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Mock Tracer
Mock Tracer Workbook
Tracer methodology is the most prevalent part of The Joint Commission

Workbook
and Joint Commission International on-site accreditation survey process.
So what’s the best way for health care professionals to learn about tracers?
Practice.

Mock Tracer Workbook

The Mock Tracer Workbook provides practical exercises to help domestic and
international health care professionals practice skills needed to conduct an
effective tracer in any health care setting. During an on-site survey, survey-
ors use tracers to evaluate the care of an individual or to evaluate a specific
care process as part of a system. By doing so, the tracer provides an accurate About Joint Commission
assessment of the daily functions at a health care organization. Resources
JCR is an expert resource for health care
Health care staff also can use tracers to examine their own systems and organizations, providing consulting
processes, identify unwanted trends, and implement changes as part of an services, educational services, and publi-
ongoing improvement process before a survey occurs. cations to assist in improving quality
and safety and to help in meeting the
Special features: accreditation standards of The Joint
• Tracer narratives describing individual, system-based, and program- Commission. JCR provides consulting
specific tracers in all health care settings services independently from the Joint
• Sample tracer questions provided with each tracer narrative Commission and in a fully confidential
• Sample tracers for security, utility systems, environmental safety, fire manner. Please visit our Web site at
safety, interim life safety measures, hazardous materials and waste, and http://www.jcrinc.com.
medical equipment
• Tips to help organizations conduct tracers in specific settings
• Worksheet template to help individuals collect and organize notes while
conducting any type of tracer

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 Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii

Section 1. Tracer Exercises for Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Exercise 1-1. Individual Tracer in a 500-Bed Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
Exercise 1-2. Individual Tracer in a Large Tertiary Care Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
Exercise 1-3. Data Use System Tracer at a 300-Bed Community Hospital . . . . . . . . . . . . . . . . . . . . . .7
Exercise 1-4. Data Use System Tracer at a Small Rural Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Exercise 1-5. Infection Control System Tracer at a 250-Bed Hospital . . . . . . . . . . . . . . . . . . . . . . . . .11
Exercise 1-6. Medication Management System Tracer at a 100-Bed Hospital . . . . . . . . . . . . . . . . . . .13
Exercise 1-7. Medication Management System Tracer at a 220-Bed Hospital . . . . . . . . . . . . . . . . . . .15
Exercise 1-8. Patient Flow Program-Specific Tracer at a Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
Exercise 1-9. Suicide Prevention Program-Specific Tracer at an Inpatient Psychiatric Care Unit . . . . .19
Tips for Conducting Tracers in a Hospital Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

Section 2. Tracer Exercises for Ambulatory Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

Exercise 2-1. Individual Tracer at an Ambulatory Surgery Center . . . . . . . . . . . . . . . . . . . . . . . . . . . .24
Exercise 2-2. Individual Tracer at a Large Hospital’s Ambulatory Care Center . . . . . . . . . . . . . . . . . .27
Exercise 2-3. Data Management System Tracer at an Ambulatory Surgery Center . . . . . . . . . . . . . . . .29
Exercise 2-4. Data Management System Tracer at Family Practice Primary Care Facility . . . . . . . . . . .31
Exercise 2-5. Infection Control System Tracer in an Ambulatory Care Facility . . . . . . . . . . . . . . . . . .33
Exercise 2-6. Medication Management System Tracer at an Ambulatory Surgery Center . . . . . . . . . .35
Exercise 2-7. Medication Management System Tracer at a Community-Based, Federally
Qualified Health Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
Exercise 2-8. Continuity of Care Program-Specific Tracer in a Community Care Center . . . . . . . . . .39
Tips for Conducting Tracers in an Ambulatory Care Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41

Section 3. Tracer Exercises for Behavioral Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43

Exercise 3-1. Individual Tracer at a Community Mental Health Center . . . . . . . . . . . . . . . . . . . . . . .44
Exercise 3-2. Individual Tracer at a Community-Based Group Home . . . . . . . . . . . . . . . . . . . . . . . . .47
Exercise 3-3. Individual Tracer at a Group Home . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49
Exercise 3-4. Data Use System Tracer in a Community Mental Health Center . . . . . . . . . . . . . . . . . .51
Exercise 3-5. Medication Management System Tracer in an Opioid Treatment Program . . . . . . . . . . .53
Exercise 3-6. Foster Care Program-Specific Tracer in a Foster Care Agency . . . . . . . . . . . . . . . . . . . . .56
Exercise 3-7. Elopement Program-Specific Tracer at a Residential Youth Program . . . . . . . . . . . . . . . .58
Exercise 3-8. Suicide Prevention Program-Specific Tracer at a Residential Program . . . . . . . . . . . . . . .60
Tips for Conducting Tracers in a Behavioral Health Care Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . .62

iii
 Section 4. Tracer Exercises for Home Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63
Exercise 4-1. Individual Tracer at a Home Health Agency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64
Exercise 4-2. Individual Tracer at a Home Medical Equipment Organization . . . . . . . . . . . . . . . . . . .66
Exercise 4-3. Individual Tracer at a Hospice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68
Exercise 4-4. Infection Control System Tracer at a Home Health Agency . . . . . . . . . . . . . . . . . . . . . .71
Exercise 4-5. Medication Management System Tracer at a Home Health Agency . . . . . . . . . . . . . . . .73
Exercise 4-6. Equipment/Supply Management Program-Specific Tracer for Home Care . . . . . . . . . . .75
Exercise 4-7. Equipment/Supply Management Program-Specific Tracer for a Home
Medical Equipment Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .78
Exercise 4-8. Fall Reduction Program-Specific Tracer in a Home Health Organization . . . . . . . . . . . .80
Tips for Conducting Tracers in a Home Care Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83

Section 5. Tracer Exercises for Long Term Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85

Exercise 5-1. Individual Tracer in a Long Term Care Facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86
Exercise 5-2. Individual Tracer in a Long Term Care and Subacute Facility . . . . . . . . . . . . . . . . . . . . .88
Exercise 5-3. Data Use System Tracer in a Long Term Care Facility . . . . . . . . . . . . . . . . . . . . . . . . . .91
Exercise 5-4. Data Use System Tracer in a Skilled Nursing Facility . . . . . . . . . . . . . . . . . . . . . . . . . . .93
Exercise 5-5. Infection Control System Tracer in a Long Term Care Facility . . . . . . . . . . . . . . . . . . . .95
Exercise 5-6. Infection Control System Tracer in a Long Term Care Facility . . . . . . . . . . . . . . . . . . . .98
Exercise 5-7. Medication Management System Tracer in a Long Term Care Facility . . . . . . . . . . . . .101
Exercise 5-8. Medication Management System Tracer in a Nursing Home . . . . . . . . . . . . . . . . . . . .103
Exercise 5-9. Resident-Centered Care Program-Specific Tracer in a Long Term Care
Facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .105
Exercise 5-10. Staffing Program-Specific Tracer in a Long Term Care and Rehabilitation
Facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .108
Tips for Conducting Tracers in a Long Term Care Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111

Section 6. Tracer Exercises for Laboratories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113

Exercise 6-1. Individual Tracer for a Laboratory at an Acute Care and Long Term Care
Facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .114
Exercise 6-2. Individual Tracer for a Laboratory at a Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .116
Exercise 6-3. Individual Tracer for a Laboratory at a Rural Hospital . . . . . . . . . . . . . . . . . . . . . . . . .119
Exercise 6-4. Laboratory Integration Program-Specific Tracer at a Large Community
Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121
Exercise 6-5. Laboratory Integration Program-Specific Tracer for a Laboratory in a
Large, Complex Teaching Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .124
Tips for Conducting Tracers in a Laboratory Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .126

iv
Section 7. Tracer Exercises for Facility Management and Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .127
Exercise 7-1. Tracer for Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .128
Exercise 7-2. Tracer for Utility Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .130
Exercise 7-3. Tracer for Environmental Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .132
Exercise 7-4. Tracer for Fire Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .133
Exercise 7-5. Tracer for Interim Life Safety Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .135
Exercise 7-6. Tracer for Hazardous Materials and Waste . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .137
Exercise 7-7. Tracer for Medical Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .139
Tips for Conducting Facility Management and Safety Tracers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .141

Appendix 1. Priority Focus Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .143

Appendix 2. Tracer Development Worksheet Template . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .147

v

T
racer methodology is an integral part of The Joint
Commission’s and Joint Commission International’s
on-site accreditation survey process. Surveyors use
tracer methodology to evaluate the care of an individual or to
evaluate a specific care process as part of a larger system. A
surveyor selects a patient, resident, or client and uses that
individual’s record as a road map through the health care
organization. The surveyor follows the specific care processes
that the individual experienced by observing and talking with
staff members in areas where the individual received care. By
doing so, the tracer provides the surveyor with an accurate
assessment of the organization’s compliance with selected
requirements and the organization’s systems of providing care
and services.
Health care organizations that are educated about tracers will
have a better understanding of the survey process, especially
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 this methodology as a
tool to make improvements before a surveyor arrives. For
example, if an organization wants to see a specific aspect of a
system on a specific unit—the medication administration
process in the intensive care unit of a hospital—that unit can
conduct a tracer of a patient who has stayed on the unit.
Although the purpose would be to learn more about how
that unit is functioning, it would also provide important
information that could signal issues for improvement or
change for the broader organization.
Tracer methodology is being used to assess health care organi-
zations beyond the United States. Health care organizations
that undergo Joint Commission International (JCI) accredi-
tation also experience tracer methodology when surveyors
visit their facilities. The concept is essentially the same for
domestic and international organizations; however, there are
slight differences. United States surveyors use such elements
as Priority Focus Areas and the Priority Focus Process to
select patients to trace, but these criteria do not apply to
international surveys. JCI surveyors use information provided
in the organization’s accreditation survey application to select
tracer patients from an active patient list. Patients 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.
Introduction
It is important to know that there are three different types of
tracers–individual, system based, and program specific. The
following is a description of each of them:
• An individual tracer follows the actual care experience of
individuals who received care in a health care organiza-
tion. To select individuals to trace in U.S. health care
organizations, surveyors take into account an organiza-
tion’s clinical/service groups (CSGs) and its top priority
focus areas. The initial areas, units, services, departments,
or homes visited as part of an individual tracer depend on
the CSGs identified in the Priority Focus Process, which
in turn helps them select the individual to trace. Although
these areas help surveyors select the first individuals to
trace, additional individuals may also be selected based on
the initial findings during the on-site survey.
• A system-based tracer is used by surveyors to analyze one
process or system across an entire organization to evaluate
how and how well it functions. To analyze a medication
management or infection control system, a surveyor can
follow an individual’s actual care experience through the
organization and assess how well that particular system
functioned related to that individual’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 improvement process,
including the management and use of data. There is no
individual care recipient to follow.
• A program-specific tracer is used by surveyors to analyze
the unique characteristics and relevant issues of a specific
type of organization. The goal of this type of tracer is to
identify safety concerns within different levels and types of
care. For example, a patient flow tracer is a program-spe-
cific tracer used in hospitals, whereas a continuity of care
tracer is a program-specific tracer used in an ambulatory
care organization.
The best way to learn about all three types of tracers is
through practice. That means developing some basic skills,
such as learning how to ask good questions. A tracer is not
performed by one person in isolation. It involves talking with
multiple staff members, the patient, and even family
members (if possible) to learn details about an individual’s
health care experience or how a particular system functions in
vii
 Mock Tracer Workbook
an organization. All important details about the individual’s
care or system’s function should be explored by asking multi-
ple questions. And how a question is asked is particularly
important. Questions should be posed to encourage the staff
member or patient to share as much information as possible.
Observation of the surroundings or how a respondent
answers one question can trigger additional questions leading
to other related issues.
This Mock Tracer Workbook is designed to help staff members
in all health care settings better understand how the different
types of tracers work and how to ask questions for each of
them. Each section of this workbook includes several tracer
exercises specific to a particular kind of health care setting,
such as hospital and critical access hospital, ambulatory care,
behavioral health care, home care, long term care, and labora-
tories. Each tracer exercise includes an example scenario to
show the reader how a surveyor can use an individual’s record
as a road map through the organization or how a surveyor
can analyze a particular system. Based on the scenario pro-
vided, sample tracer questions show how a surveyor can ask
multiple questions of staff members or the patient to learn
about the care the individual received. In addition, a
summary at the beginning of each scenario lists the priority
focus areas that emerge during each tracer exercise. For a
detailed description of each priority focus area, see Appendix
1 on pages 143–145. (Priority focus areas apply to U.S.
organizations only.)
Appendix 2, on pages 147–148, includes a worksheet that
readers can use to develop and brainstorm their organization’s
tracers and potential questions. Since this publication is
meant to be used as a workbook, it is suitable for staff train-
ing and can be applied in tracer brainstorming activities.
viii
TERMS USED IN THIS BOOK
This publication is divided into different sections that are
health care–setting specific, so each section will use terminol-
ogy appropriate for its setting. For example, patient will be
used in Section 1, “Tracer Exercises for Hospitals”; Section 2,
“Tracer Exercises for Ambulatory Care”; and Section 4,
“Tracer Exercises for Home Care.” Individual will be used in
Section 3, “Tracer Exercises for Behavioral Health Care,” and
resident will be used in Section 5, “Tracer Exercises for Long
Term Care.” Patient, individual, or resident refers to those
people who receive care, treatment, and services at a health
care organization.
The term health care is used throughout this workbook to
refer to all types of care, treatment, and services provided
within the spectrum of the health care field, including
physical, medical, and behavioral health care.
ACKNOWLEDGMENTS
Joint Commission Resources (JCR) is grateful to the multiple
reviewers and content experts for their feedback to ensure the
overall content about tracers is accurate and relevant to the
numerous health care settings. A special thank you is
extended to JCR consultants Judith Moomjian, R.N.,
M.P.A., F.A.C.H.E., C.P.H.Q., and John Hacker, M.H.A.,
for developing tracer scenarios and sample tracer questions
for different sections of the workbook. Appreciation is also
extended to Nanne Finis, executive director of JCR
Consulting Services, and Lucille Skuteris, executive director
of JCR Continuous Service Readiness Consultants, for their
support and cooperation that helped the content develop-
ment process for this workbook. We also extend our
gratitude to writer Ladan Cockshut, who helped with the
workbook’s content development and delivered a quality
manuscript.

Tracer Exercises for Hospitals
T
his section contains individual, systems-based, and
program-specific tracer exercises for hospitals. Each
exercise contains a scenario that represents what might
happen when a surveyor conducts that type of tracer in a hospi-
tal. Based on the scenario provided, the exercise includes a list
of sample tracer questions that might be asked of the chosen
tracer patient or staff members involved in that patient’s care,
treatment, or services. At the end of the section is a sidebar of
tips that staff can consider when conducting their own tracer
activities in a hospital.
Section 1
Please keep in mind that each tracer is unique; the questions
asked or hospital areas visited during a tracer will vary
depending on the patient or system chosen to follow. No two
tracers are the same. There is no way to know all of the ques-
tions that might be asked during a tracer, because the
possibilities are limitless. These exercises are examples to show
how that type of tracer can be conducted and to put the
sample questions into context. Use these tracer scenarios and
sample questions as educational or training tools for yourself
and your staff, or use them as a starting point to conducting
your own tracers.
1
 Mock Tracer Workbook
Individual Tracer Exercises for a Hospital
Exercise 1-1. Individual Tracer in a
500-Bed Hospital
Scenario
Summary: In the following scenario, a surveyor conducts an
individual tracer at a 500-bed hospital, where she explores
issues relating to the Priority Focus Areas of
• Communication
• Medication Management
• Patient Safety
The surveyor conducted an individual patient tracer in a
500-bed hospital. She selected a surgical patient who had
been in the hospital for eight days. The patient was admitted
to the hospital via the emergency department following a
motor vehicle accident. The patient had multiple injuries,
including a ruptured spleen, fractured ribs, and a fractured
femur. The patient went immediately to the operating room
(OR) from the emergency department, and was subsequently
admitted to the surgical intensive care unit (ICU). She was
transferred from the surgical ICU to the surgical unit on the
sixth day. At the time the tracer was conducted, the patient
was still on the surgical unit.
The surveyor went first to the surgical unit, where she met
with the nurse caring for the patient and asked her to review
the patient’s record. The review revealed that an open reduc-
tion repair was performed on the left sided femur fracture.
The patient also had a splenectomy. The surveyor asked the
nurse to review the course of the patient’s treatment. The
nurse indicated that the patient’s condition was improving
and that she would potentially be discharged from the hospi-
tal to a rehabilitation facility in a few days. She said that the
patient had come to this unit from the surgical ICU. The
surveyor determined that after review on this unit, she would
also visit the surgical ICU, the OR, and the postanesthesia
care unit (PACU) to trace the care and treatment provided to
this patient. She did not think there would be enough time
to also visit the ER on this tracer, but would ask relevant
questions during another tracer visit that would take her to
the ER. The organization had an electronic patient record, so
it would be possible to perform record review with staff in
each of these locations.
2
The nurse reviewed the patient’s record with the surveyor.
The nurse was asked if she had received the patient when she
was transferred from the surgical ICU and how staff received
information about a patient upon transfer. The nurse was
also asked about the patient’s learning needs, and if staff
members had provided education to the patient. The nurse
was also asked if the patient experienced pain and, if so, how
it was being managed. The physician also joined the nurse
and surveyor, and he was asked to discuss similar issues
regarding communication and pain management. He was
also asked about the patient’s medication profile.
The nurse and physician explained the medication reconcilia-
tion process and how medications were reconciled when the
patient was transferred from the ICU to this unit. The nurse
and physician also explained the patient’s discharge plan.
They added that the social worker was trying to get her
placed into a rehabilitation facility for short-term therapy.
The surveyor also met with the patient and asked her about
the education she received from staff and her knowledge of
her medications. The patient described how the physician
and nurse spent time explaining her condition and the treat-
ment before it was provided. She also knew the names of her
medications, the potential side effects, and why she was
taking them. She also showed the surveyor a brochure
explaining each medication that she said she planned to use
at home. When the surveyor asked about her pain and if she
felt it was well managed, she added that staff responded
quickly if she felt pain or any discomfort. She was able to
describe her pain, including the use of the visual analog
scale.
The surveyor then went to the surgical ICU, where she met
with a nurse who cared for the tracer patient. The nurse was
asked to review the tracer patient’s course of care and treat-
ment. This nurse was also asked about the patient’s education
and about handoff communication regarding patient
information.
During a visit to the OR suite, the surveyor met with the
charge nurse and asked her to describe the course of treat-
ment that the tracer patient received there, from entrance to
the pre-operative area, through the OR, and to the PACU.
 Section 1. Tracer Exercises for Hospitals

An OR nurse, who was the circulating nurse for the tracer
case being reviewed, was also asked to explain how the
Universal Protocol for Preventing Wrong Site, Wrong
Procedure, Wrong Person SurgeryTM was applied, including
the use of the preoperative checklist, site marking, and the
time-out process.
The surveyor then went to the PACU and observed the
handoff communication process as another patient was being
admitted from the OR following a procedure. Staff members
were also asked about which criteria were used to determine
when a patient would be discharged from the PACU.

Sample Tracer Questions

Questions for Clinical Staff:

• How was information communicated to you regarding the patient’s care and treatment upon transfer to this unit?
• How is patient information communicated from shift to shift, from discipline to discipline, and between care providers?
• Have you provided education to this patient?
– What have you or others educated her about?
– How is it documented?
– How is the effectiveness of your education evaluated?
– Has education also been provided by other caregivers?
– How do you support one another’s educational endeavors?
– Have you or anyone evaluated the patient’s ability and
willingness to learn, and also her preferred method of
learning?
• Can you tell me about the patient’s pain management program?
• Do you use telephone or verbal orders? If so, can you explain how the process works at this hospital?
• Please explain the medication reconciliation process. Show me how it is documented.

Questions for the Patient:

• How have staff members provided you education and information about your illness?
• What do you know about your medications?
• How do staff identify you before giving medications?
• What do you know about your discharge plan?
• If you have questions, are you comfortable that you can get the answers you need in a way that you can
best understand?
• Have you experienced pain? If so, how has it been managed?
• When will you be leaving the hospital? What is the plan for the next steps in your recovery?
• Who has met with you to discuss your discharge plan?

Questions for the Operating Room Staff:

• Please tell me how the patient is positively and definitively identified from entrance to this area and then
throughout the entire operative process.
• Please show me your preoperative check sheet and explain the preoperative verification process.
• How is the time-out performed?
• How is the operative site marked? How do you confirm that the correct site has been accurately marked?

3
 Mock Tracer Workbook
Exercise 1-2. Individual Tracer in a Large
Tertiary Care Hospital
Summary: In the following scenario, a surveyor conducts an
individual tracer in a large tertiary care hospital, where he
explores issues relating to the Priority Focus Areas of
• Assessment/Care Services
• Patient Safety
• Communication
Scenario
A surveyor conducted this individual patient tracer in a large
tertiary care hospital. The surveyor selected an obstetrics
patient who experienced complicated labor and delivered a
36-week gestational aged male baby via cesarean section two
days before the tracer was conducted. The baby was born
with respiratory distress and was intubated on a ventilator.
The surveyor started the tracer on the postpartum unit to
review the mother’s care, then went to the labor and delivery
area, and also met with the staff members involved in the
cesarean section. He then went to the neonatal intensive care
unit (NICU) to also trace the care of the baby.
The surveyor first met with the patient and asked her about
her care and treatment and also about the care and treatment
of her baby. The patient indicated that the staff members
were wonderful and that they provided excellent care to her
throughout every step of the process so far. She said that she
was feeling weak but was recovering and that her pain was
indeed beginning to subside. She said her baby was in the
NICU and that he seemed to be doing better. The last time
she visited the baby, staff were starting to wean him from the
ventilator. The surveyor asked her how often she was able to
see the baby and how she was able to get there, since it was at
the far end of the hall, and quite some distance away. The
mother said she had been going in a wheelchair, but that this
morning she was able to walk without feeling too tired or
dizzy. The surveyor also asked her about the discharge plan
for her and her baby.
The surveyor then met with staff on the postpartum unit. He
asked them how and when the patient came to this unit and
how they received information about the patient’s condition
and that of her baby. He asked them if the patient was
having any pain and how her pain was managed. He also
asked them if they performed a falls risk assessment for this
4
patient and if they routinely performed these assessments on
all patients. He asked them to identify the measures and
interventions they took to prevent falls and also to show him
all of this documentation in the patient’s record, including
patient education, assessments, and plans of care. He also
asked staff to review this patient’s medication profile with
him. The surveyor then went to the medication preparation
room and looked at the storage of medications, and he also
observed a nurse preparing medications for administration.
The surveyor then went to the labor and delivery area and
asked the staff to walk him through the process a patient
would follow, from admission to discharge from this area fol-
lowing delivery. He also asked them to explain staffing and
how they would assure that they had the right numbers of
competent staff at all times. He asked them to review the
patient’s record to show him the care and treatment provided
to this tracer patient. The surveyor then asked the staff to
explain the handoff communication process from one level of
care to another or from one shift to another. They were asked
if they educated the mother or father during the labor and
delivery process and how this is documented. He also asked
the staff to explain the application of the Universal Protocol
for Preventing Wrong Site, Wrong Procedure, Wrong Person
Surgery during the labor and delivery process and if anything
was done differently for a cesarean section or emergency
delivery. The nurse interviewed remembered this patient and
was able to talk knowledgeably about the care and treatment
provided to her while she was in this unit.
The surveyor went to the NICU where the baby was being
cared for. He put on a cover-gown and scrubbed his hands
prior to entering the unit, per the direction of the nurse
manager. He also observed others entering the unit following
the same protocol. The neonatologist and NICU charge
nurse met with the surveyor. They first visited the baby’s
bassinet, and the surveyor observed the baby being suctioned
and cared for by a nurse. He then asked if the nurse could be
relieved by someone else so that he could interview her and
review the baby’s care with her. The nurse gave a handoff
report to the charge nurse, who took over the care of the
baby to relieve the bedside nurse for this interview and
review. The nurse and the neonatologist reviewed the baby’s
record and plan of care with the surveyor. They explained
they also worked with a pulmonologist who was involved in
the plan for this baby. They had started weaning the baby
from the ventilator the day before and reported that the baby
appeared to tolerate this well. They were also asked about the
 Section 1. Tracer Exercises for Hospitals

performance of blood gases and other laboratory tests and
how results were communicated to them.
Following the visit to the NICU, the surveyor went back to
the postpartum unit and completed the tracer by again
meeting with the nurse and physician to close the loop on
any questions that resulted from the other visits. He also
asked staff about their discharge plans for this tracer patient
and her baby, and how the plans would be communicated to
the patient. While he was there, the surveyor saw the mother
walking to the NICU to visit with her baby. She looked a bit
unsteady, and a nursing aide asked her if she would like to be
accompanied to the NICU.

Sample Tracer Questions

Questions for the Labor and Delivery Staff:

• How do you staff for normal vaginal deliveries?
• How do you staff for an emergency delivery?
• Can you walk me through your process for preparing a patient for an emergency cesarean section?
• Who is present to care for the baby when you anticipate that a baby might have some distress?
• How was signed consent obtained for the cesarean section?
• How was signed consent obtained for sedation and/or anesthesia? How is this handled in an extreme emergency?

Questions for the Postpartum Care Staff:

• Can you tell me about this patient’s pain management program?
• Tell me about this patient’s discharge plan.
• How do you conduct falls risk assessments for your patients?
• What kinds of interventions do you implement to reduce the potential for patient falls?
• Can you talk to me about and show me this patient’s discharge plan?

Questions for the NICU Staff:

• How do you arrange for coverage if you must leave the bedside?
• How many babies does each nurse care for?
• Tell me about how you hand off information regarding your patient when you leave the bedside or at the end of your
shift.
• What kind of special training did you receive regarding the care of an infant in respiratory distress?
• What emergency equipment and supplies do you have available for intervention?
• How do you work together as an interdisciplinary group to assess the baby’s needs and to develop a plan of care?
• How are the results of laboratory tests communicated to you?
• How do you define critical tests and values? How are you made aware of the results?

Questions for the Patient:

• How does the staff provide you education and information about your baby?
• Do staff members answer your questions and explain things in a way that is clearly understood by you?
• How often are you able to visit with your baby?

5
 Mock Tracer Workbook

• Do you have pain or discomfort?

– How is your pain being managed?
– How have you been educated to describe your pain?
• What do you know about your discharge plan? What do you know about your baby’s discharge plan? How was this
information communicated to you?

6

Data Use System Tracer Exercises for a Hospital
Exercise 1-3. Data Use System Tracer
at a 300-Bed Community Hospital
Summary: In the following scenario, a surveyor conducts a
data use system tracer in a 300-bed community hospital,
where she explores issues relating to the Priority Focus Areas of
• Quality Improvement Expertise/Activities
• Staffing
• Patient Safety
• Organizational Structure
Scenario
The surveyor asked members of the hospital’s performance
improvement committee to attend this tracer and other
knowledgeable representatives familiar with related issues to
be assessed and evaluated. The surveyor asked them to bring
data regarding indicators they were currently working on and
where they had made improvements, core measures being
studied, information regarding their proactive risk assess-
ment, staffing effectiveness information, and performance
improvement committee minutes. She also asked them to be
prepared to discuss their self-assessment processes and infor-
mation regarding their compliance with the National (or
International) Patient Safety Goals.
In the discussion regarding the general performance improve-
ment program, the surveyor asked the staff to discuss the
structure of their program and the oversight and coordination
of performance improvement activities within the organiza-
tion. The performance improvement coordinator described
that they are focusing on clinical indicators that posed the
greatest challenges to them. In addition, they prioritized
patient falls and patient and staff satisfaction as key indicators
to study and improve. The surveyor asked them to explain
the focus on each of these issues and to present data to
support their performance improvement process.
In regard to patient falls, performance improvement staff said
they observed an increase in falls for patients following
surgery and in those who were close to discharge or transfer.
On further study, they recognized that many of these patients
fell while attempting to ambulate to the bathroom. When
interviewed after a fall, most patients said they wanted to
Section 1. Tracer Exercises for Hospitals
ambulate independently or that they often did not get a
quick enough response to their call bell. The staff studied
each patient care unit and focused on the units with the
highest number of falls. They then studied response time to
call bells and discovered there was indeed a relationship
between slower staff response times and an increase in the
number of patient falls. The surveyor asked staff how they
educated patients about their risk for falls, and staff said that
they did, but it was often not documented. Performance
improvement staff continued to train staff regarding the risks
of a slow response. They also changed the way they assigned
staffing to assure that there was adequate backup when the
nurse was not immediately available to respond to a call bell.
They even conducted focused patient satisfaction studies
regarding call-bell response time. They reported that they
experienced an increase in patient satisfaction over the last
two months, along with a slight decrease in the number of
patient fall incidents.
The surveyor asked the performance improvement staff if
they considered using these indicators for their staffing effec-
tiveness studies. They had not considered it because they
were studying other issues, but they agreed this might be a
good framework for their staffing effectiveness study by
looking at relationships and honing data to a patient
care unit.
The surveyor also asked performance improvement staff to
present information regarding staff satisfaction. They
explained that an external survey agency formally conducted
this annually. They said they only recently began focusing on
the key staff dissatisfiers and recognized that these might also
have an impact on patient satisfaction. Clinical staff added
that they believed they were short-staffed and were frustrated
they did not have enough time to complete their assigned
tasks and duties. This also potentially related to patients’ dis-
satisfaction regarding staff response time to call bells. The
organization already started to study the potential relation-
ships and planned to analyze whether the predominant areas
where patient satisfaction for response times ranked low were
the same as the areas in which staff satisfaction ranked low.
Performance improvement staff recognized this might require
some focused study because the annual staff satisfaction
surveys did not identify specific work areas.
7
 Mock Tracer Workbook

Sample Tracer Questions

Questions for Performance Improvement Staff:

• What are your priority areas for performance improvement study? Why did you choose these areas for focus?
• Who is involved in performance improvement study and teams? How or why are they selected?
• What type of education and training did you receive regarding performance improvement methodology?
• How can you ensure that your data are objectively studied, analyzed, and presented?
• When do you determine that focused studies might be indicated?
• If you, or any staff, believe that any issues are in need of further study, to whom do you make that recommendation?
– Might the staff member who raised the issue be involved
on a team to pursue its study?
– What kind of training and support do the teams receive
to assist them in the performance improvement process?

Questions for the Performance Improvement Director:

• What is your training and preparation to coordinate performance improvement in this hospital?
• What kind of ongoing training and education do you receive?
• What expert resources do you use and have available to you?
• How do you provide training and education to staff? Describe them to me.
• How do you determine the priorities for focus and study?
• Please explain the areas of focus for performance improvement, including clinical and nonclinical.
– Do you have baseline data to support the priority focus?
• How are data analyzed and presented?
– How are staff trained regarding use of the right tools for
the data being analyzed and presented?
• Can you explain the process used for performance improvement, such as Plan-Do-Study-Act (PDSA)?
• How are outcome data/performance improvement initiatives communicated to organization leaders? And how are they
communicated to the staff level?
• Can you walk me through a performance improvement endeavor for which you have completed at least one full cycle?
– Have you made an improvement?
– Are you able to sustain your improvements?
– How do you know?

