within the tracer, the surveyor ex-
plores issues relating to these priority focus areas:
• Communication
• Equipment Use
• Orientation & Training
• Patient Safety
• Physical Environment
Scenario
This tracer was conducted in a 350-bed teaching hospital. The
surveyor wanted to explore fire safety issues during the envi-
ronment of care tracer and so opted to conduct a short build-
ing tour to visit key elements and then conduct a longer group
discussion with staff involved with fire safety and the hospital’s
written fire response plan.
(Bracketed numbers correlate to Sample Tracer Questions on page
137.)
Observing the Hospital’s Fire Safety Equipment
with the Tracer Team. The surveyor asked the facilities
manager, safety manager, and security chief to accompany him
on a building tour to inspect any fire safety equipment and to
ascertain how often the equipment was monitored and tested
for effectiveness. [1] The surveyor determined that the equip-
ment had appropriate labeling that indicated the date of the
last test.
Visiting with Staff. He then visited one of the units
and approached a member of the nursing staff. He asked her
what she would do in the event of a fire. [2–3] The nurse
said the hospital used the RACE (Rescue, Activate alarm,
Confine the fire, Evacuate/Extinguish) and PASS (Pull the
pin, Aim low, Squeeze slowly, Sweep the nozzle side to side)
approach to address fires, and she had undergone training
about a year or two before when the hospital introduced the
fire plan. She also recalled having a fire drill for the unit two
months earlier. The surveyor asked her to show him where
the fire extinguisher was located on the unit, which the
nurse was able to do. [4] He then asked her who responds in
the event of a localized fire, such as one that breaks out in a
patient’s room. [5–6] She explained that whoever is available
responds by first evacuating the patient and then containing
136
the fire. She also added that she knew there was a fire re-
sponse team that came to the scene of a fire to help evacuate
the area and clear the floor.
Discussing Fire Safety with the Tracer Team. The
surveyor then asked to be shown where the visual and audible
fire alarms were and asked how often they were tested. [7] The
facilities manager showed the surveyor their locations and said
that the equipment is tested every 12 months.
The surveyor then asked the team members on the tour to join
him in a discussion about fire safety practices within the hospi-
tal. He also asked what kind of evaluative practices the hospital
carried out in response to either fire incidents or fire drills. [8]
The surveyor wanted to assess their response to various scenar-
ios by describing an actual situation he had observed in an-
other hospital. On a psychiatric unit in the other hospital, a
patient had barricaded himself in his room and started a fire.
The fire response team arrived on the floor intent on assisting
and was able to get to the room door. What the team had not
done, however, was guard the entry to the unit. As a result,
many additional staff members came to the scene of the fire,
offering to help, which created an excess of personnel in close
proximity to the fire. The surveyor explained that if the fire
had escalated rapidly, it could have created a significant safety
concern. The surveyor asked the team members what they
would do differently in a situation like this one. [9–10] The
facilities director mentioned that something similar to this had
come up during a drill a few years before, and the team had
opted to limit the fire response team and have a member of the
team standing at the entry to the unit or area advising other
staff members that the situation was contained. This action,
the director explained, had helped prevent an excess of staff in
the area during the drill.
Reviewing Documentation with the Tracer Team.
The surveyor asked the team to show him the documentation
on fire safety equipment testing and monitoring, along with a
record of fire drills conducted and education provided.
[11–12] He also asked the team members to share their fire re-
sponse plan. His review showed that the documentation was
up-to-date and easy to navigate.
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the topic of fire risk reduction, includ-
ing the practice of compartmentalization, an understanding of
the concept of “defend in place,” the importance of contain-
ment, and the effectiveness of fire drills.

Scenario 7-4.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 7-4. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Tracer Team:
[1] Please show me where your fire safety equipment is.
Where do you label dates and other information about
recent testing and monitoring on the equipment?
Staff:
[2] What is the plan in the event of a fire? How do you
know the plan? What kind of training have you had
on fire response?
[3] When was the last fire drill for your unit?
[4] Where is the closest fire alarm? Where is the
closest fire extinguisher?
[5] In the event of a fire localized to a patient’s room,
what do you do?
[6] Whom do you contact off of the unit when there is a
fire?
Tracer Team:
[7] Where are the visual and audible fire alarms
located? Please show me an example. How often is
the equipment tested?
[8] What are your fire safety practices? Please describe
your fire plan. How often do you review and update
it?
[9] What kind of evaluation do you perform in relation to
what you learn during a fire drill or any actual fire
incidents?
[10] In the event of an unexpected response or outcome,
how do you implement an improvement? Can you
give me an example of this?
[11] Where do you document your testing of fire safety
equipment?
[12] Please show me your log of fire drills and your fire
response plan. Who is responsible for tracking and
updating this information?
Section 7: Environment of Care
SCENARIO 7-5.
Interim Life Safety Measures
Summary
In the following scenario, a surveyor traces how an organiza-
tion addresses interim life safety measures. Within the tracer,
the surveyor explores issues relating to these priority focus
areas:
• Communication
• Organizational Structure
• Patient Safety
• Physical Environment
Scenario
The surveyor conducted this environment of care tracer in a
167-bed midsize hospital. At the time of the survey, the hospital
was undergoing construction to expand its neonatal intensive
care unit and birthing center. In addition to the general physical
environment–related issues that the surveyor considered and
asked about during the survey, she opted to focus her building
tour and discussion on the interim life safety measures the hos-
pital had put in place for the duration of the construction work.
The surveyor was accompanied on her tour by the facilities
manager and the safety director; the birthing center’s clinical di-
rector joined the group after they arrived at the center.
(Bracketed numbers correlate to Sample Tracer Questions on page
138.)
Touring the Construction Site with the Tracer Team.
The neonatal intensive care unit and birthing center were lo-
cated on the ground floor of the hospital. [1–2] Normal access
to the unit was gained through a main entrance, which was
currently inaccessible due to construction. Traffic was redi-
rected with signage through a side entrance, which had been set
up appropriately as a secure interim entrance. When the sur-
veyor arrived at the center, she asked the group when the con-
struction had started and what staff had been involved in
planning for this interim period. [3–5] The facilities manager
explained that the environment of care committee was oversee-
ing the project and had been actively involved in planning for
the construction period. The safety director indicated that she
had responsibility for overseeing the safety of the construction
area. The surveyor also asked the director of the birthing center
if she had been involved in the planning process or been kept
aware of what was happening. [6–7] The clinical director re-
sponded that she had been regularly involved and knew to con-
tact the safety director for any specific concerns.
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The side entrance was designated to remain the secondary
means of egress. However, the vendor had decided to install
drain tiles at both exits and had chained off the doors even
though the exit signs were still in place. There was now only
one way to enter and exit the unit, that being the entrance
from the interior corridor. Interim life safety measures man-
dated that one of the exterior exits be available. This exterior
exit would provide the required main and secondary means of
egress.
The surveyor asked the group members if they had known the
vendor would be working in an area where his work would
block the normal exit. [8] The clinical director said the vendor
had told her the day before that he was going to do things dif-
ferently (and consequently block a wider area) so he could fin-
ish as quickly as possible. The surveyor asked the safety
director why she did not arrange a diversion for the exit by
redirecting exit signage and ensuring that the correct doors
were unlocked. [9] The safety director explained that she had
thought the egress in this area was sufficient and had not been
aware of a change in what the vendor was doing. The surveyor
asked if she was checking the site daily, and the director ex-
plained that she did not realize that was her responsibility.
[10] The surveyor recommended that more appropriate in-
terim life safety measures be put in place immediately.
Reviewing the Construction Plan with the Tracer
Team. The surveyor asked the group members to share the
construction plan and to review roles and responsibilities as
delineated within it. [11–12] The surveyor located and
pointed out the plan’s specification that interim life safety
measures be checked daily for the duration of the construc-
tion. The surveyor also consultatively recommended that for
future, lengthy construction projects, they approach the ven-
dor to be an ad hoc member of the environment of care com-
mittee so the committee could be more aware of any changes
the vendor wanted to make and to help the vendor understand
the safety priorities of the hospital. She also recommended that
they engage other staff members to help test the temporary
signage in place to help determine and communicate whether
there are any problems with egress. [13]
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The discus-
sion might address the topics of inspecting all areas of the con-
struction site daily, clarifying whose responsibility it is to inspect
the construction site, having a checklist to define what the in-
spector should be looking for, and developing a log that docu-
ments each inspection to make sure it is done and done correctly.
138
Scenario 7-5.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 7-5. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Tracer Team:
[1] Where is the construction site located?
[2] How are you redirecting traffic and putting correct
interim life safety measures in place for the duration
of the construction?
[3] What changes to the environment have been put in
place to accommodate the construction?
[4] How long has the construction been under way?
What staff members were involved in planning for it?
[5] Who or what body has oversight responsibility for
this construction site?
[6] What involvement does management at the
construction site have in the ongoing activity?
[7] Please show me the construction site and what
interim life safety measures are currently in place.
[8] Did you know of any changes to the construction
site?
[9] What kind of arrangements do you make to check
the site for any changes? What does the plan
dictate should happen? What are the appropriate
channels of communication in the event of a
change?
[10] How regularly do you check the site to ensure that
appropriate interim life safety measures are in
place?
[11] What is the construction plan? Please outline the
details for me.
[12] Who was responsible for and involved in writing the
plan? How often do you evaluate it? Have you made
changes to it? How are those changes
communicated?
[13] Have you used additional staff to help check and
test whether the interim life safety measures are
working?

SCENARIO 7-6.
Hazardous Materials and Waste
Summary
In the following scenario, a surveyor traces how an organization
handles hazardous materials and waste. Within the tracer, the
surveyor explores issues relating to these priority focus areas:
• Communication
• Information Management
• Patient Safety
• Physical Environment
Scenario
This tracer was conducted in a 12-bed critical access hospital.
The surveyor began his tracer by visiting the medical/surgical
unit with the facilities manager and the safety specialist. The
surveyor wanted to focus on how the hospital handled its haz-
ardous materials and waste.
(Bracketed numbers correlate to Sample Tracer Questions on pages
139–140.)
Reviewing the Hospital’s Inventory with the Facilities
Manager and the Safety Specialist. The surveyor asked to re-
view the hospital’s inventory of hazardous materials and waste
that it uses, stores, or generates. [1] The facilities manager pro-
vided the book, explaining that they kept it limited to what was
required by the state. The surveyor asked when the inventory is
checked and updated. [2] The manager explained that they did a
periodic review—once every six months, according to their orga-
nizational policy—to check on the inventory, and they added
new material as soon as it came into the hospital.
The surveyor asked who had responsibility for the inventory
and where it was stored. [3–4] The facilities manager ex-
plained that he had primary responsibility but that the safety
specialist was also able to regularly update the inventory if
needed. The facilities manager added that the inventory was
kept in a spreadsheet and backed up to the hospital’s servers,
and there was a hard copy printed out and kept in the man-
ager’s office whenever a change was made.
The surveyor asked the specialist and the manager whether the
hospital used material safety data sheets in the patient areas in
the event of an accidental ingestion. [5–6] The specialist ex-
plained that she made sure there was a paper copy available on
the main patient unit, and each computer had an electronic
version of the material safety data sheets. The specialist and the
Section 7: Environment of Care
manager also provided e-mail updates to all staff in the event
of a change or update to the material safety data sheets. The
surveyor asked how often the system was updated online and
whether staff members were ensuring that their electronic ver-
sions were working properly and not waiting until an emer-
gency has taken place. [7–8] The specialist explained that she
did her best to remind people, but she had not actually physi-
cally gone to every computer to check that the tool was work-
ing properly. The surveyor asked how often an incident report
had been filed in relation to an accidental ingestion or other
event relating to hazardous materials. [9] The specialist said it
was rare, but they probably had maybe two or three per year.
Visiting with the Nurse in a Patient Care Area. The
surveyor began his tour by looking at areas where hazardous ma-
terials were stored to see if they were appropriately secured. [10]
He noticed a housekeeping cart in the hallway and was able to
verify that it was safely secured. He then approached one of the
nurses on the unit to ask her about hazardous materials and
waste. He asked her what the hospital’s policy was on waste man-
agement and what she should do in the event of an accidental in-
gestion. [11–12] The nurse referred to the used material safety
data sheets that they were using and showed the used material
safety data sheets to the surveyor on her computer. She also indi-
cated that there were specific containers designated for waste such
as sharps and certain chemicals, and she showed one of these con-
tainers to the surveyor. All looked to be in correct order, and there
were sufficient supplies such as gloves for staff to use.
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the topics of verifying staff competency
and reducing risks in the environment of care—for example,
by considering less-hazardous alternatives when selecting and
purchasing new materials.
Scenario 7-6.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 7-6. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
(continued)
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Scenario 7-6.
Sample Tracer Questions
(continued)
Facilities Manager and Safety Specialist:
[1] Please indicate how you inventory your hazardous
materials and waste. What do you keep on the
inventory?
[2] How do you check and update the inventory? How
often is this done? How do you prioritize updating
the inventory? What happens when a new
hazardous material is brought into the hospital?
[3] Who has responsibility for the inventory? Who is
responsible for updating it? How do you track this
responsibility?
[4] Where is the inventory kept? Do you have any
backups for it?
[5] Do you use any kind of material safety data sheets
in the hospital? If so, where do you store them?
[6] Do staff members know how to access them?
[7] How do you update the material safety data sheets?
How do you communicate any changes or updates?
[8] How often do you update the system?
[9] What is the frequency of reports being filed?
Nurse:
[10] How do you secure hazardous materials—for
example, those stored on a housekeeping cart?
[11] What is your hospital’s policy on waste
management?
[12] What do you do in the event of an accidental
ingestion of a hazardous material?
SCENARIO 7-7.
Medical Equipment
Scenario
The surveyor conducted this tracer in a 21-bed hospital in a
rural area. The surveyor opted to focus on equipment use dur-
ing the tracer. He began his tracer by having a discussion with
key staff members who were either directly or partially in-
volved in equipment use practices and then intended to take a
physical tour of the building to check on the status and use of
equipment.
(Bracketed numbers correlate to Sample Tracer Questions on page
141.)
Overview of Equipment Use Practices with the
Tracer Team. The surveyor began the tracer by asking the fa-
cilities manager, a biomedical engineer, and the hospital’s qual-
ity improvement nurse to discuss their general approach to
handling equipment in the hospital. [1] The manager men-
tioned that they maintained an inventory of equipment and
that the biomedical engineer handled maintaining and updat-
ing the inventory as needed. The surveyor asked the biomed-
ical engineer what kind of maintenance, inspections, and
testing he performed on the equipment. [2] The biomedical
engineer explained that he performed maintenance as specified
in the manufacturer’s guidelines and used software to track
and remind him about any necessary maintenance, upgrades,
and improvements. He showed the surveyor the inventory log
and other documentation he maintained in relation to equip-
ment management. The surveyor asked what the process is for
staff to report issues with any equipment. [3] The biomedical
engineer explained that all problems with equipment need to
be reported to him as soon as possible. Staff members either
come to see him in the storage and maintenance room or e-
mail him. The surveyor asked whether there had been any in-
stances of delay or confusion over reporting equipment
problems, locating the equipment in question, or inappropri-
ately relocating equipment. [4] The biomedical engineer an-
swered that they had experienced some staff misplacement of
items, but generally because the facility was small, he could
easily track down equipment by asking staff or doing a physi-
cal tour of the hospital.