8

Exercise 1-4. Data Use System Tracer at
a Small Rural Hospital
Summary: In the following scenario, a surveyor conducts a
data use system tracer at a small rural hospital, where he
explores issues relating to the Priority Focus Areas of
• Quality Improvement Expertise/Activities
• Medication Management
• Communication
Scenario
The surveyor focused a portion of the review on this small
rural hospital’s proactive risk assessment. He asked that those
people who were involved in the current proactive risk assess-
ment attend this portion of the data management review.
The surveyor asked the team to explain the process it uses to
conduct its proactive risk assessment. The team members
informed him that they use the failure mode and effects
analysis (FMEA) approach, and that all members of the team
have been trained in the use of FMEA tools and process.
They said that they had only recently completed the last
FMEA for the prior year and that they were just selecting a
new process for this coming year. He asked them to present
the full process and study that had recently been completed,
and also to use data and analysis to support the process
being presented.
The team was lead by the performance improvement
manager, who had also trained the team members on the
FMEA tools and process. He explained that they selected a
new project each year. They had just completed an FMEA on
the medication management process, having studied all of the
potential risk areas from prescribing all the way through to
the delivery of the medications to the patient. They also rec-
ognized that there were additional medication-related
problems with the medication reconciliation process, but
hoped that they would address that as a separate issue on this
next year’s FMEA. The driving force for the study were med-
ication-error rates and potential failures to recognize possible
errors in prescription, transcription, filling of orders, mixing
of intravenous (IV) medications, and dispensing of medica-
tion to the patients.
The team presented its process, starting with a flowchart of
the current medication process. The members then identified
ways and steps in the process that could potentially break
Section 1. Tracer Exercises for Hospitals
down. They explained that they used currently available data,
such as medication-error and discrepancy reports, and that
they also addressed additional areas where data were not yet
readily available for them, such as near misses. They
explained that they asked nursing and pharmacy staff to
begin collecting data on near misses and that they provided
them with check sheets to use so that the near-miss data
would be objectively collected. They gathered this data for
three months and then analyzed all of the data to identify
potential failure modes. They then implemented improve-
ment strategies using the staff from each of these areas as
special members to assist in developing safer interventions.
They then studied the results and compared the processes.
They said they believed that the system was made safer by
changing processes and by educating staff about the potential
results of unidentified near misses. They said they would con-
tinue to study the process over time to ensure that their
improvements were indeed sustainable.
As a result of this study, the team members believed that the
probable area of focus for the next FMEA was the medication
reconciliation process because the required steps in the
process were being done differently in various locations of the
hospital. They believed that the current system needed better
direction and that staff needed more education in the process
in order to standardize it.
The performance improvement manager said other potential
areas had also been identified for the next FMEA, but that
they were having some difficulty prioritizing which process
they should address at this time. Other potential topics were
non–medication related, but the current team was committed
to moving along to another medication-related issue. Since
the hospital could only focus on one major topic at a time,
prioritizing the appropriate high-risk areas to be studied was
a challenge.
9
 Mock Tracer Workbook

Sample Tracer Questions

Questions for the Performance Improvement Manager:

• What process is used in this hospital to study and conduct proactive risk assessments?
• How do you identify and prioritize the processes to be studied?
• Who determines the right membership and mix of participants on the FMEA team?
• How are data collected? How are they analyzed?
• To whom are the results of FMEAs reported? How frequently are they reported?
• Who sets the priorities for studying high-risk areas? How is it determined which proactive risk assessment will be
studied next?
• How are other identified high-risk processes addressed when they are not studied as an FMEA?

Questions for Members of the Proactive Risk Assessment Team:

• Are the analysis and use of information gained from the FMEA used to improve patient safety? Tell me how.
• Has the FMEA enabled you to identify system or process failures or risks for failure?
• Have you been able to build a safer system as a result of the FMEA proactive risk assessment process?
– Is it sustainable?
– How do you know?
– How will you know if you have improved the processes and systems over time?
• Why were you selected to participate on this team?
– Did you also have ad-hoc, or “just-in-time,” members as they might have been needed?
• How are lessons learned disseminated to all staff involved in the process?
• Have you had “push-back” from any members of your staff? If so, how is this handled?
• Do you think that your involvement on this team has been a positive experience in terms of promoting patient safety in
your hospital? How do you know?

10

Infection Control System Tracer Exercises for a Hospital
Exercise 1-5. Infection Control System
Tracer at a 250-Bed Hospital
Summary: In the following scenario, a surveyor conducts an
infection control system tracer at a 250-bed hospital, where
she explores issues relating to the Priority Focus Areas of
• Infection Control
• Patient Safety
• Communication
Scenario
The surveyor conducted this infection control system tracer
in a 250-bed hospital. She started the session by meeting
with the infection prevention and control (IC) director and
with representative members of the infection prevention and
control committee. She asked them to explain the commit-
tee’s mission and focus, and asked each to explain his or her
role on the committee and in the infection prevention and
control program.
The IC director explained that she was a nurse with
Association for Professionals in Infection Control and
Epidemiology (APIC) certification and that she had coordi-
nated the IC program in this hospital for about five years.
She led the program with a physician who was an epidemiol-
ogist. Committee members included representatives from the
laboratory, pharmacy, environmental service, nurses from
several areas in the hospital, and an administrator. The com-
mittee met every other month, but was involved in the
program on a daily basis.
The surveyor asked the committee representatives to identify
the greatest infection control risks that they currently deal
with. She also asked them to identify any studies in which
they currently collect data. They explained that they moni-
tored for hand hygiene, and that this was a main focus for
the committee. They also focused on potential exposures to
needle sticks and other potentially infectious body fluids. In
addition, they worked with staff regarding compliance with
isolation requirements. They described how they worked with
staff regarding identification of and interventions for prevent-
ing the spread of health care–associated infections, such as
Section 1. Tracer Exercises for Hospitals
Clostridium difficile and hospital-acquired vancomycin resist-
ance. They believed that the incidence of health
care–associated methicillin-resistant Staphylococcus aureus
(MRSA) was actually diminishing, though they saw an
increase in community-acquired MRSA infections.
The surveyor asked the staff to present their studies and to
identify how they addressed the identified challenges. The IC
director and medical IC coordinator described how they
accessed the Centers for Disease Prevention and Control data
and information on a daily basis, and how they disseminated
the relevant information to staff through the hospital’s
intranet. They also provided periodic education programs
for staff.
The surveyor asked the staff to present data regarding staff
compliance with hand hygiene requirements. She asked how
they measured compliance, if they believed that their meas-
urement strategies were reliable, and if the interventions
were effective.
The surveyor then asked the staff to explain the organization’s
requirements for isolation and when it was used. She also
asked how they monitored compliance and if they collected
data to identify the potential risk points in this process.
After the formal meeting and review, the surveyor chose a
patient with an infection for the tracer. The surveyor
observed a nurse entering the tracer patient’s room and pro-
viding care. She also observed a laboratory technician
entering the room and performing a blood draw. She noticed
that some family member visitors did not follow the guide-
line requirements posted outside the patient’s room for the
use of personal protective equipment. Staff said that they
educated the family members, but sometimes it was difficult
to hold them in compliance, so they generally did not stop
them. The laboratory technician fully followed the guidelines.
However, the surveyor witnessed that a nurse left the room,
went to the medication room, and returned to the patient’s
room wearing the same protective garb. Afterward, she was
asked if her conduct was acceptable and safe practice. The
nurse responded that she knew she should have removed the
garb when leaving the patient’s room and worn new protec-
tive garb upon re-entering, but it was often difficult to follow
all of the procedures because of her heavy caseload—due to
11
 Mock Tracer Workbook

staffing shortages—and the number of times she needed to that would be needed. She also asked staff how they could
leave the room for supplies. The surveyor asked her how she assist one another through handoffs of equipment and sup-
prepared for each entry to the patient room and if she could plies to ensure full compliance with requirements.
plan the visits to include all of the equipment and supplies

Sample Tracer Questions

Questions for the Infection Prevention and Control Director and Medical Coordinator of Infection Prevention and
Control:
• How do you obtain needed and current information regarding infection prevention and control?
• How do you disseminate this information to other staff at all levels?
• What are the greatest infection control risks facing your organization?
• What are you doing to diminish the risks and impact on outcomes of care?
• How do you monitor compliance with infection control requirements such as hand hygiene and contact precautions or
isolation room requirements?
• How do you intervene when you observe noncompliance?
• How do you collect and analyze data regarding risky or problematic trends and patterns?

Questions for Members of the Infection Prevention and Control Committee:

• What is your involvement on the committee?
• Why were you selected to be on this committee?
• What data are being studied?
• How are the data communicated to you?
• Do you compare and benchmark your data and outcomes with others? Describe this process. How do you compare?
• What improvements have you implemented?
– Are they effective?
– How do you know?
• How is your staff performing regarding hand hygiene requirements?
– How is hand hygiene monitored?
– Have you identified risk areas? If so, how do you address these identified risks?
– Has compliance improved?
– Is improvement sustained and is it sustainable?
– How do you know?

Questions for the Nurse:

• How do you monitor hand hygiene compliance in staff, visitors, and patients?
• Do you intervene if you believe the required guidelines for infection prevention and control are not being complied
with? How?
• How do you educate patients and families regarding hand hygiene and infection prevention and control principles and
requirements?
• How do you document this education?
• Are you aware of the requirements for the use of personal protective equipment for entering the rooms of patients on
contact precautions or isolation?

12

Medication Management System Tracer Exercises for a Hospital
Exercise 1-6. Medication Management
System Tracer at a 100-Bed Hospital
Summary: In the following scenario, a surveyor conducts a
medication management tracer at a 100-bed hospital, where
he explores issues relating to the Priority Focus Areas of
• Medication Management
• Quality Improvement Expertise/Activities
• Information Management
Scenario
The surveyor conducted this medication management system
tracer at a 100-bed hospital. He asked that the director of the
pharmacy and members of the medication management and
safety committee participate in the discussion. He asked them
to explain the medication management process, including the
planning, selection, and procurement of medications; storage;
ordering, preparing, and dispensing; administration; monitor-
ing; and evaluation of the medication management process. He
also asked them to provide committee meeting minutes and
data and analysis of processes they studied.
The surveyor also asked them to explain the highest risk areas
they had identified in their medication management process.
They said that medication errors had been much higher the
prior year, but that they had installed the Pyxis system and
electronic order entry this year, which both had a positive
impact on reducing errors. They also said they previously had
no data on near misses and that they were now focusing on
identification and reporting of near-miss events.
The surveyor asked them to explain their requirements for the
storage of high-risk medications, and also if they had identified
the look-alike and sound-alike medications in the hospital. He
asked how these were stored and labeled. He said that when he
and the other surveyors conducted individual patient tracers,
they also observed medication storage areas on the patient care
units. He said those tracer observations demonstrated that
nurses were generally not aware of the identified high-risk
medications, nor were they aware which look-alike and sound-
alike pairs of medications had been selected. Nursing staff
responded they assumed this was controlled within the auto-
mated dispensing system, but that they were not aware of any
special labeling.
The pharmacist said the pairs had been selected and were
reviewed at least annually, and that they were labeled and iden-
Section 1. Tracer Exercises for Hospitals
tified in the pharmacy. He described how the nursing staff
received information regarding the selected pairs and high-risk
medications, so they should have been aware of it. He also
explained how medications were segregated within the auto-
mated dispensing system and how this assured safe dispensing
and selection of medications.
The surveyor visited the pharmacy to observe the storage,
labeling, and mixing of medications. She asked a pharmacist to
demonstrate the entire process, from receipt of an electronic
order all the way through to the release of the medications to
the patient care units. It was demonstrated that pharmacists
generally checked that the medications were safely ordered,
how the pharmacy technicians generally filled the prescrip-
tions, and how the pharmacists reviewed all orders once they
were filled. The pharmacist showed how this system of quality
control effectively identified and caught near misses.
The surveyor toured the pharmacy and observed the medica-
tion storage areas. The high-risk medications were identified
and stored in separate storage containers. But the surveyor
noticed that some of these containers actually contained other
medications or dosages that were not identified on the boxes.
The pharmacists explained they often have “overflow” from
higher shelves. They had identified this potential risk and
assured that they conduct frequent checks of the medications
stored in each box, and that they also looked into purchasing
other types of storage bins that might prevent this overflow
from occurring. They also used green fluorescent labeling on
the shelves and boxes for look-alike and sound-alike medica-
tions, but they said special labeling was only done in the
pharmacy.
The surveyor also observed the intravenous (IV) mixing areas.
He noticed one identified area for all sterile mixing of com-
pounds and a separate chemotherapeutic mixing area. Each
had a laminar flow hood. The surveyor noted that boxes of
diluents were stored on top of the hood in the IV mixing room
and asked the staff if this was acceptable practice. They
explained that the policy required nothing be stored on top of
the hoods, but that they were short on storage space. Other
boxes were observed to be stored directly on the floor. Staff
said that they knew this too was not acceptable, but they
needed more space and more shelves.
13
 Mock Tracer Workbook

Sample Tracer Questions

Questions for the Pharmacy Director:

• Have you identified the look-alike and sound-alike medications for this hospital?
– How are staff members made aware of these selected medications?
– How are the medications stored and labeled to ensure safe practice?
• How are training and education provided to staff regarding the requirements for safe medication management practices?
• How do you determine and ensure required competencies for your staff?

Questions for the Pharmacy and Therapeutics Committee Members:

• What are the priority medication-related processes that you are studying to improve safe patient care?
• How do you ensure that staff members are made aware of requirements for safe practice?
• What improvements have been made to the medication management system?
– How are they sustainable? How are these improvements sustained?
– How do you know?

Questions for the Pharmacy Staff:

• Can you show me how and where you store high-risk medications in the pharmacy?
• How do you identify look-alike and sound-alike medications?
– How do you ensure that this is a safe process throughout all medication storage areas?
• What are your systems for quality control when medication orders are filled?
• What is the role of the pharmacy technician?
• What is the role of the pharmacist?
• How and where are sterile preparations mixed?
– How do you assure compliance with defined processes?
• How should supplies and medications be stored?
• If you are short on space and shelving, what other safe and appropriate alternatives have you considered?

14

Exercise 1-7. Medication Management
System Tracer at a 220-Bed Hospital
Summary: In the following scenario, a surveyor conducts a
medication management system tracer at a 220-bed hospital,
where she explores issues relating to the Priority Focus Areas of
• Medication Management
• Communication
• Quality Improvement and Expertise/Activities
• Patient Safety
Scenario
A surveyor conducted this medication management system
tracer at a 220-bed hospital. She asked the pharmacy director
and members of the pharmacy and therapeutics committee to
meet with her during the first part of this review. The sur-
veyor also asked the chemotherapy pharmacist to attend this
meeting. She asked them to present the medication require-
ments for the oncology program, regarding the use of
chemotherapeutic medications. Following the meeting, she
visited the oncology patient treatment area and the oncology
mixing area in the pharmacy to observe the storage, mixing,
dispensing, and disposal of chemotherapeutic medications
and related supplies and equipment. She conducted an oncol-
ogy medication–focused patient tracer for an oncology
patient who was receiving infusion on that day.
Staff described the ordering process and policy, and also
explained the steps implemented to ensure that the right dose
of the right medication was always administered to the right
patient at the correct infusion rate. Staff collected data on
each of these steps and explained that they had no known
errors that involved unsafe administration in the last year.
They had experienced some near misses, but those errors
were caught prior to dispensing because the system required
two signatures for each step in the process. The staff ’s data
and analysis for medication errors for the past two years
showed they had reduced the error rates significantly since
making changes to the mixing and dispensing processes.
The oncology pharmacist was asked about his training and
preparation and how he stayed up to date on important
information. He was also asked about coverage when he was
not on duty or was not available. He said he was the only
oncology pharmacist, but that another pharmacist was
trained on the requirements so he could provide backup for
the oncology mixing and preparation.
Section 1. Tracer Exercises for Hospitals
The surveyor selected a patient to trace who was scheduled to
receive chemotherapy infusion during the surveyor’s visit (on-
site survey). She went to the oncology treatment area and was
introduced to the patient. The patient was in the process of
finishing her infusion and agreed to be interviewed. The
patient said she received safe treatment from very caring and
knowledgeable staff. She further described her medications
and their risks and side effects.
The surveyor was introduced to the nurse caring for the
patient and observed her discontinuing the infusion at the
end of the treatment. She watched how the nurse used spe-
cially identified receptacles to dispose of the tubing and the
bag. She then reviewed the patient’s record with the nurse.
She asked the nurse about any education provided to the
patient and how and where it was documented.
The surveyor visited the pharmacy and met with the
chemotherapy pharmacist. The pharmacy had a separate
intravenous mixing room that was used only for the prepara-
tion of chemotherapy medications. The pharmacist was asked
to explain how the safe storage and preparation of these med-
ications were assured, and also how the accuracy and
appropriateness of prescriptions were assured. He was also
asked to explain the quality control processes required for this
area. The oncology pharmacist said he was the only desig-
nated oncology pharmacist and that he had special training
and certification for this role. In case of his absence, another
pharmacist had been trained on the required process and
policies to serve as a backup.
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Sample Tracer Questions

Questions for the Pharmacy Director:

• What are the high-risk medications and processes that have been identified?
• How do you reduce risk in the oncology preparation areas?
• What segregated areas are available for the storage and preparation of oncology admixtures?

Questions for the Oncology Pharmacist:

• What are your training and credentials for the job that you do?
• How do you assure safe mixing of oncology medications?
• What do you do if a spill or a splash occurs?
• How do you ensure that the right medication and safe dosing have been prescribed?
• Who prepares the oncology admixtures when you are not present or available?

– What training have they received? How do you ensure their competency?
– Who oversees the process to ensure there is consistency in meeting safe practice requirements?

Questions for the Nursing Staff:

• How do you ensure that you have the correct admixture?
• How do you ensure that you are administering the IV preparation to the correct patient?
• How do you ensure that you are administering the infusion at the correct rate?
• How do you dispose of chemotherapeutic supplies?
• Do you provide education and training to the patients? If so, where and how do you document it?
• Are all nurses who work in this area trained and deemed competent for the administration of chemotherapy medica-
tions?
• What does your training consist of? And how does your manager assess your competency?

Questions for the Oncology Patient:

• How does staff identify you prior to starting an infusion?
• Do you feel that your privacy and dignity are respected in this area?
• What kind of education have you received regarding your chemotherapy? Who has provided it?
• Do you feel that your questions are adequately addressed?

16

Patient Flow Program-Specific Tracer Exercise
Exercise 1-8. Patient Flow
Program–Specific Tracer at a Hospital
Summary: In the following scenario, a surveyor conducts a
patient flow program–specific tracer at a hospital, where he
explores issues relating to the Priority Focus Areas of
• Communication
• Staffing
• Patient Safety
Scenario
The surveyor conducted this patient flow program–specific
tracer during a hospital accreditation survey in a 300-bed terti-
ary care hospital. During a previous individual tracer, he
noticed a backup of patients in the halls of the emergency
department, and discussions with staff indicated this was a
common occurrence. The surveyor went back to the emer-
gency department to focus on the patient flow–related issues
and to trace how the backup affected other areas of
the hospital.
The surveyor met with emergency department staff and asked
them to explain how they move patients through the system.
They noted how certain times of the day posed greater chal-
lenges to them, such as late afternoons and evenings. The
organization recently expanded the emergency department, but
staff said it still experienced backup situations at times. Patients
were observed on stretchers and beds in the corridor, close to
the nursing station. Staff said some of those patients waited to
be seen and others waited to be admitted. The surveyor asked
if any areas of the hospital experienced the longest waits for
admission. Staff responded that the intensive care units often
had the longest wait periods. They added that overnight and
early in the day patients might be backed up in the emergency
department awaiting admission to beds on the general medical
and surgical care units. Patients who were discharged generally
did not leave until midday, which seemed to cause delays in
admissions and transfers from the intensive care unit (ICU) to
those beds.
The surveyor asked the emergency department staff if they
were able to provide the same level of care and services to
patients in the emergency department as they would receive if
they were admitted to the level of care they were waiting for.
Section 1. Tracer Exercises for Hospitals
Staff said they could provide the same care and services and
that, at times, an ICU nurse would come to the area to care
for the patient awaiting admission to the emergency depart-
ment. But they added that the patients would be better served
if they were transferred to the appropriate hospital bed sooner.
The surveyor noted he saw a lot of proximal activity, discus-
sion regarding other patients, and a noted lack of privacy for
the hall patients in the emergency department. Staff said
screens were available and could be used, but only two screens
were observed in use while eight patients were observed on
stretchers and beds in the corridor.
The surveyor then visited the medical intensive care unit. He
met with staff and asked them if they were awaiting any
patient admissions from the emergency department. He also
asked them to explain how they made beds available and
assured rapid admission of patients awaiting transfer to the
medical intensive care unit. The staff responded that they also
had difficulty transferring patients out of their unit because
beds are often not available on the regular units until patients
have been discharged. They have a step-down unit, but the
same backup occurs there because it is only a four-bed unit.
The surveyor asked the staff if they had admission and dis-
charge criteria defined for the ICU and step-down units.
The surveyor then met with staff leaders to discuss the patient
flow issues. They explained that the organization’s patient flow
team met monthly and included representatives from all areas
of the hospital. They also attempted to implement a discharge
process requirement earlier in the day to allay some of the
problems with patient backup, but they had difficulty getting
the physicians to see the patients sooner and write earlier dis-
charge orders. Other difficulties included the patients not
being picked up early enough from the hospital. They further
described how they expanded and redesigned the emergency
department and created the step-down unit to help allay some
of the patient flow–related issues, but some issues have not
been fully resolved. They added they were very aware of the
patient flow issues and tried to implement safe systems to
assure that the appropriate level of care and service were
applied to every patient, but the patient backup still posed
challenges. The surveyor asked them to review the data they
collected, as well as the changes and policies implemented to
date. They shared the information and pointed out some of
the improvements that occurred that could be supported by
the data.
17
 Mock Tracer Workbook

Sample Tracer Questions

Questions for Emergency Department Staff:

• Can you tell me about the reasons for the backup of patients in the emergency department?
• How do you protect and respect the privacy and dignity needs of patients in the emergency department, especially those
who are located in the corridor?
• What are you doing to improve patient flow conditions?
• Can you assure that the appropriate level of care and services is provided to every patient in the emergency department
who is awaiting admission to the hospital? How?
• How has the expansion and redesign of the emergency department helped allay any of the patient flow issues?

Questions for Intensive Care Unit Staff:

• Do you have admission and discharge criteria for the intensive care unit?
• What criteria do you use to discharge patients from the intensive care unit?
• How often do you need to move patients because you must make room for other patients awaiting admission?
• Have you seen improvements with patient flow since the step-down unit was created?
• Are there admission and discharge criteria for the step-down unit?

Questions for Leaders:

• How do you identify patient flow–related issues?
• Who is involved in the patient flow team? How are they chosen for the team?
• What are the “bottlenecks” that you have identified?
• What have you done, and what are you planning to do to address these patient flow issues?
• How are data collected and measured regarding patient flow issues?
• Have you seen improvements since implementing some of your interventions?
• How are you addressing issues that have not shown improvement?

18

Suicide Prevention Program-Specific Tracer Exercise
Exercise 1-9. Suicide Prevention
Program–Specific Tracer at an Inpatient
Psychiatric Care Unit
Summary: In the following scenario, a surveyor conducts a
suicide prevention program–specific tracer at a small rural
hospital with a psychiatric inpatient setting, where she
explores issues relating to the Priority Focus Areas of
• Assessment and Care/Services
• Patient Safety
• Communication
Scenario
The surveyor conducted this suicide prevention
program–specific tracer during an accreditation survey in a
hospital with a psychiatric inpatient care unit. The surveyor
went to the psychiatric care unit and interviewed staff about
their efforts to prevent suicide and to identify patients who
might be at risk for committing suicide. She asked them
about their initial assessment and ongoing risk assessments.
For this tracer, the surveyor selected a patient who had been
initially assessed as being at risk for suicide. She asked staff to
review the patient’s file with her, starting with the initial
assessment. The file stated the patient had attempted suicide
at home by taking an overdose of sleeping medication. She
was admitted to the hospital via the emergency department
and from there was transferred to the medical intensive care
unit. After the patient was medically stabilized, she was trans-
ferred to the inpatient psychiatric care unit. This was a
28-year-old patient with a history of depression and one prior
known suicide attempt. She was admitted to the hospital 10
days prior to this survey review, and was transferred to this
unit on day 3 of her hospital admission.
Staff said the patient seemed quiet, but participated in
therapy and group sessions. She had not demonstrated any
further suicidal ideations or any signs of suicide attempts
since her admission. The surveyor asked the staff to review
the patient’s plan of care and discuss how the plan was devel-
oped and how often it was revised. They were planning to
discharge her in about a week, to be followed up by her
private psychiatrist and outpatient group sessions. The sur-
veyor asked them about family involvement. She also asked
Section 1. Tracer Exercises for Hospitals
them if they educated the patients and their families about
access to a hotline as part of their discharge planning. She
asked to see documentation regarding this patient’s educa-
tion. The staff indicated that they provided brochures,
conducted one-on-one discussions, and offered phone
numbers for a crisis hotline, but no documentation was kept
as evidence that this education and information was provided
to this patient or her family.
The surveyor then visited the medical ICU to interview staff
about the care provided to this patient. She asked them if
they were aware of the patient’s suicide attempt, and also if
they conducted a suicide risk assessment on her. They said
the emergency department had done the initial assessment,
which identified her as being a suicide risk. The surveyor
asked the staff to explain how they protected this patient and
provided her with a safe environment while she was a patient
in their area.
The surveyor then visited the emergency department to
inquire about the assessment, care, and treatment this patient
received there. Staff said the patient was not responsive while
she was a patient there, but they relied on the family history
provided by her mother. They assessed her as being a suicide
risk based on an interview with the mother and her present
condition. The patient received one-to-one care from a nurse,
who also transferred her to the medical ICU. The surveyor
inquired about the competency of the nurse caring for this
patient, in regard to her ability to care for an at-risk suicidal
patient. The nurse explained how she attended classes and
received ongoing training to care for these types of patients.
She also indicated that she had been deemed competent for
care of behavioral health and potentially suicidal patients.
19
 Mock Tracer Workbook

Sample Tracer Questions

Questions for Staff in the Psychiatric Care Unit:

• How do you assess patients who might be at risk for suicide?
• Has this patient expressed any further suicidal ideations? If so, how is that handled?
• How are you addressing the immediate safety needs of this patient?
• How are you addressing the long-term safety needs for this patient?
• If this is not the most appropriate setting to meet the safety needs of this patient, how will the patient’s needs best be
met?
• How do you provide information to patients and their families regarding access to a crisis hotline?
• How do you develop a treatment plan or plan of care? Who is involved in this process?
• Can you show me the patient’s treatment plan?

Questions for Emergency Department Staff:

• How do you assess patients who might be at risk for suicide?
• How do you protect patients who might be at risk for suicide while they are in the emergency department?
• Who assesses and cares for patients in the emergency department?
• Are your staff in this area trained and competent to assess and care for patients who might be at risk for suicide?
• What is your process to ensure there are no dangerous items with the patient?
• What is your monitoring system?
• Who cares for patients with extended emergency department stays while conducting bed search?

Questions for the Intensive Care Unit Staff:

• How did you assess this patient as being at risk for suicide?
• What interventions were taken to protect this patient?
• Are staff in this unit trained and competent to care for potentially suicidal patients?
• What type of ongoing training or education do you receive to help you care for suicidal patients?

20
 Section 1. Tracer Exercises for Hospitals

Tips for Conducting Tracers in a Hospital Setting

Consider the following tips and strategies when conducting tracers in a hospital setting.

• Use the scenarios in this section as a starting point for your own tracer activities. To gain familiarity with
tracers, consider using these example tracers as a guide, and select patients to trace based on a similar back-
ground. The sample questions can also be used as a starting point.

• Integrate tracers into other ongoing improvement activities. Use tracers in concert with other improvement
methodologies, such as patient safety rounds. Both engage staff in discussing their work and patient care, treat-
ment, and services, and both allow for the encouragement of high-quality, safe patient care being delivered.

• Use closed medical records for practice tracers. To help start the tracer process or to gain familiarity with it,
use a closed medical record as a training approach. In the same vein as an individual tracer, you can “walk
through” the record as a way to trace that patient’s experience. A closed record can be used for a one-on-one
training session or with a group of trainees using role playing. Also, you can bring the closed records to the
places where the patient was treated and ask staff to review the record with you.

• Ask open-ended questions. You want to give those you interview an opportunity to explain or describe instead
of just providing yes or no answers.

• Focus on issues of particular concern for hospital settings. Consider those issues that are of particular
concern to hospital patient safety, such as patient falls prevention, health care–associated infections, medication
safety, and patient flow. Use those issues as topics to explore as part of your practice tracer.

• Involve multiple levels of staff. Encourage and involve as many staff as possible in tracer activity, such as dieti-
tians, physicians, nurses, housekeeping, and physical therapists. By engaging more staff in the process,
individuals working at all levels can learn more about how their jobs and caring for the patient relates to The Joint
Commission standard and tracer activity. You can also collect important insight and perspectives about
processes and policies and learn potential areas that need improvement. Consider meeting with mutliple staff
members together to observe the team process and communication.

• Take detailed notes during interviews and about what you observe. The notes you record during the tracer
need to be useful later on to make assessments or recommend areas for improvement and also to look for trends
and patterns and to relate back to standards requirements. Do not rely on your memory alone. Write down
enough information so you will accurately remember what you were told or what you observed.

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 Mock Tracer Workbook

22

Tracer Exercises for Ambulatory Care
T
his section contains individual, systems-based, and
program-specific tracer exercises for ambulatory care
organizations. Each exercise contains a scenario that
represents what might happen when a surveyor conducts that
type of tracer in an ambulatory care setting. Based on the
scenario provided, the exercise includes a list of sample tracer
questions that might be asked of the chosen tracer patient or
staff members involved in that patient’s care, treatment, or
services. At the end of the section is a sidebar of tips that
staff can consider when conducting their own tracer activities
in an ambulatory care organization.
Section 2
Please keep in mind that each tracer is unique; the questions
asked or ambulatory care areas visited during a tracer will
vary depending on the patient or system chosen to follow.
No two tracers are the same. There is no way to know all of
the questions that might be asked during a tracer, because the
possibilities are limitless. These exercises are examples to
show how that type of tracer can be conducted and to put
the sample questions into context. Use these tracer scenarios
and sample questions as educational or training tools for
yourself and your staff, or use them as a starting point to
conducting your own tracers.
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 Mock Tracer Workbook
Individual Tracer Exercises for Ambulatory Care
Exercise 2-1. Individual Tracer at an
Ambulatory Surgery Center
Summary: In the following scenario, a surveyor conducts an
individual tracer at an ambulatory surgery center, where she
explores issues relating to the Priority Focus Areas of
• Assessment and Care/Services
• Medication Management
• Patient Safety
Scenario
The surveyor conducted an individual patient tracer in an
ambulatory surgery center. She selected a patient to trace who
had a hernia repair that morning. The patient was now in the
postanesthesia recovery area. The surveyor met with nursing
staff to review the patient’s record prior to admission to the
center for the procedure. She also met with the surgeon and
with the operating room (OR) staff.
The surveyor asked the nurse to review the patient record with
her and to indicate which documentation should be on the
record prior to the scheduled procedure. The nurse said that an
assessment from the patient’s physician and preoperative testing
results should be on the record, and there should also be evi-
dence that the surgeon reviewed both pieces of information.
She added that the record also should contain a signed consent
from the patient, which was obtained at admission. She said the
surgeon always discussed the procedure with the patient prior
to the scheduled date, but that the signed consent is not always
done at that time. The surveyor asked the nurse if staff would
prepare a patient for a procedure in the absence of a signed
informed consent. The nurse answered that they would not.
The surveyor also asked about the consent for anesthesia or
sedation, the process and timing for when that was obtained
and by whom.
The surveyor asked to follow the steps that the patient took
through the organization, from scheduling of the procedure all
the way through to discharge. She met with the schedulers and
asked them to explain the scheduling process that was used for
the patient she was tracing. She also asked them how they com-
municated the scheduled date with the patient. Staff said that
procedure scheduling was generally done directly with the
surgeon’s office staff, but that the schedulers place a phone call
24
to each patient two days before the scheduled procedure to
verify the patient and procedure and to review the requirements
regarding diet, preparation, and time of arrival.
The surveyor observed staff turning over the OR between cases.
She also observed the room upon setup. She noted that a bowl
with clear liquid and a syringe containing clear liquid were on
the setup table, but that the syringe and liquid were not labeled.
The nurse said this was just sterile water. The surveyor made a
note to herself to make sure to mention later to the leadership
that all liquids must be labeled appropriately. The surveyor also
observed unattended medications on the anesthesia cart. She
queried staff about the security of all medications at all times.
She asked staff to describe and demonstrate the use of a preop-
erative check sheet and the time-out process used prior to
surgery. She also asked staff to explain how and when proce-
dural site marking occurs and by whom.
The surveyor then went to the postanesthesia recovery area. She
met with staff in this area and also with the patient. The sur-
veyor asked staff how they educate their patients about surgical
site infection prevention. She asked staff to explain the medica-
tion reconciliation process that they used with this patient,
including any short-term medications, and to indicate what
they did upon patient discharge when a patient is confused or
unable to comprehend directions adequately. The staff member
said they provided the patient with a medication list and also
document the circumstances. Staff members then viewed the
patient’s closed to see how this was documented.
The surveyor then observed a pain assessment being completed
for a patient, and noted that the tool for measuring pain was
used as a reference for the patient. But she noted that the nurse
only asked for a number, rather than also asking about the
quality and location of the pain, as required by the center’s
policy. Documentation of the pain assessment only revealed the
score of “8,” with no other qualifying information. The patient
received medication for the pain, and approximately 30
minutes later the surveyor observed that the nurse again asked
the patient what the level of pain was. The nurse documented
that the patient’s pain score was reduced to a score of “4.”
The surveyor asked the staff about discharge procedures, and
they indicated that patients would only be discharged to
 Section 2. Tracer Exercises for Ambulatory Care

someone who accepted responsibility for them. A patient con- up procedures that they used with patients. Staff said they
firmed that staff explained this requirement before she arrived made a follow-up phone call to every patient one day after
at the facility for procedures. Staff was also asked about follow- the surgery.

Sample Tracer Questions

Questions for Clinical Staff:

• What information is required for informed consent?
• When must an informed consent be obtained and by whom?
• When must the patient assessment be performed and by whom?
• Please explain the medication reconciliation process and show me how it is documented.
• What two patient identifiers do you use? When do you use them?
• How do you provide education to your patients?
• How do you document that education?
• How do you ensure that you are providing care, treatment, and medications to the right patient, at all times?
• What are your requirements for the assessment of pain?
• What are your requirements for reassessing pain for patients?
• How is information regarding assessment and reassessment for pain documented?

Questions for the Operating Room Staff:

• How and when do you label solutions that are used on and off the sterile field?
• How do you ensure that you have the right patient, right site, and right procedure?
• Who marks the operative site? When and how should it be marked?
• Can you tell me how you conduct your time-out?
• How do you educate patients about the prevention of surgical site infections?

Questions for the Patient:

• Did you sign an informed consent for the surgery that was performed?
– Do you recall a discussion regarding the risks, benefits, and alternatives for this procedure?
– Who provided you with the information about the informed consent?
• Did you sign an informed consent for anesthesia?
– Do you recall who obtained this consent from you?
– Did they also provide you with information regarding the potential risks, benefits, and alternatives to the
anesthesia?
• Have you been asked about pain and/or discomfort?
– Do you believe that your pain is adequately managed?

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 Mock Tracer Workbook

• Do you believe that your privacy and dignity have been respected?
• Do you know what medications you will be taking? Do you know what they are being taken for?
• How were you educated about your medications?
• How were you advised regarding the need to have transportation home arranged and available prior to arriving for your
surgery today?
• Who will be taking you home today?

26

Exercise 2-2. Individual Tracer at a Large
Hospital’s Ambulatory Care Center
Summary: In the following scenario, a surveyor conducts an
individual tracer at a large hospital’s ambulatory care center,
where she explores issues relating to the Priority Focus Areas of
• Assessment and Care/Services
• Medication Management
• Patient Safety
Scenario
The surveyor conducted this individual patient tracer in an
ambulatory care program of a large hospital. He visited the
outlying clinics, where he selected patient tracers to observe
standards compliance. One of the visits was to an ambulatory
care site that provided community-based care to an indigent
population. Upon entrance to the center, he noticed that the
entrance door was propped open, although there was a
buzzer at the reception desk to allow for safe entrance to the
facility. Staff said that during busy hours it is difficult to keep
buzzing people in, as they are coming and going continu-
ously, and many of the patients go outside to smoke while
waiting to be called in. They explained that the door is
locked before and after hours, but that they generally prop it
open during office hours. Staff members were also asked
about fire safety, and if this was a fire door that would need
to remain closed to ensure a fire-safe environment.
Upon entrance to the reception area, the surveyor noted that
many patients were waiting, and some were standing due to
lack of sufficient seating. Children and adults were in the
same waiting room. Toys and books were located in a desig-
nated play area. Patients were called in by their first and
last names.
The surveyor selected a pediatric patient to trace as an indi-
vidual tracer. This was a 2-year-old boy with a history of
asthma and skin rash who was at the center for a follow-up
visit because he had recently been hospitalized with an
asthma attack. The surveyor requested that the staff ask for
permission from the mother for him to observe the examina-
tion of her child. The mother granted the permission. The
boy was brought into the examination room by a nurse who
then took his vital signs and got a brief history from the
mother. The boy was crying, and the mother and nurse tried
to comfort him. The nurse handed him a toy from a cabinet
in the room. The physician came in to examine the patient
Section 2. Tracer Exercises for Ambulatory Care
after the nurse had completed the vital signs and brief
history. The physician examined the patient and reviewed his
medications and treatment plan with the mother. She was
told to bring the child back again in one month and to call if
there were any questions or problems between visits. The
physician also reviewed the prescribed diet with the mother.
After the patient left, the surveyor reviewed the patient’s
record with the nurse and the physician. He asked them to
describe their assessment process and to show him the docu-
mentation of the assessments. He also asked how they
received communication from the hospital regarding the
patient’s recent admission and discharge. The physician said
that he received a call from the physician who cared for the
child in the hospital and that he also received a discharge
summary and medication reconciliation form. He reviewed
both prior to seeing the boy at the ambulatory care center
and again at the time he examined the boy. He explained
that this child had been hospitalized several times in the last
year. The boy lived in a home with smokers and animals, and
the physician had requested that social services assess the
home environment and work with the family to assure a safer
home environment for him. The physician reviewed the con-
sultation request form and the social services assessment form
with the surveyor.
The surveyor then traced the patient’s care provided by the
clinical staff and asked about where they store the medical
records to determine if they are maintained in a secure loca-
tion. The staff said that they lock them in metal file cabinets
overnight and on weekends, but the cabinets were open
during operating hours. They pull the files for the next day’s
patients, but those are also stored in a locked cabinet until
operating hours.
Because the patient being traced was a young child, the sur-
veyor asked the staff about training in abuse and neglect and
what their process would be if they identified evidence of
such behavior in this patient. He also asked if the reception
staff had similar training and what their responsibility would
be if they believed they observed such behavior.
Lastly, while in the exam room, the surveyor observed that
the center had mercury-containing sphygmomanometers.
The surveyor therefore asked staff what they would do if
there was a mercury spill. They said that they had mercury
spill kits and that the housekeeping staff was trained on how
to clean these spills.
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 Mock Tracer Workbook

Sample Tracer Questions

Questions for the Reception Staff:

• How do you ensure safe entrance and egress from your building?
• What type of training have you received regarding fire safety? Please tell me about it.
• When was the last time that you participated in a fire drill?
• How do you ensure the privacy needs of patients?
– Are patients given an option if they would not like to be identified in a public area by their names?
• What would you do if abusive behavior toward a child or other patient occurred in the waiting area?
• What kind of training and orientation have you received regarding recognition of abuse and neglect?

Questions for Clinical Staff:

• How do you ensure the privacy of patient information?
– Are medical records stored in a secure and safe location?
– Are the medical records protected from unauthorized access?
• Please explain the medication reconciliation process and show me how it is documented.
• How often are toys cleaned?
– How are they cleaned?
– Who is responsible for the cleaning of toys?
– Are there any toys that might not be acceptable because they cannot be adequately cleaned? What happens to these
toys?
• How would you respond if you believe you have recognized signs of abusive or neglectful behavior toward any of your
patients?
• How do you communicate with other caregivers and providers regarding the care and treatment of a patient?

Questions for the Patient:

• How long do you generally wait to be seen once you have checked in with the reception staff?
• Do you believe you are treated with dignity and respect?
• Are you provided with the information you need?
• Are you able to have your questions answered?

28

Exercise 2-3. Data Use System Tracer
at an Ambulatory Surgery Center
Summary: In the following scenario, a surveyor conducts an
individual tracer at an ambulatory surgery center, where she
explores issues relating to the Priority Focus Areas of
• Assessment and Care/Services
• Medication Management
• Patient Safety
Scenario
The surveyor conducted a data use system tracer in an ambu-
latory surgery center. Minor surgeries and endoscopic
procedures were performed in this center. She asked the per-
formance improvement coordinator and members of the
center’s performance improvement committee to attend the
session.
The surveyor asked the performance improvement coordina-
tor to explain the performance improvement process in this
facility and to explain her training and preparation for her
role as performance improvement coordinator. The perform-
ance improvement coordinator explained that she is a
registered nurse whose primary job is as a postanesthesia care
unit (PACU) nurse in this facility. She also functions as the
performance improvement coordinator and chairs the organi-
zation’s performance improvement committee. She said that
she has had training in performance improvement from her
previous job and also is certified in health care quality. The
surveyor asked her how she obtains current and relevant
information and keeps up to date with related topics. The
performance improvement coordinator answered that she
receives quality journals and also subscribes to professional
networks for data and information related to surgical care
and services quality. She said that she has established a
“quality library” at the center that is available to all staff and
shared with members of the performance improvement com-
mittee. She also provides ongoing education to staff
regarding the performance improvement process.
The surveyor then met with members of the performance
improvement committee, which included the administrator,
the chief of surgery, a surgeon, an endoscopist, the admission
nurse, an OR nurse, an endoscopy technician, the PACU
charge nurse, and the equipment technician. Not all of the
members were available to meet with the surveyor, but a rep-
resentative sample was available. The surveyor asked them to
explain their roles on the committee and also to explain how
Section 2. Tracer Exercises for Ambulatory Care
they received their education and training regarding perform-
ance and quality improvement. The surveyor asked them to
also explain the committee’s mission and function.
The team was asked which indicators it is studying, and why
it selected these indicators. Team members were also asked to
present data and analysis on these indicators, and for all of
the indicators required by The Joint Commission or Joint
Commission International. The members were also asked to
identify those areas where they were not meeting expectations
or were not having desired outcomes and to explain their
processes for improvement. They were asked to show how
they studied these processes and how they implemented
improvement strategies.
The performance improvement committee members were
asked if there were other indicators that they also worked
with and where they have been able to implement and
sustain improvements. They said that they had been collect-
ing data on patient satisfaction for the past year. Patients
indicated that they were not satisfied with wait times and
that their procedures often started late. Patients also said they
were concerned with privacy issues. Upon a further focused
review of these issues, the performance improvement com-
mittee noted that it has been able to reduce patient wait
times. They now inform patients in advance that there might
be a wait time of up to an hour, as previous cases might run
over predicted time. They again repeat this information when
the patients arrive at the surgical center. The committee then
showed the surveyor data that patient satisfaction rates for
wait times had improved. Staff accomplished this by schedul-
ing procedures carefully and allowing extra time in case a
procedure runs late and by providing more information to
patients about possible wait times.
Regarding privacy issues, upon focused review, it was deter-
mined that the patients’ privacy concerns involved patient
interviews and discussions and postprocedure reports to fam-
ilies. The performance improvement committee has worked
with staff on how to speak more quietly with patients. The
committee also has provided private rooms for physicians to
meet with patients when obtaining consents or when dis-
cussing procedures and also for meeting with family
members to inform them about the status of a loved one’s
procedure. The performance improvement committee had
not yet collected updated information since this process was
only recently implemented, but they believed that they will
see increased satisfaction in this area too.
29
 Mock Tracer Workbook

Sample Tracer Questions

Questions for the Performance Improvement Coordinator:

• Describe the training and preparation for your job as performance improvement coordinator.
• How do you provide education and training to staff and members of the performance improvement committee?
• How do you obtain current and relevant information regarding quality and performance improvement processes for this
organization?
• Who is represented on the performance improvement committee?
• How are priorities set for indicator selection and data collection?

Questions for Members of the Performance Improvement Committee:

• What is your role as a performance improvement committee member?
• What is the purpose and function of the performance improvement committee?
• How do you select the indicators that you are studying?
• How do you obtain information regarding appropriate performance indicators and expected outcomes?
• Which indicators are you currently studying?
– Why were these indicators selected?
– How is your performance on these indicators?
– How do you collect data regarding performance? How do you study and analyze the data?
• Are there any indicators that you have focused on in which you have made significant improvement?
– How do you know?
– Have you studied and compared performance over time?
– Are you able to benchmark performance against the industry norm?
• Are you collecting data on the following required indicators:
– Significant discrepancies between preoperative and postoperative diagnoses, including pathologic diagnoses?
– Adverse events related to sedation and anesthesia?
– The use of blood and blood components?
– Confirmed transfusion reactions?
– Significant medication errors?
– Significant adverse drug reactions?
– Patient perception of the safety and quality of care?
– Medical necessity of procedures?
– Appropriateness of care?
• How are you collecting these data? How is your organization performing?
• Are there other areas that you are studying? If yes, then where have you been able to see improved outcomes?

30
 Section 2. Tracer Exercises for Ambulatory Care

have identified any key issues in this area. The community is

Exercise 2-4. Data Use System Tracer
at a Family Practice Primary Care Facility
Summary: In the following scenario, a surveyor conducts an
individual tracer at a family practice primary care facility,
where he explores issues relating to the Priority Focus Areas of
• Quality Improvement Expertise/Activities
• Communication
Scenario
The surveyor conducted a data use system tracer in a family
practice primary care facility located in a rural area. The facil-
ity serves as the primary care provider for the majority of
families in this community. All of the family practice physi-
cians on staff at this facility also have privileges at the
community hospital located approximately 20 miles away.
The surveyor asked to meet with the staff involved in per-
formance improvement for this facility. The medical director
said that he serves as the performance improvement coordi-
nator for the facility. They do not have a performance
improvement committee, but they have monthly staff meet-
ings, and performance improvement discussion is a standing
agenda item for these monthly meetings. The surveyor asked
the medical director to review the minutes of these meetings
with him, focusing on the performance improvement discus-
sion and reviews. He also asked him to identify any
indicators that the committee is studying and to show him
data and analysis for these indicators.
a small one, so if a patient has a complaint or issue, it is
raised when the patient is there. The surveyor asked staff if
they collect any data to identify if there are any patterns or
trends regarding the kinds of complaints that patients have
made. The staff members said that they have not collected
any information regarding complaints, as complaint report-
ing is generally an informal process. The surveyor suggested
that staff might want to record these complaints and then
categorize them to identify any potential trends or patterns.
The surveyor then asked the attendees to show him data that
had been collected for any of their performance improvement
activities, as well as analysis and improvement activities. They
were not able to demonstrate any real analysis of any of the
data that they had collected. They had some raw numbers
regarding the timeliness of reports, but had not yet fully ana-
lyzed these data. They also had numbers regarding
hospitalizations, but had not studied the data to identify
trends or patterns.
The surveyor recommended that staff use tools to assist them
in analyzing and presenting their performance improvement
data, such as control charts or other graphic tools as appro-
priate to the data being analyzed.

The performance improvement coordinator indicated that

the organization is studying indicators regarding patient satis-
faction. The surveyor asked if members of the staff could also
participate in this discussion. Once the staff joined the dis-
cussion, the staff members and performance improvement
coordinator indicated that they are also studying follow-up to
outside pathology and laboratory reporting, mainly because
they have identified that they often do not recognize when
reports have not been received. They have developed a
spreadsheet that indicates when all testing is requested and
identifies expected turnaround times for the results. When
the date and time have passed, the spreadsheet flashes a red
flag, alerting staff that the report has not yet been received.
Staff now will follow up on those reports.

Staff also said they plan to pay more attention to improving

patient satisfaction, although they are not aware that patients

31
 Mock Tracer Workbook

Sample Tracer Questions

Questions for the Performance Improvement Coordinator:

• What is the focus of performance improvement activity in this organization?
• What is the structure for performance improvement in this organization?
• Have you received training and education regarding performance improvement methodology and processes?
• Who is involved in the performance improvement process?
• What indicators are you studying?
• How do you collect and analyze data?
• Can you show me data and analysis for any processes that you have studied and where you have implemented improve-
ment strategies?
– Have you been able to improve these processes and outcomes?
– How can you demonstrate this improvement?
– Are the improvements sustained, and are they sustainable?

Questions for Staff:

• What is your involvement in performance improvement?
• Have you received training and education regarding performance improvement methodology and process?
• How do you identify and set priorities for improvement activity?
• Have you identified any patterns or trends that require further study and focus?
• How do you present your data, and to whom is it presented?
• Are there other areas that you are studying? If yes, then where have you been able to see improved outcomes?

32

Infection Control System Tracer Exercise for Ambulatory Care
Exercise 2-5. Infection Control System
Tracer in an Ambulatory Care Facility
Summary: In the following scenario, a surveyor conducts an
infection control system tracer at an ambulatory care facility,
where she explores issues relating to the Priority Focus Areas of
• Infection Control
• Communication
• Patient Safety
Scenario
The surveyor conducted an infection control system tracer in
an ambulatory care facility that is part of a multicenter
organization. He asked to meet with the infection prevention
and control (IC) coordinator to review the policies and pro-
cedures that were in place regarding infection prevention and
control. He added that any indicators and data that were col-
lected and studied should also be brought to this meeting.
The IC coordinator explained that she is a nurse who is also
certified as an IC practitioner. She coordinates infection pre-
vention and control activities at all of the outpatient centers
that are part of this organization. She indicated that she
chairs the IC committee, which has representative members
from each of the four facilities, and that she also comes to
each facility at least weekly. The surveyor asked her to iden-
tify the priority areas of focus and intervention in this facility
and for the organization. She said that hand hygiene is a key
area of focus and that she has provided ongoing education to
all staff regarding requirements for appropriate hand hygiene.
She added that they have recently installed antibacterial gel
dispensers in all of their facilities. Upon observation, the sur-
veyor noted that the gel dispensers were placed in the waiting
room and outside of each of the examining and treatment
rooms. She also observed that staff used the dispensers upon
entering and leaving the rooms. The IC coordinator added
that she observed how staff used the gel dispensers and
washed their hands and that she has collected data on both
topics. She said staff compliance has been steadily rising,
with significant improvement observed after the gel dis-
pensers were installed.
Section 2. Tracer Exercises for Ambulatory Care
The IC coordinator was asked to describe what other type of
education she provides to staff members. She said she has
been educating staff about influenza and that she has been
encouraging all staff to receive the influenza vaccine. Staff
rates for receiving the vaccine are still not where she would
like them to be, but this year she saw a 5% improvement rate
in staff vaccination. She said that she also provided staff with
ongoing education regarding emerging community-acquired
infections, including community acquired MRSA. Staff
members also provide educational materials to patients
regarding prevention and identification of these infections.
The surveyor asked which representatives of this facility are
members of the IC committee and asked to meet with them.
The medical director, laboratory technologist, and a staff
nurse served as this facility’s IC committee members and met
with the surveyor. The committee members said they help
provide education and training to staff regarding infection
prevention and control and work with staff to identify poten-
tial risks in the facility. They recently noticed increased
occurrences of Rotavirus in their pediatric population. They
collected data and plan to investigate whether this is a com-
munitywide trend also being observed in other facilities or if
it is unique to their population. They added that more com-
munity education might be needed since they were seeing an
increase in the prevalence of Rotavirus, and they had already
hung posters alerting patients to what Rotavirus is, how to
recognize it, and how to prevent it from occurring. They also
ordered educational brochures, but they were not
yet available.
The surveyor asked the committee members to review the
record of a patient who was recently infected with the
Rotavirus. He asked them to review the assessments and the
plan of care. He also asked if education was provided to the
parents regarding transmission risk, prevention, and treat-
ment. They were able to demonstrate that education was
provided to the mother and that it was clearly documented.
The surveyor asked them how they diagnosed the Rotavirus
and if they had the ability for rapid detection. They
explained that they did have access to rapid detection in their
on-site laboratory.
33
 Mock Tracer Workbook

Sample Tracer Questions

Questions for the Infection Prevention and Control Coordinator:

• How do you share information with staff at this facility and in your organization?
• How do you set priorities for study and focus?
• Describe the elements of your hand hygiene program.
• How do you study trends and patterns in each facility?
• How do you study trends and patterns throughout your organization?
• How do you benchmark your data?
• How do you obtain information regarding emerging trends and recommendations regarding infection prevention and
control?
• What is your process to make changes or improvements in infection prevention and control?

Questions for the Physician, Laboratory Technologist, and Nurse:

• What is your role on the Infection Control Committee?
• How do you communicate information regarding infection prevention and control to staff and to patients?
• Do you provide infection prevention and control education to patients?
– How do you document education provided to patients and their families?
– How do you know that patients and their families understand the information you have taught them?
• How do you communicate patient information from one practitioner to another?
• How are infection control risks identified?
• How do you improve processes for risk reduction?

34

Medication Management System Tracer Exercise for Ambulatory Care
Exercise 2-6. Medication Management
System Tracer at an Ambulatory Surgery
Center
Summary: In the following scenario, a surveyor conducts a
medication management system tracer at an ambulatory
surgery center, where she explores issues relating to the Priority
Focus Areas of
• Medication Management
• Orientation and Training
• Patient Safety
Scenario
The surveyor conducted a medication management system
tracer in an ambulatory surgery center. She first met with
staff responsible for the storage and preparation of medica-
tions to discuss the center’s pertinent procedures and policies.
She then focused the tracer on the storage and security of
medications.
During the tour of the facility, the surveyor asked the staff to
show her the route medications take, from delivery into the
facility to the storage of the medications and to the prepara-
tion and dispensing areas. Staff explained that they use an
outside pharmacy. All medications are delivered directly to a
nurse in the facility, who signs for all of the medications on
delivery. The staff said the nurse stores the medications
immediately in the medication room located in the postanes-
thesia care unit (PACU).
The surveyor was shown the medication room, which was
locked with a keypad. The surveyor asked who had access to
the keypad code and was told that only nursing staff
members were aware of the code. When asked how the room
is cleaned and by whom, staff members explained that it is
cleaned by the nurses during operating hours because the
housekeeping staff who clean at night are not allowed access
to this room and do not know the keypad code. In the med-
ication room, narcotics and controlled substances were
observed to be locked in a double-locked cabinet. The sur-
veyor was shown a sign-out sheet for all narcotics. She also
saw that the initial signature for each controlled substance
was signed by the delivering pharmacist and the nurse receiv-
Section 2. Tracer Exercises for Ambulatory Care
ing the order. Other medications were stored on shelves in
unlocked cabinets in the medication room and also in a
refrigerator. The nurse said that this refrigerator is used for
medications only. She was asked if and how the temperature
of the refrigerator is monitored and what the acceptable tem-
perature range was for this refrigerator. The nurse said that
the range was posted and that the temperatures were to be
checked daily and recorded on a log. When the surveyor
looked at the log, she noted that several dates were missing
each week and that data for the entire third week of the
month had not been recorded. She asked if anyone had
responsibility for assuring that these checks were indeed per-
formed and recorded.
The surveyor also asked if anesthesiologists or other physi-
cians were allowed access to the medication storage area. She
was told that the facility did not administer deep sedation or
anesthesia, but that any medications needed for each case
were dispensed to the nurse anesthetist or anesthesiologist at
the beginning of each day. They then stored the medications
they needed in their locked carts in the procedure rooms.
Staff showed her a separate sign-out sheet for these medica-
tions. In addition, some stock medications were stored in
locked cabinets in each procedure room. These were keyed
cabinets that could be accessed by the nurses.
The surveyor also asked if any high-risk medications were
identified for this facility, and if so, how they were labeled
and stored. She was shown the high-risk medications and
observed that these were stored in separate containers and
were labeled appropriately. The surveyor also noted that
look-alike and sound-alike medications were identified by the
center and were labeled by the pharmacy with pink fluores-
cent labels. The nurse then showed the surveyor the list of
look-alike and sound-alike medications that they had devel-
oped based on their formulary and reference to both Web
sites of The Joint Commission and the Institute for Safe
Medication Practices. The surveyor visited several of the pro-
cedural rooms and did not observe any unsecured
medications in any of the rooms.
The surveyor then met again with the nurse, the medical
director, and the consulting pharmacist. Based on her obser-
vations, the surveyor inquired about the security of
35
 Mock Tracer Workbook

medications and who had overall responsibility for safe
storage and use of all medications. She asked how medica-
tions are prepared and labeled, both on and off of the sterile
field. She asked about the mixing of intravenous (IV) prepa-
rations, and was told that staff order as many premixed
compounds and admixtures as possible, but those that
needed to be mixed immediately before use were mixed in
the operating rooms or in the PACU by either the nurse or
the anesthesiologist or anesthetist. Staff was also asked about
their formulary and how they determined the right medica-
tions and right amounts of medications to store on site.

Sample Tracer Questions

Questions for the Nurse:

• How are medications secured in this facility?
• What processes exist to ensure that medications are safely stored?
• How is the stability of medications ensured?
• Can you show me the route that medications take from delivery to the facility to storage, dispensing, and ultimately the
return of medications?
• How often is documentation checked to assure that all staff are following the required procedures?

Questions for the Pharmacist:

• What is your role in helping to develop the medication formulary?
• Do you work with staff in identifying look-alike and sound-alike medications?
• Are you responsible for inspecting medication storage and dispensing areas? If so, how often does this occur?
• Do you provide education and training to staff?
• Do you assist with the identification and labeling of high-risk medications?

Questions for the Physician:

• How do you ensure that medications are safely used, stored, and admixed by licensed independent practitioner staff?
• How do you educate the patient about his or her medication?
• What is the procedure for prescribing and providing medications to patients?
• How often do you receive training about medications and your organization’s medication administration process?

Questions for Other Meeting Attendees:

• Do staff meet to review medication protocols and requirements?
• Do you have a pharmacy and therapeutics committee or structure?
• What is the process for determining the formulary of medications in this facility?
• How are medication errors and near misses reported? How are those reports responded to?
• Do you collect data that is used to calculate error and discrepancy rates?
• How are these data used to make improvements?

36

Exercise 2-7. Medication Management
System Tracer at a Community-Based,
Federally Qualified Health Center
Summary: In the following scenario, a surveyor conducts a
medication management tracer at a community-based, feder-
ally qualified health center, where he explores issues relating to
the Priority Focus Areas of
• Medication Management
• Physical Environment
• Infection Control
• Patient Safety
Scenario
The surveyor conducted this medication management system
tracer in a community-based, federally qualified health
center. The surveyor was told at his meeting with selected
clinical and administrative staff that the center stored very
few medications other than stock medications, such as
Tylenol and vaccines. However, he learned that they also
stored many sample medications that were provided to their
patients. The stock medications were stored in an unlocked
cabinet in the inner area of the center while the sample med-
ications were stored in a separate locked storage closet that
was used only for the storage of the sample medications. The
staff explained that they also had a medication refrigerator
that was identified for medication storage only, with the
primary medications stored in the refrigerator being vaccines.
The surveyor was told that no medications were stored in
examination or treatment rooms.
The surveyor then asked the staff to show him all of the
medication storage areas. He observed the cabinet where the
stock medications were stored. In the cabinet he observed
Tylenol, aspirin, and other over-the-counter medications. He
asked staff where these medications were purchased and how
they were supplied to the organization. It was explained that
staff order the over-the-counter medications from a contract
pharmacy that delivers the medications to the center. He was
told that they store no controlled substances. The surveyor
asked if the cabinet could be locked or how staff could
ensure that the medications were stored securely at all times.
Staff said that the cabinet could not be locked, but that there
were no medications that really posed any risk. He asked if
unauthorized persons, such as patients or nonlicensed staff,
could access these medications because the area is not moni-
Section 2. Tracer Exercises for Ambulatory Care
tored by staff members. They could not assure the surveyor
that the medication would not be accessible to unauthorized
individuals.
The surveyor then asked the staff to show him where they
stored the refrigerated medications. The medication refrigera-
tor was also located in this same inner area, and also did not
have a lock on it. A label was posted on the refrigerator iden-
tifying that it was for medication storage only. However, after
opening the refrigerator, the surveyor found a sandwich and
some beverages. The staff said that the food items should not
have been put inside and generally were not allowed to be
kept there. The food items were immediately removed from
the refrigerator. The surveyor looked at the temperature log
posted on the side of the refrigerator. The log included data
showing that staff diligently recorded the refrigerator’s tem-
perature on a daily basis, which followed the center’s required
policy. All temperatures recorded were within an acceptable
range for the type of medications stored inside
the refrigerator.
The surveyor asked staff members about their use of sample
medications and asked them to show him where and how
they stored and dispensed these medications. Staff explained
that they served an indigent population and that they relied
on receiving and dispensing the sample medications. Their
process included having all medications signed out by the
nurse accessing the locked closet and also by the physician
providing the medication to the patient. Staff also docu-
mented in the patient’s record what sample medications were
dispensed and the time they were dispensed. The surveyor
confirmed this documentation by reviewing some patient
records that contained information on sample medications.
The surveyor also asked staff members if they monitored pre-
scribing patterns, in regard to the use of antibiotics and pain
medication prescriptions. They said that they did not
monitor this process, and therefore were unaware of physi-
cian prescribing patterns. The surveyor asked if there were
any other medication-related data that they studied or moni-
tored. They said that they monitored the vaccination rates for
influenza vaccine for both patients and for staff. They said
they had an aggressive education program to promote the use
of this vaccine. They showed the surveyor data that demon-
strated a significant rise in the immunization rates this year
for both patients and staff.
37
 Mock Tracer Workbook

Sample Tracer Questions

Questions for Nurses:

• How do you safely and securely store your medications?
• How do you ensure the stability of all medications, especially those requiring refrigeration?
• What is the protocol if you observe an unauthorized individual handling medications or accessing an area in which
medications are stored?
• What is your procedure for checking the expiration dates on medications?
• What is your procedure for discarding medications that are expired?
• How do you monitor prescribing patterns?
• How do you secure your prescription pads?
• How do you control the sample medications that you store? How do you prevent them from being diverted?
• What processes related to medication management are you studying and improving?
• Can you show me your data related to your program for influenza vaccination?
• How do you educate patients about a medication?
• How do you verify that the patient understands the medication information?
• What do you do if you notice that a patient’s record does not contain adequate documentation for medications?
• What type of training have you received about handling and storing medications? Please describe the training.
• How often do you receive training regarding your organization’s medication policies and procedures? Please describe the
training.