Summary Talking with the Nurse in the Hospital. The surveyor

In the following scenario, a surveyor traces how an organization then walked through the hospital, stopping at the medical/
uses equipment in an inpatient environment. Within the tracer, surgical unit’s nurses’ station to speak with the nurse who was
the surveyor explores issues relating to these priority focus areas: working there. He asked her if she could identify a key piece of
• Equipment Use equipment on the unit. [5] She indicated the crash cart. The
• Organizational Structure surveyor asked her how often the crash cart is used and how
• Patient Safety she would know whether the equipment would require main-
• Physical Environment tenance. [6–7] The nurse said the crash cart was not used

140

often, but she did have competency training to use it. She said
that the equipment biomedical engineer checked it regularly.
The surveyor then closely inspected the crash cart and verified
that the equipment was labeled as being checked recently and
appeared to be in good working order.
The surveyor then asked the nurse what she would do when
patients bring their own oxygen equipment with a concentra-
tor into the hospital with them. [8] The nurse explained that
when that happens, the respiratory therapist, the facilities
manager, or the biomedical engineer would come and check
the equipment. The surveyor asked what would happen at
9:00 P.M., when those staff members are not there. [9] The
nurse said that although she does not know as much as the ex-
perts, she has a good idea of what a safe, functioning oxygen
concentrator should look like; therefore, she could do a basic
check based on the equipment’s specifications and wait for the
appropriate staff to arrive in the morning to do the more de-
tailed check.
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the topic of equipment management,
including the following:
• Developing a guidance document for clinical staff on what
to look for regarding equipment brought in by patients
during off-hours
• Establishing written documentation that identifies the
activities for maintaining, inspecting, and testing of all
medical equipment on the inventory
• Identifying, in writing, frequencies for inspecting and
maintaining medical equipment on the inventory
Scenario 7-7.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 7-7. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Tracer Team:
[1] How do you handle equipment use issues in the
hospital? How do you organize your process?
Section 7: Environment of Care
[2] What kinds of maintenance, inspection, and testing
do you perform on the equipment? How often?
[3] What process do you follow for staff to report any
issues with equipment (missing, needing repair, and
so on)?
[4] Have you ever had issues of lost or missing
equipment? If so, what is your process to resolve it?
Nurse:
[5] Could you point to a key piece of equipment that is
used on this unit?
[6] How often is it used and what maintenance is
performed on it? How would you know if there is a
need to repair anything?
[7] What kind of competency training have you had to
use this piece of equipment?
[8] What is the process to deal with patients bringing in
their own medical equipment, such as oxygen? How
do you check that the equipment is functioning?
[9] If the patient arrives in the hospital at 9:00 P.M., what
process would you follow to check the equipment if
the regular staff members are not working when the
equipment arrives? What kind of training have you
received to help you check the equipment?
SCENARIO 7-8.
Sterilizer Maintenance
Summary
In the following scenario, a surveyor traces how an organiza-
tion conducts maintenance for sterilizers. Within the tracer,
the surveyor explores issues relating to these priority focus
areas:
• Equipment Use
• Orientation & Training
• Patient Safety
• Infection Control
Scenario
During the environment of care session at a large tertiary care
center, a surveyor asked to see the organization’s sterilizer
maintenance policy as well as the sterilizers’ Instructions for
Use (IFU)—the equipment manual developed by the manu-
facturer and the U.S. Food and Drug Administration. After
reviewing these documents, the surveyor noted that the
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organization’s sterilizer maintenance policy did not match the
manufacturer’s recommendations, nor did the organization
have a standardized process for sterilizer maintenance. This sit-
uation triggered the need for a second generation tracer. This
scenario is an example of a second generation tracer, which
takes an in-depth look at a high-risk topic (see Introduction,
page 2).
(Bracketed numbers correlate to Sample Tracer Questions on page
143.)
Meeting with the Manager of the Sterile Processing
Department. The surveyor first met with the manager of the
sterile processing department, asking the manager what he
knew about sterilizer maintenance activities. During this con-
versation, the surveyor tried to determine whether the man-
ager understood how the sterilizers should be maintained, who
is in charge of that maintenance activity, and how communica-
tion with that department occurs. [1–5]
The surveyor asked the manager how a sterilizer in his depart-
ment receives appropriate maintenance. [6] The manager
replied that the biomedical equipment department is in charge
of maintaining the organization’s sterilizers. The manager ex-
plained that when maintenance is scheduled, someone from
the department comes to the center, performs the mainte-
nance, performance tests the machine, and releases it back to
the organization for use. Before using the sterilizer, the man-
ager said, he performs another set of parametric, chemical, and
biological tests to double-check that the equipment is func-
tioning properly.
The surveyor then asked the manager of the sterile processing
department a series of questions to learn details of repair ef-
forts: How does the sterile processing department determine if
a sterilizer is malfunctioning and needs repair? How does the
department communicate with the biomedical equipment de-
partment about that repair? Is the equipment failure docu-
mented? Does a representative from the biomedical equipment
department come on site at regular intervals or only when the
sterilizers malfunction? [7–10]
Speaking with the Biomedical Equipment Man-
ager. The surveyor spoke next with the biomedical equipment
manager in charge of the organization’s medical equipment
management program. The surveyor probed for information
about how the department performs maintenance on the ster-
ilizers, asking the manager for details about the steps involved
in maintenance efforts, who conducts the maintenance, the
142
training those individuals receive, and how often the training
occurs. He also asked the manager how frequently the depart-
ment performs preventive maintenance. [11–16]
The surveyor asked the biomedical equipment manager about
the IFU recommendations for maintaining the sterilizers, in-
cluding the manufacturer’s recommendations regarding pre-
ventive maintenance. The biomedical equipment manager said
he was not familiar with the IFU recommendations, and he
was unable to fully describe the organization’s policy for steril-
izer maintenance. The surveyor and the biomedical equipment
manager discussed the IFU recommendations and why meet-
ing those recommendations is critical to ensuring the safety of
patients. [17]
In addition to questions about maintenance, the surveyor
asked the biomedical equipment manager about repair efforts,
including how his department receives repair requests from
various units housing sterilizers, including the sterile process-
ing department; how his department ensures timely repairs;
and whether those repairs are documented. [18–21]
At the close of this conversation, the surveyor stressed the
need to update the sterilizer maintenance policy and verify
that practice matched the new policy. The surveyor and the
biomedical equipment manager discussed how to develop a
standardized process for sterilizer maintenance. The surveyor
said that the organization could consider forming a task
force to review and address the issue; the task force could
consult not only the IFU recommendations but also the As-
sociation for the Advancement of Medical Instrumentation
(AAMI) recommendations. The surveyor emphasized the
need for training associated with the new standardized
process to make sure all sterilizers are maintained and re-
paired appropriately.
Talking with the Facility Manager. The surveyor con-
cluded the tracer by talking with the facility manager. The sur-
veyor wanted to determine how the organization ensures the
adequate supply of quality steam for the sterilizers. The sur-
veyor and the facility manager discussed the importance of
quality steam in an effective steam sterilization process. Dur-
ing the conversation, the surveyor probed for information
about the dryness of the steam and the level of noncondens-
able gas in the steam. The facility manager indicated that
steam dryness follows AAMI recommendations and is between
97% and 100%, with noncondensable gas maintained at a
level that will not impair steam penetration into sterilization
loads. [22–24]

The surveyor followed up this exchange with questions about
steam pipe insulation and design, verifying that they met
AAMI recommendations as well. The surveyor pressed for in-
formation on how steam quality is maintained and whether
the organization had processes in place for monitoring and
controlling steam generation; maintaining steam traps, boilers,
and generators; and periodically assessing sterilization loads to
support proper sterilizer performance. [25–26]
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the topic of equipment maintenance,
including the idea of developing a standardized maintenance
policy and the need for the facility manager to be a part of the
task force to update and implement the new policy and associ-
ated training efforts because this issue is so important in pre-
serving the safety of patients.
Scenario 7-8.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 7-8. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Manager of Sterile Processing
Department:
[1] How does a sterilizer in this department receive
appropriate maintenance?
[2] Who is in charge of sterilizer maintenance efforts?
[3] How do you communicate with the department in
charge of maintenance efforts?
[4] How often should the sterilizers be maintained?
[5] Does the sterile processing department have access
to the sterilizer maintenance records?
[6] How does a sterilizer in this department receive
appropriate maintenance?
[7] How do you determine whether a sterilizer is
malfunctioning and needs repair?
Section 7: Environment of Care
[8] How do you communicate with the biomedical
equipment department about the repair?
[9] Is the equipment failure documented? If so, how?
[10] Does a representative from the biomedical
equipment department come on site at regular
intervals or only when the sterilizers malfunction?
Biomedical Equipment Manager:
[11] Is sterilizer maintenance part of the organization’s
overall medical equipment management program?
[12] What are the steps involved in sterilizer
maintenance?
[13] Who conducts the maintenance?
[14] What training do those individuals receive?
[15] How often does training occur?
[16] How frequently is preventive maintenance
performed?
[17] What are the IFU recommendations for maintaining
sterilizers? Why is it important to be familiar with
these recommendations?
[18] How do you respond when a sterilizer fails a
performance test on a unit?
[19] How do you receive repair requests from various
units, including sterile processing?
[20] How do you ensure timely repairs?
[21] Are repairs documented? If so, how?
Facility Manager:
[22] Why is steam quality important for sterilizers?
[23] How does your organization ensure the adequate
supply of quality steam?
[24] What is the appropriate level of dryness? Gas
concentration?
[25] Please tell me about steam pipe insulation. How
does your organization’s piping meet AAMI
recommendations?
[26] What processes are in place for maintaining steam
quality; monitoring and controlling steam generation;
maintaining steam traps, boilers, and generators;
and periodically assessing sterilization loads to
support proper sterilizer performance?
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Sample Tracer Worksheet: Scenario 7-3.

The worksheet below is an example of how organizations can A correct answer is an appropriate answer that meets the re-
use the sample tracer questions for Scenario 7-3 in a worksheet quirements of the organization and other governing bodies.
format during a mock tracer. The bracketed numbers before An incorrect answer should always include recommendations
each question correlate to questions described in the scenario. for follow-up.

Tracer Team Member(s): Dan Chang Data Record(s): incident reports

Subjects Interviewed: Eric Johannson, Lupe Unit(s) or Department(s): hospital building tour
Gonzalez, Dorothy Zipfel
Tracer Topic or Care Recipient: environmental
safety

Interview Subject: Tracer Team (Facilities Manager, Safety Director, and Quality
Improvement Director)
Questions Correct Incorrect Follow-Up Comments or
Answer Answer Needed Notes
[1] What interventions do you ✓ Staff answered
put in place to ensure that your appropriately.
environment is safe when the
floor is being cleaned or there is
inclement weather?

[2] How do you ensure that your ✓ Need to do a review of all Saw a sign but unclear
signage is correct and safe for signage. which side of sign floor
patients, staff members, and was wet.
visitors?

[3] What do you do in the event ✓ Good response.

of a fall or injury in relation to
the environment? What kind of
response is required?

[4] Who receives incident ✓

reports? What is the process to
enter data from the report for
the purposes of data use?

[5] When you have inclement ✓

weather, what is your response
plan? Who is responsible for
tracking and implementing the
plan?

144
 Section 7: Environment of Care

Interview Subject: Tracer Team (Facilities Manager, Safety Director, and Quality
Improvement Director) (continued)
Questions Correct Incorrect Follow-Up Comments or
Answer Answer Needed Notes
[6] What are the components of ✓ Review and clarify roles Some confusion over
the plan? Who has responsibility through EC committee. leadership responsibility
for carrying it out? for plan.

[7] What types of data do you ✓ Review data collection Some data collected but not
collect in relation to process with quality entered.
environmental safety? improvement staff.
[8] Who is responsible for ✓
collecting the data? Who
analyzes the data? What
methods do you use for
collection and analysis?

[9] What kinds of environmental ✓ Good example by facilities

safety issues have you manager.
discovered and addressed as a
result of your data collection and
aggregation?

[10] Who was responsible for ✓

planning and designing the
improvement? How did you
implement the improvement?
How are staff members
educated about the
improvement?

[11] How are you monitoring ✓ Need to review and revise Very inconsistent
results? procedure to remedy the monitoring approach.
inconsistency.

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146

Tracer Scenarios for
INTERNATIONAL
NOTE: No Two Tracers Are the Same
Please keep in mind that each tracer is unique. There is no
way to know all of the questions that might be asked or
documents that might be reviewed during a tracer—nor
what all the responses to the questions and documents
might be. The possibilities are limitless, depending on the
SECTION 8
tracer topic and the organization's circumstances. These
tracer scenarios and sample questions are provided as an
educational or training tool for organization staff; they are
not scripts for real or mock tracers.
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Section Elements
This section includes sample tracers—called scenarios—relevant to health care organizations outside the United States.
Individual and system tracers are represented. The section is organized as follows:

Scenarios: Each scenario presents what might happen when a

surveyor conducts a specific type of tracer. The scenarios are
presented in an engaging narrative format in which the reader
“follows” the surveyor through the tracer scenario. Within the
narrative are bracketed numbers that correspond to numbered
sample tracer questions following the tracer.

Sample Tracer Questions: After each scenario narrative is a list

of sample questions a surveyor might ask during that scenario.
These questions can be used to develop and conduct mock tracers
in your organization on topics similar to those covered in the
scenario.

Sample Tracer Worksheet: At the end of the section is a sample

worksheet that shows how the sample tracer questions for one
select scenario in the section might be used in a worksheet format.
The example shows how the worksheet might be completed as
part of a tracer for that scenario. A blank form of the worksheet is
available in Appendix B.

148

INDIVIDUAL
Tracer Scenarios
SCENARIO 8-1.
Large Hospital
Summary
A surveyor conducts this tracer in a large hospital that offers
many services, including surgery, cardiology, and general
medical and surgical care. It also has a cancer treatment cen-
ter in a separate building located next to the hospital. The
surveyor chooses to trace a patient who had come for cancer
treatment and surgery. During the tracer she explores issues
relating to communication, consent, cultural competency,
and pain management.
Scenario
The surveyor selected a 57-year-old female patient who had
been admitted to the hospital from another country to re-
ceive breast cancer treatment and undergo surgery for a par-
tial mastectomy.
(Bracketed numbers correlate to Sample Tracer Questions on
pages 150–151.)
Visiting Admissions Staff. The surveyor first visited
admissions staff to ask about the process to admit a new pa-
tient to the hospital, particularly one from a different coun-
try with a different primary language. [1–2] The admissions
secretary explained that the hospital would have been in
contact with the patient and her family before admission
and provided registration material and information in ad-
vance. The secretary added that the hospital used a transla-
tion service to speak with the patient and family to ensure
that they understood the process and to answer any ques-
tions prior to admission. On admission, the secretary said,
the patient was provided with additional information, which
the secretary remembered was also communicated to the
patient’s husband and son, who accompanied her on
admission.
Talking with the Nurse on the Surgical Ward. The
surveyor then visited the surgical ward where the patient was
recovering from surgery. She asked what kind of special as-
sistance was offered or provided to patients, particularly in
Section 8: International
relation to those from different countries or cultural back-
grounds. [3] The nurse explained that because the patient
was of a Muslim religious background, she had requested fe-
male clinical care as much as possible. She added that hospi-
tal staff members had done their best to accommodate the
request, although in some cases—such as with the physi-
cians—it was not always feasible.
The surveyor asked the nurse to describe how pain was as-
sessed and managed for this patient. [4] The nurse checked
the record and indicated that the patient had pain assessed
and received pain management medication both in advance
of the surgery and while in recovery. The surveyor also asked
how frequently the pain was reassessed since the patient re-
turned to the surgical unit. [5] The nurse showed the sur-
veyor the pain assessment tool that she used, which was
translated into a number of languages. The tool also had a
facial expression chart to help identify pain in case the pa-
tient did not understand a numerical pain scale. The nurse
explained that pain was assessed regularly when vital signs
were assessed, and also one hour after administration of pain
medication.
Observing the Phlebotomist. The surveyor then vis-
ited the patient as she was having blood drawn for testing.
An interpreter accompanied the surveyor on the visit to help
facilitate the discussion. [6–7] The surveyor observed the
phlebotomist appropriately identifying the patient during
collection and ensuring that the specimens were correctly
labeled in the presence of the patient. The surveyor then
asked and received permission to speak with the patient
and the patient’s daughter, who was sitting in the room with
her.
Speaking with the Patient and Family. The sur-
veyor asked the patient to describe her experience with care
in the hospital so far and whether she had received educa-
tion about what was going to happen and understood how
to ask questions. [8–10] The patient replied that she had
been very happy with the care and that the doctors were
doing a good job. The daughter added that her mother did
receive some education, but it was difficult for her to retain
this information in her condition. The daughter said that
she had taken the materials and was explaining the informa-
tion to her mother as best she could.
Speaking with the Surgeon. The surveyor then met
with the surgeon to discuss the patient’s case. She asked him
what kind of preoperative assessment the surgical team
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conducts and what kind of postoperative care he ordered for
the patient, and asked him to show her the documented as-
sessments. [11] The surgeon indicated that the surgical team
members conduct a preoperative check to confirm the cor-
rect surgical site and patient and that they mark the surgical
site and confirm it with the patient if possible. [12] They
also check for the correct administration of prophylactic an-
tibiotic shortly before surgery. The surgeon also mentioned
the time-out process that the team follows right before sur-
gery to verify the correct patient, procedure, and surgical
site. He authorizes the time-out and signs off on it before
the surgery. [13] In the case of this surgery, the surgeon re-
membered that the surgical team worked well together. He
noted that he ordered postoperative pain management and
had been checking the patient’s postoperative progress daily.
The surveyor was able to verify this follow-up upon review
of the patient’s record. [14–16]
Discussing Discharge Planning with the Senior
Nurse. The surveyor then spoke with the senior nurse on
the surgical ward to ask whether there was a discharge plan
for the patient. [17] The nurse responded that the patient
was still recovering from surgery but once stabilized would
be discharged into outpatient care at the cancer treatment
center. The surveyor found no evidence of a written dis-
charge plan. Because the patient had traveled from overseas,
the hospital had helped arrange temporary accommodations
for the patient and her family while she was receiving
chemotherapy. The surveyor asked the nurse whether the
family had been involved in discharge planning. [18] The
nurse replied that the discharge process had just begun and
the staff had started explaining the process to the patient
and family in preparation for discharge.
Moving Forward. Based on the tracer, the surveyor
may discuss areas of improvement in the Daily Briefing. The
discussion might address the following topics:
• Periodic review of the assessment process to be sure that
it considers the varying cultural needs of patients, partic-
ularly in relation to pain or nutritional needs
• Monitoring the effectiveness of patient and family educa-
tion, particularly when family members expect to be ac-
tively engaged
150
Scenario 8-1.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 8-1. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Admissions Staff:
[1] What is your process to admit new patients? What
do you do in preparation for the patient’s arrival?
[2] What do you do if the patient does not speak the
primary language of the hospital? What translation
services do you provide? Where is this information
documented? Who participates in documenting the
patient education?
Nurse on Surgical Ward:
[3] With regard to cultural competency, what kind of
special assistance do you provide to patients and
families? How do you accommodate special needs?
[4] How do you assess and manage pain? How are
pain assessment and management documented?
What assessment tool do you use?
[5] How and when do you reassess for pain? How is
this reassessment documented?
Phlebotomist:
[6] What is the procedure for collecting blood from a
patient?
[7] How do you ensure the correct patient identification
and correct test? What is the process for labeling
blood collection specimen tubes?
Patient and Family:
[8] How has your experience of care been in the
hospital? Are you able to get all of your questions or
concerns answered?
[9] What type of educational materials or instructions
have staff members provided to you?
[10] Are interpreters provided as needed? Is written
material available in a language you can read and
understand?

Surgeon:
[11] What kind of preoperative check do you perform for
patients? What do you verify?
[12] Is the operative site marked? Can you describe the
required process?
[13] Is a time-out conducted? Can you describe the
required process? Is it always conducted prior to
surgery?
[14] What kind of postoperative care did you order for
this patient? How are you kept apprised of the
patient’s condition?
[15] How often do you visit the patient and assess the
patient’s condition?
[16] How are referrals made for additional care and
services such as for ongoing cancer treatment?
Senior Nurse:
[17] What is the discharge plan for this patient? Is it
documented?
[18] How have you informed and involved the patient
and family in the discharge plan? How do you
accommodate any questions or concerns?
SCENARIO 8-2.
Nursing Home
Summary
In the following scenario, a surveyor conducts an individual
care continuum tracer in a nursing home. The surveyor
explores issues relating to safety, medication management, and
assessment.
Scenario
This individual tracer was conducted in a nursing home. The
surveyor selected a resident who had been in the nursing home
for the previous eight months. This resident was an 87-year-
old man who had dementia and had experienced difficulty
with mobility after a fall preceding his admission to the nurs-
ing home.
(Bracketed numbers correlate to Sample Tracer Questions on page
152.)
Talking with the Nurses. The surveyor began her tracer
by talking with the nurses on the resident’s unit. She asked
Section 8: International
them what kinds of assessments they conduct for residents.
She also asked them to describe how they care for a resident
with dementia and what kind of medication management was
being provided for the resident. [1–4] One nurse explained
that the primary concern for the resident was his safety and
comfort. The nurse added that the nursing home had identi-
fied the resident as being at risk for a fall and for wandering,
and therefore the nurses conducted more regular checks on the
resident, including providing more controlled support to allow
him to ambulate safely.
The resident’s family members came to visit him regularly and
were actively involved in helping him and supporting his mo-
bility exercises. The surveyor asked the nurses how they helped
orient the resident’s family to the nursing home and what in-
formation they gave them about the resident’s condition and
prognosis. [5–6] One nurse responded that it was common
practice for the family to spend time at the nursing home and
to help care for the resident. Nurses would often provide infor-
mation about hand hygiene and other rules about visiting and
use of public spaces within the nursing home. The nurse re-
called providing some guidance to the resident’s son on how to
assist the resident with walking.
Speaking with the Resident’s Family. The surveyor
then received permission to visit the resident and his family in
the resident’s room. The resident was sitting in a wheelchair,
and his daughter and granddaughter were sitting with him.
The surveyor greeted the resident and then spoke with the
family. The surveyor asked the daughter about her experience
in the nursing home and whether she felt supported as the
nurses there cared for her father. [7] The daughter indicated
that they were satisfied with the nursing home and that the
nurses had been very welcoming of her father. The surveyor
also noted that the daughter had brought in a lot of food for
her father. She asked whether the family had received any spe-
cial instruction about the food. [8–9] The daughter answered
that nothing was said in particular, though they were asked to
remove or dispose of any leftover food when they went home
at night; the daughter added that she understood that was be-
cause they did not want her father hurting himself and because
the nursing home needed to be kept clean.
Following Up with the Nurses. The surveyor then
asked the nurses what kinds of practices they followed in rela-
tion to geriatric nutritional needs and issues relating to food
being brought into the facility. [10] One nurse responded that
the nurses provided information when the family came into
the facility but that the family rarely paid attention to it.
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Another nurse added that they had seen instances of residents
sharing food and had intervened for residents who were on re-
stricted diets.
Observing the Nursing Aide. The nursing aide then
came to assist the resident with his ambulation exercises, and
the surveyor asked to observe. The resident was assisted by the
aide and his daughter to get out of his wheelchair and walk
about halfway down the hall and back. The surveyor observed
that the resident was not wearing slip-proof shoes and clearly
struggled in a few instances. The surveyor asked the nursing
aide what kind of foot support was provided to the resident, to
which the aide replied that the family provided the walking
support. [11]
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the following topics:
• Resident safety regarding footwear to minimize falls risk
• Resident and family education about ambulation and
nutrition
Scenario 8-2.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 8-2. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Nurses:
[1] What is your plan of care for a resident with
dementia? How do you administer medication or
other health-related products?
[2] How do you assess residents? What reassessments
do you conduct?
[3] If a resident is designated as being at risk for falls,
what do you do in response? What documentation is
there? How do you educate the family and the
resident on the risk of falls?
[4] If a resident is prone to wandering, how do you
prevent it? What safety measures do you put in
place?
152
[5] What involvement do families have in the nursing
home? How do you involve them in the care and
support of the resident?
[6] What education and training do you provide to
families to enable them to support the resident
safely?
Resident’s Family:
[7] What kind of experience have you had with the
nursing home? Do you believe your concerns or
questions have been answered?
[8] What instructions have you been given about
bringing food into the nursing home?
[9] Do you understand why there might be limitations in
relation to food storage in the residents’ rooms?
Nurses:
[10] How do you work with families in relation to the
nutritional needs of their resident family members?
What measures do you have in place to monitor and
intervene for residents sharing food with those on
restricted diets?
Nursing Aide:
[11] Is the resident provided with nonslip socks or other
safe footwear? Who is responsible for making sure
the resident has safe footwear?
SCENARIO 8-3.
Ambulatory Care Center
Summary
In the following scenario, a surveyor conducts an individual
tracer at an ambulatory care center that provides same-day eye
surgery services. The surveyor explores issues relating to the
time-out process, assessment, and patient education.
Scenario
The surveyor selected a 78-year-old male patient who had
been at the center for cataract surgery the day before. The sur-
veyor reviewed the patient’s closed record. He began his tracer
with admissions and moved through the center.
(Bracketed numbers correlate to Sample Tracer Questions on page
153.)