38
 Section 2. Tracer Exercises for Ambulatory Care

Continuity of Care Program-Specific Tracer Exercise

asked them to describe the systems in place to assure that

Exercise 2-8. Continuity of Care there was thorough and timely follow up and intervention as
Program-Specific Tracer in a Community needed. They reviewed several patient records with the sur-
Care Center veyor to focus on the initial referral through the final follow
up in the center. The surveyor asked them if they use a form
Summary: In the following scenario, a surveyor conducts a
or tool to document prescribed or recommended tests, and if
continuity of care program-specific tracer in a community care
they follow up by certain dates if reports are not received and
center, where she explores issues relating to the Priority Focus
so on. The nurse and physician both said that they did not
Areas of
use such a tool, but that they thought it might be useful
• Communication to implement.
• Assessment and Care/Services
• Medication Management The surveyor also asked the staff about patient education and
• Patient Safety if it is documented. Staff generally did not document educa-
tion, but they had educational brochures that they gave to
Scenario patients. The surveyor asked how staff would follow up with
The surveyor conducted this continuity of care tracer in a the patients to determine if they needed additional education
community ambulatory care center. She reviewed with staff and information and how they would know which brochures
records for patients seen in the clinic on that date. It was or information had been previously provided to the patients.
noted that the same physician does not see the same patient The nurse and physician both said this would only be known
on subsequent visits. The surveyor asked the physician to through discussion with the patients.
explain how he communicates the needs and follow-up
requirements for each patient from one physician to another.
In one patient record, it was noted by the physician on the
prior visit in the previous month that the patient was advised
to get a kidney ultrasound for right flank tenderness. On
review of the record, however, there was no record of whether
this had ever been done and no report was on file. The physi-
cian who had examined the patient on this date did not
inquire if it was ever done and also did not comment on the
right flank pain tenderness. It appeared that there was no oral
communication and the physician did not apparently read
the referral note from the prior visit.

Another patient record that was reviewed contained the dis-

charge medication list from the hospital. The physician who
examined the patient in the clinic on this date signed the list
from the hospital and did not rewrite the list of patient med-
ications on the center’s required medication order record.
The patient record also showed no evidence that the dis-
charge medications had been reconciled against the previous
list of medications.

The surveyor then met with the nurse and physician and
asked them about the documentation requirements, from
prescribing through follow-up of diagnostic studies. She

39
 Mock Tracer Workbook

Sample Tracer Questions

Questions for the Physician and Nurse:

• How are the needs and follow-up requirements for each patient communicated from one physician to another?
• How are the needs and follow-up requirements for each patient communicated from one nurse to another?
• What are the requirements for prescribing through follow-up of diagnostic studies and tests?
• What type of information from the previous visit do you look for when you review a patient’s record?
• How do you document in the patient’s record that certain procedures or medications have been prescribed?
• How will another physician know to follow up on the patient procedure or medication during the next visit?
• Please describe your medication reconciliation process and documentation requirements.
• What forms or tools do you use to follow up on tests and studies performed?
• How do you provide education and training to your patients?
• How is this patient education and training documented?
• How do you build on the patient education and follow-up if it was previously initiated by another caregiver?
• How often do you receive training on the organization’s documentation procedures?
• Please describe the type of training you receive regularly from the organization.
• How often are patient records reviewed to ensure that all staff are following documentation procedures? If so, who is
responsible for that review?
• How does your organization address or rectify staff members’ failure to provide adequate follow up for a patient? Please
describe the protocol that is followed.

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 Section 2. Tracer Exercises for Ambulatory Care

Tips for Conducting Tracers

in an Ambulatory Care Setting
Consider the following tips and strategies in conducting tracers in the ambulatory care setting:

• Hold practice sessions with staff. Hold a training session with staff and have them practice asking each
other sample questions such as the ones in this chapter to help them become more familiar with answering
questions and discussing their jobs with each other.

• Encourage participation. Encourage all staff to participate in the tracer process by training different staff to
conduct tracers. Use these scenarios as starting points, and encourage staff to use the sample questions to
get familiar with the process. As staff become more familiar with asking questions, recommend that the staff
begin to formulate their own questions

• Trace closed records. Use closed medical records as a starting point for tracer training activity. Using a
closed record can be an effective training approach to help staff get familiar with the process.

• Focus on issues of particular concern for ambulatory care settings. Consider those issues that are of
particular concern to patient safety, such as medication safety or continuity of care, and use those to plan spe-
cialized tracers. Use some of the sample questions included in these tracer scenarios to frame questions.

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42

Tracer Exercises for Behavioral Health Care
T
his section contains individual, systems-based, and
program-specific tracer exercises for behavioral
health care. Each exercise contains a scenario that
represents what might happen when a surveyor conducts that
type of tracer in a behavioral health care setting. Based on
the scenario provided, the exercise includes a list of sample
tracer questions that might be asked of the chosen tracer
individual or staff members involved in that individual’s care,
treatment or services. At the end of the section is a sidebar of
tips that staff can consider when conducting their own tracer
activities in a behavioral health care setting or organization.
Section 3
Please keep in mind that each tracer is unique; the questions
asked or behavioral health care programs/services visited
during a tracer will vary depending on the individual or
system chosen to follow. No two tracers are the same. There
is no way to know all of the questions that might be asked
during a tracer, because the possibilities are limitless. These
exercises are examples to show how that type of tracer can be
conducted and that put the sample questions into context.
Use these tracer scenarios and sample questions as educa-
tional or training tools for yourself and your staff, or use
them as a starting point to conducting your own tracers.
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 Mock Tracer Workbook
Individual Tracer Exercises for Behavioral Health Care
Exercise 3-1. Individual Tracer at a
Community Mental Health Center
Summary: In the following example, a surveyor conducts an
individual tracer at a community mental health center, where
he explores issues relating to the Priority Focus Areas of
• Assessment and Care/Services
• Medication Management
• Communication
• Information Management
Scenario
This county-funded community-based mental health center
treats individuals in the local community with a variety of
mental health needs, and its staff members include individual
and group therapists, clinical case managers, psychiatrists, and
nurses. The surveyor selected a female individual who had been
receiving treatment at the center for more than two years for
bipolar disorder. She participated in group therapy on a regular
basis and received medication monitoring and clinical case
management services.
The surveyor met with the clinical social worker who con-
ducted the emotional, behavioral, and psychological assessment
on the individual when she was first admitted to the center.
They discussed the social worker’s process for evaluating and
speaking with the individual in addition to the individual’s
involvement in the assessment process. The surveyor also asked
the social worker to describe the center’s policy on initial assess-
ment with regard to the time frames for assessment and
documentation. He then asked what kinds of evaluations are
included in the initial assessment, to which the social worker
responded that staff perform a mental health status and physical
health status screening.
After the initial comprehensive assessment was completed, the
social worker explained that the interdisciplinary team then met
to discuss findings and develop a plan of treatment. The sur-
veyor asked to meet with the staff involved to go over their
planning of treatment process. The therapist, social worker, and
clinical case worker met with the surveyor to discuss the chosen
individual tracer’s planning of treatment process. They
explained that, based on the initial assessment process, the
interdisciplinary team devises the best plan of treatment and
44
then completes the plan of treatment, which is signed by all the
staff involved.
The surveyor asked the facility’s psychiatrist to explain the
approach for medication management for an individual on psy-
chotropic medications. The psychiatrist explained that the
individual’s use of medication was assessed on admission to the
organization, and that the assessment factored into the plan of
treatment for the individual. The psychiatrist explained that he
worked closely with the individual to monitor the effectiveness
of her medication on an ongoing basis. The surveyor then asked
the nurse to discuss the medication reconciliation process and
what steps were taken to ensure medication safety.
Because the individual was at the center that day for an individ-
ual therapy session, the surveyor asked permission to speak with
her after her therapy session concluded. The individual con-
sented. To put the individual at ease, the surveyor explained
what The Joint Commission was doing at the organization. He
asked her about her participation in the assessment process and
asked her to explain some details in her plan of treatment. She
noted that she had been involved and appreciated how the staff
took time to talk to her about her treatment plan. The surveyor
asked the individual if she understood her plan of treatment
and the management of her symptoms. She said she felt com-
fortable with the process and felt that she had been treated with
dignity and respect.
The individual said that she was taking a new medication that
the center’s psychiatrist prescribed for her. She said that the psy-
chiatrist talked with her about the medication, how it should be
taken, and its possible side effects. She also received a brochure
that she and her clinical care manager read together. She said
she felt staff had done a good job educating her about the new
medication and its potential risks.
The surveyor noted that the individual was receiving employ-
ment services at the center by working part time in the center’s
food pantry. The surveyor asked the individual to describe her
work experience and how the center supported her employment
goals. The individual explained that adjusting to work had
taken time, but she appreciated the support she received at the
center and understood who she should talk to if she had any
issues. She also explained that she understood the scope of her
work duties and felt confident she could manage them.
 Section 3. Tracer Exercises for Behavioral Health Care

Sample Tracer Questions

Questions for the Clinical Social Worker:

• What is the process for assessing a new individual?
• What is the process for reassessing a returning individual?
• What is your process to assess an individual’s mental health status?
• What specific items or conditions do you check for during the initial assessment?
• What do you document during an initial assessment?
• What types of additional assessments might be conducted if indicated?
• Tell me how you screen new individuals for such things as nutrition.
• What is your medication reconciliation process?
• What kind of education do you provide to the individual at admission?
• What types of reassessments are conducted after the individual has been admitted? When do they take place?

Questions for the Clinical Case Manager:

• What is your organization’s process for developing a plan of treatment for a new individual? What about for a returning
individual?
• Which staff members are usually involved in developing a new individual’s plan of treatment?
• Which staff are members of the interdisciplinary team? How do they work together to help an individual?
• What is your process for continued assessment of an individual?
• Tell me how you document an individual’s plan of treatment.
• How do you update or change the individual’s plan of treatment over time?
• How does the individual’s plan of treatment address special circumstances, such as specific medication use?
• Do you offer supportive employment services at the center? If so, explain the process.

Questions for the Psychiatrist:

• What is the process for prescribing medications for an individual?
• How is the individual monitored for these medications over time?
• What is the protocol for changing an individual’s medication? How is the medication changes communicated to other
staff members?

Questions for the Tracer Individual:

• Please tell me how the center involved you in your plan of treatment.
• What do you think about your plan of treatment?
• Do you understand the treatment prescribed for you?
• What kind of medication are you currently taking? What are they for? What are their side effects?
• What kind of education has the center provided to you about your medications?
• Do you have any concerns about your medications?

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• Have you had your concerns about your plan of treatment addressed?
• What do you do when you have a concern about your safety or treatment?
• How have you been treated by staff members?
• What kind of support and assistance have you received with employment services?

46
 Section 3. Tracer Exercises for Behavioral Health Care

Exercise 3-2. Individual Tracer at a provide ongoing support to the youth, ensuring that the
Community-Based Group Home youth’s academic needs are met and to help the youth adjust
to the new school environment. Staff is available to go to the
Summary: In the following example, a surveyor conducts an school to offer support to the youth and her teachers at any
individual tracer at a community-based group home for time needed during the school day.
female adolescents, where she explores issues relating to the
Priority Focus Areas of The surveyor then spoke with the youth and asked her to
• Assessment and Care/Services describe her experience at the group home. The youth said
• Medication Management that she felt supported at the group home and had not had a
• Communication difficult time adjusting. The surveyor also asked the youth
• Information Management about her experiences in the local high school and what
support the group home staff provided to her. The youth
described the school as “OK,” but added she was still strug-
Scenario gling with making new friends. She said that she didn’t like
The surveyor selected a 16-year-old female individual who doing the homework, but she appreciated the additional
had been admitted to the group home three weeks prior for tutoring assistance she was receiving on her math.
problems with marijuana and alcohol use and aggressive
behavior toward parents and teachers. The admission was
based on court involvement. The surveyor began the tracer
by speaking with admissions staff to determine how the
youth was received into the home and what assessments took
place. The staff showed the surveyor the admission material
and explained how the information was shared with the staff
assessing and caring for the youth. The surveyor then asked
how the youth’s state case worker and probation officer were
involved in the intake, assessment, and planning of
care processes.

The surveyor then spoke with the staff member who com-
pleted the initial physical health assessment. She explained
the home’s policy for setting up an appointment at the local
health clinic for a comprehensive medical history within a
specific time frame and for a physical examination by a pedi-
atrician within seven days of admission. The surveyor asked
what other staff members were involved in the screening and
assessment process and was told that a social worker or coun-
selor conducted an emotional/behavioral/psychosocial
assessment. Staff explained that within the initial screening/
assessment were triggers to determine if additional assess-
ments were warranted, such as a mental health status
evaluation or a nutritional, educational, or legal assessment.

In the case of this youth’s assessment, the surveyor noted that

the tracer individual was attending the local public high
school. The surveyor asked the staff to explain the process to
help the youth enter the school and what therapeutic support
for the youth’s educational or academic needs was provided
by the group home staff. The staff explained that they

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 Mock Tracer Workbook

Sample Tracer Questions

Questions for Admissions Staff:

• What is your process for admitting a new youth into the program?
• Tell me about your initial screening process.
• What triggers do you have in place to determine special assessments?
• How do you involve parents or guardians in the initial assessment and screening process?
• How is an individual’s information documented?
• How is an individual’s information shared with other staff members?

Questions for Multidisciplinary Treatment Team Members:

• What is your process to complete and document initial assessments?
• What is the process for creating an individual’s plan of treatment?
• Which staff members are involved in developing an individual’s plan of treatment?
• How do you involve the youth in the planning to treatment process?
• How is the individual’s family or guardian involved in the planning of treatment process?
• How is an individual’s plan of treatment communicated to other staff?
• What kind of education do you provide to the youths on involvement in their safety and care?
• What is your process for altering or changing a youth’s plan of treatment?
• How does the staff support the youth and public school staff in meeting the youth’s academic needs?

Questions for the Youth Chosen to Trace:

• Can you describe your experience at the group home?
• What kind of explanations did the staff provide to you when you were admitted to the group home?
• What support does the staff provide to you with your schoolwork and attending the high school?
• What do you do when there is a problem with your experience at the high school?
• Were you provided with information about any rules for residents of the group home? Is so, tell me about some of
them.

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Exercise 3-3. Individual Tracer at a
Group Home
Summary: In the following example, a surveyor conducts an
individual tracer at a group home for persons with intellectual
disabilities, where he explores issues relating to the Priority
Focus Areas of
• Staffing, Orientation and Training
• Assessment and Care/Services
• Rights and Ethics
Scenario
This tracer was conducted at a group home for persons with
intellectual disabilities. Residents were adults and they
received employment services as part of their residency. The
surveyor began the tracer by speaking with home support
staff, including a social worker and a home director. He
asked them how individuals were admitted into the home
and what they do to ensure an individual’s smooth transition.
The director explained that newly admitted individuals are
carefully assessed for disabilities issues and are helped to
adapt to the new home. He also explained that individuals in
the home are provided with employment services, whereby
the home helps provide work placement and supports the
employee with work preparation training and ongoing
skills development.
The surveyor then selected an individual residing at the
home to trace. He selected a 28-year-old woman with Down
syndrome who had been living at the home for three years.
The individual had also been working at a local supermarket
as a grocery bagger, a position that the home helped secure
for her. The surveyor asked support staff and the social
worker to describe the process they took to determine job
placement for the individual and how they had helped her
with any necessary skills development. The social worker
explained that she had performed a careful skills assessment
of the individual when she began staying at the home and
had worked closely with the individual to ensure she was
comfortable with the proposed placement. The social worker
stated that the individual had been in the same position for
the previous 2 1/2 years and had not reported any dissatisfac-
tion with the position.
The social worker explained that she met with the individual
on a regular basis to ensure that she was doing well in the
Section 3. Tracer Exercises for Behavioral Health Care
home and benefiting from the work experience. She added
that six months prior the individual expressed dissatisfaction
with her new roommate in the home because the roommate
acted aggressive toward her. Staff then fixed the problem with
the living arrangements by finding the roommate another
place to stay. The social worker added that the tracer individ-
ual was much happier and more settled once the housing
issue was resolved.
The surveyor asked the social worker about her work load
and training experiences. The social worker expressed that
the home provided ongoing training and professional devel-
opment for her and that although the work load was at times
heavy, she did not feel overwhelmed by it. She also expressed
satisfaction with the ability of support staff in the home and
that staff had a good work rapport with each other.
The surveyor then received permission from the individual to
speak about her experiences in the group home. The surveyor
asked her how her experience at the home had been and if he
had any concerns about living there. The individual
responded she had many good friends at the home and loved
her work. She added that she was hoping to work in a restau-
rant someday because she loved to cook for everyone in the
home. The surveyor asked her what kind of training and
skills development she received and asked her about any
responsibilities she had in the home. The surveyor also asked
the individual to tell him about any difficult experiences she
had experienced in the home and how she felt about the
group home support staff assisting with conflict resolution.
The individual said that she had some problems with a new
roommate, but the staff helped them talk about their differ-
ences. When that did not help, the staff helped to place them
with other roommates.
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 Mock Tracer Workbook

Sample Tracer Questions

Questions for the Group Home Director and Support Staff:

• What assessment and admission process do you perform for new individuals coming to the group home?
• How do you help new individuals adjust to the group home living environment?
For leaders:
– What kind of training and orientation process do you provide to new staff at the group home?
– How do you support staff and provide ongoing training?
For staff:
– What kind of training and orientation did you receive when you started at the group home?
– What kind of continuing education do you receive?
– Do you feel your training and learning needs are met?
• What process do you have in place to help support individuals with their employment and skills training?
• How do you support individuals once they have employment?
• What kind of social environment do you provide in the group home? How do you meet social needs of individuals in
the group home?
• What process do you follow to resolve any conflicts?
• How do you ensure safety in the group home’s environment?
• How do you ensure safety within the group home’s neighborhood?

Questions for the Social Worker:

• What kind of assessment do you perform for newly admitted individuals to the group home?
• How do you monitor and assess ongoing adjustment and living within the group home?
• What is your process to help individuals adjust to the home?

Questions for the Tracer Individual:

• Please describe how your experience has been in the group home.
• What kind of support do you receive from the staff?
• Can you describe your work experience and how you receive work training from the group home and from your place
of employment?
• What do you do if there is a problem in the group home? To whom should you speak?

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Data Use System Tracer Exercise for Behavioral Health Care
Exercise 3-4. Data Use System Tracer in
a Community Mental Health Center
Summary: In the following example, a surveyor conducts a
data use system tracer in a community mental health center,
where she explores issues relating to the Priority Focus Areas of
• Staffing
• Orientation and Training
• Quality Improvement and Expertise/Activities
• Rights and Ethics
Scenario
The surveyor conducted a data use system tracer at a busy
urban mental health center that serves individuals in a pre-
dominantly lower income community of a large city. She
invited the performance improvement director, who was also
a therapist at the center, and any available members of the
performance improvement committee to participate in the
discussion. The surveyor began the discussion by asking the
participants to describe any recent improvement efforts that
they had made at the organization in relation to ensuring
individual safety.
The performance improvement director shared that the com-
mittee, of which she is the coordinator, had recently
conducted a failure mode and effects analysis (FMEA) on its
rights and ethics processes, particularly in relation to privacy
issues among individuals. The committee members had
found that there was a poor satisfaction rating among indi-
viduals and staff in relation to individual privacy. The mental
health center’s reception area was one large room, and during
the busiest times the noise in the reception room made it so
that staff felt they needed to almost shout to call an individ-
ual into a session or to discuss any appointment issues with
the individuals. Also due to the busy nature of the center,
appointments often ran late, leaving individuals waiting a
long time in the reception area. The surveyor asked the com-
mittee what kind of data it had collected on this issue. Staff
members said that individual and staff satisfaction surveys
had reported poor results, and anecdotally reported concerns
from individuals to staff had also been factored into the
improvement focus.
The committee reported that it opted to introduce a few
changes to the reception area in an attempt to improve
Section 3. Tracer Exercises for Behavioral Health Care
privacy. Rather than calling out full individual names, staff
asked individuals to sign in and provided them with a
number to be called out when it was time for their appoint-
ment. The committee also decided to work with reception
staff on communicating with individuals when appointments
were running behind. These changes had only been in place
for approximately three months, but preliminary survey data
showed an improvement in individual and staff satisfaction.
The surveyor asked the team what kind of process was in
place to prioritize the selection of an improvement effort.
The performance improvement director explained that, as a
resource-limited center, the committee could focus on one or
two improvement efforts at a time, and its first priority had
been based on the poorest results in the most recently col-
lected individual and staff satisfaction survey. The team
admitted that, beyond this consideration, there was no spe-
cific methodology behind what put one particular
improvement effort ahead of another. The performance
improvement director explained that the team’s next area of
focused improvement was education.
The surveyor took time to ask the performance improvement
director about how she managed her performance improve-
ment work and training in light of her additional work load
as a center therapist. The performance improvement director
was new to the position, having only just filled it six months
before when the center implemented budgetary cutbacks.
The previous full-time performance improvement director
left, but the center decided not to fill this position. Instead,
center leaders decided to assign the performance improve-
ment director duties to another staff member who had some
background in performance improvement–related work. The
performance improvement director explained that she had
worked on some performance improvement initiatives in her
previous position and had attended a number of seminars on
data collection and analysis. She also used online resources
through a number of national organizations that support
behavioral health center organizations’ performance improve-
ment work, but she sometimes felt stressed trying to manage
the responsibilities of the performance improvement director
and center therapist. She stated that she did not always feel
well-trained on all that a performance improvement director
is asked to do, indicating that the FMEA the team had just
completed was also her first experience conducting one. The
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surveyor suggested that the performance improvement direc-
tor might want to speak to the center director about receiving
additional training on performance improvement.
The surveyor concluded the tracer by speaking with the
center’s director. She asked the center director what the
staffing and training process was for a position like the per-
formance improvement director. The director explained the
decision, based on budgetary limitations, to assign the role of
performance improvement director to a staff therapist with
some performance improvement background. The surveyor
asked the director to share what kind of additional training
and support the center was providing to the performance
improvement director. The director explained that the center
was planning to increase the funding for performance
improvement training and that she was pursuing ways for the
performance improvement director to collaborate with other
local behavioral health center organizations for additional
training and resources on the performance
improvement work.

Sample Tracer Questions

Questions for the Performance Improvement Director:

• What kind of training and experience do you have regarding performance improvement?
• How do you stay up to date on performance improvement issues?
• How do you educate other staff members about performance improvement?
• What is your role as performance improvement director?
• What kind of data have you been collecting at the center?
• How do you collect the data?
• How do you analyze and study the data?
• What is your role on the performance improvement committee?
• What process do you apply to prioritize improvement efforts?
• What are your long-term goals for the performance improvement committee? What is your plan to meet those
long-term goals?

Questions for the Performance Improvement Committee:

• How often does your committee meet?
• What is the goal and focus of the committee?
• What is your individual role on the committee?
• What kind of proactive improvement planning is the committee working on? If so, please describe it to me.
• What topics or areas have you focused your recent attention on?
• How did you choose these topics or areas for improvement?
• How do you involve other staff members in the performance improvement initiative?
• How do you measure progress when you launch a new improvement initiative?
• How do you educate staff members about an improvement initiative?
• What recent performance improvement accomplishments have you made? How did you measure and conclude the
accomplishment?

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Medication Management System Tracer Exercise for
Behavioral Health Care
Exercise 3-5. Medication Management
Tracer in an Opioid Treatment Program
Summary: In the following example, a surveyor conducts a
medication management system tracer in an opioid treatment
program, where she explores issues relating to the Priority
Focus Areas of
• Medication Management
• Orientation and Training
• Quality Improvement and Expertise/Activities
Scenario
This system tracer was conducted at an opioid treatment
program. The surveyor asked to meet with the clinical direc-
tor, nursing staff, and the medical director. She asked them
what the medication management process was for the
program. The medical director and nurse stated that the
program works closely with patients to ensure that medica-
tion reconciliation is performed and that the medication
treatment is safely provided to patients.
The surveyor asked the medical director and nurse to explain
the organization’s medication reconciliation process. The
medical director and nurse explained that at admission, each
patient is asked to provide a list of medications used—
including over-the-counter, herbal remedies, and nutritional
supplements. The surveyor asked the nurse to describe how
staff updates the list. The nurse replied that staff asks each
patient during each visit if anything has changed since the
last time the list was updated.
The surveyor asked the clinical director how she stays
apprised of any new developments in medication safety
issues. The clinical director explained that she regularly
checks the major professional, state, and federal agencies for
updates and is on mailing lists for medication safety updates.
She also explained that during monthly staff training ses-
sions, she sets asides time to discuss any safety issues,
including medication safety concerns.
The surveyor then toured the clinic, asking the nurse to show
her where the methadone is stored and how the dispensing
process takes place. She observed the storage area for the
methadone and noted safe storage practices. She asked who
Section 3. Tracer Exercises for Behavioral Health Care
has access to these areas, and the nurse explained that she has
access along with the medical director, clinic director, and
other nursing staff. The surveyor asked what kind of safe
medication education is communicated to the patients and
how staff provides ongoing education. The medical director
and nurse explained how, during initial assessment and
ongoing assessment, the medical director and nursing staff
closely monitor medications and communicate safe practices
to the patient.
The surveyor noticed that the medication storage room con-
tained, in addition to liquid and tablet-form methadone and
sample over-the-counter medications such as antidepressants.
The surveyor asked the nurse what the additional medication
was used for. The nurse explained that sometimes staffs are
the sole source of care for some patients. The surveyor also
noted the presence of automatic dispensing equipment in the
medication room. The nurse explained that the program was
moving to an electronic system to help administer the liquid
doses to patients. The surveyor asked the nurse to show how
the process worked and what labeling system was used. The
nurse explained that staff was being trained on the computer
system that was linked to the dispensing system and that was
intended to ensure accurate dosing to patients.
The surveyor also asked the nurse how staff ensures that
take-home medications are labeled correctly. The nurse
demonstrated the labeling system on the computer and
showed how she labels each set of medications that go home
with the patient in conformance with the medication label
protocols.
The surveyor then asked the nurse to show her how staff dis-
poses of medications. The nurse explained that it was rare
that they had to dispose of medication, but that if staff ever
had any to dispose of, they were collected in a separate con-
tainer and placed in a Drug Enforcement Agency
(DEA)-approved safe in the dosing room, which the nurse
showed to the surveyor. She wasn’t sure what happened to
the disposed medication after that, but she offered to call the
medical director to further explain the procedure. The
medical director then joined them and explained additional
details, such as how the medication is disposed of in the pres-
ence of a DEA agent or state authority.
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The following morning, the surveyor returned at 5:30 A.M. to patients and undertook appropriate measures to correctly
to observe methadone dosing to patients. The surveyor saw identify the patient receiving the medication by asking for
that the nurse dosed and administered medication correctly two identifiers.

Sample Tracer Questions

Questions for the Clinical Director:

• What are the program’s policy and procedure for medication management?
• Please describe your organization’s medication reconciliation process.
• What is the medication management process for the opioid treatment program?
• How is the medication process monitored for the opioid treatment program?
• What kind of medication-related data does your organization collect?
• How do you orient and train new staff on your medication management practices?
• What kind of patient education do you provide about medication?
• How do you verify that the education was understood?
• What kind of automated systems do you use to track dosing and administration of medication? How have you trained
staff on this process?
• What is your process for the safe, legal disposal of methadone?
• Do you store any other medications in the dosing room? If so, please explain what they are and why they are there.
• What process do you follow to ensure they are safely stored and labeled?

Questions for the Medical Director:

• Please show me where the methadone is stored.
• Who has access to the methadone?
• What is your medication dispensing process?
• How do you keep up to date on safe medication practices?
• If you use an automated system, please demonstrate it and explain how it works.
• How were you educated on the automated system?
• What kind of improvements or changes have you helped implement as part of a quality improvement initiative in rela-
tion to dosing?
• How are you involved in educating patients about methadone?

Questions for the Nurse:

• How do you assess a patient for medication safety?
• Tell me how you perform medication reconciliation.
• How is the medication reconciliation list updated? By whom?
• How do you educate patients about medications?
• How do you identify patients before dispensing medications?
• What happens if you need to dispose of methadone? Explain the disposal process.

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 Section 3. Tracer Exercises for Behavioral Health Care

Questions for the Patient:

• What is your experience of treatment here at the program? Describe the experience.
• How does staff ensure you receive the correct dosing?
• How does staff identify you when they are giving you medication?
• Do you think the program is meeting your needs?
• If you have a concern about your treatment, how do you report it?

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Foster Care Program-Specific Tracer Exercise

Exercise 3-6. Foster Care Program-
Specific Tracer in a Foster Care Agency
Summary: In the following example, a surveyor conducts a
tracer in a foster care agency, where he explores issues relating
to the Priority Focus Areas of
• Assessment and Care/Services
• Communication
• Orientation and Training
Scenario
The tracer took place in a foster care agency. During an
earlier data management system tracer, the surveyor had
learned that according to its own data collection and bench-
marking, the agency had been experiencing an increase in
children moving to different foster homes within the agency.
Three children had moved to two or more foster homes
within 12 months at this particular agency. As a result, the
surveyor opted to conduct a foster care program-specific
tracer. The surveyor asked to meet with the foster care direc-
tor and staff about their foster care placement process.
The surveyor selected the record of a child who had under-
gone three changes in foster homes to trace with the staff. He
first asked the director to describe the process that the agency
follows when matching a child to a foster home. The director
reviewed with the surveyor the criteria developed by the
agency to match a child with a foster home/family.
in the matching process. He also suggested that the organiza-
tion apply tracer methodology to help ascertain how well the
current process worked in order to help determine what
changes may need to be made.
The surveyor then talked with a foster care case worker on
staff at the agency. He asked her about her case load and the
average amount of time she works on a case. She said that she
has a large case load due to staffing cutbacks made in the pre-
vious year. She said her goal is to find a foster family and
foster child that would make a good fit with each other and
also to follow the criteria that the agency has set for foster
placement. The surveyor asked to review that criteria list. The
case worker was asked about how she handles a case in which
a child must be taken from one home and placed in another.
The case worker described how the child is placed in a tem-
porary safe place until another foster care home can be found
for him or her. She also described how her agency provides
ongoing training each year on handling the stress of the job;
talking with children, especially those with special emotional
needs; and interviewing potential foster parents as part of the
organization’s screening process. She indicated that she
thought that if she had more time to support the foster child
and foster family, then she could have saved the placement.

The surveyor asked if the agency had conducted any proac-

tive work to try and determine what the cause of the multiple
foster homes might be. The director said that they were plan-
ning to conduct a failure modes and effects analysis (FMEA)
on multiple foster home placements. The surveyor asked the
director what kinds of assessments are performed on the child
and how the assessments factor into effective planning and
placement. He also asked what kind of skills training and
development were provided to foster home parents. The
director shared the current process and procedure for both
planning and placement and skills training, and noted that
the FMEA would be carefully studying the entire system to
see what improvements could be made.

The surveyor recommended that the agency focus on study-

ing what systems and process issues may be causing problems

56
 Section 3. Tracer Exercises for Behavioral Health Care

Sample Tracer Questions

Questions for the Foster Care Agency Director:

• Describe your process for receiving a new foster care child.
• What is your process for assessing a child?
• Tell me how you place a foster child.
• How effective is your process to prevent multiple placements?
• What do you do to ensure the best placement?
• How do you verify that you are ensuring effective continuity of foster care?
• What is your agency’s process for screening potential foster parents?
• Tell me about your skills training process for foster parents.
• What type of ongoing support, if any, is provided to foster parents?

Questions for the Foster Care Case Worker:

• How many foster care cases do you handle at one time? How many cases in one year?
• What type of assessments or screening is done to provide the child with what he or she needs?
• What type of screening is done for potential foster parents?
• How do the foster child and foster family get acquainted with each other?
• What type of follow-up is done when a child is placed with a foster family?
• What is the procedure when you need to place a foster child in another home?
• What type of analysis and data collection is performed for examining a case with multiple placements?
• What kind of ongoing training or education do you receive that helps you do your job?

Questions for the Foster Care Family:

• Describe how you are trained to be foster parents.
• What happens when you are about to receive a new child?
• How do you interact with the agency?
• Describe the kind of support that you receive in your work from the agency?
• What happens when there is an issue or problem in your ability to care for a child?

Questions for the Foster Child:

• What happened when you first came to the foster home?
• How did you get to know your foster parents and family?
• Can you describe what your school is like?
• What kind of support or help to do receive with your school work?