Meeting with Reception Staff. The surveyor started his
tracer at reception. He asked the reception staff members to
describe what they typically do when a patient arrives in the
center for surgery. [1–2] A staff member replied that they
check that they had the appointment scheduled and then go
over some basic information with the patient, including con-
sent forms and additional health information. The surveyor
observed that the waiting area was very noisy and the recep-
tion staff members were speaking loudly to patients. He asked
the reception staff members how they can be sure they can
hear the correct information when it is so noisy and what they
do if the patient wants to discuss something in private. [3–4]
The reception staff members said they do not have any other
space and that they just have to accept the situation.
Visiting the Nurse in the Surgical Preparation
Area. The surveyor then visited the surgical preparation area
to see how the nurse received and educated a surgical patient.
[5–6] The nurse explained that she gives instructions in ad-
vance of surgery and then goes over some key teaching points
again on the day of surgery. The surgeon, she said, also comes
in and checks the patient while they wait in the preoperative
area and verifies and marks the correct site on the eye for sur-
gery with the patient and nurse present. The surveyor asked
what kinds of assessments the nurse conducts in advance of
surgery. [7–9] The nurse explained that she conducts a physi-
cal assessment, takes down the patient’s history, and asks the
patient about any current medications.
Visiting the Anesthesiologist in the Surgical Suite.
The surveyor spoke with the anesthesiologist in the surgical
suite. He asked him what kinds of presedation assessments and
checks are done in advance of administering anesthesia. [10]
The anesthesiologist explained that he spoke with the patient
and explained the process in detail. Because the patient had
already done a medication use check with the nurse earlier, the
anesthesiologist was able to review current medication use. In
the case of this patient, the surveyor noticed that the patient
had a number of existing medications that he was taking. [11]
The surveyor was able to verify that the assessment was cor-
rectly documented. The surveyor then asked the anesthesiolo-
gist to describe the surgery’s time-out process. [12–14] The
anesthesiologist explained that they check the patient and the
patient’s surgical site, and then the surgeon signs the checklist.
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the topics of patient and family rights
for privacy as well as patient safety.
Section 8: International
Scenario 8-3.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 8-3. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Reception Staff:
[1] What happens when a patient enters your center for
surgery?
[2] What special material or education do you share at
admission?
[3] How do you accommodate patients in a noisy, busy
waiting area? How are you able to have a sensitive
discussion in such an environment?
[4] What do you do if the patient wants to speak in a
more private setting?
Nurse in Surgical Preparation Area:
[5] How do you educate patients?
[6] What other preoperative activities are taking place
for a patient like this?
[7] What kind of preoperative assessment do you
conduct?
[8] What checks does the surgeon perform?
[9] What is your process to verify the surgical site? How
do you involve the patient in the process?
Anesthesiologist:
[10] What kind of presedation assessment do you
perform? How do you check medication use?
[11] Where is your presedation documented in the
patient’s record? How do you update it?
[12] What is your time-out process? Please describe it to
me. Who is responsible for it? Where do you
document it?
[13] What kind of perioperative care do you provide?
[14] What is your process in the event of resuscitation?
How is this process documented?
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SYSTEM
Tracer Scenarios
SCENARIO 8-4.
Midsize Hospital
Summary
This improvement in quality and patient safety system tracer is
conducted in a midsize hospital that provides general medical,
surgical, and obstetrical care to patients. It also specializes in
cardiac care and opened a dedicated cardiac care surgery center
two years earlier. During this system tracer, the surveyors
explore issues relating to data use and management, clinical
guidelines, patient and family education, and patient safety
and conclude the tracer by visiting units in the hospital to
validate the processes that the hospital has in place.
Scenario
Two surveyors conducted this tracer on the second day of the
on-site survey. The surveyors first asked to meet with the med-
ical director, the nurse quality improvement specialist, and the
hospital’s vice president for patient safety (who was also a
physician). They conducted the tracer review in a meeting
room provided by the hospital.
(Bracketed numbers correlate to Sample Tracer Questions on page
155.)
Overview with the Medical Director, Nurse Quality
Improvement Specialist, and Vice President for Patient
Safety. At the outset of the system tracer, the surveyors asked
the group members to describe their approach to using data to
assist in their quality improvement and patient safety activities.
[1–3] The medical director explained that the hospital col-
lected data relating to patient outcomes and particular proce-
dures conducted in the hospital, such as a coronary artery
bypass graft. It also collected data related to surgical site infec-
tions and patient and family education, he added. The survey-
ors asked the group to describe what methods and approaches
the hospital had toward data collection and who was primarily
responsible for it. [4–6] The medical director responded that
his department had oversight responsibility for quality im-
provement but that the hospital’s quality improvement com-
mittee, which met regularly, also had input into the hospital’s
quality improvement activities and methods.
154
The surveyors asked the group members to describe what five
clinical measures they had selected out of the Joint Commis-
sion International Library of Measures on which to submit
data. The group members explained that they were submitting
data on acute myocardial infarction, Surgical Care Improve-
ment Project (SCIP), and heart failure. The surveyors asked
the group members what processes they were using to collect
and submit data. [7] The medical director explained that the
hospital was already collecting data on heart failure and acute
myocardial infarction and had been working with surgical staff
to ensure that SCIP data on prophylactic antibiotic adminis-
tration were being submitted to the quality improvement staff
as well. He added that so far there had been no problems with
data being submitted in a timely manner.
Focusing on a High-Risk Process with the Medical
Director, Nurse Quality Improvement Specialist, and
Vice President for Patient Safety. The surveyors then
asked the group members to present information on data col-
lected and analyzed regarding one high-risk process for which
they had designed a quality improvement effort and then
monitored on an ongoing basis. [8–10] The nurse quality im-
provement specialist responded that they had been paying par-
ticular attention to surgical site infection rates in relation to
their coronary artery bypass graft patients. This increased at-
tention was due to a recent failure mode and effects analysis
that had indicated a higher surgical site infection rate among
those patients than among the general surgical population.
The failure mode and effects analysis, she noted, had also in-
cluded a literature search and benchmarking comparisons. She
added that this higher infection rate also became apparent
after the hospital opened its cardiac care surgery center two
years earlier. After conducting a failure mode and effects analy-
sis, they identified some inconsistencies in patient and family
education and antibiotic use as compared to Joint Commis-
sion International hospital standards. The medical director ex-
plained that this inconsistency was possible because of the
ability to observe and document the presurgical procedures as
standardized by the hospital and cardiac surgeons.
The surveyors asked the group members to describe their
process to design an improvement and how they had been
monitoring its progress. [11] The medical director explained
that the quality improvement committee created an action
team that included the medical director, the nurse quality
improvement specialist, the nursing director of the cardiac
care surgical center, and the chief cardiac surgeon. The ac-
tion team implemented a plan to link a surgical nurse with
the patient and family before and on admission. The goal of

the nurse was to ensure that any questions about surgery
were answered, along with performing any necessary pre-
and postoperative care. The nurse worked with the patient
before admission when the patient came to the cardiac cen-
ter for a presurgical check. The surveyors asked the tracer
group members to describe how staff members were edu-
cated and trained on the new initiative. [12] The nurse
quality improvement specialist explained that she worked
with the nursing director to devise a series of training ses-
sions for the nurses and monitored the patient education
provided periodically to ensure that it was done correctly.
The group members showed the surveyors a short educa-
tional video presentation they created to help patients and
families learn about the surgery and what steps were neces-
sary to ensure the patient’s safety and to prevent infection.
The surgical nurse said she showed the video to the patient
and family after the patient was admitted to the hospital.
The surveyors noted that the video addressed hand hygiene,
antibiotic use, and postoperative care, including wound care
and signs of an infection. [13]
After implementing the improvement effort, the hospital col-
lected data on actual surgical site infections among coronary
artery bypass graft patients, conducted medical chart audits on
patient and family education, and monitored prophylactic an-
tibiotic use. [14] The vice president for patient safety added
that all cardiac surgeons were sent information on surgical site
infection rates among their own patients, along with data on
timely administration of antibiotics. The surveyors asked the
group members whether they had noticed a reduction of surgi-
cal site infections among cardiac patients. The medical director
replied that early data indicated a 17% drop in surgical site in-
fections among cardiac patients. [15] The vice president for
patient safety said that if the initiative was successful, hospital
leaders were considering expanding these education techniques
to the entire surgical population.
The surveyors concluded the tracer by visiting units in the
hospital to learn how the quality improvement activities they
had explored during the group discussion were in place at the
patient level.
Moving Forward. Based on the tracer, the surveyors
may discuss areas of improvement in the Daily Briefing. The
discussion might address the internal process for validating
data collected and the importance of sharing findings with
staff throughout the hospital to encourage their participa-
tion in and understanding of the quality improvement
activities.
Section 8: International
Scenario 8-4.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 8-4. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Medical Director, Nurse Quality
Improvement Specialist, and Vice
President for Patient Safety:
[1] What is your hospital’s approach to data collection?
[2] What kinds of data do you collect?
[3] How do you integrate the data into your ongoing
quality improvement and patient safety efforts?
[4] What methods do you use to collect data?
[5] Who is involved in the data collection process?
[6] Who is responsible for your quality improvement
work and who has oversight?
[7] What five clinical measures have you selected out of
the Joint Commission International Library of
Measures? Please describe the processes you are
using to collect and submit data.
[8] What data have you collected and analyzed relating
to a high-risk process?
[9] What type of analysis did you conduct? Who was
involved?
[10] What action have you taken in response to these
data?
[11] How did you design your improvement initiative?
Who was involved in the planning and design?
[12] How was it implemented? What type of education
and training have you provided to staff members
and patients?
[13] What examples of this initiative can you share with
me?
[14] How have you been monitoring progress? What are
your goals and measures of success? What type of
reporting have you done?
[15] What progress have you documented so far? What
additional measures will you consider putting in
place if this initiative is successful?
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SCENARIO 8-5.
Primary Health Center
Summary
In the following scenario, a surveyor conducts an infection
control system tracer at a primary health center that provides
general medical care to its local population. During the system
tracer she explores issues relating to the safe handling of waste,
hand hygiene practices, and patient education.
Scenario
The surveyor conducted this system tracer with the health cen-
ter’s medical director, head nurse, infection control preven-
tionist, housekeeping manager, and one of the staff physicians
who also had oversight responsibility for infection prevention
and control. The goal was to explore the center’s infection con-
trol process and to determine what kind of data it collects.
(Bracketed numbers correlate to Sample Tracer Questions on page
157.)
Overview of Infection Control Activities with the
Tracer Team. The surveyor began the tracer by meeting with
the team members to discuss their overall approach to infec-
tion prevention and control. She also asked what kinds of data
they collect and what kinds of infection control–related im-
provement activities they have in place. [1–4] Although the
health center did not have an infection control committee, the
physician with infection control responsibilities said he met
with the medical director periodically to discuss infection con-
trol issues. In addition, infection control issues were discussed
during staff meetings, as needed. The medical director added
that the center has tried to do what it can to mitigate infection
control risks by focusing on areas that were of highest risk.
Focusing on High-Risk Areas of Infection Control
with the Tracer Team. The surveyor asked the group to
describe what high-risk areas they focused on for infection
control. [5] The physician explained that hand hygiene and
appropriate cleaning techniques were important topics. The
medical director added that the center ensured that it met
Joint Commission International requirements for handling
waste and disposing of hazardous materials. The surveyor
asked the group to pick a specific high-risk process and de-
scribe the center’s related efforts and any improvement activi-
ties. [6–7] The physician said that the center conducted staff
education on hand hygiene techniques during orientation and,
later on, the nursing supervisor conducted periodic compli-
156
ance monitoring. The surveyor asked to review any data
that the center had collected in relation to hand hygiene
compliance.
The surveyor asked if the physicians were monitored for hand
hygiene compliance. [8] The medical director answered that
all staff were monitored and compliance rates were recorded
regularly. Ongoing monitoring results showed that newer staff
demonstrated better compliance with hand hygiene rules com-
pared to longtime staff. The surveyor asked what the center
had done in response to this inconsistency. [9–10] The physi-
cian said that proper hand hygiene techniques are discussed at
department or unit staff meetings. But because compliance
rates are inconsistent, the physician said they are considering
conducting additional staff training sessions and one-on-one
mentoring sessions to improve compliance rates. The surveyor
added that these additional, ongoing interventions could be
effective in improving hand hygiene compliance.
Discussing Environmental Factors and Infection
Control with the Tracer Team. The surveyor described
how, during an individual tracer earlier in the day, she ob-
served that the center’s toilets used by the patients had empty
soap dispensers and cloth hand towels hanging near the sink.
[11–12] The medical director said the center’s housekeeping
manager was responsible for ordering cleaning supplies, but
the person who had held the position resigned a few weeks
ago, and no one else had thought to reorder the supplies. The
new housekeeping manager, who had just been hired, said she
had ordered supplies, including hand soap, that were expected
to arrive later that day. In the meantime, the nursing supervi-
sor added that the staff purchased some hand soap and put
some paper towels in those toilet areas. The surveyor asked the
team members if the center had any contingency plan in place
to address staff turnover, particularly related to infection con-
trol risks. [13] The physician explained that they were going
to review all infection control–related areas and make sure
there was some overlap in roles and responsibilities in case the
same thing happened again.
Touring the Building with the Nursing Supervisor.
The surveyor continued her system tracer by touring the
health center. She was able to verify that staff had placed tem-
porary supplies in the patient and staff toilet areas. She then
observed the nursing staff handling and disposal of sharps. In
addition, she noted that the center appeared to manage its
waste appropriately. The surveyor asked the nursing supervisor
what kind of training and education the center provided for
nursing staff on the safe handling of sharps and waste. [14]

The nursing supervisor explained that training was included
during new employee orientation, and afterward the employee
was expected to demonstrate competency. The surveyor then
asked to review one of the nurse’s training records in which she
could identify that the nurse had received training on the han-
dling of sharps and that competency was demonstrated.
Meeting with the Housekeeping Manager. Finally,
the surveyor met with the housekeeping manager to discuss
the overall cleanliness of the center. The surveyor asked the
housekeeping manager to demonstrate surface disinfection
technique. [15]
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the topic of infection prevention and
control.
Scenario 8-5.
Sample Tracer Questions
Scenario 8-5. Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 8-5. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Tracer Team:
[1] What is your approach to infection control in the
center?
[2] What kinds of data do you collect in relation to
infection control?
[3] Do you conduct any infection control–related
improvement activities? If so, please describe.
[4] Who has oversight responsibility for infection
control? What kind of monitoring do you have in
place?
[5] What high-risk areas have you focused on in
infection control? How have you prioritized hand
hygiene in the center?
[6] Please give an example of a high-risk process.
What monitoring and improvement activities do you
have?
Section 8: International
[7] What kind of ongoing monitoring do you conduct?
How do you track it? Do you monitor hand hygiene
practices?
[8] How do you involve physicians in your ongoing
monitoring? What information do you share?
[9] If there have been inconsistencies in compliance,
what has your response been?
[10] What kind of interventional response have you
planned?
[11] Who is responsible for ensuring that appropriate
hand soap dispensers and supplies are stocked and
available to staff and patients?
[12] Who monitors supplies?
[13] What kind of contingency plan do you have in place
in the event of a turnover in staff responsibility?
Nursing Supervisor:
[14] What kind of training and education do you provide
to nursing staff in relation to infection control–related
risks? How and where do you document this training
and education?
Housekeeping Manager:
[15] Will you please demonstrate the cleaning technique
for surface disinfection?
SCENARIO 8-6.
Private Hospital
Summary
In the following scenario, a surveyor conducts a facility man-
agement and safety system tracer for security in a private hos-
pital located in an urban area. The hospital offers general
medical, surgical, and obstetrical services. The surveyor ex-
plores issues of safety, security, and emergency management
during the tracer.
Scenario
The surveyor focused on security issues during the tracer at the
hospital. He began his tracer with a building tour and con-
cluded it with a review of documentation involving the staff
members responsible for the facility, patient safety, and security.
(Bracketed numbers correlate to Sample Tracer Questions on pages
158–159.)
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Touring the Building with the Facilities Director,
Patient Safety Director, and Security Officer. The sur-
veyor began his tracer by walking through the hospital. He
began at the entrance of the hospital and asked the facilities di-
rector what the hospital did to secure the building, if needed.
[1–2] The facilities director answered that they did lock the en-
trance to the building in the evenings and placed a security offi-
cer at the entrance for any late evening arrivals. The surveyor
then checked the door and found it locked appropriately on the
outside while allowing egress from the building. The surveyor
asked the security officer what emergency situations they have
identified as likely to happen in this location and what the secu-
rity staff’s plans and roles are in the event of an emergency, such
as a terrorist threat. [3–4] The security officer responded that he
participated in the emergency planning for the hospital, and the
security staff had a particular role in securing the building. The
surveyor asked if the hospital had conducted an emergency drill
relating to an external threat. [5] The security chief said that
they had completed a drill about 18 months earlier, but he did
not know when the next one was scheduled. The surveyor asked
the staff who analyzed the data from drills. [6] The patient
safety officer replied that he and the facilities director worked
with the performance improvement specialist to analyze the
drills and identify any gaps in the response. They were planning
to hold another drill soon, he added.
The surveyor then went to the obstetrics department, asking
the team members what additional security measures were in
place for a high security risk area such as this one. [7] The
security officer explained that the hospital had controlled
access through the main entrance, which allowed entry with a
secure pass card or through the intercom with the nurses’ area
in the department. [8] The surveyor asked who had access to
cards and who monitored their use. The security officer said
that he maintained a log. [9]
Talking with the Nurse on the Medical/Surgical
Ward. The surveyor then visited a general medical/surgical
ward, where he checked doors and access. He asked a nurse on
the ward who had access to the medications cart, to which the
nurse responded only nursing staff on the ward had access. [10]
He then asked where the cart is stored when not in use. The
nurse showed him a storage room, which he verified was able to
be locked. It did not, however, allow egress from the inside if
the door was locked on the outside. [11] The surveyor pointed
this out to the team as a potential threat to life because a staff
member could be trapped in the storage room with no way out
in the event of an emergency. The facilities manager responded
that they would correct the issue immediately.
158
On the way to a conference room to review documentation,
the surveyor observed the exit signage in the hospital. It was all
universally posted in both English and the primary language of
the country where the hospital was located. He also observed
the use of alarms and checked the labeling and documentation
to verify that it was tested and up-to-date.
Reviewing Documentation with the Tracer Team.
The surveyor then met with the team in a conference room
to review documentation. He reviewed the log for staff
members with pass cards to the obstetrics department,
looked at the record of the most recent emergency response
drill, and asked to see training records for security staff in
relation to security issues within the hospital. [12–14] The
surveyor emphasized that planning and drilling will not be
beneficial to the organization’s compliance efforts unless the
results and improvements are communicated and imple-
mented throughout the organization.
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the topics of security, emergency pre-
paredness, and medication safety.
Scenario 8-6.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 8-6. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
Facilities Director, Patient Safety
Director, and Security Officer:
[1] How do you secure the building? Do you lock the
doors at any time? If so, why? Do you do so in a
way that allows for safe egress?
[2] What staffing provisions do you provide at the
hospital’s main entrances and exits?
[3] What are security staff members trained to do in the
event of an emergency, such as a terrorist threat?
[4] What kind of training have you provided to staff on
emergencies?

[5] Has the hospital conducted a drill to test your
planning? If so, when did this drill take place?
[6] How do you analyze the results of your drills? Who
is responsible for this analysis? How is it
communicated?
[7] What additional security measures do you put in
place in high security risk areas, such as the
obstetrics department?
[8] Who has access to this department?
[9] How do you track and monitor access? What kind of
logging mechanism do you use? Who is
responsible?
Nurse on Medical/Surgical Ward:
[10] Who has access to medication carts?
[11] Where are medication carts stored? How is the
room secured? Does it allow safe egress?
Tracer Team:
[12] Please show me documentation on logging of
access to secure areas of the hospital.
[13] What kind of documentation do you keep on
emergency drill activity? How do you document the
data analysis and results?
[14] Will you please show me any documentation you
have to demonstrate training for security staff?
SCENARIO 8-7.
Primary Care Facility in Hospital
Summary
In the following scenario, a surveyor conducts a facility man-
agement and safety system tracer for hazardous materials and
waste in a primary care facility that is part of a larger hospital.
The primary care facility provides general medical care to pa-
tients, including urgent care. During the system tracer, the sur-
veyor explores the facility’s management of hazardous materials
and waste.
Scenario
The surveyor began the system tracer by meeting with the
medical director of the primary care facility, the building
manager of the primary care facility, and the safety director
of the hospital. He wanted to review any documentation
they maintained regarding hazardous materials and waste
Section 8: International
management. Then the surveyor asked the medical director
and the building manager to accompany him on a building
tour. The safety director later joined the group. The sur-
veyor was primarily interested in exploring the handling of
hazardous waste materials, including the disinfection of
blood products.
(Bracketed numbers correlate to Sample Tracer Questions on page
160.)
Talking with the Building Manager. After first veri-
fying that the primary care facility maintained a log and
tracked the handling of the waste material, the surveyor
asked the building manager to describe what processes were
followed to manage waste and hazardous materials. [1–4]
The building manager explained that the facility was collect-
ing data on any negative events, such as staff injuries or ad-
verse patient events related to blood products or sharps
injuries. The building manager added that the facility re-
ceived periodic visits from the national occupational health
and safety agency to monitor its handling of hazardous ma-
terials and waste. [5–6]
Speaking with the Safety Director. The surveyor
asked the safety director to explain what kind of interaction
he had with the building manager to ensure that the facil-
ity’s handling of hazardous materials was consistent with the
broader hospital policy. [7] The safety director explained
that, during the past year, he had been working with the
building manager to ensure that the primary care facility’s
procedures for environment and safety issues were the same
as the hospital’s. They had implemented the same procedure
in the facility and monitored periodically to make sure that
the procedure was being carried out, he added. The surveyor
was able to verify the same documented procedure during
his document review. [8–9]
Touring the Building with the Tracer Team. The
surveyor then began his building tour. He asked the medical
director, the building manager, and the safety director to
join him on the tour. The surveyor first went to observe a
patient treatment room. He asked the group to show him
where any hazardous materials are stored and what kind of
blood product disinfection is done in each treatment room.
[10–13] The surveyor observed an excellent management of
waste, with no excess and all containers appropriately
labeled. The building manager showed the surveyor the
cleaning products used, which met Joint Commission Inter-
national requirements. The surveyor noticed another bottle
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of what appeared to be a cleaning product, but it was not la-
beled. The surveyor asked the building manager what the
product was. [14] The manager was unable to verify what
the product was and removed the bottle, noting that he
would make a subsequent tour of the facility to ensure that
there were no other unlabeled products stored in the
facility.
The surveyor asked the building manager how he is able to
verify that the treatment room is really clean. The building
manager explained that he periodically checks the treatment
room. Also, the hospital provides rigorous training for
housekeeping staff members to make sure they understand
how to clean and maintain the room. The surveyor asked
the medical director what kinds of procedures staff members
are expected to follow if there is a blood spill or breakage.
[15–16] The medical director said that nursing staff mem-
bers are trained to use a sterile field when changing wounds
or taking blood, and any waste must be disposed of immedi-
ately and appropriately. The surveyor visited the storage
rooms in the facility. He observed the appropriate handling
of waste products in preparation for periodic removal from
the facility. [17]
Observing a Staff Member. The surveyor concluded
his tour by observing a facility staff member drawing blood
from a patient. He saw the staff member handle and label
the blood product appropriately, as well as using a sterile
field. [18]
Moving Forward. Based on the tracer, the surveyor may
discuss areas of improvement in the Daily Briefing. The dis-
cussion might address the following topics:
• Culture of safety that encourages blame-free reporting of
errors
• Storage and handling of hazardous materials and wastes
Scenario 8-7.
Sample Tracer Questions
The bracketed numbers before each question correlate to
questions, observations, and data review described in the
sample tracer for Scenario 8-7. You can use the tracer
worksheet form in Appendix B to develop a mock tracer
(see an example of a completed tracer worksheet at the
end of this section). The information gained by conducting
a mock tracer can help to highlight a good practice and/or
determine issues that may require further follow-up.
160
Building Manager:
[1] What kind of documentation do you maintain in
relation to hazardous waste and materials
management?
[2] What monitoring logs or checklists do you maintain?
[3] What organization process and procedure exists for
handling hazardous material and waste?
[4] What kinds of data do you collect?
[5] What is your reporting process?
[6] Are there any external agencies that you must
report to? What kinds of reports do you submit?
How frequently do you provide them?
Safety Director:
[7] What kind of interaction do you have with the
hospital? How do you collaborate on
organizationwide policies?
[8] What monitoring do you conduct in relation to
following your organization’s processes?
[9] What kind of documentation can you show me?
Tracer Team:
[10] Where do you store hazardous materials?
[11] How do you label the containers?
[12] What kind of disinfection do you perform in relation
to blood products and related waste?
[13] Where do you store the products that you use? If
possible, please show me.
[14] How do you correctly label cleaning products? What
do you do if you find an unlabeled product?
[15] What do you do if a blood spill or breakage occurs?
What process do you follow?
[16] How are staff members trained to mitigate risks
associated with handling blood products?
[17] How are waste products handled? How are they
stored for disposal? How often are they removed
from the facility?
Staff Member:
[18] How do you handle and label blood products?
 Section 8: International

Sample Tracer Worksheet: Scenario 8-4.