57
 Mock Tracer Workbook

Elopement Program-Specific Tracer Exercise

Exercise 3-7. Elopement Program-
Specific Tracer at a Residential Youth
Program
Summary: In the following example, a surveyor conducts an
elopement program-specific tracer in a youth program, where he
explores issues relating to the Priority Focus Areas of
• Assessment and Care/Services
• Communication
• Orientation and Training
Scenario
This elopement program-specific tracer was conducted at a
youth residential program treating youths with addiction and
behavioral problems. The surveyor had learned of a youth
who had been designated as an elopement risk while he con-
ducted an individual tracer earlier during the on-site survey.
The surveyor asked to speak with the program director,
counselors, and security staff to discuss their process to
prevent and deal with elopement at the facility.
The surveyor asked the staff to describe the elopement pre-
vention and response process. They explained that at
admission a youth is assessed for elopement risk. The sur-
veyor asked staff to elaborate on how they respond to youth
at risk of elopement. The director explained that the staff
increase their frequency of checking on the youth and ensure
that planning of treatment includes a response to the elope-
ment risk. The staff also described how their focus is on
designing appropriate therapeutic interventions into the plan
of treatment for youth at risk for elopement.
supervision of youth with this type of risk. One staff
member, who was new to the organization, said he had not
yet been trained in this area. Another staff member indicated
that this staff member was still in the orientation phase, was
assigned to a trained staff member, and would not be without
supervision until fully oriented, trained, and deemed
competent.
A veteran staff member described how she receives ongoing
training regarding the organization’s elopement prevention
and response process. She also described how earlier that year
she discovered an individual missing from her room and
immediately followed protocol to notify staff. A search of the
building and grounds was conducted, and the individual was
found within the hour hiding in a tree on the property. The
staff member also described how the elopement was docu-
mented and a review process conducted to determine how
the incident occurred and what could be done to prevent it
from happening in the future. Apparently, the individual
walked away from a designated recreational area when multi-
ple staff members tended to residents arguing. The veteran
staff member also described how she is working with a new
colleague to help familiarize him with the rules and other
procedures for at-risk individuals.

The surveyor asked for the clinical social worker who had
designated the youth as being at high elopement risk to join
the discussion. The surveyor asked the social worker to
describe what triggers in the assessment indicated the youth
as an elopement risk. He then asked what happens once the
elopement risk is established. The social worker explained
that elopement risk is communicated to staff for planning of
care and prevention purposes and that the social worker
herself conducts the therapy sessions.

The surveyor then went to visit with the youth’s care and
teaching staff, who asked how staff members were trained in

58
 Section 3. Tracer Exercises for Behavioral Health Care

Sample Tracer Questions

Questions for the Program Director:

• What is your process to prevent or reduce the incidence of elopement?
• Have you performed any proactive reduction work on this issue, such as an FMEA?
• What improvements have been made as a result of an FMEA or other proactive work?
• What protocol is established in the event that an elopement occurs?
• How are new staff oriented and trained about elopement risk and how to respond to youth at risk?
• What type of ongoing training is provided to veteran staff regarding youth who are at risk of elopement?

Questions for the Clinical Social Worker:

• How do you assess a youth for elopement?
• What do you do once a youth is determined to be at risk?
• What kinds of considerations are involved in planning of care for youth deemed to be at elopement risk?
• How do you respond in the event of a youth attempting to elope?
• What measures do you put in place once you know that a youth is at high risk for elopement?
• What type of ongoing training do you receive to help you work with youth at risk or high risk of elopement?
• Have you ever been directly involved with a youth who eloped? If so, describe what happened.

Questions for Direct Care Staff:

• How do you know that a youth is at risk or high risk of elopement?
• How do you handle an individual who is at risk or high risk of elopement?
• How many individuals do you supervise at any one time?
• What training and orientation did you receive on dealing with elopement?
• Have you ever been directly involved with a youth who eloped? If so, describe what happened.
• What is the protocol for handling a youth who tried to elope but was brought back inside the facility?

Questions for the Youth Involved in Elopement:

• Can you describe what made you want to leave the facility?
• Do you understand why the program puts measures to keep you in the program and keep you safe?
• What did the program do to help you when you eloped?

59
 Mock Tracer Workbook

Suicide Prevention Program-Specific Tracer Exercise

Exercise 3-8. Suicide Prevention
Program-Specific Tracer at a Residential
Program
Summary: In the following example, a surveyor conducts a
suicide prevention program-specific tracer at a residential
program, where she explores issues relating to the Priority Focus
Areas of
• Assessment and Care/Services
• Patient Safety
• Orientation and Training
Scenario
The surveyor conducted a suicide prevention program-spe-
cific tracer at a residential program. The surveyor interviewed
staff about their efforts to prevent suicide and to assess resi-
dents for suicide risk. She asked them about their initial
assessment and ongoing risk assessments.
The surveyor then traced an individual who had been
assessed as at risk for suicide. She asked staff to review the
individual’s file with her, starting with the initial assessment.
It was indicated that the individual had been admitted for
severe depression, alcohol addiction, and for threatening to
harm herself. The individual was admitted to the program
several weeks earlier. This was a 43-year-old individual with a
history of depression and no prior known suicide attempt.
This tracer took place on the third day after the individual’s
admission. The surveyor asked the staff how they assessed the
individual and how they were continuing to assess her after
she was admitted. Staff members said that she seemed quiet,
but did participate in therapy and group sessions when
called on.
hotline as part of discharge planning. The surveyor asked
staff to show her documentation regarding this education.
The staff said they provided brochures, education, and phone
numbers for a crisis hotline, but there was no evidence of
documentation that education was provided or that informa-
tion was provided to the individual or her family.
The surveyor then went to talk with admissions staff to
inquire about the initial assessment, care, and treatment of
this individual when she was admitted. Staff explained that
they assessed the individual as being a suicide risk based on
her responses to questions about harming herself and based
on information from her husband, who said that she had
been expressing suicidal statements.
The surveyor asked to see the suicide assessment, which
included questions such as “Do you feel like hurting your-
self?” In addition to asking how the assessment process was
adopted by the organization, the surveyor also discussed the
protocol they would follow if a resident seemed at risk for
suicide. The staff described that they received training on the
organization’s protocol for handling suicide residents during
initial orientation and during an all-day seminar provided
annually. Staff also received some additional print materials
to read after the seminar. However, only trained staff con-
ducted suicide screening and qualified mental health
professionals conducted suicide assessments, per the organiza-
tion’s policy.

The surveyor asked the staff to review the individual’s plan of

treatment and to talk about how the plan was developed and
how often it was revised. They were planning to discharge the
individual in about one week, to be followed by her private
psychiatrist and outpatient group sessions. The surveyor
asked staff about whether the woman’s family has been
involved in the plan of treatment process or in her ongoing
treatment. The surveyor also asked staff if they provided or
referred the family members to a crisis hotline and if they
educated the individuals and their families about access to a

60
 Section 3. Tracer Exercises for Behavioral Health Care

Sample Tracer Questions

Questions for Staff in the Residential Program:

• How do you assess individuals who might be at risk for suicide?
• Has this individual expressed any further suicidal statements?
• How are you addressing the immediate safety needs of this individual?
• How are you addressing the long-term safety needs for this individual?
• If this is not the most appropriate setting for the safety needs of this individual, how would an individual’s needs best
be met?
• Do you provide information regarding crisis hotlines to individuals and their families?
• How do you develop a plan of treatment?
• Which staff members are involved in developing the plan of treatment?
• How is the plan of treatment communicated to the individual? And to other staff members?
• How are the individual’s family or loved ones involved in the plan of treatment process?

Questions for Admissions Staff:

• How do you screen individuals who might be at risk for suicide?
• What is the protocol if you determine that an individual is at risk for suicide?
• How do you protect that individual who might be at risk for suicide when they arrive at the program?
• How do you protect other individuals and visitors to the residential center?
• How do you protect staff members at the center?
• How are staff members trained to assess and care for individuals who might be at risk for suicide?
• What type of additional training or education would you like to receive to help you screen and care for individuals at
risk of suicide during admission?

61
 Mock Tracer Workbook

Tips for Conducting Tracers

in a Behavioral Health Care Setting

Consider the following tips and strategies in conducting tracers in the behavioral health care setting:

• Hold training sessions for the sake of practice. Hold a training session with staff and have them practice
asking each other sample questions such as the ones in this chapter to help them become more familiar with
answering questions and discussing their jobs with each other.

• Empower all staff. Encourage all staff to participate in the tracer process by having different staff trained on
and used to conducting tracers. Use these scenarios as starting points, and encourage staff to use the sample
questions to get familiar with the process.

• Pinpoint tracer subject selection. Use these example tracers for selecting individuals based on an organiza-
tion’s mission, scope of care, treatment or services, and populations served.

• Focus on issues of particular concern for behavioral health care settings. Consider those issues that are
of particular concern to behavioral health care individual safety, such as elopement risk, suicide prevention, or
violence prevention, and use those to plan specialized tracers. In addition, each behavioral heath care setting
is different and faces its own safety challenges. Facility-based institutions, community-based or 24-hour care
settings, and in-home services should all consider their particular settings and their related safety concerns
when planning tracers. Use some of the sample questions included in these tracer scenarios to frame
questions.

• Use a closed clinical case record for tracer practice. Use closed clinical case records as a starting point
for tracer training activity. Use a closed record as a training approach to help familiarize staff with tracers.

62

Tracer Exercises for Home Care
T
his section contains individual, systems-based, and
program-specific tracer exercises for home care pro-
grams. Each exercise contains a scenario that
represents what might happen when a surveyor conducts that
type of tracer in a home care setting. Based on the scenario
provided, the exercise includes a list of sample tracer ques-
tions that might be asked of the chosen tracer patient or staff
members involved in that patient’s care or treatment. At the
end of the section is a sidebar of tips that staff can consider
when conducting their own tracer activities in home care
programs or settings.
Section 4
Please keep in mind that each tracer is unique; the questions
asked or home care areas visited during a tracer will vary
depending on the patient or system chosen to follow. No two
tracers are the same. There is no way to know all of the ques-
tions that might be asked during a tracer, because the
possibilities are limitless. These exercises are examples to
show how that type of tracer can be conducted and to put
the sample questions into context. Use these tracer scenarios
and sample questions as educational or training tools for
yourself and your staff, or use them as a starting point to
conducting your own tracers.
63
 Mock Tracer Workbook
Individual Tracer Exercises for Home Care
Exercise 4-1. Individual Tracer at a Home
Health Agency
Summary: In the following scenario, a surveyor conducts an
individual tracer at a home health agency, where she explores
issues relating to the Priority Focus Areas of
• Communication
• Assessment and Care/Services
• Infection Control
• Medication Management
Scenario
The surveyor conducted a tracer at a home health care
agency that provided home health, personal care, and home
medical equipment services to its patients. Patients were
often referred into the agency from several area hospitals. The
surveyor selected a 66-year-old female patient recently dis-
charged from the hospital to home and recovering from knee
surgery. The patient also had Type 2 diabetes.
The home agency had already been to the patient’s home the
week before to conduct an initial assessment and evaluation
of the patient. The patient was receiving wound care and per-
sonal care support from the agency. The same nurse who
conducted the initial assessment was going to visit the patient
on this day, and after the agency called and secured permis-
sion from the patient for the surveyor to accompany the
nurse on the home visit, they headed to the patient’s home, a
two-story house. The nurse explained to the surveyor that the
patient lived at home with her husband, who was her
primary caregiver. Her husband was 68 years old and retired
and suffered from arthritis.
On arrival at the home, the patient’s husband welcomed the
nurse and surveyor into the home and escorted them into the
front room, where the patient was resting on the couch.
There was a walking stick within arm’s reach of the patient.
As the nurse prepared for her visit, the surveyor asked the
patient and her husband for permission to speak with them
for a short while. She explained to them that she was a sur-
veyor from The Joint Commission and that she was
interested in hearing what the patient and her husband felt
about their care experience in the organization.
64
The patient stated that she had been very satisfied with the
quality of care delivered and that the agency had been very
good at contacting the patient and her husband and at caring
for her. She said that she already had two visits from nurses
since being admitted to care in the past week and that a
home health aid had been to visit already that morning to
help with bathing needs.
The surveyor asked if the patient and her husband had
received any patient safety education, particularly in relation
to falls. The patient indicated that during the first visit the
admitting nurse had taken time to tour the home with the
patient’s husband and pointed out the elements in the envi-
ronment that needed changing to keep the home safe from
falls. The husband explained that his son had come to the
home and helped him make some changes, as his arthritis
prevented him from doing some things.
The surveyor then asked if the patient and her husband knew
what to do if they needed to reach the agency during evening
or weekend hours. The husband brought over the folder the
agency provided for the surveyor to review. It included
contact information, along with other pertinent information
about wound care, falls risk, safety in the home, and the care
plan for the patient. The surveyor asked the patient if the
nursing assessment had included any medication reconcilia-
tion. The patient said that it had but that the medications list
was provided to the patient at a later date, so she could not
recall now where it had been placed. The nurse said she
would arrange to send another list over to them and advised
them to store it with the other material in the folder.
The nurse then performed her visit with the patient. She
employed observable good hand hygiene practices by using
hand gel. She then donned gloves and provided wound care
treatment for the patient. While she was assessing and treat-
ing the wound, the nurse asked the patient if she was
experiencing any pain or any other discomfort from the
wound or medications. The patient said that she had felt
some pain but took some over-the-counter medications,
which seemed to help. The patient’s husband also noted that
she had been instructed to use some prescription pain med-
ication as needed.
 Section 4. Tracer Exercises for Home Care

When the surveyor and nurse returned to the agency, the sur-
veyor asked to speak with the nurse and agency director
about the medication reconciliation process. She asked when
the assessment takes place and when the patient is provided
with a list of medications used. The director explained that
the process is for the nurse to prepare a medication reconcili-
ation list after she completes her initial assessment notes and
that the list is sent to the patient at that time, whereas the
folder of information is prepared in advance and given to the
patient on admission.

Sample Tracer Questions

Questions for the Nurse:

• Please describe your assessment process.
• What kind of falls risk assessment do you perform for a patient in this condition?
• What triggers do you have in your process to alert yourself or other care providers about risk factors, such as falls or
polypharmacy?
• What initial information and education do you provide to a patient during the first visit?
• How do you educate patients and families about their care?
• How do you document each home visit?
• How do you assess the home for safety risks?
– If you see any risks, how do you work with the patient on this issue?
• What is your medication reconciliation process?
– How do you provide this information to the patient?
– Where is the medication reconciliation stored in the record?

Questions for the Patient and Family:

• What kind of patient safety instruction has the agency provided to you?
• Do you know what to do if you have a concern or complaint about your care?
• Do you understand what risks there are for safety in the home?
– How were you educated about these risks?
– Have you been able to ask any questions?
• Are you satisfied with your care?
• As this is a two-story home, where are you staying in your home while you are recuperating? Are you getting assistance?
• Do you know what to do in the event that you have to contact the agency during evening and weekend hours?

65
 Mock Tracer Workbook
Exercise 4-2. Individual Tracer at a Home
Medical Equipment Organization
Summary: In the following scenario, a surveyor conducts an
individual tracer at home medical equipment organization,
where he explores issues relating to the Priority Focus Areas of
• Communication
• Patient Safety
• Orientation and Training
• Infection Control
• Equipment Use
Scenario
The surveyor conducted this individual tracer at a small
organization that provides durable home medical equipment
to its customers. This was an initial survey for the organiza-
tion, which provides walkers and beds to patients in their
homes. Sales representatives set up the equipment in patients’
homes. The sales representatives were responsible for their
patients from start to finish and also performed sales calls to
physician offices and physical therapy departments.
The organization’s leaders stated that their mission was to
provide the best care possible to their patients. They related
that many of their competitors were mailing or delivering the
equipment to the patient without any home visit or face-to-
face instruction. They attributed much of their success to
their policy of patient education and follow-up. Also, their
referral sources appreciated having one person to go to with
any concerns or issues.
During the orientation to the organization, the surveyor was
shown information on the kinds of patients that the organi-
zation tends to care for, typically geriatric patients with poor
ambulation. Many of these patients appeared to be at high
risk for falls based on their underlying medical conditions.
The surveyor selected the tracer patient based on a call from
this patient indicating that her bed was malfunctioning and
that she was unable to repair it because she lacked strength in
her hands. The surveyor wanted to see how the organization
handled follow-up calls of this nature and how the patient,
who was too immobile to fix her bed, managed alone at
home. Also, this patient was receiving therapy on her lower
limbs for lymphedema, indicating she may be at risk for
falling.
66
The tracer was initiated with a review of the patient’s record.
It contained appropriate intake and insurance information, as
well as an environmental assessment, particularly as it relates
to fall hazards. The patient had been set up on the equip-
ment one week prior to the current visit. The environmental
assessment also indicated that the sales representative had
noticed risk factors in the home to increase the hazard of
falls, including throw rugs and a cluttered environment. The
assessment noted that the representative had made sugges-
tions for the patient’s family to help ensure the home
environment was safe.
The organization secured permission from the patient for the
surveyor to accompany the sales representative on the home
visit. The surveyor visited the patient at her apartment,
accompanied by the sales representative assigned to her. This
representative was new, but had six months of training for
the position. The patient welcomed the surveyor and sales
representative to her home. After introductions, the sales rep-
resentative went to the bed to determine how to restore its
positioning. The patient also used a walker.
During an interview, the patient reported that the nurse who
visited once a day to treat her wound was able to restore the
bed. The sales representative checked the bed to ensure it was
operating correctly. The sales representative also noted to the
patient that he had seen that she had moved the rugs out of
the way. The patient explained that her daughter had come
to help her rearrange some things in the apartment based on
the agency’s recommendations.
The surveyor spoke with the patient to investigate her per-
ception of the care provided. The patient said she received
excellent care from the organization and received prompt
service when required. When the sales representative asked
her if she experienced any falls, the patient said she fell fre-
quently, but not lately. Further investigation revealed her
most recent fall occurred about one week prior, and she said
she most often fell in the bathroom. She added that she
usually fell suddenly and didn’t know why. She thought her
physician had been notified by the visiting nurse who came
daily, but she was not sure. The patient added that she just
completed a course of antibiotics to treat an infected wound
on her limb that was affected by lymphedema.
 Section 4. Tracer Exercises for Home Care

After completion of the visit, the sales representative and the
surveyor returned to the organization. The surveyor asked the
sales representative to complete any usual paperwork and
asked him to trace the serial number of the bed. Without dif-
ficulty, the representative located the name of the patient
who had the equipment. This patient received a new bed,
not one that had previously been in a patient’s home. The
surveyor asked the representative about his training and ori-
entation to this position and how he received continuing
education. He mentioned that he was new in the position
and had received extensive training, but that every month he
attended additional training sessions.
The surveyor asked the sales representative if he was familiar
with the home medical equipment organization’s falls reduc-
tion process. He explained that he assessed for falls risk in the
environment and in the patient’s home and that it should be
documented in her file. The surveyor reviewed the file and
located the patient’s assessment. While reviewing the file, the
surveyor wasn’t sure if the information on the falls in the
bathroom was reported to the physician because it was not
noted or documented.

Sample Tracer Questions

Questions for the Sales Representative:

• What is your process for receiving an order and setting up an appointment with a patient for new equipment?
• What kind of training and education do you provide to patients?
• If, during an equipment visit, the patient reports a health concern to you, what process do you have to document and,
if necessary, report or respond to it?
• What initial screening and assessment is performed on a new patient.
– Can you describe the screening and assessment process?
– What forms are used?
– What is the documentation?
– Do you have any special screening or assessment processes that you use?
• What is your process for responding to calls regarding repairs or equipment failure?
• What happens during the hours or days when your office is closed?
• How do you maintain your equipment? What happens when equipment is returned to your organization?
• What kinds of falls risk education and intervention do you provide to the patient at home?
– How do you document this?
– How do you follow up?
– What do you do in the event that a patient is noncompliant with your recommendations and the home remains
unsafe?

Questions for the Home Care Patient:

• What has your care experience been like with this organization?
• Can you describe what kind of education you have received on using your equipment?
• What do you do in the event of an equipment failure or breakdown?
• What should you do if you have a problem when the office is closed?

67
 Mock Tracer Workbook
Exercise 4-3. Individual Tracer at a
Hospice
Summary: In the following scenario, a surveyor conducts an
individual tracer at a hospice, where she explores issues relat-
ing to the Priority Focus Areas of
• Communication
• Assessment and Care/Services
• Equipment Use
Scenario
The surveyor conducted this tracer at a small hospital-owned
home-based hospice. The hospital owned a certified home
health agency, and the hospice was under the home care
umbrella. Although the staff of the hospice was not shared
with the home health agency, the administrator of home
health was responsible for both programs. Both programs
were housed within the hospital building.
The surveyor selected a patient to trace who had end-stage
chronic obstructive pulmonary disease and had been on the
program for more than a year. The staff also told the surveyor
that the patient did not leave her home and was dependent
on oxygen 24 hours a day. The primary caregiver was her
daughter.
Prior to the home visit, the surveyor reviewed the clinical
record. Notes were included from nursing, the home health
aide, the social worker, the chaplain, a volunteer, and the
interdisciplinary team meetings. There was also a physical
therapy note from early in the admission, which addressed
teaching the patient’s daughter how to assist with transfers
from bed to wheelchair and to the commode.
In the record, the surveyor noted that the patient was on very
few medications, but did have nebulizer treatments three
times a day. The chart stated that she was independent in
these treatments, after her daughter brought her the medica-
tion. There was a home health aide care plan in the record,
and aide supervisions had been performed every two weeks as
required by regulation.
Once the organization secured permission from the patient
and family for the surveyor to accompany the staff on a
home visit, the surveyor went to the home with the nursing
supervisor, planning to meet with the social worker there,
who was visiting the patient to provide continued emotional
68
support. The patient had a very supportive family, with the
patient moving in with her daughter and family two years
previously.
The visit took place in the patient’s bedroom, which the
patient stated was where she spent all of her time. Before the
social worker began her visit, the surveyor asked the patient
and caregiver to describe their feelings about the service they
were receiving and if they were satisfied. They were very
complimentary of the organization and said it was because of
its support that the patient had been able to stay at home all
this time. The surveyor and patient also discussed rights and
responsibilities and if they had ever needed to call the hospice
on weekends or at night. They said they had earlier in the
admission, when the patient originally had a Foley catheter
that was clogged and the daughter had been unable to fix it.
The daughter stated that the nurse responded very quickly
and changed the catheter during that visit.
The daughter also showed the surveyor the information
packet that the organization had provided, which contained
all the information on calling the agency, communicating
with the state, and contacting The Joint Commission. In
addition, the folder contained a current drug list and some
communication notes the organization used to share infor-
mation between the providers when they were visiting. The
folder also addressed allergies and do-not-resuscitate status.
The home health aide care plan was also in the folder. The
patient was very pleased with the aide services, which came
three days a week to help with her bath. They discussed how
she received medications, and she said medications were
delivered to her. She also had a “comfort kit” in her refrigera-
tor. This kit had been replaced because the patient had been
on the program for an extended period of time, and the
drugs in the kit expire after a six-month period.
Because the patient was on continuous oxygen, the surveyor
asked the daughter about the concentrator and the education
she received. She knew how frequently to change the cannu-
las and how to wash the external filters. She said the
equipment company comes to change the internal filter. The
concentrator was in another room so the noise would not
bother the patient. The surveyor went to look at the concen-
trator and recorded the serial number so that she could do
some follow-up with the equipment company when she
returned to the office. The surveyor asked the daughter if the
company had left them any backup tanks in case there was a
power failure. The surveyor pointed out that she was aware
 Section 4. Tracer Exercises for Home Care

that power failures were a common occurrence in this area in
the winter. The daughter stated that she had three tanks and
showed the surveyor where they were stored. They were
properly stored and secured.
The surveyor then observed the social work visit. The social
worker was talking to the patient about a recent visit from
the patient’s son and grandchildren and how that had gone.
There was also a discussion about friends in the area who
came to visit and some reminiscences about parties that had
been held in the home for various holidays during the year. It
appeared that the patient had an excellent support system in
place, was well aware of the progression of the illness, and
had pretty much put everything in order. The daughter did
express that her time was very limited due to having to
provide ongoing care for her mother as the primary caregiver,
though she was grateful for the support that she received
from her husband and children.
Because the patient had been in hospice care for a significant
amount of time, the surveyor checked the maintenance
records for the oxygen tank’s concentrator and learned that
maintenance had not been performed on this machine. The
staff explained that because this patient had been on the
program for so long and the concentrator had been in the
home for more than a year, the maintenance had been
missed. The supervisor explained that concentrators are
usually maintained between patients because they generally
come back to the company prior to a year.
The administrator and surveyor discussed that even though it
was understandable that this might occur, it was also the
responsibility of the hospice to make sure that equipment
they provided was properly maintained. The administrator
said she would follow up with the equipment company.

Sample Tracer Questions

Questions for the Home Care Nurse:

• How do you perform an initial assessment and an ongoing assessment of patients?
• How do you document care planning and monitoring in the patient’s record?
• If a patient is receiving equipment for his or her care, what kind of education and training do you provide?
• What kind of education and training have you provided to the patient’s family and/or primary caregivers?
• For a patient with a more prolonged case, are there any variations in the care?
• How do you reassess the environment for any safety hazards, such as falls risk or home fire risk?

Questions for the Home Care Patient and Family Members:

• How have you found the care, treatment, and services provided at the hospice?
• Have you been provided with any education about your treatment and equipment, as appropriate?
• Do you have any backups for your equipment?
– If you do, can you show me where they are stored?
– Have you been provided with any education or training on the safe storage of this equipment?
• What are you supposed to do in the event that you have an equipment failure?
• Have you ever had to call the hospice during the evenings or weekends?
– If so, what happened? What did you do?

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Questions for the Social Worker:

• What social and emotional assessments have you performed on the patient and family?
• What kind of ongoing treatment are you providing?
• How is ongoing treatment documented?
• What is the process to communicate concerns or changes?

Questions for the Hospice Director:

• What are your organizational processes for assessment of and care for long-term care hospice patients?
• What is your equipment maintenance and repair process?
– What should a patient do in the event of an equipment failure?
– How is this documented?
– How do you monitor and coordinate services provided by your equipment company?

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 Section 4. Tracer Exercises for Home Care

Infection Control System Tracer Exercises for Home Care

hand hygiene rates. The nurse said that staff had begun
Exercise 4-4. Infection Control System tracking health care–associated infection problems but had
Tracer at a Home Health Agency yet to see any improvement in compliance.

Summary: In the following scenario, a surveyor conducts an
infection control system tracer at a home health agency, where
she explores issues relating to the Priority Focus Areas of
• Communication
• Infection Control
• Quality Improvement and Expertise/Activities
Scenario
The surveyor conducted this infection control system tracer
at a home health agency. The home health agency is hospital
owned and sees patients discharged from its own hospital as
well as from neighboring hospitals and physician offices. The
surveyor asked the agency director, the infection prevention
and control specialist (who was also the performance
improvement nurse), the nursing supervisor, and a nurse and
home health aid to join the meeting. The surveyor asked that
any indicators and data that are being collected and studied
in relation to infection prevention and control be brought to
the meeting.
The surveyor asked if the home health agency had a process
to track and report on cases of hospital readmission due to
infections acquired in the hospital. The nurse reported that
the agency had an effective process in place to communicate
with its hospital, but there had been a higher incidence of
hospital readmissions in relation to patients who had been
admitted to the agency from other hospitals. The nurse, as
she was also the agency’s performance improvement nurse,
and agency director said that they were working on a new
approach to improve communication between the hospitals
and home care agency, particularly in relation to effective dis-
charge communication.

The surveyor asked the infection prevention and control spe-

cialist to explain what her role is in the agency and what kind
of infection control activities the home care agency has
undertaken. The specialist reported that she not only has
responsibility for infection prevention and control activities
at the home health agency, but she also sits on the hospital’s
infection prevention and control committee as the home care
representative. The surveyor asked the specialist if she had
any special training for her position, and the nurse explained
that she had been given infection control training and
attended training at the hospital hosted by the infection
control department.

The surveyor asked what kinds of special intervention and

prevention work was being conducted by the home health
agency. The nurse pointed out that the primary focus was on
hand hygiene, as the agency cared for a large geriatric popu-
lation, many of whom were vulnerable to infection.
Intervention strategies included staff training and in-services
and ongoing patient and family education. The surveyor
asked if the agency was collecting any data in relation to

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Sample Tracer Questions

Questions for the Infection Prevention and Control Practitioner:

• What kind of training and certification have you received to fill this role?
• How do you remain knowledgeable about new developments in infection prevention and control?
• If you are part of a larger organization, do you participate on the organizationwide infection prevention and control
committee?
• What kind of data are you collecting?
• How are you studying it?
• Can you describe any changes or improvements made as a result of infection control data collection and analysis?
• What proactive infection prevention and control activities are you conducting at your agency?
• How are you tracking or monitoring improvement?
• What kind of hand hygiene interventions are you doing with staff, patients, and family?
• How do you reinforce these interventions?
• How do you provide education on hand hygiene to staff?

Questions for Home Care Staff:

• How and when do you employ hand hygiene practices?
• How do you educate patients and families on good hand hygiene practices?
• What kind of infection risks do you identify during the assessment process? How are these risks documented in the
record?

Questions for Home Health Agency Leaders:

• What kind of infection prevention and control initiatives have you done at the agency?
• How do you prioritize and determine improvement projects, such as those for effective infection prevention and
control?
• How do you select and train staff for infection prevention and control?
• What kind of organizationwide support can you offer to your infection prevention and control practitioner?

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 Section 4. Tracer Exercises for Home Care

Medication Management SystemTracer Exercise for Home Care

Exercise 4-5. Medication Management
System Tracer at a Home Health Agency
Summary: In the following scenario, a surveyor conducts a
medication management system tracer at a home health
agency, where he explores issues relating to the Priority Focus
Areas of
• Communication
• Medication Management
• Quality Improvement and Expertise/Activities
The surveyor asked the pharmacist what medications were
stored at the home care agency, and the pharmacist took the
surveyor on a tour of the pharmacy. The surveyor checked
the storage room of the pharmacy and determined that the
medications were stored safely, with high-risk medications
clearly marked. The surveyor asked who had access to the
pharmacy. The pharmacy director explained that only he
himself, the other pharmacist, and the pharmacy technicians
had access to the room.

Scenario
The surveyor conducted the tracer at a large home care
agency that provided home health, pharmacy, and home
medical equipment services. The surveyor asked the phar-
macy director, the agency director, the performance
improvement specialist (also a nurse), and a pharmacy tech-
nician to attend the meeting. He also asked them to bring
along any data and indicators they had gathered in relation
to medication management.

The pharmacy director explained to the surveyor that the

agency has a small medication safety team comprised of
himself, the performance improvement nurse, a pharmacy
technician, and a nurse. The team’s aim, he explained, is to
track and implement improvements in medication safety in
the organization. The surveyor asked the staff if they were
focusing on any particular area of medication management.

The director explained that they had a large number of

patients on high-risk medications, such as anticoagulants.
Because of the ongoing care and need for monitoring of such
patients and the chance of adverse events due to inadvisable
interactions while on the medications, the team had decided
to conduct a failure mode and effects analysis (FMEA) on
the effectiveness of the agency’s medication reconciliation
process. The director had noted a slight increase in adverse
reactions to medications among home care patients. One risk
the team saw patients facing was adverse drug events related
to medication interactions. The surveyor asked the team
what the current process was. The director explained that
nurses currently conduct a medication reconciliation assess-
ment at admission of the patient into home care, and they
reassess for any further medications at each home visit.