The worksheet below is an example of how organizations can A correct answer is an appropriate answer that meets the re-
use the sample tracer questions for Scenario 8-4 in a worksheet quirements of the organization and other governing bodies.
format during a mock tracer. The bracketed numbers before An incorrect answer should always include recommendations
each question correlate to questions described in the scenario. for follow-up.

Tracer Team Member(s): Jayden Lim, Anna Data Record(s):

Schmidt Unit(s) or Department(s): hospitalwide
Subjects Interviewed: Kadin Ahmed, Amina Jabir,
Talan Aggarwal
Tracer Topic or Care Recipient: data use and
management, clinical guidelines, patient and
family education, patient safety

Interview Subjects: Medical Director, Nurse Quality Improvement Specialist, and

Vice President for Patient Safety
Questions Correct Incorrect Follow-Up Comments or
Answer Answer Needed Notes
[1] What is your hospital’s ✓ Staff answered
approach to data collection? appropriately.
[2] What kinds of data do you ✓ May need additional The hospital leadership was
collect? methods to share and not completely aware of
communicate data to data collected or circulated
key staff members. among them.

[3] How do you integrate the ✓ Staff members were clear

data into your ongoing quality
improvement and patient safety
efforts?
[4] What methods do you use to
collect data?
[5] Who is involved in the data
collection process?
on their process to integrate
data. QI staff heavily
involved and well educated.
✓ Acceptable examples of
methods used and
demonstrated.
✓ QI committee understands
roles and responsibilities.

[6] Who is responsible for your ✓ Need to improve VP was unaware of roles in
quality improvement work and communication with the QI department. May be
who has oversight? leadership. due to new to role.

(continued)

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Interview Subjects: Medical Director, Nurse Quality Improvement Specialist, and

Vice President for Patient Safety (continued)
Questions Correct Incorrect Follow-Up Comments or
Answer Answer Needed Notes
[7] What five clinical measures ✓ Organization has clearly
have you selected out of the delineated its selected
Joint Commission International measures.
Library of Measures? Please
describe the processes you are
using to collect and submit data.

[8] What data have you ✓ Discuss need for Staff did not bring all
collected and analyzed relating appropriate material. material to the tracer
to a high-risk process? activity, so unable to
verify.

[9] What type of analysis did ✓ Excellent example by team.

you conduct? Who was
involved?

[10] What action have you taken ✓

in response to these data?

[11] How did you design your ✓ Should consider

improvement initiative? Who expanding to other areas
was involved in the planning of the hospital.
and design?

[12] How was it implemented? ✓ Excellent example.

What type of education and
training have you provided to
staff members and patients?

[13] What examples of this ✓

initiative can you share with
me?

[14] How have you been
monitoring progress? What are
your goals and measures of
success? What type of reporting
have you done?
✓ Recommend reinforce Staff members were unable
process. to delineate their progress
in monitoring.

[15] What progress have you
documented so far? What
additional measures will you
consider putting in place if this
initiative is successful?
✓ Need to develop plan to Leadership did not have a
sustain project success. clear plan for the project
once it had seen more
success.

162
 Appendix A
At the beginning of each tracer scenario in this workbook is
a brief summary that includes the priority focus areas (PFAs)
that are focused on in the scenario. The PFAs are processes,
systems, or structures in a health care organization that
significantly impact safety and/or the quality of care pro-
vided. There are 14 PFAs that are generally universal across
health care settings. All Joint Commission standards are re-
lated to PFAs. During the on-site survey process, surveyors
link the PFAs within standards compliance issues to identify
potential areas of risk. The PFAs, along with clinical/service
groups (CSGs) from the Priority Focus Process (PFP), form
the foundation of the tracer process. The CSGs categorize
care recipients and/or services into distinct populations for
which data can be collected. The PFP is a data-driven tool
that helps focus survey activity on issues most relevant to
care recipient safety and quality of care at the specific health
care organization being surveyed.
The PFAs are summarized in the following sections.
Analytic Procedures
The laboratory’s main function is that of conducting
preanalytic, analytic, and postanalytic procedures.
NOTE: This PFA is applicable to Laboratory accreditation
programs only.
Subprocesses for Analytic Procedures include the following:
• Request
• Specimen collection
• Transportation
• Receipt
• Processing
• Testing
• Interpretation of results
• Data report/dissemination
* Please note that PFAs are relevant only to Joint Commission U.S.
standards, not to JCI’s standards.
Priority Focus Areas*
Assessment & Care/Services
Assessment & Care/Services for care recipients comprise the
execution of a series of processes that are fluid in nature to
accommodate needs of care recipients, including, as relevant,
screening; assessment; planning care, treatment, and/or
services; provision of care; ongoing reassessment of care; and
discharge planning, referral for continuing care, or discontinu-
ation of services. Although some elements of Assessment &
Care/Services may occur only once, other aspects may be re-
peated or revisited as the care recipient’s needs or care delivery
priorities change. Successful implementation of improvements
in Assessment & Care/Services relies on the full support of
leadership. NOTE: For Behavioral Health Care, this PFA is
called Screening, Assessment & Care, Treatment, and
Services.
Subprocesses of Assessment & Care/Services include the following:
• Screening
• Assessment
• Planning care, treatment, or services
• Provision of care, treatment, or services
• Reassessment
• Discharge planning or discontinuation of services
Communication
Communication is the process by which information is ex-
changed between individuals, programs/services, or organiza-
tions. Effective Communication successfully permeates every
aspect of a health care organization, from the provision of care
to performance improvement, resulting in a marked improve-
ment in the quality of care delivery and functioning.
Subprocesses of Communication include the following:
• Provider– and/or staff–care recipient communication
• Care recipient and family education
• Staff communication and collaboration
• Information dissemination
• Multidisciplinary teamwork
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Credentialed Practitioners Information Management

Credentialed Practitioners are health care professionals whose Information Management is the interdisciplinary field con-
qualifications to provide care, treatment, and services have cerning the timely and accurate creation, collection, storage,
been verified and assessed, resulting in the assignment of clini- retrieval, transmission, analysis, control, dissemination, and
cal responsibilities. The Credentialed Practitioners category use of data or information, both within an organization and
varies from organization to organization and from state to externally, as allowed by law and regulation. In addition to
state. It includes licensed independent practitioners and others written and verbal information, supporting information tech-
who are permitted to provide care, treatment, and services to nology and information services are also included in Informa-
care recipients under the direction of a sponsoring physician. tion Management.
Licensed independent practitioners are permitted by law and
the health care organization to provide care, treatment, and Subprocesses of Information Management include the
services without clinical supervision or direction within the following:
scope of their license and consistent with individually assigned • Planning
clinical responsibilities or individually granted privileges. • Procurement
• Implementation
Equipment Use • Collection
Equipment Use incorporates the selection, delivery, setup, and • Recording
maintenance of equipment and supplies to meet the needs of • Protection
care recipients and staff. It generally includes movable equip- • Aggregation
ment, as well as management of supplies that staff members • Interpretation
use (for example, gloves, syringes). (Equipment Use does not • Storage and retrieval
include fixed equipment such as built-in oxygen and gas lines • Data integrity
and central air-conditioning systems; such items are included • Information dissemination
in the Physical Environment PFA.) Equipment Use includes
planning and selecting; training and orientation; maintaining, Medication Management
testing, and inspecting; educating and providing instructions; Medication Management encompasses the systems and
delivery and setup; and risk prevention related to equipment processes used to provide medication to individuals served by
and/or supplies. NOTE: This PFA is not applicable to Behav- the organization. This is usually a multidisciplinary, coordi-
ioral Health Care accreditation programs. nated effort of health care staff who implement, evaluate, and
constantly improve the processes of selecting, procuring, stor-
Subprocesses of Equipment Use include the following: ing, ordering, transcribing, preparing, dispensing, administer-
• Selection ing (including self-administering), and monitoring the effects
• Maintenance strategies of medications throughout the care recipients’ continuum of
• Periodic evaluation care. In addition, Medication Management involves educating
• Orientation and training care recipients and, as appropriate, their families about each
medication, its administration and use, and potential side ef-
Infection Control fects. NOTE: This PFA is not applicable to Laboratory accred-
Infection Control includes the prevention, surveillance/identi- itation programs.
fication, and control of infections among care recipients, em-
ployees, physicians and other licensed independent Subprocesses of Medication Management include the
practitioners, contract service workers, volunteers, students, following:
and visitors. Infection Control is a systemwide, integrated • Selection
process that is applied to all programs, services, and settings. • Procurement
• Storage
Subprocesses of Infection Control include the following: • Prescribing or ordering
• Prevention and control • Preparing
• Surveillance/identification • Dispensing
• Reporting • Administration (including self-administration)
• Measurement • Monitoring

164

Organizational Structure
Organizational Structure is the framework for an organization
to carry out its vision and mission. The implementation is ac-
complished through corporate bylaws and governing body
policies, organization management, compliance, planning, in-
tegration and coordination, and performance improvement.
Organizational Structure includes the organization’s gover-
nance, as well as business ethics, contracted organizations, and
management requirements.
Subprocesses of Organizational Structure include the
following:
• Management requirements
• Corporate bylaws and governing body plans
• Organization management
• Compliance
• Planning
• Business ethics
• Contracted services
Orientation & Training
Orientation is the process of educating newly hired staff in
health care organizations to organizationwide and department-,
program-, service-, and job-specific competencies before they
provide care, treatment, or services to care recipients. Newly
hired staff includes, but is not limited to, regular staff employ-
ees, contracted staff, agency (temporary) staff, float staff, vol-
unteer staff, students, housekeeping, and maintenance staff.
Training refers to the development and implementation of
programs that foster staff development and continued learn-
ing, address skill deficiencies, and thereby help ensure staff re-
tention. More specifically, training entails providing
opportunities for staff to develop enhanced skills related to re-
vised processes that may have been addressed during orienta-
tion, new care techniques for care recipients, or expanded job
responsibilities. Whereas orientation is a one-time process,
training is a continuous one.
Subprocesses of Orientation & Training include the following:
• Organizationwide orientation
• Program/service orientation
• Job-specific orientation
• Training and continuing or ongoing education
Patient Safety
Patient Safety entails a framework for proactively identifying the
potential and actual risks to safety, identifying the underlying
cause(s) of the potential or actual risk, and making the necessary
Appendix A: Priority Focus Areas
improvements to reduce risk. It also entails establishing processes
to respond to sentinel events, identifying risks through root cause
analysis, and making necessary improvements. This involves a
systems-based approach that examines all activities within an or-
ganization that contribute to maintaining and improving care re-
cipient safety, including performance improvement and risk
management, to ensure that the activities work together, not in-
dependently, to improve care and safety. This systems-based ap-
proach is driven by organization leadership; anchored in the
organization’s mission, vision, and strategic plan; endorsed and
actively supported by medical staff and nursing leadership; im-
plemented by directors; integrated and coordinated throughout
the organization’s staff; and continuously reengineered using
proven, proactive performance improvement modalities. In addi-
tion, effective reduction of errors and other factors that con-
tribute to unintended adverse outcomes in an organization
requires an environment in which care recipients, their families,
and organization staff and leaders can identify and manage actual
and potential risks to safety. NOTE: For Behavioral Health Care,
this PFA is called Individual Served Safety. For Long Term Care,
it is called Resident Safety.
Subprocesses of Patient Safety include the following:
• Planning and designing services
• Directing services
• Integrating and coordinating services
• Reducing and preventing errors
• Using Sentinel Event Alerts
• The Joint Commission’s National Patient Safety Goals
• Clinical practice guidelines, if available
• Actively involving care recipients in their care, treatment, or
services
Physical Environment
The Physical Environment refers to a safe, accessible, functional,
supportive, and effective physical environment for care recipients,
staff members, workers, and others by managing physical design;
construction and redesign; maintenance and testing; planning
and improvement; and risk prevention, defined in terms of utili-
ties, fire protection, security, privacy, storage, and hazardous ma-
terials and waste. The Physical Environment may include the
home in the case of in-home programs and foster care.
Subprocesses of Physical Environment include the following:
• Physical design
• Construction and redesign
• Maintenance and testing
• Planning and improvement
• Risk prevention
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Quality Improvement Expertise/Activities
Quality Improvement Expertise/Activities identifies the collab-
orative and interdisciplinary approach to the continuous study
and improvement of the processes of providing health care
services to meet the needs of consumers and others. Quality
Improvement Expertise depends on understanding and revis-
ing processes on the basis of data and knowledge about the
processes themselves. Quality Improvement involves identify-
ing, measuring, implementing, monitoring, analyzing, plan-
ning, and maintaining processes to ensure that they function
effectively. Examples of Quality Improvement Activities in-
clude designing a new service, flowcharting a clinical process,
collecting and analyzing data about performance measures or
care recipient outcomes, comparing the organization’s per-
formance to that of other organizations, selecting areas for pri-
ority attention, and experimenting with new ways of carrying
out a function.
Subprocesses of Quality Improvement Expertise/Activities
include the following:
• Identifying issues and establishing priorities
• Developing measures
• Collecting data to evaluate status on outcomes, processes,
or structures
• Analyzing and interpreting data
• Making and implementing recommendations
• Monitoring and sustaining performance improvement
Rights & Ethics
Rights & Ethics includes care recipient rights and organiza-
tional ethics as they pertain to the care of care recipients.
166
Rights & Ethics addresses such issues as care recipient privacy,
confidentiality, protection of health information, advance di-
rectives (as appropriate), organ procurement, use of restraints,
informed consent for various procedures, and the right to par-
ticipate in care decisions.
Subprocesses of Rights & Ethics include the following:
• Care recipient rights
• Organizational ethics pertaining to care recipient care
• Organizational responsibility
• Consideration of care recipient
• Care sensitivity
• Informing care recipients and/or family
Staffing
Effective Staffing entails providing the optimal number of
competent personnel with the appropriate skill mix to meet
the needs of a health care organization’s care recipients based
on that organization’s mission, values, and vision. As such, it
involves defining competencies and expectations for all staff
(the competencies of licensed independent practitioners and
medical staff are addressed in the Credentialed Practitioners
PFA for all accreditation programs). Staffing includes assessing
those defined competencies and allocating the human re-
sources necessary for care recipient safety and improved care
recipient outcomes.
Subprocesses of Staffing include the following:
• Competency
• Skill mix
• Number of staff
 Appendix B
You can use the worksheet on the following pages to record in-
formation during a mock tracer. Make as many extra copies of
the second page as needed. Below are explanations of terms on
the worksheet.
Worksheet Terms
• Mock Tracer Name: Give your mock tracer a name for easy
reference. This may be as simple as Mock Tracer 1.
• Date(s) Conducted: Indicate the date(s) on which the
mock tracer took place.
• Tracer Team Member(s): List the person or people per-
forming the tracer in the surveyor role.
• Subjects Interviewed: List all the people who were inter-
viewed during the entire tracer.
• Tracer Topic or Care Recipient: Note the topic or care
recipient traced by the person or people performing the sur-
veyor role in the mock tracer. You may also think of it as
the focus of the mock tracer.
• Data Record(s): List any documents—paper or elec-
tronic—consulted during the mock tracer.
• Unit(s) or Department(s): List all places visited during the
mock tracer. They should conform to the places where the in-
terview subjects work or were encountered during the tracer.
Mock Tracer Worksheet Form
• Interview Subject: Fill in the name of the person inter-
viewed. If the person is a member of the staff or adminis-
tration, add his or her job title as well.
• Questions: Record each question asked of the particular
interview subject. You might want to use some of the
sample tracer questions from the scenarios in this work-
book for mock tracers with a similar focus to those
scenarios.
• Correct Answer and Incorrect Answer: Check the ap-
propriate column to indicate whether the interview sub-
ject provided a correct or incorrect answer. A correct
answer is an appropriate answer that meets the require-
ments of the organization and other governing bodies.
An incorrect answer should always include recommen-
dations for follow-up.
• Follow-Up Needed: When the interview subject gives an
incorrect answer, specify follow-up. This may be recom-
mendations for further evaluation of an issue, staff educa-
tion, or even another mock tracer.
• Comments or Notes: Add anything else you need to re-
mark on. Use this spot as a place to record positive im-
pressions for correct answers as well.
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Mock Tracer Name: Tracer Topic or Care Recipient:

Date(s) Conducted: Data Record(s):
Tracer Team Member(s):
Unit(s) or Department(s):
Subjects Interviewed:

Interview Subject:

Questions Correct Incorrect Follow-Up Comments or

Answer Answer Needed Notes

168
 Appendix B: Mock Tracer Worksheet Form

Interview Subject:

Questions Correct Incorrect Follow-Up Comments or

Answer Answer Needed Notes

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Interview Subject:

Questions Correct Incorrect Follow-Up Comments or

Answer Answer Needed Notes

170
 Comprehensive Organization
Appendix C Assessment Form*

You can use this form as a tool to help define the topics and scope of mock tracers for your organization.

Area of Assessment and Related Questions Response

Scope and Overall Structure

• What is the size and scope of your organization? Are
you large, medium, or small?
• What is the general structure of your organization—
are you private, not-for-profit, educational?
• What services do you provide? What population(s) do
you serve?
• What level of care do you provide?

Condition of Resources
• What types of resources are available in your
organization?
• Would you describe your organization as resource-
rich or resource-poor?
• How easily can new funds be made available for new
projects, such as mock tracers?
• What is the general time frame needed to request
and receive resources for new initiatives?

Size and Complexity — Administrative Structure

• Are you a facility-based organization?
• Are you a multisite organization that provides more
than one level or type of care in more than one type
of setting and that requires the use of standards and
elements of performance from at least two
accreditation manuals?
• Are you part of a health care system?
• If you have many sites, how far apart are they?
• Does each site require extensive travel to reach it?
• Does each site have a stand-alone department or
staff designated to perform quality improvement
activities, or are those activities centralized in one
“corporate” location or headquarters?

* Does not apply to JCI accreditation. (continued)

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Area of Assessment and Related Questions Response

Staff Experience, Training, and Resources

• How well-seasoned are the staff in your
organization?
• Do you have a mix of experienced and newer staff?
• What types of staff positions do you have in your
organization?
• Do you need a lot of training on basic quality
improvement concepts, or are you well versed and
well trained?

Data Collection and Analysis

• What types of data do you collect in your
organization?
• What departments, areas, or units collect data?
• Who in your organization collects data?
• What area of the organization is responsible for
gathering and studying the data?
• What types of external sources of data do you report
to or gather data from?
• What benchmarking, if any, do you use?
• How do you track and collect data?
• Do you use any electronic system for data collection
and analysis? If so, who is trained to use it?

Staff Expertise
• Do you have any staff with accreditation survey
experience?
• If not, how do you prepare for accreditation surveys?
• Do you have any staff on site with expertise in data
analysis?
• If not, how do you analyze your organization’s data?

Safety Concerns
• Are there any areas of concern related to the delivery
of safe, high-quality care that have emerged in the
organization?
• Are there any systems or processes that leadership
would like to study and assess?
• Have any external data pointed to areas of concern
that might benefit from a tracer?

172
 Appendix C: Comprehensive Organization Assessment Form

Area of Assessment and Related Questions Response

Near Misses and Sentinel Events

• Has the organization experienced any recent near
misses or sentinel events that point to any
breakdowns in processes or systems that would
benefit from tracer work?

High-Risk Processes and Concerns

• What, if any, high-risk processes and concerns exist
in your organization?
• How have those high-risk processes been identified?

Staff Strengths and Expertise

• Have you conducted an assessment of the overall
skills and expertise that staff bring to the
organization?
• Do any staff members possess training or expertise
in such areas as facilitation, education, training,
systems thinking, or other areas that could be helpful
in conducting tracers?

Policies and Procedures Related to Care, Treatment,

or Services
• Is there ready access to the policies and procedures
in the organization?
• How often are policies and procedures reviewed and
updated in the organization?

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174
 Index
A 24-hour therapeutic school scenario, 63–64, 77–78
Accreditation. See Standards; Surveys, on-site
Ambulatory care centers
individual tracer scenarios, 45–47, 152–153
international tracer scenario, 152–153
program-specific tracer scenario, 56–58
system tracer scenario, 48–50
Analytic Procedures
laboratory scenarios, 117–127
as PFA, 163
Anticoagulation clinic scenario, 28–30, 39–41
Assessment & Care/Services
individual tracer scenarios
for ambulatory care centers, 45–47
for behavioral health care, 63–64
for home care, 81–85
for hospitals, 17–20
for long term care, 101–102
for office-based surgery practices, 47–48
as PFA, 163
program-specific tracer scenarios
for ambulatory care centers, 56–58
for behavioral health care, 70–76
for home care, 91–98
for hospitals, 35–38
for long term care, 107–109, 111–113
system tracer scenarios
for behavioral health care, 64–66, 67–69
for long term care, 102–105
for urgent care center, 51–53, 59–60
B EC tracer scenarios, 136–140
Behavioral health care
community mental health center scenarios, 64–66, 67–69
foster/therapeutic foster care scenario, 70–71
individual tracer scenario, 63–64, 77–78
program-specific tracer scenarios, 70–76
residential drug and alcohol treatment program scenario, 74–
76
residential treatment center scenario, 66–67
system tracer scenarios, 64–69
24-hour adult mental health setting scenario, 73–74
youth group home scenario, 71–72
Blood products and transfusion scenario, 120–122
C
Cancer treatment and surgery scenario, 149–151
Care continuum tracer scenario, 151–152
Certification surveys, timing and frequency of, 8
Cleaning, disinfection, and sterilization (CDS), 2, 10
Clinical/service groups (CSGs)
characteristics and purpose of, 1, 8, 163
survey process, role in, 163
tracer selection and, 1, 9
Communication
individual tracer scenarios
for behavioral health care, 63–64
for home care, 81–85
for hospitals, 17–20
for laboratories, 117–123
for long term care, 101–102
for office-based surgery practices, 47–48
as PFA, 163
program-specific tracer scenarios
for ambulatory care centers, 56–58
for behavioral health care, 73–74
for home care, 93–98
for hospitals, 34–35, 37–38
for long term care, 107–113
system tracer scenarios
for behavioral health care, 64–67
for community health center, 53–54
for family practice primary care facility, 54–56
for home care, 85–91
for hospitals, 20–22
for long term care, 102–107
for office-based surgery practices, 50–51
Community health center scenario, 53–54
Community mental health center scenarios, 64–66, 67–69
Comprehensive Organization Assessment, 8, 171–173
Construction and interim life safety measures scenario, 137–138
Continuity of care
ambulatory care center scenario, 56–58
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continuity of foster/therapeutic foster care scenario, 70–71
long term care scenario, 109–110
as program-specific tracers, 9
Contracted services, 2, 10
Credentialed Practitioners, 164
Critical access hospitals
laboratory in, scenario for, 124–125
survey team for, 5
system tracer scenario, 22–24
D Foster care
Data management, 17–20
improvement in quality and patient safety tracers, 2, 6, 9,
154–155, 161–162
selection of system tracers, 9
as system tracer, 1–2, 6
ambulatory care center scenario, 48–50
community mental health center scenario, 64–66
home care scenarios, 85–89
hospital scenarios, 20–24
long term care scenario, 102–104
office-based surgery practice scenario, 50–51
Diabetes management scenario, 107–109, 111–113
Diagnostic imaging, 2, 10
E home medical equipment organization scenario, 91–93
Elements of performance (EPs), 14
Elopement program scenario, 71–72
End-of-life care scenario, 83–85
Environment of care (EC) tracers
characteristics and purpose of, 2, 6
environmental safety scenario, 134–135, 144–145
facility management and safety tracers, 2, 6, 10, 157–160
fire safety scenario, 136–137
hazardous materials and waste scenario, 139–140
interim life safety measures scenario, 137–138
medical equipment scenario, 140–141
security scenario, 131–132
selection of, 10
sterilizer maintenance scenario, 141–143
system tracer scenarios, 131–145
utility system scenario, 132–134
Equipment, medical
as EC tracer, 10
Equipment Use (PFA), 164
EC tracer scenarios, 131–134, 136–137, 140–143
home care scenarios, 91–93, 95–96
home medical equipment organization scenario, 91–93
hospital program-specific tracer scenario, 35–37
hospital system tracer scenario, 31–33
mock tracer selection, 8
Eye surgery services scenarios, 45–47, 152–153
F primary care facility in hospital scenario, 159–160
Facility management and safety tracers, 2, 6, 10, 157–160
176
Fall prevention and reduction
home health agency scenario, 95–96
long term care scenario, 101–102
as program-specific tracers, 9–10
Family practice primary care facility scenario, 54–56
Feedback form, 12
Fire safety
as EC tracer, 10
EC tracer scenario, 136–137
Focused professional practice evaluation (FPPE), 2, 10
continuity of foster/therapeutic foster care scenario, 70–71
as program-specific tracers, 9
H
Hazardous materials and waste
as EC tracer, 10
EC tracer scenario, 139–140
facility management and safety tracers, 159–160
mock tracer selection, 10
High-volume/high-risk activities, 8
Hip repair surgery scenario, 17–20
Home care
home-based hospice agency scenario, 83–85
home health agency scenarios, 81–83, 95–96
hospital-affiliated home health agency scenario, 87–89
individual tracer scenarios, 81–85
Medicare-certified home health program scenario, 93–94, 97–
98
pharmacy dispensing services scenario, home health agency
with, 89–91
program-specific tracer scenarios, 91–98
readmission scenario, 93–94, 97–98
on-site pharmacy scenario, home care program with, 85–87
system tracer scenarios, 85–91
Hospice agency scenario, home-based, 83–85
Hospitals
anticoagulation clinic scenario, 28–30, 39–41
children’s hospital scenario, 26–28
community hospital with laboratory scenario, 122–123
hospital-affiliated home health agency scenario, 87–89
individual tracer scenarios, 17–20, 149–153
international tracer scenarios, 149–151, 154–155, 157–159,
161–162
laboratories in
laboratory function scenario, 37–38
large teaching hospital scenario, 117–118
rural hospital scenario, 118–120, 126–127
large hospital scenarios, 17–20, 28–30, 34–35, 39–41, 149–
151
large teaching hospital scenario, 24–26, 117–118
midsize hospital scenarios, 20–22, 31–33, 35–37, 154–155,
161–162

private hospital scenario, 157–159
program-specific tracer scenarios, 34–38
rural hospital with laboratory scenario, 118–120, 126–127
survey team for, 5
system tracer scenarios, 20–33, 39–41, 154–155, 157–162
I hospital scenarios, 149–151, 154–155, 157–159, 161–162
Improvement in quality and patient safety tracers, 2, 6, 9, 154–
155, 161–162
Individual Safety
community mental health center scenario, 67–69
residential drug and alcohol treatment program scenario, 74–
76
24-hour adult mental health setting scenario, 73–74
24-hour therapeutic school scenario, 63–64, 77–78
youth group home scenario, 71–72
Individual tracers
ambulatory care center scenarios, 45–47, 152–153
behavioral health care scenario, 63–64, 77–78
characteristics and purpose of, 1, 6
home care scenarios, 81–85
hospital scenarios, 17–20, 149–153
international tracer scenarios, 149–153
laboratory scenarios, 117–127
long term care scenario, 101–102
office-based surgery practice scenario, 47–48
selection of, 1, 9
Infant’s respiratory care scenario, 81–83
Infection control
individual tracer scenarios
for ambulatory care centers, 45–47
for laboratories, 117–118
for office-based surgery practices, 47–48
international tracer scenario, 156–157
as PFA, 164
selection of system tracers, 9
as system tracer, 1–2, 6
behavioral health care scenario, 66–67
community health center scenario, 53–54
EC tracer scenarios, 141–143
family practice primary care facility scenario, 54–56
home care scenario, 87–89
hospital scenarios, 24–28
long term care scenario, 104–105
urgent care center scenario, 51–53, 59–60
Information Management
individual tracer scenarios for laboratories, 117–127
as PFA, 164
program-specific tracer scenarios for hospitals, 37–38
system tracer scenarios
for ambulatory care centers, 48–50
for behavioral health care, 64–66
EC tracer scenarios, 139–140
for home care, 85–89
for hospitals, 20–30, 39–41
Index
Interim life safety measures scenario, 137–138
International Patient Safety Goals, 5, 10, 14
International Survey Process Guide, 7, 10
International tracers
ambulatory care center scenario, 152–153
facility management and safety tracers, 2, 6, 10, 157–160
improvement in quality and patient safety tracers, 2, 6, 9,
154–155, 161–162
individual tracer scenarios, 149–153
long term care scenario, 151–152
primary care facility in hospital scenario, 159–160
primary health care center scenario, 156–157
system tracer scenarios, 154–162
Interviewing practice and techniques, 11
J
JCI Survey Process Guide, 2
Joint Commission Connect extranet site
PFP, access to, 8
Survey Activity Guide, access to, 7, 10
Joint Commission International (JCI). See also International
tracers
accreditation and certification, timing and frequency of
surveys, 8
international survey process, 2
scenarios for mock tracers, 11, 147–162
survey process guides, 7, 10
Joint Commission Perspectives, 8, 10
L
Laboratories
community hospital with laboratory scenario, 122–123
critical access hospital with laboratory scenario, 124–125
hospital with laboratory scenario, 37–38
individual tracer scenarios, 117–127
large teaching hospital with laboratory scenario, 117–118
nursing facility with laboratory scenario, 120–122
rural hospital with laboratory scenario, 118–120, 126–127
surveys, timing and frequency of, 8
Leadership
mock tracer team participation, 9
on-site pharmacy scenario, home care program with, 85–87
Life Safety Code® Specialist, 5
Long term care
individual tracer scenario, 101–102
international tracer scenario, 151–152
large nursing facility scenarios, 102–104, 109–110
long-stay nursing facility scenario, 105–107
midsize nursing facility with subacute care unit scenario, 104–
105
nursing facility with laboratory scenario, 120–122
program-specific tracer scenarios, 107–113
small nursing facility scenario, 101–102
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small nursing facility with rehabilitative care scenario, 107– program-specific tracer scenarios
109, 111–113 for ambulatory care centers, 56–58
system tracer scenarios, 102–107 for behavioral health care, 70–71
Low-volume/high-risk activities, 8 for hospitals, 37–38
system tracer scenarios
M EC tracer scenarios, 137–138, 140–141
Measure of Success (MOS), 14 for long term care, 104–107
Medical records, closed records as practice tools, 10–11 for office-based surgery practices, 50–51
Medicare-certified home health program scenario, 93–94, 97–98 Orientation & Training
Medication management individual tracer scenarios
individual tracer scenarios for ambulatory care centers, 45–47
for behavioral health care, 63–64, 77–78 for behavioral health care, 63–64, 77–78
for home care, 83–85 for home care, 81–83
as PFA, 164 for laboratories, 122–125
selection of system tracers, 9 for long term care, 101–102
as system tracer, 1–2, 6 as PFA, 165
community mental health center scenario, 67–69 program-specific tracer scenarios
family practice primary care facility scenario, 54–56 for behavioral health care, 70–72, 74–76
home care scenarios, 85–87, 89–91 for long term care, 109–110
hospital scenarios, 20–22, 28–33, 39–41 system tracer scenarios
long term care scenario, 105–107 for ambulatory care centers, 48–50
Mock tracers for community health center, 53–54
analyzing and reporting results, 7, 13 for community mental health center scenario, 67–69
applying results of, 7, 14 EC tracer scenarios, 132–137, 141–145
benefits of conducting, 1, 2, 8 for family practice primary care facility, 54–56
characteristics and purpose of, 5 for home care, 89–91
checklist and timeline, 7 for hospitals, 26–28, 31–33
conducting and evaluating, 7, 11–12 for long term care, 102–104
debriefing after conducting, 12 for office-based surgery practices, 50–51
how to conduct, 2, 5–14
PI activities and, 7, 14 P
planning and preparing for, 6–11 Patient flow program-specific tracers
reporting results of, 13 hospital scenario, 34–35
sample tracer worksheet, 11 as program-specific tracers, 2, 6, 9
scenarios for, study of, 11 second generation tracers to explore, 2, 10
scope of and selection of, 8–10 Patient Safety
skills for conducting, 2, 9 Individual Safety
team to conduct, 9–10, 11–12 community mental health center scenario, 67–69
training to conduct, 2, 10–11 residential drug and alcohol treatment program scenario,
worksheet form, 11, 13, 167–170 74–76
24-hour adult mental health setting scenario, 73–74
N 24-hour therapeutic school scenario, 63–64, 77–78
National Patient Safety Goals, 5, 10 youth group home scenario, 71–72
Neonatal intensive care unit, 10, 137–138 individual tracer scenarios
for ambulatory care centers, 45–47
for home care, 81–83
O for hospitals, 17–20
Office-based surgery practices for laboratories, 117–118, 120–123
individual tracer scenario, 47–48 for office-based surgery practices, 47–48
system tracer scenario, 50–51 as PFA, 165
Ongoing professional practice evaluation (OPPE), 2, 10 program-specific tracer scenarios
Open forum, 12 for ambulatory care centers, 56–58
Ophthalmologic surgery scenario, 45–47 for home care, 93–98
Organizational Structure for hospitals, 34–37
as PFA, 165 Resident Safety long term care scenario, 109–110

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 Index

system tracer scenarios Q

for ambulatory care centers, 48–50 Quality Improvement Expertise/Activities
for community health center, 53–54 as PFA, 166
EC tracer scenarios, 131–145 program-specific tracer scenarios
for family practice primary care facility, 54–56 for home care, 93–94, 97–98
for home care, 89–91 for hospitals, 37–38
for hospitals, 24–33, 39–41 system tracer scenarios
for urgent care center, 51–53, 59–60 for ambulatory care centers, 48–50
Performance improvement (PI) and mock tracers, 7, 14 for behavioral health care, 64–66
Periodic Performance Reviews (PPRs), 8, 14 for home care, 85–89
Pharmacy services for hospitals, 20–33, 39–41
pharmacy dispensing services scenario, home health agency for office-based surgery practices, 50–51
with, 89–91
on-site pharmacy scenario, home care program with, 85–87
Physical Environment R
individual tracer scenarios Readmission scenario, 93–94, 97–98
for home care, 83–85 Residential drug and alcohol treatment program scenario, 74–76
for hospitals, 17–20 Residential treatment center scenario, 66–67
for laboratories, 118–120, 126–127 Resident Safety long term care scenario, 109–110
for long term care, 101–102 Respiratory care scenario, 81–83
as PFA, 165 Rights & Ethics
program-specific tracer scenarios as PFA, 166
for behavioral health care, 71–76 program-specific tracer scenarios
for home care, 91–93, 95–96 for behavioral health care, 70–71, 73–74
for long term care, 107–113 for home care, 91–93
system tracer scenarios for hospitals, 35–37
for behavioral health care, 66–67 for long term care, 107–109, 111–113
EC tracer scenarios, 131–141, 144–145 system tracer scenarios for behavioral health care, 66–67
for long term care, 102–104
for urgent care center, 51–53, 59–60 S
Physicians, mock tracer team participation, 10 Safety and security. See also Patient Safety
Point-of-care testing scenarios, 117–118, 122–123 as EC tracer, 10
Primary health care center EC tracer scenario, 131–132
family practice primary care facility scenario, 54–56 environmental safety scenario, 134–135, 144–145
international tracer scenarios, 156–157, 159–160 facility management and safety tracers, 157–159
primary care facility in hospital scenario, 159–160 mock tracer selection, 10
Priority focus areas (PFAs) Second generation tracers
characteristics and purpose of, 1, 8, 163 characteristics and purpose of, 2, 6
standards, relationship to, 163 cleaning, disinfection, and sterilization, 141–143
summary of, 163–166 contracted services, 31–33
survey process, role in, 163 patient flow across care continuum, 34–35
tracer selection and, 1 selection of, 10
Priority Focus Process (PFP) Sentinel Event Alerts, 8
access to, 8 Staff
characteristics and purpose of, 8 mock tracer team participation, 2, 9–10
tracer methodology and, 1, 9, 163 training to conduct mock tracers, 2, 10–11
Program-specific tracers Staffing
ambulatory care center scenario, 56–58 individual tracer scenarios
behavioral health care scenarios, 70–76 for laboratories, 124–125
characteristics and purpose of, 2, 6 for long term care, 101–102
home care scenarios, 91–98 as PFA, 166
hospital scenarios, 34–38 program-specific tracer scenarios
long term care scenarios, 107–113 for behavioral health care, 70–72
selection of, 9–10 for hospitals, 34–35
for long term care, 109–110

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system tracer scenarios office-based surgery practice scenario, 50–51

for community mental health center scenario, 67–69 primary health care center scenarios, 54–56, 156–157, 159–
EC tracer scenarios, 131–132, 134–135, 144–145 160
for long term care, 102–104, 105–107 selection of, 9
Standards urgent care center scenario, 51–53, 59–60
compliance with, 8, 14
elements of performance (EPs), 14 T
learning and mock tracers, 10 Time-sensitive tasks, 8–9
Measure of Success (MOS), 14 Tracer methodology
new standards and requirements, 8 international surveys, role in, 2
PFAs, relationship to, 163 number completed during survey, 5
Sterilizer maintenance scenario, 141–143 PFP and, 1, 9, 163
Suicide prevention purpose of, 1
hospital scenario, 35–37 range of observation, 6
as program-specific tracers, 6, 9 survey process, role in, 1, 5–6, 7
24-hour adult mental health setting scenario, 73–74 time requirement for, 5
Surgical-related testing scenario, 122–123 types of tracers, 1–2, 6
Survey Activity Guide, 7, 10 understanding, benefits of, 1
Surveyors/survey team understanding, how to, 2
membership of team, 5 uniqueness of tracers, 15, 43, 61, 79, 99, 115, 129, 147
mock tracer team to play role of, 9–10, 11–12 Transfusion and blood products scenario, 120–122
Surveys, on-site 24-hour adult mental health setting scenario, 73–74
agenda for, 7 24-hour therapeutic school scenario, 63–64, 77–78
CSGs, role of in, 163
PFAs, role of in, 163
timing and frequency of, 7–8 U
tracer methodology, role of in, 1, 5–6, 7 Universal Protocol for Preventing Wrong Site, Wrong Procedure,
System tracers Wrong Person SurgeryTM, 45
ambulatory care center scenario, 48–50 Urgent care center scenario, 51–53, 59–60
behavioral health care scenarios, 64–69 Utility system scenario, 132–134
characteristics and purpose of, 1–2, 6
community health center scenario, 53–54 V
community mental health center scenario, 64–66 Violent behavior scenario, 74–76
EC tracer scenarios, 131–145 Vulnerable populations, 9
family practice primary care facility scenario, 54–56
home care scenarios, 85–91
hospital scenarios, 20–33, 39–41, 154–155, 157–162
W
improvement in quality and patient safety tracers, 2, 6, 9, Waived testing scenario, 124–125
154–155, 161–162
international tracers, 154–162 Y
long term care scenarios, 102–107 Youth group home scenario, 71–72

180