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Sample Tracer Questions

Questions for the Pharmacy Director:

• What data and indicators are you collecting in relation to medication management?
• What process improvement work have you planned and conducted in relation to medication management?
• How are medications secured in this facility?
• Who has access to these medications?
• How do you ensure that medications are safely stored?
• How is the stability of medications ensured?
• Can you show me the route that medications take from delivery to the warehouse/receiving, to storage, to dispensing,
and ultimately to the return of medications?
• Do you inspect medication storage and dispensing areas?
• How do you ensure adequate supplies of medications?
• What education and training do you provide to staff?
• How do you train staff on safe medication practices?
• Do you assist with the identification and labeling of high-risk medications and look-alike and sound-alike medications?

Questions for the Nurse:

• How do you provide education to patients or family members on medication safety?
• What kind of education and training have you had on medication management and safety?
• Describe your medication reconciliation process.
• What kind of medication reconciliation do you perform for patients?
• How do you update medication reconciliation documentation?

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Equipment/Supply Management Program-Specific Tracer
Exercises for Home Care
Exercise 4-6. Equipment/Supply
Management Program-Specific Tracer for
Home Care
Summary: In the following scenario, a surveyor conducts an
equipment/supply management program-specific tracer at a
home care agency, where he explores issues relating to the
Priority Focus Areas of
• Physical Environment
• Equipment Use
• Communication
• Patient Safety
Scenario
The surveyor conducted this tracer for an agency that pro-
vides home care, personal care, and support, pharmacy, and
home medical equipment (HME) services. The agency is
hospital based. The surveyor wanted to assess the organiza-
tion’s management of equipment and supply, so he selected a
tracer patient who was receiving services from home care for
private-duty nursing, pharmacy services for enteral feedings
and an enteral feeding pump, and HME for ventilators, a
suction machine, an oxygen concentrator, and a hospital bed.
Because the patient was receiving care from multiple services,
the surveyor could assess care coordination across the contin-
uum of care. The agency had also identified ventilator care as
a high-risk service for both home care and HME. The
patient required 24-hour nursing care. He was ventilator
dependent and on tube feedings. He had a history of recur-
rent pneumonia. He did not have any history of skin
breakdown.
The surveyor reviewed the patient record prior to the home
visits. He reviewed the physician orders, looking specifically
for orders for the nurses for assessment parameters, medica-
tion administration, ventilator settings, suction frequency,
tube feeding orders, and oxygen orders. The surveyor
reviewed the agency policy for supervisory visits, time frames
for assessments, and documentation. The surveyor then
reviewed the nurses’ notes to see if the nurses were following
agency policies. The surveyor noted how often supervisory
notes were written.
Section 4. Tracer Exercises for Home Care
When the surveyor arrived at the patient's home, he intro-
duced himself to the patient and the nurse in the home. The
patient was unable to speak due to the trach, but was able to
communicate with a communication board. The surveyor
asked the patient about care provided by the nurses, how
long he had had nurses, who usually came, and what tasks
they usually performed. He had seen in the patient record
that the patient was listed as a full code, so he asked him
about advance directives. The patient had been given infor-
mation about advance directives and had appointed his
brother as durable power of attorney for medical and busi-
ness decisions. The patient said he wanted everything done if
his heart stopped.
The surveyor reviewed the medication administration record
and spoke to the nurse about how he communicates changes
in medications to the other shift nurse and to the office. He
was able to verbalize how handoff communication works
between shift nurses. The surveyor also questioned him about
changes in the ventilator settings. He said he never changed
the settings and that the respiratory therapist (RT) for HME
is the only one who changed the settings. He showed the sur-
veyor the communication notebook in which the staff wrote
notes to each other and about changes in the medications
or equipment.
The surveyor wrote the serial and rental numbers for the
oxygen concentrator, ventilators (patient had two ventilators
and a backup battery provided by the HME), suction
machine, enteral pump, and hospital bed so he could trace
these items through the warehouse when he returned to the
agency. While in the home he asked how often HME staff
check the equipment. The nurse said someone comes out
every month to check the concentrator and deliver the
enteral formula. The surveyor asked specifically about the
ventilators, and the nurse said the RT from the HME
company comes every four to six weeks and checks the venti-
lator. The surveyor asked if the RT checks both ventilators,
and the nurse said yes. He noticed that the ventilators both
had preventive maintenance stickers on them. One ventilator
had a sticker that read “preventive maintenance due 10/05,”
and the other ventilator had a sticker that read “preventive
maintenance due 1/07.” (This survey was conducted in
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Spring 2006). The surveyor asked if the ventilators had ever
failed, and the nurse said no. He also asked about power
outages because the area had just had a tornado three weeks
before the survey. The nurse was able to tell the surveyor how
long the internal battery would last and how to change to the
external battery if needed. The patient’s brother had pur-
chased a generator for the home for extended power outages.
The surveyor asked the home nurse about the education he
had received for the specific ventilator. He told him that the
HME provided an RT to train on the ventilator, the home
care agency held an annual skills fair to review policies and
procedures, and certain pieces of equipment were set up in a
skills lab where the nurse could demonstrate competency on
the equipment. The nurse also said the skills lab usually
included infusion and enteral pumps and suction machines.
The surveyor was able to verify documentation of training in
the personnel file. (He also followed up with the HME when
he returned to the organization.)
While the surveyor was in the home, the nurse added
formula for the tube feeding. The surveyor observed him
changing the bag, cleaning the gastric tube site, and adding
the formula. The nurse showed the surveyor where the
enteral formula was stored. The formula was provided by the
pharmacy of this organization. The cases of the formula were
labeled from the pharmacy. The case label had an expiration
date of 9/2/09, whereas the formula had an expiration date
of 5/17/09. The surveyor asked the nurse if the formula had
just been delivered and he told him no, that the formula was
delivered the first week of the month (usually). The surveyor
asked him about the expiration date. He stated he never
looked at the date on the label, but only looked at the date
on the cases and on the bottom of the cans. They also dis-
cussed storage requirements for the formula. The nurse was
aware of the need to store the product in a temperature-con-
trolled environment.
On return to the organization, the surveyor met with the
pharmacist to discuss labeling of the enteral formula. The
pharmacist said the label expiration date was for one year
after the prescription was filled. He went on to explain that
the expiration date on the label did not reflect the expiration
date of the product and that the computer automatically
entered the expiration date for one year after the prescription
was filled. Because the pharmacy dispensed the formula, he
said it had to have a label. The surveyor asked about the
76
process for supplying the formula to the patient. The phar-
macist told him that the label for the formula was printed in
the pharmacy; then the pharmacy tech pulled the formula
from the enteral room and placed the labels on the case. The
HME drivers actually delivered the formula to the patient.
The surveyor asked about the process for when the formula
expired sooner than the date on the label, and the pharmacist
said that was never a problem. The surveyor asked the phar-
macist about the cases delivered to this patient, and the
pharmacist said the product would be used before it expired.
The surveyor discussed (consultatively) with the pharmacist
about possibly changing the process to have the pharmacy
tech pull the case of formula before printing labels and
writing the product expiration date on the label. The phar-
macist agreed that the process needed to be changed and that
the agency would explore improvements.
Next, the surveyor spoke with the pharmacy tech. The tech
explained the same process as the pharmacist regarding how
he gathers the formula and supplies to be sent to the patient.
They also talked about the expiration dates. The pharmacy
tech tracks and performs functional tests on enteral pumps.
The surveyor gave him the rental number and serial number
for the enteral pump at the patient's home and asked him to
track this pump for him. He was able to show the surveyor
the tracking for the pump. He also showed the surveyor how
to do the functional test on the pump and showed him the
manufacturer’s recommendations for testing the pump. They
discussed the tech’s orientation and training, and the surveyor
was able to verify competency training on enteral pumps.
The surveyor then went to the warehouse to talk to the RT
about the ventilators. The RT was very knowledgeable about
home ventilators and the care of the patient. He also verbal-
ized the use of the communication notebook at the patient’s
home that the nurse had shown the surveyor. He described
his role in training agency nurses on the ventilator and care
of the patient in the home setting. He was the person who
developed the skills checklist for ventilator care for the
agency. The surveyor asked about preventive maintenance for
the ventilator. He told the surveyor how he tested the venti-
lator at each visit, but he did not know about sending the
ventilator to the manufacturer for annual testing. The sur-
veyor asked for a copy of the manufacturer’s
recommendations, and the RT referred him to the warehouse
manager. He spoke to the warehouse manager, who pulled
 Section 4. Tracer Exercises for Home Care

the preventive maintenance files for the two ventilators at the
patient’s home. The backup ventilator had not been returned
to the manufacturer since 2004. The main ventilator had
been sent in 2008, but not in 2007. The RT observed that
he had read the manufacturer’s manual wrong. He thought
the ventilator had to be sent back only after 6,000 hours of
use. The recommendations were “preventive maintenance to
be performed after 6,000 hours of use and annually.”
The surveyor then met with the agency director, the HME
manager, technicians, warehouse employees, and drivers to
discuss the organization’s processes for receiving and main-
taining supplies and equipment. He explored the
organization’s processes in relation to inventory control,
storage, delivery, patient education, maintenance, and
returns, particularly in relation to high-risk equipment. He
also explored the orientation, training, and competency eval-
uation processes for equipment and supply management.

Sample Tracer Questions

Questions for the Home Medical Equipment Manager:

• Describe your process for ensuring your work environment is safe.
• How do you educate patients on equipment when it is delivered?
• What is your process to educate staff on equipment and supplies?
– Tell me about your orientation and training process.
– How do you ensure competency?
– What is your process for continued education?
• Show me where you store your equipment and supplies, particularly your high-risk ones.
• Describe the process from receiving a physician order to delivering the equipment or supply to the patient.
• How do you prepare, deliver, and set up equipment?
• What follow-up education and training do you provide to patients and their family members about equipment?
• How do you assess the environment for safety risks?
• What specific training do you provide to patients in using this equipment?
• Tell me what you do in the event of equipment failure. How do you advise patients?
• What is your equipment repair process?

Questions for Delivery Staff:

• Can you describe your process for checking, repairing, and assessing equipment?
• Please show me the maintenance logs for this piece of equipment.
• Who is responsible for completing the log?
• What is the process for filling the log?
• What is your process to handle patient reports of broken or malfunctioning equipment? What kind of after-hours
service do you offer?

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Exercise 4-7. Equipment/Supply
Management Program-Specific Tracer for
a Home Medical Equipment Organization
Summary: In the following scenario, a surveyor conducts an
equipment/supply management program-specific tracer at a
home medical equipment organization, where he explores
issues relating to the Priority Focus Areas of
• Staffing
• Equipment Use
• Communication
• Patient Safety
Scenario
The surveyor conducted this tracer during a regional survey
taking place at a large national home medical equipment
(HME) organization that provides home medical equipment
and clinical respiratory services. After the opening conference
presented by the organization’s management, which included
a description of the services provided, the surveyor selected a
tracer patient, a clinical respiratory service patient who was
receiving home oxygen services.
In preparation for the actual visit, the surveyor reviewed the
patient’s chart. He was particularly interested in documenta-
tion noting dates service had been provided to see if unique
maintenance-requirement time frames related to the equip-
ment provided to the patient had been met by the
organization. He was also noting whether the staff was fol-
lowing the organization’s own policy time frames for
assessment/reassessment visits to the clinical respiratory
service patients. The surveyor also noted that the chart
included complete and current orders for the equipment and
services being provided the patient. During the chart review,
the surveyor also noted the staff who completed visits to the
tracer patient. The chart review also revealed the types of
visits the organization had made to the patient, whether
planned or unplanned, and the results of those visits.
During the actual tracer activities, the surveyor had conversa-
tions with the staff members who had cared for or who were
involved with care processes for the selected tracer patient.
The questions were related to the organization’s processes for
maintaining systems dealing with equipment maintenance
and staffing to ensure maintenance time frames were being
met and organizational guidelines were being addressed
regarding the frequency of clinical visits. Since these conver-
78
sations involved different staff, the surveyor was directed to
different areas of the organization, such as the warehouse.
The surveyor wanted to see how an oxygen concentrator, like
the one the patient was using, was maintained, tested, and
inspected to ensure proper functioning. He wanted to see
how the system had been set up to safely and adequately
handle the volume of business the organization
was providing.
The surveyor also visited the clinical services area to visit with
the RTs who had cared for the tracer patient. The surveyor
was interested in the services they were providing to this
patient and exactly what their involvement detailed from a
clinical standpoint. He spoke with clinical staff relating to
their work load and how they managed and organized
clinical visits.
During the actual tracer visit to the selected patient, the sur-
veyor observed the care being delivered and the competency
levels of the staff providing the care. He questioned staff
members on the orientation process the organization had
used in preparing them to care for patients like the tracer
patient being visited.
The surveyor also visited with the patient, asking if he felt
comfortable with the knowledge level of the staff from the
organization. He also asked questions related to the equip-
ment, how the patient had been educated to use the
equipment safely, and if he had been taught about any
unique safety considerations related to oxygen equipment.
The surveyor also asked the patient whether he had ever had
to use the organization's service after hours. After the actual
visit to the tracer patient, the surveyor then proceeded back
to the organization’s site.
Due to significant recent growth in the HME’s business, the
surveyor met with organization leadership to ask the organi-
zation how it was managing meeting time frames for required
equipment maintenance checks, particularly for its high-risk
equipment. Organization leadership discussed how these
processes could be fixed and provided the organization with
planning tools it could use to get a better handle on staffing
levels and equipment maintenance. Discussions also centered
on how the organization needed to update or implement new
tools to ensure key processes like equipment maintenance
and the scheduling of maintenance were adequate to meet
the needs of its growing patient population.
 Section 4. Tracer Exercises for Home Care

Sample Tracer Questions

Questions for Home Medical Equipment Staff:

• What are your time frames for equipment delivery to a patient?
• How do you manage the process of equipment maintenance?
• How do you orient and train a patient on new equipment?
• What is your policy for selecting suitable equipment for patients?
– How do you monitor and track this?
• Please share what your process is to assess a patient when delivering equipment.
• Where do you store the equipment used?
• How do you maintain equipment?
• Describe your process to clean equipment.
• How do you separate dirty equipment from clean?
• What do you do in the event of equipment failure?
• What process do you follow for recalled equipment?
• How do you educate patients on what to do when their high-risk equipment fails?
• What kind of continuing training do you receive on equipment maintenance?
• How have you been trained in patient safety? What kind of patient safety education do you provide to patients?

Questions for Home Medical Equipment Organization Leaders:

• What data and indicators are you collecting on equipment management, from procurement to inventory, cleaning,
maintenance, and decommissioning?
• What systems do you have in place to monitor patients with high-risk equipment?
• What proactive risk assessment have you done in relation to ensuring high-risk equipment safety?
• What processes have you put in place to effectively manage high-risk equipment?

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Exercise 4-8. Fall Reduction
Program-Specific Tracer in a Home Health
Organization
Summary: In the following scenario, a surveyor conducts a
fall reduction program-specific tracer at a home health organi-
zation, where she explores issues relating to the Priority Focus
Areas of
• Orientation and Training
• Assessment and Care/Services
• Communication
• Patient Safety
Scenario
The surveyor conducted this tracer at a small, sole-ownership
home health organization. This survey was the organization’s
first triennial survey, and it was also a deemed status survey.
The organization had a census of approximately 32 patients
on service when the surveyor arrived. The organization had a
small office staff of the administrator, the director of nursing,
and office clerical staff, and field staff included nursing and
home health aides. The physical therapist, occupational ther-
apist, and social worker were all contracted staff.
The surveyor chose a 96-year-old bed- and wheelchair-bound
patient, living in a second floor apartment and being cared
for by an 85-year-old sister. The patient had been on service
for almost two months, and had nursing, home health aide,
physical therapy, and social work services. She was scheduled
to be seen that day by nursing and home health aide services.
The patient had a small decubitus ulcer on the buttocks,
requiring dressing changes by the nurse. Although the patient
had visits with both the nurse and home health aide that day,
the surveyor asked to accompany the nurse on her visit. The
patient’s primary diagnosis was muscle weakness, with a sec-
ondary diagnosis of Type 2 diabetes and a pressure ulcer.
During the initial chart review the surveyor went over basic
areas she wanted to follow through with on the visit. She
checked the referral information; there were no unusual
orders on the referral. The surveyor checked the initial paper-
work for patient signatures. She noticed the patient was listed
as having an advance directive, but nothing further was noted
and the patient did not have a do-not-resuscitate status even
at her advanced age. The surveyor checked the nursing
orders, particularly the wound care orders and any orders
regarding the diabetes (since it was listed as secondary). The
80
surveyor looked for medication changes and saw there were
none. The surveyor checked the patient care plan and noticed
the nurse or the organization had not received verbal orders
before starting the care. The surveyor looked at the home
health aide assignment for anything unusual and noticed the
registered nurse had not addressed the fall risk with any
special precautions. The surveyor briefly checked over the
home health aide visit notes and noticed the home health
aide was taking vitals each visit, with no parameters to report
for abnormalities. She noted the “falls risk assessment” and
that the patient was determined to be at high risk for falls,
but there was no indication of communication of such with
the physical therapist or the home health aide.
The surveyor interviewed the nurse outside the home regard-
ing her goals for this patient. She found out that the nurse
was not really addressing the diabetes because the patient had
been a diabetic for many years and the diabetes was under
control. The nurse was concentrating on clearing up the pres-
sure ulcer and generally assessing the patient. Although she
did identify the patient as at “high risk” for falls, she had
never discussed this with the therapist or the aide. The nurse
knew the patient had an advance directive, but did not ques-
tion the sister as to the contents.
The patient was challenging to interview due to dementia.
The surveyor and nurse arrived at 10 A.M. to the apartment
and the sister was awake; however, the patient and the sister’s
husband were still sleeping. As the visit progressed, many
other people started to appear from other rooms in the apart-
ment. It was apparent that many people lived there. The
sister appeared a bit overwhelmed with her sister’s care. The
surveyor questioned her regarding the contents of the
advanced directive. The sister stated that the patient was
adamant about not wanting to be resuscitated. The surveyor
observed the nurse’s infection prevention and control with
the wound care, and both were well and safely performed.
However, when questioned, the nurse seemed a bit confused
about the latest Centers for Disease Control and Prevention
hand-washing recommendations. She believed it was still nec-
essary to use soap and water rather than gel for hand
sanitizing. The sister of the patient spoke of having to get the
patient down the stairs for a doctor’s appointment, and she
and family members had to slide her down on a mattress and
carry her back up the stairs.
The surveyor looked in the home care home record/file and
noted no home health aide assignment. The nurse thought it
 Section 4. Tracer Exercises for Home Care

was there. The sister remembered seeing it at one time. The
aide came to bathe the patient while the surveyor was still
there. The aide was unclear where the assignment was, but
she stated she knew the contents and could give the patient a
shower with a chair. The caregiver seemed pleased with the
services of home care. She felt the staff discussed with her
their goals and plans. She stated that the social worker was
trying to get her more help, although she was opposed to the
possibility of placing her sister in a skilled facility. The sur-
veyor discovered the patient had fallen and fractured her arm
while on service and was hospitalized for a couple of days.
The surveyor investigated the fall and found no incident
report of an unwitnessed fall. The chart indicated a resump-
tion outcome and assessment information set, but had no
resumption orders after the short hospitalization and no
orders for follow-through with the patient’s cast.
Once back at the agency, the surveyor met with the agency
administrator and director of nursing. In addition to issues
relating to orientation and training, communication, and
documentation, the surveyor wanted to explore fall reduction
processes with the agency. The surveyor questioned the
leaders regarding the organization’s fall reduction program.
While the agency did have a falls reduction program and it
had procedures to assess and reassess a patient for high falls
risk, leadership noted that the program was not consistently
followed, there was no consistent process in place to follow
through on patients designated as being at risk for falls, and
there was no process for evaluating the effect of the fall risk
program.

Sample Tracer Questions

Questions for Home Health Agency Staff:

• What is your falls reduction program? Please describe it to me.
• How do you determine falls risk in your patients?
• Describe your falls risk assessment process.
• What measures do you have in place for reassessment?
• Once a patient has been determined as being at high risk for falls, what do you do?
– What steps do you put in place to reduce risk for patients?
– How do you reassess patients to reduce the risk of injury?
• What should you do in the event of a patient fall?
• Have you assessed a patient’s medication in relation to falls risk?
• How did you determine this?
• What have you done to advise a patient and his or her family about safe practices in the home to prevent falls?
• When you visit the home, how do you assess for falls risk? If you identify a falls risk, what do you do? Can you explain
your process?

Questions for Home Health Agency Leaders:

• What is your organization’s falls reduction program?
• How do you measure the program for success?
• How have you identified processes and system issues contributing to a high re-hospitalization rate among patients?

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• How do you work with those organizations from whom patients are admitted into your care (such as hospitals) to
ensure they communicate any identified falls risk for the patient?

Questions for the Patient:

• How has your experience of care been with this organization?
• What kind of education have you received on safety?
• What should you do in the event that your equipment is not working or needs repair?

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 Section 4. Tracer Exercises for Home Care

Tips for Conducting Tracers in a Home Care Setting

Consider the following tips and strategies when conducting tracers in a home care setting:

• Focus on issues of particular concern for home care settings. Consider those issues that are of particular
concern to home care patient safety, such as fire safety or medication safety, and use those to plan special-
ized tracers. Choose patients with multiple disciplines or multiple programs (for example, home health, home
medical equipment, and pharmacy) to assess care coordination. Choose patients who have been on services
at least 60 to 90 days or more to assess recertification, equipment maintenance, and updated orders. Use
some of the sample questions included in these tracer scenarios to frame questions.

• Use these scenarios as a starting point. To gain familiarity with tracers, consider using these example
tracers as a guide and select patients to trace based on a similar background. The sample questions can also
be used as a guide.

• Use closed records. To start the process of tracers or to gain familiarity with it, use a closed record as a
training approach. In the same vein as an individual tracer, you can “walk through” the record as a way to
trace that patient’s experience.

• Involve multiple staff. Encourage and involve as many staff as possible in tracer activity. When engaged in
the process, staff better understand how tracers can work and can lend important insight and perspective into
improvement efforts.

• Conduct a hospital readmission program-specific tracer. In addition to the equipment and falls program-
specific tracers, The Joint Commission has also designated another program-specific tracer for home care
organizations relating to hospital readmissions. This applies to Medicare-certified home health organizations.
To conduct a hospital readmission tracer, consider the following elements for which The Joint Commission will
assess Medicare-certified home health organizations: evaluating the action taken to reduce the hospital read-
mission rate; evaluating the accuracy of medication reconciliation and education, a leading cause of
re-hospitalization; and identifying process- and possibly system-level issues contributing to a high re-hospital-
ization rate.

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84

Tracer Exercises for Long Term Care
T
his section contains individual, systems-based, and
program-specific tracer exercises for long term care
organizations. Each exercise contains a scenario that
represents what might happen when a surveyor conducts that
type of tracer in a long term care setting. Based on the sce-
nario provided, the exercise includes a list of sample tracer
questions that might be asked of the chosen tracer resident or
staff members involved in that resident’s care, treatment, or
services. At the end of the section is a sidebar of tips that
staff can consider when conducting their own tracer activities
in a long term care organization.
Section 5
Please keep in mind that each tracer is unique; the questions
asked or long term care areas visited during a tracer will vary
depending on the resident or system chosen to follow. No
two tracers are the same. There is no way to know all of the
questions that might be asked during a tracer, because the
possibilities are limitless. These exercises are examples to
show how that type of tracer can be conducted and to put
the sample questions into context. Use these tracer scenarios
and sample questions as educational or training tools for
yourself and your staff, or use them as a starting point to
conducting your own tracers.
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Individual Tracer Exercises for Long Term Care
Exercise 5-1. Individual Tracer in a Long
Term Care Facility
Summary: In the following scenario, a surveyor conducts an
individual tracer in a long term care facility, where she
explores issues relating to the Priority Focus Areas of
• Physical Environment
• Assessment and Care/Services
• Patient Safety
Scenario
The surveyor conducted this individual resident tracer in a
long term care facility. She selected an 80-year-old long term
care resident with a diagnosis of dementia. During orienta-
tion to the organization, the surveyor learned there were no
resident care units in this facility specifically designated as
dementia units and residents with various cognitive abilities
resided on each resident care unit.
After entry to the resident care unit where this resident
resided, the surveyor noticed that the elevators freely opened
and closed, although apparently confused residents, including
the selected tracer resident, were observed ambulating on the
unit. The surveyor met with the nurse who was caring for
this resident on this day. The surveyor asked the nurse to
explain the tracer resident’s physical condition and also to
talk about her cognitive status. The nurse explained that the
resident walked and frequently wandered, and that she some-
times entered other residents’ rooms and opened their closets
and bedside table drawers. The resident shared a semiprivate
room with another resident who also had dementia. The
nurse also stated that the resident was sometimes unsteady,
and that she had had several falls, one recently resulting in
severe bruising to her right hip and leg.
The surveyor asked the nurse to review the resident’s record
with her and to show her the assessments that had been
recently performed as well as the current plan of care. The
record and assessments showed that the resident had been on
this unit for more than five months, and that her cognitive
ability and physical abilities were showing signs of deteriora-
tion. They also indicated that the resident was confused and
could not readily communicate her needs or answer ques-
tions. The nurse explained the written plan of care showed
86
that the resident ambulated freely and did not have any issues
related to communication. She was assessed as at risk for falls,
but there were no specific interventions identified on the
plan of care, other than to use the falls protocol to prevent
falls, and there was no reference on the plan to her recent fall
that resulted in injury.
The surveyor asked if the resident received any therapy to
assist her with her unsteady gait and ambulation, and also
asked if occupational therapy or physical therapy were
involved in her care and treatment. It was indicated that she
does not receive specific occupational or physical therapy, but
that the certified nursing assistant (CNA) provides range-of-
motion exercises during her daily care of the resident. The
surveyor then met with the CNA and asked her about the
range-of-motion exercises provided to the resident. The CNA
was also queried about her observations of the resident’s
strength and ability and if she had noted recent deterioration
in the resident’s ambulation abilities.
The surveyor asked if the resident attended any therapeutic
recreational activities and then asked to meet with the activi-
ties coordinator who might be involved in the resident’s care
and treatment. The surveyor also observed a recreational
activity program that was currently being conducted in the
activities room. The activities coordinator explained that all
activities are posted and that the residents may attend any of
the posted activities, wherever they occur in the facility. The
activities coordinator also explained that there are special pro-
grams geared specifically to the cognitively impaired residents
on a daily basis, but that they are conducted in multiple loca-
tions within the building and not consistently on this
particular resident care unit. She explained that nursing staff
would need to transport residents to the activities throughout
the building. The traced resident was observed attending a
crafts activity in the unit’s activities room, but seemed con-
fused, as the observed activity seemed to require a higher
level of cognitive function and ability than the resident was
capable of. It did not appear that any of the staff at this activ-
ity were assisting her with her special needs. During further
review of the plan of care for this resident, the surveyor noted
that the plan contained a note that the resident should be
encouraged to attend activities planned for lower functioning
residents and that she should receive one-on-one assistance
with participation in these activities.
 Section 5. Tracer Exercises for Long Term Care

The surveyor met with the resident following the observed surveyor or by the staff. The CNA guided her back to her
activity. The resident was able to say hello and smiled freely. room and appeared to be known and trusted by the resident.
She was not able to answer any questions posed to her by the

Sample Tracer Questions

Questions for the Nurse:

• Are you the nurse who regularly cares for this resident? When you are not here or are not caring for this resident, who
cares for the resident, and how do you ensure continuity of care?
• How is resident-specific information passed from shift to shift, caregiver to caregiver, or discipline to discipline?
• How was this resident assessed for potential falls risk? And how often is risk for falls reassessed?
• What have you implemented to ensure that the resident is free from the potential for falls or injury?
• How do you ensure that this resident is safe and that she does not wander off the floor or to an area where she might
not be safe or observed?
• How do you ensure that the resident’s plan of care is current and is individualized to meet the resident’s current needs?
• How often are care plans updated and revised?
• How do you protect the privacy of all residents on this unit?
• How does the resident communicate her needs to you?

Questions for the Certified Nursing Assistant:

• Do you care for this resident on a regular basis?
• Have you seen changes in the resident’s physical ability and ability to communicate?
• Are you involved in the team care-planning meetings, or are you asked to contribute information to these meetings?
• How do you provide range-of-motion activities to this resident? Has anyone told you specifically which range-of-
motion activities should be performed?
• How do you communicate with this resident?
• Are you able to teach the resident or reinforce behaviors related to safety?

Questions for the Activities Coordinator:

• How do you ensure that staff is aware of appropriate programs and activities for the cognitively impaired residents?
• Do you assist in coordination to safely transport residents to activities?
• Are you involved in interdisciplinary resident care plan meetings?
• Have you observed any deterioration in this resident’s abilities, and have you made or suggested appropriate revisions to
her activities plan of care?
• Are you aware if this resident has been determined to be at risk for falling? And what interventions would or do you
take to prevent falls during attendance and participation in your programs?
• How often do you reassess each resident?

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 Mock Tracer Workbook
Exercise 5-2. Individual Tracer in a Long
Term Care and Subacute Facility
Summary: In the following scenario, a surveyor conducts an
individual tracer at a long term care and subacute facility,
where she explores issues relating to the Priority Focus Areas of
• Assessment and Care/Services
• Communication
• Patient Safety
Scenario
The surveyor conducted this individual resident tracer in a
combined long term care and subacute facility. The surveyor
selected a resident who had been admitted one week ago for
rehabilitation following a hip repair. The 72-year-old male
resident had fallen at home and sustained a right-sided hip
fracture, so he was receiving care on the rehabilitative unit.
He lived at home by himself, and the plan was for him to
return home following rehabilitation in this facility.
The surveyor met first with the nurse on the orthopedic
rehabilitation unit and asked her to provide a short tour of
the unit. The surveyor observed that residents had access to a
physical and occupational therapy room where residents were
receiving physical therapy. The surveyor observed other resi-
dents being ambulated by therapists and nursing staff in the
corridors. Linen carts and treatment carts were observed in
the corridors, blocking ambulation rails. Other items, such as
chairs and boxes, were also observed in the corridors. There
was also a dining room on the floor, where only two residents
were observed finishing their breakfasts. The nurse indicated
that most of the rehabilitation residents preferred to eat their
meals in their rooms.
The surveyor met with the nurse who was currently caring
for this resident. She asked the nurse to explain the assess-
ment process and the frequency of resident assessments, and
also how plans of care are developed for the residents. The
surveyor also asked the nurse to review the specific assess-
ments and plan of care for this resident. The nurse was asked
if the resident had any pain, and if so, how the pain was
being treated. The nurse reviewed the medication profile for
the resident, including the medications ordered for pain
management. The nurse indicated that the patient had com-
plained of hip pain since admission and that he feared the
88
pain whenever he was asked to ambulate and when he went
to his daily therapy session.
The surveyor noted that other disciplines involved in the care
and treatment of this resident included the physician, physi-
cal therapy, social services, and a dietitian. The surveyor
learned from the nurse and the physician that the resident
had a history of insulin-dependent diabetes mellitus and that
the resident had a history of hypertension. Both conditions
were being treated with diet and medication management.
The nurse was asked if the resident had a falls risk assessment
performed and if he was determined to be at risk for falls.
The surveyor met with the physical therapist, who indicated
that the tracer resident was making slow progress, as he was
often in pain and appeared fearful of exertion. The therapist
had recommended that he receive pain medication prior to
coming to the sessions, but the resident appeared sleepy and
had difficulty with balance after receiving the pain medica-
tion, so he had opted not to receive the medication prior to
therapy and generally asked to receive it after therapy instead.
The surveyor asked to meet with the resident. He was in his
room in a wheelchair, eating his breakfast. He indicated that
he was to go to therapy in two hours. He said that he had
some pain and that he had last received pain medication
during the night. He indicated that he thought he was
making some progress, but was disappointed that he was not
making faster progress, and that he feared that he would not
be able to go home to independent living again. He said that
no one had spoken to him about potential alternative
arrangements and that he feared becoming a “nursing home”
resident if he did not progress to a level that he could be dis-
charged home independently. He indicated that his children
lived far away and that all had busy lives, so family assistance
was not an option for him.
The surveyor asked to meet with the social service worker,
but she was not available to meet with the surveyor, as she
was only present once per week. The social service written
assessment and plan of care were reviewed with the nurse.
They indicated that the initial plan was for the resident to
stay in this program for approximately four weeks of therapy
and that he would be discharged home. There were no notes
regarding family involvement or discussion with the resident
for alternatives to independent living in his home. The nurse
indicated that if his progress was slow, the social service
 Section 5. Tracer Exercises for Long Term Care

worker would probably look into some type of assistance in
the home. But the social service worker had not yet met with
the interdisciplinary team, and her plan of care was separated
from the interdisciplinary care plan. There was no evidence
that the social service worker had been in communication
with any other team members regarding this resident’s status
and needs.
The nurse met with the dietitian, who indicated that the
tracer resident was on a diabetic diet and that he seemed to
understand his diet, as he had been diabetic for more than 20
years. She indicated that his diabetes was in control. When
asked if he would be able to continue to prepare his meals at
home, she said that she did not think it would be an issue,
except that he had previously shopped for himself and
cooked his own meals, and it was assumed that he would be
able to continue to do the same following his discharge. She
had not had a discussion regarding this with the social service
worker, nor had she documented a plan in the plan of care.

Sample Tracer Questions

Questions for the Nurse:

• When is the first comprehensive assessment conducted for a short-stay resident?
• How soon after admission is the plan of care developed?
• Who is involved in developing the interdisciplinary plan of care?
• How do you assess pain in residents?
• When and how do you reassess pain for the effectiveness of your intervention?
• Do you work with therapy to ensure that pain is managed in a way to maximize the effectiveness of physical therapy?
• How do you ensure a safe environment?
• What kind of tool do you use for assessing potential for falls? Do you consider medications as potential risk factors?

Questions for the Physician:

• Are you aware if this resident is having any pain and what might precipitate the pain?
• What have you prescribed for pain management?
• How do you communicate the resident’s status and needs to other physicians who might be covering for you in your
absence?
• Do you meet with other disciplines and members of the interdisciplinary team to discuss the needs of and plans for this
resident?

Questions for the Social Service Worker:

(Note: A phone call could be made to the social service worker, or she could potentially be met with on an alternate day when she
is in the facility.)
• How often do you reassess the needs of this resident, and how do you communicate your reassessments with other
members of the team?
• How are you made aware of reassessments by other members of the team?
• Do you participate and contribute to the interdisciplinary plan of care?
• Are you aware if the resident is making progress toward rehabilitation as was planned on admission?

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 Mock Tracer Workbook

• Have you discussed the resident’s home and support systems with the resident and/or his family?
• If he does not progress to the level of independent discharge, what other arrangements might be made for this resident?

Questions for the Physical Therapist:

• Do you work with the nurse to ensure that pain is appropriately managed to maximize the effectiveness of therapy?
• Do you know if this resident has been assessed as being at risk for falls?
• What interventions should be implemented to minimize the potential for falls in the facility, and also in the resident’s
home?
• Do you provide education to the resident, and if so, how and where do you document this?
• Do you know if any other staff members are also providing education to the resident, and are you aware if an educa-
tional assessment has been completed for this resident?

Questions for the Dietitian:

• Does the resident understand his diabetic diet?
• Are there any changes to the patient’s diet that he must be aware of as preparation for potential discharge?
• Will the patient need assistance in preparing his meals at home, and if so, have you met with the social service worker to
discuss this?
• Has anyone informed you if the patient misses his meals when he is in pain?
• How do you communicate the needs and care of this resident with other dietitians who might be covering for you and
with other members of the interdisciplinary team?

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Data Use System Tracer Exercises for Long Term Care
Exercise 5-3. Data Use System
Tracer in a Long Term Care Facility
Summary: In the following scenario, a surveyor conducts a
data use system tracer at a long term care facility, where she
explores issues relating to the Priority Focus Areas of
• Quality Improvement and Expertise/Activities
• Information Management
• Patient Safety
Scenario
The surveyor conducted a data use system tracer in a long
term care facility. After performing individual resident tracers
and interviews with staff, the surveyor noted that staff in the
facility was unfamiliar and uninvolved with quality improve-
ment functions and analysis. Staff indicated that they
submitted information such as incident and occurrence
reports or medication errors, but that they generally just
responded to individual incidents and were not aware of any
trends or patterns. Staff was also not aware if any changes
had been made to reduce the occurrence and potential sever-
ity of these types of errors.
The surveyor asked for representatives from administration,
performance improvement, nursing, medicine, and other rel-
evant disciplines to attend the data management systems
tracer meeting. She asked them to bring data and any analy-
ses that they might have performed from the last year
regarding any performance or quality improvement indica-
tors, including incidents and occurrences and medication
errors or discrepancies. She asked them to first discuss how
they ensured resident safety in their environment. She also
then asked them if and how they used data to understand
current performance and to identify opportunities for
improvement.
The performance improvement coordinator explained that he
reviewed incidents and accidents and that he compared
numbers of occurrences rather than the types or severity of
these incidents. He said that the numbers were down over
the last six months, but could not explain why the numbers
were down. He said that he knew that the numbers of resi-
dent falls were up, but believed that the numbers of injuries
Section 5. Tracer Exercises for Long Term Care
might have been lower. The nursing representative indicated
that was because the same residents had repeat falls. Data
reports did not differentiate or identify if this was indeed the
case. There were no trend reports and no evidence that pat-
terns had been studied or analyzed. Reports were number
grids only, and there were no graphic displays of
analysis of data.
The surveyor asked if any teams were put together to study
the data regarding incidents and accidents. She was told that
the director of nursing studies this data and produces
monthly reports, but that no teams involving other staff have
met to study the data. The meeting attendees indicated that
the manner in which they addressed these reports were on a
case-by-case basis and that they believe that they have had an
impact on the reduction of injuries resulting from these
occurrences.
The surveyor asked the administrator about the role of
administration in performance improvement and asked how
leaders support the process. The administrator replied that
the individual departments studied issues identified by their
departments with the support of the performance improve-
ment coordinator. She also indicated that she received
monthly reports from all departments and that departments
were expected to identify which issues they were working on.
She indicated that she received raw numbers, but rarely saw
actual analysis. She said that she was not aware of any inter-
disciplinary teams formed for the purpose of performance
improvement study, but that interdisciplinary teams met to
discuss resident care and to develop plans of care for
the residents.
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Sample Tracer Questions

Questions for the Performance Improvement Coordinator:

• What are your education and training regarding performance improvement and the use and analysis of data?
• How do you maintain and improve your knowledge and expertise?
• What structure or process is used for the study of data and for performance improvement in this organization?
• Do you provide performance improvement training to staff?
• Are teams used for performance improvement, and if so, how do you determine who should be on these teams?
• How are data studied and analyzed?
• Can you walk me through a recent performance improvement study?
• Have you been able to attain improvements as a result of this performance improvement study?
• Are you able to sustain improvements? How do you know?
• Do you use graphic reports to demonstrate performance improvement process and analysis? And if so, which kinds of
reports do you use, and how do you determine the right kinds of reports for the data you are trying to represent? To
whom are these reports presented?
• Do you determine when interdisciplinary and collaborative teams are needed to study and improve processes?

Questions for the Staff Attending the Meeting:

• Are you informed regarding data analysis and potential information gained from this analysis?
• How are you and your staff educated regarding the performance improvement process?
• Are you and your staff involved in the performance improvement process?
• How do you identify if there are issues that might need further study and analysis?
• To whom do you report these issues?
• Have you or your staff been asked to serve on performance improvement teams?
• How is staff informed regarding continuing studies, results of studies, impact on work and resident care, and so forth?
• Are you presented with graphic reports demonstrating data analysis and studies? If so, have you been trained regarding
how to interpret and understand these reports?
• How do you use data and analysis to improve outcomes of care?

Questions for the Administrator:

• Have you received education and training regarding the performance improvement process?
• How do you support the performance improvement process in your organization?
• How is the board of directors informed regarding performance improvement and indicator selections?
• How do you use data and analysis to study and improve programs and services?

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Exercise 5-4. Data Use System Tracer
in a Skilled Nursing Facility
Summary: In the following scenario, a surveyor conducts a
data use system tracer in a skilled nursing facility, where he
explores issues relating to the Priority Focus Areas of
• Staffing
• Quality Improvement and Expertise/Activities
• Patient Safety
Scenario
The surveyor conducted this data use system tracer in a facil-
ity that had both long term care residents and short-term
rehabilitation residents. The surveyor focused this session on
the organization’s staffing effectiveness process, and he asked
staff involved in the process to attend this session.
Representatives from nursing management, quality manage-
ment, and human resources attended.
The surveyor asked the attendees to present their staffing
effectiveness data and to discuss the process they had imple-
mented. The human resources representative explained that
she was the primary person who analyzed the data, but that
the director of nursing had identified the indicators they
were using. The director of nursing indicated that she
selected both the long term care population and the rehab
population as their identified resident populations, but that
they did not hone this population down to individual
nursing care units and were therefore having difficulty in
getting reliable data on all units. They indicated that they
thought it would indeed be more useful if they could focus
on just two units, but they did not understand that they had
that option. They explained that staff on the resident care
units collected the requested information, but that they were
not actually involved in the study and analysis or in the
staffing effectiveness meetings. The surveyor encouraged
them to involve the staff and to be certain to include them in
“drill-down” analyses and provide them with ongoing results
of analysis.
The participants in this meeting explained that they chose
four indicators for the long term care population and four
indicators for the subacute population. Some of the indica-
tors were the same, and some were different. The surveyor
asked the attendees first to present the indicators they
selected for the long term care setting. They said that they
had selected prevalence of falls and prevalence of pressure
Section 5. Tracer Exercises for Long Term Care
ulcers as their clinical indicators and use of overtime and
agency usage for their human resource indicators. They indi-
cated that they had been studying this for the last six
months, but still did not see obvious cause and effect. They
have not conducted a drill-down analysis to study the process
in more detail.
Attendees explained that they also selected falls and overtime
use for the rehabilitation population, but that they selected
different secondary indicators. They also looked at pain
assessment and management as an additional clinical indica-
tor and nursing hours per resident day as a human resource
indicator. The surveyor asked them to explain why they had
selected those indicators. They explained that their rehabilita-
tion residents were generally recent admits from the hospital
and that many came for rehabilitation following surgery.
They believed that the indicators they selected were appropri-
ate, but explained that they had difficultly learning anything
regarding relationships, as most of their residents were
shorter-stay residents and they could not follow the data over
the long term.
The surveyor asked the attendees to explain how they aggre-
gate their data and to show her the data analysis that had
been performed to date. They shared some line charts that
had been used and numbers regarding the individual indica-
tors. They explained that they were beginning to recognize
some potential relationships, but they had not yet recognized
any real trends. They explained that this was difficult,
because many areas of the facility contributed to the overall
data. They agreed that it would be useful to separate the data
by areas.
Staff members were encouraged to continue with their
process and to make changes to indicators and populations as
they deemed appropriate. They were also encouraged to
include staff members actively in the process. The surveyor
congratulated them on achievements made to date and recog-
nized that they used appropriate criteria in selecting the
populations and indicators to study.
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Sample Tracer Questions

Questions for the Director of Nursing and Quality Management and Human Resources Staff [Note: Questions are
asked during a special session with the surveyor]:
• Who is involved in the process to collect data and study staffing effectiveness?
• What indicators have you identified for each area of the home?
• Why did you select the indicators that you selected?
• Have you seen any relationships that you expected to see between the indicators selected for each population?
• Have you seen any potential relationships that you did not expect to see?
• Did you define numerators and denominators for the indicators that you have chosen, and how do you use these?
• Did you standardize data element definitions for each of your selected indicators?
• Who collects your data, and how is it collected?
• How is the data analyzed and by whom?
• Who is involved in reviewing the data?
• Have you conducted drill-down analysis?
• Who is involved in the drill-down process?
• What have you learned?
• Have you made improvements as a result of these studies?
• Have you been able to maintain your improvements?
• If you have implemented improvements, how do you know if the improvements are sustainable and if they are sus-
tained?
• Are the staffing improvement results reported to leadership? If so, how are the results reported and how often?

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Infection Control System Tracer Exercises for Long Term Care
Exercise 5-5. Infection Control System
Tracer in a Long Term Care Facility
Summary: In the following scenario, a surveyor conducts an
infection control system tracer at a long term care facility,
where he explores issues relating to the Priority Focus Areas of
• Assessment of Care/Services
• Infection Control
• Patient Safety
Scenario
The surveyor conducted an infection control system tracer in
a long term care facility. He started the tracer by meeting
with a team of staff including the infection prevention and
control coordinator and members of the infection prevention
and control committee. He continued the tracer by focusing
on a resident with a facility-acquired urinary tract infection
(UTI) and by going to the area where that resident resided.
During the meeting with the infection prevention and
control committee representatives, the surveyor asked the
committee members to introduce themselves and to explain
their roles in the group. Present were the infection prevention
and control coordinator, the medical director, director of
nursing, a physical therapist, the housekeeping director, the
administrator, and the food service director. The group told
the surveyor that the infection prevention and control coor-
dinator collects clinical data regarding infections in the
organization by receipt of reports from the laboratory and by
notification by nurses and doctors of residents with known
or suspected infection. She also conducts surveillance rounds
and collects additional information during these tours to the
residents’ areas.
The surveyor asked the committee members if they also
identify infection prevention and control risks and collect
data in their respective areas of responsibility. The environ-
mental facilities representative and housekeeper indicated
that they make rounds weekly and identify potential infec-
tion prevention and control risks as well as safety risks. They
use a “find and fix” approach and do not collect data or look
at trends. The infection prevention and control coordinator
Section 5. Tracer Exercises for Long Term Care
indicated that she occasionally makes rounds with them but
that she also does not collect this information. They
explained that when they think they have identified condi-
tions in the environment that could pose risk to infection
prevention and control, they either fix the condition immedi-
ately or they notify others who might have some
responsibility for the areas and conditions identified.
The group presented data to the surveyor regarding infec-
tions in the organization. The infection prevention and
control coordinator identified that she believed that UTIs
were not an uncommon infection among the long term care
residents. The committee members identified that they were
aggressively focusing on early identification of potential risks
and a proactive approach to preventing UTIs. The surveyor
decided to continue the systems tracer on the resident care
unit with the highest current incidence of UTIs. The director
of nursing, physician, and infection prevention and control
coordinator accompanied him to the unit.
The surveyor first met with director of nursing on the
selected resident area. He asked her to identify the types of
residents cared for in the designated area and to talk about
those residents who had known or suspected UTIs. The
nurse identified that there were 45 residents on the unit and
that most of them were not ambulatory. She explained that
prevention of UTIs in this resident population was a chal-
lenge, as many of the residents were also incontinent. She
indicated that the rates were much higher the year prior, but
that they were focusing on reduction of indwelling catheters
and were also implementing aggressive toileting programs for
the residents. The surveyor toured the area with the director
of nursing and observed residents being ambulated with
assistance. He interviewed a certified nursing assistant and
asked her if she had received any information regarding the
prevention of UTIs. She said that she noticed that not as
many residents seemed to have indwelling catheters, but that
to her knowledge nothing else had changed. She did indicate
that she tried to toilet residents when it was possible, but that
many of them were incontinent and therefore needed to
remain in incontinence briefs.
The surveyor asked to meet with a nurse that was caring for a
resident with a recent UTI. The surveyor asked the nurse if
the interdisciplinary team had met to discuss this and if this
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had been addressed in the resident’s plan of care. The written
care plan indicated that there was recent revision to the plan
for treatment and prevention of recurrent UTIs. The inter-
ventions included getting the resident out of bed and offering
her the bedpan at least every two hours. The resident also was
to be encouraged to drink more liquids. The surveyor also
met with the resident. The resident indicated that she had
had several UTIs over the last year, but that she informed the
staff when she thought that the current UTI was reoccurring.
She said that she could not independently ambulate and that
she was dependent on staff to get her to the bathroom, but
that they were very busy and sometimes could not get her to
the bathroom on time. She said that she was generally placed
in “diapers,” but that staff members were currently trying to
get her to the bathroom on a more frequent schedule so that
she would not need to rely on the “diapers.” She still was not
fully confident of her ability to get to the bathroom in a
timely manner to “prevent accidents.”

Sample Tracer Questions

Questions for the Infection Prevention and Control Committee:

• What are the mission and function of the infection control committee?
• Have you received education and training regarding infectious disease risks and prevention of infections?
• What is your incidence of health care–acquired infections?
• What data are being collected, and how are they analyzed?
• With whom is this information shared?
• Have you identified high-risk indicators for study and analysis?
• Does your committee focus on all risks to infection prevention and control, including environmental and food borne as
well as clinical risks?
• Do you identify trends and patterns?
• Do you have an infection control plan, and can you review it with me?
• How is the plan developed, and how frequently is it reviewed and revised?
• Do you also look at antibiotic usage related to infection control activities?
• Do you as a committee work with staff in the organization to identify and reduce the rates of infection?
• What is your focus on hand hygiene, and how do you monitor it?
• Do you have data regarding hand hygiene compliance?

Questions for the Direct Care Staff:

• Are all staff educated regarding infection prevention and control during orientation?
• Do you receive ongoing education and training regarding infection prevention and control?
• Are you aware of infectious disease trends or patterns?
• What interventions do you implement to reduce the potential for UTIs?
• Do you know if these interventions are effective? If so, how do you know?
• Do you include infection prevention strategies on your resident plans of care?
• How often and when do you revise plans of care based on potential risk or evidence of infection?

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 Section 5. Tracer Exercises for Long Term Care

• Who do you notify when you believe you have identified an infection?
• Do you receive reports from the infection prevention and control committee, and are you aware of its focus and
activities?

Questions for the Resident:

• Have you been taught about hand hygiene?
• Have you observed doctors, nurses, and other employees washing their hands before and after they care for you?
• Have you been told that you have an infection?
• Do you know how your infection is being treated?

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 Mock Tracer Workbook
Exercise 5-6. Infection Control System
Tracer in a Long Term Care Facility
Summary: In the following scenario, a surveyor conducts an
infection control system tracer in a long term care facility,
where he explores issues relating to the Priority Focus Areas of
• Infection Control
• Communication
• Medication Management
• Patient Safety
Scenario
The surveyor conducted an infection control system tracer in
a long term care facility that treated long term care residents
as well as subacute and rehabilitation residents. The facility
has two resident care units for ventilator-dependent residents.
The surveyor started the tracer with a sit-down meeting with
the infection prevention and control coordinators and
members of the infection prevention and control committee.
He then continued the tracer by focusing on a resident with
a ventilator-associated pneumonia and visiting the resident
care unit where that resident resided.
The infection prevention and control team was asked to
describe the types of residents they treat in the facility and to
identify any types of residents who pose particular challenge
regarding infection prevention and control. The team
members said that they dealt with the typical nursing home
types of challenges, such as urinary tract infections and pneu-
monias. But they said that a unique challenge was related to
the number of ventilator-dependent residents that they
treated. Some of the ventilator-dependent residents were long
term residents who could not be weaned, and others were
residents that had active weaning programs and were gener-
ally shorter-stay residents. The team members explained that
they had two infection control coordinators: one who prima-
rily focused on the short-term and subacute population and
one whose focus was on the long term care population. Both
collected data and reported to the infection prevention and
control committee, which meets bimonthly.
The infection prevention and control coordinators were
asked to present their data from the prior year and to discuss
the trends and challenges that they had identified. The coor-
dinator for the subacute program presented data showing
that the organization had an increase in ventilator-associated
pneumonias and that he was working actively with staff on
the ventilator units to analyze the data and to identify
98
improvements that could be made to reduce the occurrence
rates. The residents posing the highest challenges were those
that were difficult to wean and those who were on ventilators
for more than one week. Generally the organization was iso-
lating Pseudomonas.
The surveyor asked the laboratory representative to identify
the laboratory’s involvement in reporting the results of blood
and sputum cultures. The physician was asked to talk about
early detection and antibiotic usage. Nursing staff were asked
to discuss their approach to early detection and prevention.
They explained that they were meeting as an interdisciplinary
team to address this issue and that they believed they were
beginning to see early signs of a turnaround in their
numbers.
The surveyor selected as a tracer a resident with a ventilator-
associated Pseudomonas infection who resided on a ventilator
unit. Some members of the committee accompanied him to
the unit where the resident resided. The respiratory unit was
a 12-bed unit, comprised of four rooms with 2 beds each and
four private rooms. The resident being traced was in a semi-
private room with another resident who also had
ventilator-associated pneumonia.
The surveyor observed care and treatment of the resident,
including the administration of intravenous antibiotics and
suctioning. He also observed family members as they entered
the room and sat with the other resident in the room. She
watched staff and visitors enter and leave the rooms of resi-
dents who were on isolation.
The surveyor then asked the nurse and any other members of
the care team who were present to meet with him and to
review the resident’s record. The nurse, respiratory therapist,
and physician met with him and discussed and reviewed their
assessments and their written plan of care for this resident as
it related to the current infection.
 Section 5. Tracer Exercises for Long Term Care

Sample Tracer Questions

Questions for the Infection Prevention and Control Coordinators:

• How do you stay current regarding infection control knowledge and information?
• How do you obtain your information regarding emerging infectious disease challenges and appropriate and current pre-
vention techniques and interventions?
• Do you educate the members of the infection prevention and control committee and also members of the staff regard-
ing current trends and knowledge?
• What tools do you use to analyze your data?
• Please share your data and analysis for the current year.
• Please identify and discuss the greatest infection prevention and control challenges you are seeing in your facility.
• Do you monitor hand hygiene compliance?
– Can you show me your data and analysis?
– What are the challenges identified?
– How is your compliance?
– What are you doing to improve compliance and understanding?
• Do you work with the laboratory, pharmacy, and physicians?
• How does your occurrence of ventilator-associated pneumonias compare among your ventilator units, and how does it
compare to other organizations with similar populations? Do you benchmark your data?

Questions for the Infection Prevention and Control Committee Members:

• What is your role on this committee?
• How do you communicate with the staff regarding infection control?
• Do you share data with staff, and do you help them to understand the data analysis?
• Do you have an infection prevention and control plan, and if so, how is it developed?
• Have you identified trends in the facility, and if trends are identified, how are they studied?
• Are you a role model for good infection prevention and control compliance, and how do you support compliance
throughout the facility?

Questions for the Staff on the Resident Care Unit:

• How is this unit staffed?
• What is the ratio of nurses to residents?
• Can you explain your isolation procedure and process?
• Are family members educated and advised regarding hand hygiene and compliance with isolation procedures? What
have they been advised to do to ensure compliance?
• Please show me your documentation of education for residents and families.
• Are you aware of the current trend in this facility regarding ventilator-associated pneumonia?
– Are you involved in studying and analyzing the process?

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– Have you made any changes and improvements to your processes and interventions?
– Have the changes made a difference, and if so, are you able to sustain this?
– How do you know if incidences and outcomes have improved?
• Please review your assessments and plan of care for this resident as they relate to the infectious disease process?
– How often are the assessments and plan of care reviewed and revised?
– Is it an interdisciplinary plan? What members of your team are involved in the care-planning process?
• What are your long-range and short-range goals and plans for this resident?

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Medication Management System Tracer Exercises for Long Term Care
Exercise 5-7. Medication Management
System Tracer in a Long Term Care
Facility
Summary: In the following scenario, a surveyor conducts a
medication management system tracer in a long term care
facility, where he explores issues relating to the Priority Focus
Areas of
• Communication
• Medication Management
• Patient Safety
Scenario
The surveyor conducted a medication management system
tracer in a long term care facility that had both short-term and
long-term residents. He first met with the pharmacy director
and members of the pharmacy and therapeutics committee and
then selected a complex resident to trace following the
sit-down meeting.
The surveyor asked the committee representatives to discuss the
role of the pharmacy and therapeutics committee and to discuss
their roles on this committee. They were also asked to share
data and analysis regarding the reporting of errors, systems
breakdowns, near misses, and overrides. Data was presented
and trends were identified. The committee representatives said
that they always focus on medication error rates, but that the
individual departments, such as nursing, addressed these issues
within the departments.
The surveyor then asked the representatives which issues posed
the greatest number of medication management–related chal-
lenges. They explained that a key area of focus was to address
polypharmacy and to try to reduce of the number of medica-
tions per resident. They said that many of their residents
received more than 20 medications, and they were trying to
qualitatively determine if and how many medications could be
systematically removed from the patients’ profiles.
The surveyor went to the pharmacy to meet with pharmacy
staff and to observe the process of filling prescriptions. While
there, the surveyor also observed the storage and preparation of
medications. Pharmacy staff told the surveyor that pharmacy
technicians prepare the medications, but that the medications
are signed out by pharmacists before being sent to the resident
Section 5. Tracer Exercises for Long Term Care
care units. The surveyor asked the staff if they identified any
near misses and if they collected and analyzed data regarding
errors and near misses.
The surveyor then went to a resident care unit and met with
nursing and medical staff to discuss their involvement in the
medication management process. He asked staff to explain their
process for addressing issues related to polypharmacy drug use
and asked if they were aware that this was a focus of the phar-
macy and therapeutics committee. The surveyor then asked the
staff to identify a resident on their unit who was on more than
20 medications and to review the medication ordering process
and profile with him.
The resident selected was a long term resident who had been in
the facility for more than three years. Staff said that the resident
had multiple diagnoses and comorbidities, including diabetes, a
history of stroke, a recent hip fracture secondary to a fall, and
pain resulting from this fall. Staff also said that he had a history
of depression. The surveyor asked staff to review the medication
profile. There were a number of medications that the resident
was taking that staff believed could not be eliminated. But staff
also were able to identify some redundant medications that they
said could potentially be reduced. The surveyor asked them to
review the medication reduction process and asked if these
endeavors are generally undertaken as an interdisciplinary
review and plan. Staff also were asked if they considered other
alternatives to any of the medications, such as positioning or
activities in lieu of pain medication or diet and ambulation to
assist with diabetes management.
Staff indicated that they were definitely focusing on alternatives
to pain medication and that they were working with therapy
staff to learn massage and alternative positioning techniques.
They said that they have not collected any data to see if this
was effective, but they believed that it did contribute to their
ability to reduce the types of medications they were administer-
ing for pain to the selected resident and other residents. They
said that therapy staff also come to their unit to help provide
some of these new massage and positioning techniques.
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Sample Tracer Questions

Questions for the Pharmacy and Therapeutics Committee Members:

• Can you explain the continuity of your medication management process, from procurement of medications through moni-
toring of usage and effectiveness?
• Can you explain your medication reconciliation process and requirements?
• Can you tell me about the mission and focus of the pharmacy and therapeutics committee?
• What is your role on this committee?
• What medication management trends have been identified that you believe require focused review and improvement?
– What are you doing to address these trends?
– Have you made a difference?
– How do you know?
• Where are intravenous medications mixed?
• Who is involved in reviewing the appropriateness of medications for each resident?
– How is that data shared and with whom?
– Do you focus on the number of medications per resident, and are you working with prescribing staff to
potentially educe the number of medications?

Questions for Pharmacy Staff:

• Do you have any medication errors or discrepancies that originate in the pharmacy?
• Do you have any near misses, and do you collect and analyze data regarding your near misses?
• How do you ensure that safe dosing is prescribed for the residents, and what do you do if you have identified a potentially
unsafe dose or medication?

Questions for Clinical Staff:

• Do you have any medication errors on this unit?
– How do you identify medication errors, and how do you report them?
– Do you also identify near misses, and are these also reported?
• How is information handed off from one caregiver to another or from one unit to another?
• Do you work as a team to focus on appropriate medication management for your residents?
• Do you educate residents regarding their medications?
– Do you document this education and the resident’s involvement in the medication management program?
• Can you show me where you store medications?
• Do you mix intravenous preparations on this unit? If so, which ones do you mix, and where do you mix them?
• Do you have a plan to reduce the number of medications for this resident?
– How is that done?
– Do you track the safety and effectiveness of your medication reduction endeavors?
• Have you considered alternatives to some of the resident’s medication, such as diet, ambulation, activities, or positioning?
Anything else?
• Are you looking at qualitative as well as quantitative reduction of medications?
• How are you working with other disciplines to provide alternative therapies and approaches to resident care?

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Exercise 5-8. Medication Management
System Tracer in a Nursing Home
Summary: In the following scenario, a surveyor conducts a
medication management system tracer at a nursing home,
where she explores issues relating to the Priority Focus Areas of
• Assessment and Care/Services
• Medication Management
• Patient Safety
Scenario
The surveyor conducted a medication management system
tracer in a nursing home. She first met with the medical
director, director of nursing, and the administrator and then
selected a process to trace following the sit-down meeting.
There was no in-house pharmacy in this facility, and it relied
on an outside pharmacy to fill prescriptions and to provide
medications. The pharmacist who services this facility was
invited to attend the meeting with the surveyor. A separate
agency provided drug regimen reviews, and the pharmacist
who provided this function was also invited to attend the
meeting.
The surveyor asked the committee representatives if they
have a defined formulary, and if so, how this is developed
and reviewed. They explained that they have a formulary and
that they work with the pharmacy to ensure that all medica-
tions on the formulary can be provided. The surveyor also
asked the representatives if medications are available on an
around-the-clock basis. It was explained that the pharmacy is
open from 7:00 A.M. until 10:00 P.M. six days a week, and
that it provides the 24-hour dosages needed, as well as stock
medications. The care units also store emergency backup
medications in a lock box in the nursing office. The nurse on
duty during those hours has access to this lock box. If other
medications are needed that are not readily available, they
would either be deferred until the morning or a pharmacist
on call would be accessible to prepare and provide the needed
medication. If there is a true emergency that could not wait,
the nearby hospital also is available to provide off-hour med-
ications. In that case, the order would be called in and
security would be used to pick up and deliver the medica-
tion. Staff indicated that they could only recall needing to
rely on the hospital for this service once or twice during the
last year.
Section 5. Tracer Exercises for Long Term Care
The surveyor asked for their data regarding off-hours medica-
tion use. The surveyor also asked about pharmacist oversight
of this process. The surveyor then asked to tour the facility to
observe areas for storage and preparation of medications, and
she also observed a medication pass. She was shown the lock
box in the nursing office. The box was locked and the key
was carried by the nurse on duty for each shift. An inventory
list was present, and the surveyor noted that it had been
signed off appropriately. The pharmacist indicated that this
area was checked when they also checked all medication
storage rooms throughout the facility. There were no con-
trolled substances stored in this area.
The surveyor went to the medication room, which was
unlocked with no staff present. The surveyor observed that
the nurse was administering medications to the residents
from a medication cart in the wing down the hall from the
medication storage room. Unsecured medications were
observed, however, on the counter, in an unlocked cabinet,
and in a refrigerator in this room. There were no other
authorized staff members in the vicinity that could have been
ensuring the security of these medications.
The surveyor then observed the nurse dispensing medica-
tions. The nurse addressed the residents by their names and
then gave them their medications. She was not observed to
use the two resident identifiers. When queried, she said, “Oh
I know these residents very well.” The surveyor asked her if
she knew what the required two resident identifiers were and
also if she knew when they should be used. The surveyor also
asked her if she would use them for an unfamiliar resident.
The nurse also was observed to use alcohol-based gel for
hand hygiene before and after preparing medications. But she
poured the medications into some of the residents’ hands,
and did not ask them to first cleanse their hands.
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Sample Tracer Questions

Questions for the Medical Director and/or Director of Nursing:

• Can you explain the continuity of your medication management process, from procurement of medications through
monitoring of usage and effectiveness?
• How do you ensure that you have all of the medications you need whenever you need them?
• What kinds of issues or risks have you identified that require further study and improvement?
• What is the system for pharmacist oversight when medications are ordered and dispensed during off-hours?
• What is the expectation for response time when an on-call pharmacist is called?
• Does the pharmacist inspect the medication storage areas?
– What kinds of discrepancies or problems have been identified?
– Do you maintain data on these inspections, and have you analyzed this data?
– What do you do with the findings and analysis?

Questions for Nursing Staff:

• How often must you request the service of the on-call pharmacist?
• How quickly does the on-call pharmacist respond?
• Who cleans the medication rooms? Please explain the required process.
• Do you ever need to obtain medications from the hospital?
– Can you explain how the medications are then prepared and delivered to the nursing home?
– How long might preparation and delivery take?
• What are the two resident identifiers that are used when administering medications?
• When should these two identifiers be used?
• What must you do to ensure the security and safe storage of medications at all times?
• Do you ever mix intravenous medications on this unit? How and where is that done?
• How do you ensure that medications are distributed to residents in a clean and sanitary way?
• Do you educate residents regarding their medications?
• Is this education documented, and can you review this with me following your medication pass?

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Resident-Centered Care Program-Specific Tracer Exercise
Exercise 5-9. Resident-Centered Care
Program-Specific Tracer in a Long Term
Care Facility
Summary: In the following scenario, a surveyor conducts a
resident-centered program-specific tracer at a long term care
facility, where she explores issues relating to the Priority Focus
Areas of
• Assessment and Care/Services
• Communication
• Rights and Ethics
Scenario
The surveyor conducted a resident-centered care program-
specific tracer in a long term care facility. She met with staff
to review the types of residents cared for in the facility and
selected an 85-year-old long term care female resident with a
history of stroke and left-sided hemiparesis. The resident was
able to speak and communicate, but her speech was slightly
slurred and slow. The resident was confined to a wheelchair
and was not able to self-propel or ambulate without assis-
tance. She could walk a short distance with a two-person
assist. She had bowel and bladder incontinence. The resident
had been in the facility for four months. Prior to her stroke
she had lived at home independently.
The surveyor asked staff to ask the resident if it would be all
right for the surveyor to meet with her and to track some of
her care and experiences in the facility. She said that she
would be happy to meet with the surveyor. The surveyor met
with the resident in her room and asked her to tell her about
her condition and about the care and treatment she received
in the facility. The resident said that she had had a stroke at
home approximately four months earlier and that she was
able to call for help from home and was brought to the local
hospital where she was originally cared for. She then came to
this facility for stroke rehabilitation. She said that she had
received occupational, physical, and speech therapy. Her left-
sided weakness continued, and it was ultimately decided that
she would remain in this facility for long term care. She said
that she realized that she could no longer support herself at
home, and she was happy with the care she received here, so
she determined that this would be the best long-term place-
ment for her. She spoke slowly, but her speech was
understandable.
Section 5. Tracer Exercises for Long Term Care
The resident said that the nurses provided good care to her
and that they were friendly and generally treated her with
respect. She said that occasionally someone would be “curt,”
but that this was not the norm. She also said that sometimes
she had to wait longer than she would like for someone to
respond to her call bell, but that the facility was short-staffed
and there were other residents that were needier than her, so
she understood. She had full confidence that staff would be
able to respond to an emergency if she had one. She knew
her doctor and was happy with the doctor, but was surprised
at how infrequently she actually saw her doctor. She said that
she had thought that “If you are in a nursing home, you
would see your doctor every day.” She said that no one told
her how often she should expect to see her doctor.
The surveyor asked the resident if she was aware if there was
a resident council in the facility, and if so, if she was involved
with it. She said that there was a resident council and that
she tried to attend the meetings. She said sometimes it was
difficult to attend, because she could not always get someone
to transport her to the meetings, but that she did try to
attend. She said she thought the council meetings were pri-
marily “complaint sessions,” but that residents also were
given follow-up reports to their complaints. She said that she
thought some things, such as food, were improving as a
result of these resident council meetings.
The surveyor also asked the resident about what she liked at
the facility and what she would like to see improved. She said
that the activities program was good. She also said that the
activities in the nursing home were sometimes good and
interesting, especially the games and crafts programs. She said
that the food was not so good, but she really believed that
the facility was trying to improve the food and that some of
the meals and preparations were beginning to improve.
The nursing aide told the resident that it was time for her
ambulation, and the surveyor asked the resident if it was OK
with her if she observed her care. The resident said that
would be fine. She was walked from her wheelchair approxi-
mately halfway down the hall and back. She used the
ambulation rail on the corridor, but it was blocked by linen
carts and other wheelchairs, and she seemed to struggle when
the aides guided her away from the rail. The surveyor then
reviewed the resident record with the nurse and focused on
assessments, plan of care, and the interdisciplinary process.
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Sample Tracer Questions

Questions for the Resident:

• Can you tell me about your care and treatment here?
• What issues would you like to see improved?
• What are you happy with?
• Do you feel safe here?
• Do you feel that you are treated with dignity and respect?
• Do you feel you receive the information you need about your care and treatment options?
• Do you have the opportunity to socialize with other residents?
• Are you satisfied with the activities options, and do you participate in activities programs?
• How can you get help when you need it?
– Are you satisfied with the response?
– Are you satisfied with the response time?
• If you have a complaint or concern, to whom would you report it?
• Do you feel safe if you report a concern?
• Do you believe that your concern is taken seriously and is addressed?

Questions for the Nurse’s Aide:

• Are you aware of the resident’s plan of care, and do you participate in team meetings regarding the resident's plan of
care?
• Have you received training regarding the safe and appropriate way to ambulate residents?
• Can you get help and assistance if and when you need it?
• Do you believe that your assignments allow for you to provide the amount of time and care needed to each of the resi-
dents to whom you are assigned care?

Questions for the Nurse:

• How do you communicate the residents’ needs to the nurses’ aides?
• Who is involved in the development of and revisions to the plans of care?
• How can you assure that residents can attend meetings and activities sessions that they are interested in?
• Do you meet and speak with all residents and/or their families regarding their perceptions of care?
• How would you address resident concerns or complaints?

Questions for the Recreational Therapist (Facilitator of the Resident Council):

• Is the resident council self-governing?
• What kind of attendance do you get at resident council meetings?
• What do you do to increase attendance and to make residents aware of meetings?
• Are you involved in arranging for transport of residents to and from meetings?
• How do you involve residents who cannot attend the meetings?

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Questions for the Dietitian:

• How do you determine resident satisfaction with food?
• Do you ever attend resident council meetings?
• Have you made changes and improvements as a result of resident feedback?
• Have the changes made a difference, and how would you know?
• Have you reported back to residents when you make changes as a result of their requests and concerns?

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Staffing Program-Specific Tracer Exercise

Exercise 5-10. Staffing Program-Specific
Tracer in a Long Term Care and
Rehabilitation Facility
Summary: In the following scenario, a surveyor conducts a
staffing program-specific tracer at a long term care and reha-
bilitation facility, where she explores issues relating to the
Priority Focus Areas of
• Staffing
• Orientation and Training
• Communication
Scenario
The surveyor conducted a staffing program-specific tracer in
a long term care and rehabilitation facility. She first met with
a small group of the organization’s leaders, including the
administrator, the human resources director, the director of
nursing, and the program directors for long term care and for
the short-term rehabilitation programs.
The surveyor asked the leaders to talk about how they deter-
mined appropriate staffing for the facility, including the right
number as well as the right mix of staff. They were also asked
to share and explain their staffing plans. The surveyor also
asked if leaders had difficulty filling required positions, and if
so, in which disciplines. She asked them to speak about their
recruitment strategies.
The surveyor met with several residents. When the residents’
families were present she also interviewed the family
members. She asked them to talk about their satisfaction
with staffing and with the way they were treated by staff. She
asked them to talk about their confidence in the abilities and
responsiveness of staff. They were asked if they are generally
treated and cared for by the same staff or if there are fre-
quently new faces and personnel. They generally indicated
that they knew most of the staff and that when new ones
were present they felt confident that knowledgeable staff
members were available as backup. The residents on the
short-term units indicated that there generally seemed to be
adequate numbers of competent staff. But the long term care
residents and families indicated that the nurses’ aides seemed
overworked and that there did not seem to be enough
“regular” nurses always available. They said that they often
had to wait a long time or ring their call bells multiple times
before they got adequate response. They said that often
someone would answer and say, “Someone will be with you
shortly,” but that no one would actually come for a long
time. The surveyor asked them if they were comfortable in
reporting concerns and to whom would they report these
concerns. She asked if they were comfortable with the orga-
nization’s channels for reporting concerns and with the
response and follow-up to these concerns.

Following the meeting with leaders, the surveyor met with

some individual staff members, representatives of the clinical
and support staff. She also met with an agency nurse on a
long term care unit. She asked each of these staff members to
explain their jobs and to tell her how long they have worked
in the facility. She asked them to explain how they were ini-
tially oriented and if they received ongoing education and
training. She also asked them to talk about their relationships
with other staff and how they were able to ensure effective
communication with other staff and also with the residents
and their families.

The surveyor also asked staff to explain the reporting require-

ments for near misses and potential sentinel events. She also
asked them if they were ever involved on any teams or com-
mittees to address resident safety issues. Staff members were
also asked about their knowledge and training regarding per-
formance improvement and resident safety.

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Sample Tracer Questions

Questions for the Leadership Group:

• How do you ensure that you have the right number and right mix of staff to provide safe care and treatment through-
out your facility?
• Do you use agency or contract staff?
– For what services are they used?
– How often are they used?
– Do they receive orientation and ongoing training and in-service education?
– Who provides this training and education to the agency staff?
• Do you have a staffing plan? Describe it to me.
• Do you have frequent staff turnover?
– How does that impact resident care, safety, and outcomes?
• Do you have mandatory overtime? How frequently must you rely on overtime usage?
– How does that impact resident care and outcomes?
• How are staff made aware of changes to policies and procedures and to other organizational requirements?
• Are you experiencing staff shortages in any disciplines?
– If so, how do you still ensure safe resident care and treatment?
– What are you doing to address these shortages and difficulties in recruitment?
• How do staff cover for potential staff shortages?
• Do you conduct resident and family satisfaction surveys and staff satisfaction surveys?
– Do you ask questions regarding staffing-related issues?
– How do you address concerns brought up by these efforts?

Questions for the Residents and Families:

• Do staff members introduce themselves to you?
• Do you generally know the staff members who are caring for you?
• Do you feel that there are adequate numbers of staff available at all times of the day?
• Are you satisfied with response times when you ring your call bell or ask for assistance?
• Do staff members answer your questions and provide you with the information you need to understand your care,
treatment, and services?
• To whom would you speak if you are unsatisfied with staff response times or response to your needs and questions?

Questions for Staff:

• How do you communicate resident care needs and care from one caregiver to another? from one shift to another? How
about from one discipline or service to another?
• What is your training and support process for new nurses or other personnel?
• Are you trained regarding cultural sensitivity?
• Have you received training and education regarding quality and performance improvement?
– Have you been included and involved in any of these processes?

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• Do you know how to identify a sentinel event or a near miss, and do you know what to do if you have identified one?
• Do you have the opportunity to work with leadership regarding staff-related issues?

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Tips for Conducting Tracers in a Long Term Care Setting

Consider the following tips and strategies in conducting tracers in a long term care setting:

• Focus on issues of particular concern for long term care settings. Consider those issues that are of par-
ticular concern to resident safety, such as falls, elopement, or pressure ulcers, and use those to plan
specialized or focused tracers. Use some of the sample questions included in these tracer scenarios to frame
questions.

• Involve multiple staff. Encourage and involve as many staff as possible in tracer activity. When engaged in
the process, staff better understand how tracers can work and can lend important insight and perspective to
improvement efforts.

• Use these scenarios as a starting point. To gain familiarity with tracers, consider using these example
tracers as a guide and select residents to trace based on a similar background. The sample questions can
also be used as a guide.

• Use closed records. To help start the tracer process or to gain familiarity with it, use a closed record as a
training approach. In the same vein as an individual tracer, you can “walk through” the record as a way to
trace that resident’s experience. This will also provide you with an opportunity to trace a resident’s experience
through discharge, transfer, or death.

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Tracer Exercises for Laboratories
T
his section contains individual and program-specific
tracer exercises for laboratories. These tracers are
slightly different that the other sections because a
laboratory deals directly with patients during specimen col-
lection activities and conducts tests and works with other
departments of a health care organization to provide infor-
mation used to make decisions about a patient’s care. Each
exercise contains a scenario that represents what might
happen when a surveyor conducts that type of tracer in a lab-
oratory setting. Based on the scenario provided, the exercise
includes a list of sample tracer questions that might be asked
of the staff members involved in the testing process in the
laboratory. At the end of the section is a sidebar of tips that
Section 6
staff can consider when conducting their own tracer activities
in a laboratory.
Please keep in mind that each tracer is unique; the questions
asked during a tracer will vary depending on the individual
or system chosen to follow. No two tracers are the same.
There is no way to know all of the questions that might be
asked during a tracer, because the possibilities are limitless.
These exercises are examples to show how that type of tracer
can be conducted and to put the sample questions into
context. Use these tracer scenarios and sample questions as
educational or training tools for yourself and your staff, or
use them as a starting point to conduct your own tracers.
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Individual Tracer Exercises for a Laboratory

Exercise 6-1. Individual Tracer for a
Laboratory at an Acute Care and Long
Term Care Facility
Summary: In the following scenario, a surveyor conducts an
individual tracer at an acute care and long term care facility,
where he explores issues relating to the Priority Focus Areas of
• Communication
• Analytical Procedures
• Patient Safety
• Equipment Use
Scenario
The surveyor conducted this laboratory tracer in an acute
care and long term care facility. During the environment of
care tour of the laboratory, the supervisor of the microbiology
area identified a blood culture specimen that showed signifi-
cant growth during the 11:00 P.M. to 7:00 A.M. shift. The
surveyor chose this specimen and the owner patient as one of
the tracers during the survey.
A review of the medical record of this tracer patient revealed
that the patient entered the hospital through the emergency
department. Besides microbiology, the patient had tests per-
formed in the coagulation, hematology, and chemistry areas.
The surveyor chose to trace the blood culture, a Prothrombin
and the activated partial thromboplastin, and three analytes
from a basic metabolic profile (creatinine, chloride, calcium).
The surveyor reviewed all supporting documentation to
assure the validity of the test results for the month of testing.
In the chemistry area, the surveyor reviewed the quality
control and calibration records for the three analytes, as well
as the maintenance records for two other instruments.
Because the interlaboratory comparative data allowed the
viewing of a year’s worth of information, he noticed there
was a problem with chlorides for three consecutive months
(none of which were the month of the tracer patient’s
testing).
The surveyor asked the chemistry supervisor how they would
investigate the quality control values for June, July, and
August. Except for contacting the quality control manufac-
turer to see if it noticed a shift, the supervisor said that no
other investigation was conducted. Since in September the
mean returned to the level that had been obtained in May
and before, the surveyor indicated that those three months
may need investigating.
The surveyor asked for the data from the second instrument
and found that its mean shifted as well. That meant that
there was not an instrument problem. The pathologist joined
the discussion and immediately went to the computer to pull
data that gave the patient mean chloride values before,
during, and after the June, July, and August quality control
shift. There were no differences in patient mean chlorides.
The surveyor asked the staff what their policy was on investi-
gating quality control shifts.

The surveyor asked to review the quality control records for

the cards used on the instrument that was used to identify
the organism(s) growing in the blood culture. He also asked
for the quality control for the media, Gram stains, and bio-
chemicals used during that month. He also reviewed the
incubator temperatures, the maintenance of the Vitek, and
carbon dioxide validation records.

In the coagulation area the surveyor looked at the quality

control for the month of testing and also asked for the
normal patient study for the current lot number of pro-
thrombin reagent. The surveyor asked the staff what their
quality control processes were.

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Sample Tracer Questions

Questions for the Laboratory Manager:

• What is your process for maintaining quality control in the laboratory?
• Can you describe your process for assessing any changes in quality control?
– How are you tracking for changes or shifts?
– How do you investigate and/or report these shifts?
– What do you do in the event of a shift?
• What kind of training and orientation are provided to laboratory staff in relation to quality control and investigating
shifts?
• How do you communicate changes or issues to staff?

Questions for Laboratory Staff:

• Can you tell me your quality control process for this equipment?
• How do you report variation?
• What process do you follow when investigation may be warranted?
• Please describe your documentation process.

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Exercise 6-2. Individual Tracer for a
Laboratory at a Hospital
Summary: In the following scenario, a surveyor conducts an
individual tracer for a laboratory at a hospital, where he
explores issues relating to the Priority Focus Areas of
• Information Management
• Analytical Procedures
• Patient Safety
• Assessment and Care/Services
• Equipment Use
Scenario
The surveyor conducted this tracer during a laboratory survey
at a hospital. This organization also provides ambulatory care
services at a nearby facility, including outpatient transfusions.
The surveyor selected this tracer from a number of suspected
transfusion reaction workups that had been conducted by lab-
oratory staff during the previous six months.
The patient was a 63-year-old woman who was currently
receiving chemotherapy and frequently required transfusions.
On this occasion the physician had ordered two units of
packed cells because the patient’s hemoglobin was 6.2 grams.
The type- and cross-match was performed by the laboratory
early in the day, with plans to administer the two units at the
ambulatory care center later that day. In addition, the labora-
tory performed a chemistry profile, a thyroid profile, and a
complete blood count (CBC).
The surveyor began the tracer by reviewing the closed medical
record. The surveyor reviewed the record with the laboratory
director, the quality improvement specialist, and the nursing
supervisor. He asked the staff to review all laboratory testing
performed on the tracer patient with him, not just the initial
reason for tracer selection.
The patient received the first unit of packed cells without
demonstrating any signs and symptoms of a suspected transfu-
sion reaction according to the organization’s own policy.
During administration of the second unit, nursing docu-
mented a rise in the patient’s temperature of 2.5 Fahrenheit
(1.4 Celsius), and a suspected transfusion reaction response
was initiated. Nursing continued to monitor the patient’s vital
signs, and the patient’s temperature continued to rise to more
than 4 Fahrenheit (2.2 Celsius)—even though the administra-
tion of the blood had been discontinued. As part of the
116
laboratory’s protocol, the laboratory was notified of the sus-
pected reaction. The attending physician made the decision to
have the patient transferred from the ambulatory care center
to the hospital emergency department via ambulance. On
arrival at the emergency department, the emergency physician
ordered a basic metabolic panel (BMP) and CBC.
The surveyor then visited hematology and asked for instru-
ment maintenance on the hematology analyzer for the day of
testing. Staff showed him the daily start-up and shutdown
documentation. They were able to identify all lot numbers of
reagents used on the analyzer for this time period. This labo-
ratory’s policy was to run all three levels of quality control
every 8 hours. The surveyor reviewed the appropriate quality
control records. The first 8-hour period indicated that the
normal control level was performed with results that
exceeded that laboratory’s 2 standard deviation (SD) quality
control range. The normal control was repeated and the tech-
nologist had documented appropriate corrective action. The
laboratory submitted quality control results monthly to the
instrument vendor for interlaboratory comparison. The sur-
veyor reviewed the report for this month, and all data had
agreed with peer data. Calibration of this hematology ana-
lyzer was performed every six months, and the hematology
supervisor was able to show the surveyor the data.
The surveyor was able to speak to the technologist who had
performed the BMP on the tracer patient during the emer-
gency department visit. The technologist told the surveyor
that two levels of quality control material were run every 24
hours for analytes performed on the chemistry analyzer.
Typically quality control was performed on the third shift;
however, on the day the tracer patient was tested, a new lot
of reagents had been started for glucose, and quality controls
had been repeated after calibration of the new lot number.
Each month data from quality control were submitted to the
quality control vendor for interlaboratory comparison. The
chemistry supervisor located the file and presented it to the
surveyor for review. For the particular month when the tracer
patient was tested, creatinines were running slightly higher
than the peer group. A service call had been initiated on this
analyzer, and the surveyor reviewed a report left by the
service representative. Apparently the service representative
had to replace a part that he felt had caused a certain amount
of carryover between samples and probably caused the eleva-
tion that had been noticed when the data were compared to
the peer group. As part of the monthly quality control review,
 Section 6. Tracer Exercises for Laboratories

a summary of the quality control data, interlaboratory com-
parison data, and maintenance records was reviewed by the
laboratory’s administrative director and the medical director.
This report included documentation of a discussion of the
elevated creatinine results. The medical director had deter-
mined that this creatinine elevation was not significant
enough to consider reviewing patient results. The surveyor
reviewed data reports that showed verification of the
reportable ranges currently in use. Daily maintenance was
reviewed for the day the tracer patient was tested, and evi-
dence was provided for the results of the daily absorbance
testing. This analyzer had been purchased by the laboratory
since the previous survey, and appropriate method validation
documentation was available for review.
In the blood bank, the surveyor had a chance to review the
workup of the suspected transfusion reaction. The laboratory
had developed a workup form for the technologist to use. For
this particular tracer patient, the blood bank technologist had
documented a clerical check only. Although the laboratory
had a policy requiring a new patient sample to confirm the
blood group, Rh type, and direct antiglobulin test (DAT), a
post-transfusion sample had never been received. The tech-
nologist who had performed the workup said that he waited
for a sample but never received one. Upon further investiga-
tion, it was learned the ambulatory care facility had sent the
patient to the hospital’s emergency room for her continuing
post-transfusion symptoms and she had additional blood
samples collected. In the blood bank, the surveyor observed
the laboratory used gel technology for antibody screens. She
also noted the blood bank’s information system was com-
pletely manual. The documentation was on cards and in logs.
The quality control was well documented. The laboratory
director indicated that the technologist could have searched
the laboratory information system to locate a sample that
may have allowed him to do the required testing. The sur-
veyor also noted that this suspected transfusion reaction was
not reviewed by the laboratory’s medical director for six
weeks after the reaction, even though the pathologist is avail-
able every weekday. Quality control records were reviewed for
the date on which the type and cross-match were performed
by gel technology. It was noted that the laboratory did not
test the gel card used for antibody detection with a known
negative daily as required by the manufacturer. The labora-
tory had all of the required temperature records, and a review
of recording graphs indicated that quarterly alarm checks had
been performed. All pipets used in the preparation of cell
suspensions had been calibrated on a semiannual basis.
Samples from antibody screens and cross-matches were rou-
tinely saved by the laboratory for 10 days. Unfortunately, no
one in the laboratory realized that the organization had
samples from this very patient and that their workup could
thus have been completed. As a result the medical director
was unable to make a definitive diagnosis, which normally
would have been included in the patient’s medical record.

Sample Tracer Questions

Questions for the Laboratory Director:

• Describe your process to deal with transfusion reactions.
• What training and orientation have you provided to staff to deal with these events?
• What data and analysis have you done on the incidence of transfusion reactions in your organization?
– What measures have you introduced, if any, to reduce the incidence of transfusion reactions?
• What initial assessment do you perform for new transfusion patients?

Questions for Nursing Staff:

• What is your assessment process for a new patient?
• Please describe your entire process for administering blood to a patient.

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• What do you do in the event of a transfusion reaction?

Questions for Blood Bank Staff:

• What is your organization’s process for handling a new patient?
• Can you tell me what your documentation process is?
– How is that documentation reported?
– If you have a question or a problem with documentation or necessary information, what do you do?
• Please describe your quality control process.

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 Section 6. Tracer Exercises for Laboratories

Exercise 6-3. Individual Tracer for a The surveyor then spoke to the nurse who transfused the
Laboratory at a Rural Hospital patient. The chart was reviewed for an order and informed
consent. The nurse described in great detail the process of
Summary: In the following scenario, a surveyor conducts an ordering, acquiring, and transfusing the blood. She was able
individual tracer at a rural hospital, where he explores issues to describe suspected transfusion reactions and the expected
relating to the Priority Focus Areas of actions should symptoms be observed.
• Information Management
• Analytical Procedures
• Communication
• Physical Environment
• Equipment Use

Scenario
The surveyor conducted this tracer at a rural hospital. While
awaiting the arrival of the chief executive officer and the lab-
oratory manager, the surveyor reviewed proficiency test
results. The regulatory review and the proficiency review
showed that the test menu was consistent with the applica-
tion and that proficiency scores were maintained at an
acceptable level.

The surveyor then conducted an environmental tour of the

laboratory. He noted that there was inadequate space in the
lab. He also noted that the blood specimen refrigerator con-
tained food and that a glucose beverage for patient
consumption was stored in a refrigerator alongside urine
specimens. He asked the chemistry technologist to describe
the policy relating to food in the laboratory. She explained
that the policy prohibited the storage of food or medications
in laboratory general refrigerators but that staff didn’t know
where else to store products such as food or the glucose bev-
erage in the laboratory.

The surveyor chose to trace a patient who was about to

receive blood, but as no patients were scheduled for a trans-
fusion, he reviewed the logbook and found two transfused
patients who were still in the hospital. Of these, he selected
an orthopedic patient who had experienced some complica-
tions in surgery. He began in the laboratory by interviewing
the phlebotomist regarding how compatibility test orders
were received. As the hospital had a paper-based system, the
phlebotomist described the paper requisition process and
produced the actual requisitions for the tests of the tracer
patient. During the discussion, the surveyor asked the phle-
botomist to show him the supplies she used to collect the
blood specimens from patients and to describe the identifica-
tion process she used. Her phlebotomy tray contained several
specimen collection tubes that were expired.

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Sample Tracer Questions

Questions for the Laboratory Manager:

• Describe your process for conducting proficiency testing.
• What is your process for ensuring an adequate stock of inventory for the laboratory?
• What kind of training and orientation do you provide to new staff?
• What is your policy regarding the use of space in the laboratory?
• Can you describe your process for correctly storing food and medications in the laboratory?
• How do you monitor quality control activities in the laboratory?

Questions for the Laboratory Staff:

• How do you receive orders for tests in the laboratory?
• How do you complete those orders?
• What is the policy on reporting a critical test result?
• What is the policy for storing food and medications in the laboratory?
• What do you do in the event of a quality control issue?
• Who is responsible for checking inventory supplies in the laboratory?
– What do you if you notice that a certain stock is getting low?
– How do you verify that the stock on trays is current?
– What is your quality control process for the trays?

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Laboratory Integration Program-Specific Tracer Exercises
Note: This kind of program-specific tracer is applicable only to
those laboratories, or laboratory departments, that are in a hospi-
tal or critical access hospital setting. This would not apply to
stand-alone laboratories. Although this is not a program-specific
tracer that applies across the board to all types of laboratories
accredited by The Joint Commission, it is one that could impact
laboratories within a hospital setting. The Joint Commission
describes the purpose of the laboratory integration program-spe-
cific tracer as to evaluate the consistent application of processes
related to laboratory testing throughout the hospital; to evaluate
the exchange of information (specimen collection, test results
including critical test results, specimen collection and handling,
specimen identification) and the integration of the laboratory
process in the hospital setting; and to identify hospital process-
and possibly system-level issues contributing to a lack of
integration.
Exercise 6-4. Laboratory Integration
Program-Specific Tracer at a Large
Community Hospital
Summary: In the following scenario, a surveyor conducts a
laboratory integration program-specific tracer at a large com-
munity hospital, where she explores issues relating to the
Priority Focus Areas of
• Organizational Structure
• Orientation and Training
• Communication
• Equipment Use
Scenario
A surveyor conducted this tracer at a large community hospi-
tal with a broad spectrum of services, including open heart
surgery, a large orthopedic service with tissue implantation,
and a full-service laboratory with multiple departments.
The surveyor selected a patient with a relatively long length
of stay. The tracer started in the intensive care unit (ICU).
The surveyor went to the unit to see the nurse manager. The
patient was a 62-year-old man admitted through the emer-
gency department for chest pain. In the emergency
department, physicians ordered a basic metabolic profile, a
cardiac panel, complete blood count (CBC), prothrombin
time (PT), partial thromboplastin time (PTT), and
urinalysis.
Section 6. Tracer Exercises for Laboratories
From the emergency department, the patient was immedi-
ately sent to cardiac catheterization, which was not
successful. During the case, there were no activated clotting
times (ACTs) performed. Blood gases were drawn and sent to
the cardiopulmonary lab. The patient was sent to the ICU to
prepare for a coronary artery bypass graft (CABG).
The patient was admitted to the ICU at 2:00 P.M. At that
time physicians ordered the general ICU admission profile—
a CBC, comprehensive metabolic profile (CMP), urinalysis,
magnesium, phosphorus, uric acid, lactate dehydrogenase
(LDH), and cholesterol. Also, four units of fresh frozen
plasma (FFP), six units of packed red blood cells (PRBCs),
and two “super packs” of platelets were ordered.
The patient had surgery the next day. He used only two units
of FFP and one super pack unit of platelets. No PRBCs were
used so they were returned to inventory. During the case,
seven ACTs were performed. Numerous blood gases were
performed, again by sending specimens to the cardiopul-
monary lab.
During his recovery, the patient had a number of blood cul-
tures drawn, all of which were negative. He also had sputum,
urine, and stool cultures performed. All of those were nega-
tive as well. He was discharged from the ICU and had an
uneventful recovery.
The surveyor observed that the test result reports from both
the central laboratory and the cardiopulmonary lab were
acceptable. They properly identified the location of the
respective laboratories, the test name, and dates and times of
testing. The reference ranges and units were all correct.
There was one critical value for a prolonged PTT. The facil-
ity had a form in the patient record where critical values were
expected to be recorded. There was no documentation in this
patient’s medical record of that critical value. After looking
closely at the issue, and with much discussion, the staff
explained that because the patient had a CABG, he would
have been on a heparin protocol, and as such, the organiza-
tion did not require documentation. In this case, the proper
place was in the nurses’ notes, which is where they found the
notation.
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In the laboratory, the surveyor continued the tracer by
observing blood gases. The surveyor visited the cardiopul-
monary lab, where she found that the instruments were well
maintained. She reviewed preventive maintenance, automated
quality control, instrument calibration, and correlation.
These were all acceptable. The proficiency testing had been
reviewed by the surveyor at the outset of the survey. The
results were graded at 100% for the past two years.
Inside the laboratory, the survey started with routine hema-
tology and chemistry testing. The activated clotting time
records from the cardiac catheterization lab were reviewed.
The surveyor found the equipment maintenance, tempera-
ture checks, and routine documentation were well done. She
observed that the quality control for CBCs was suboptimal.
The hematology lead tech indicated that calculated data was
previously used for quality control limits, but that he was
currently using manufacturer’s assayed limits because it was
easier this way.
and procedure to ensure that the process runs smoothly as
they have noticed that there have been incidences of delay or
missed communication in the past in relation to communica-
tion. She also noted that the laboratory has been collecting
data on slower than benchmarked time frames for communi-
cating test results and plans to study if those are related to
laboratory integration. The surveyor asked if the laboratory
director sits on the hospitalwide performance improvement
committee and the infection control committee, and the
director said that she does participate regularly on those com-
mittees, though her participation is a relatively recent
occurrence. She felt that her involvement had gone a long
way toward helping her effectively communicate laboratory
concerns and understand systemwide issues that could impact
the laboratory.

When reviewing proficiency testing, the surveyor noted a

large variation in performance. On the rare occasions when
there were proficiency test outliers, the documentation indi-
cated random error or the corrective action documented
identification of the problem but the documentation did not
note the actions taken to correct the problem noted. The
chemistry lead tech indicated that rather than using the in-
house calculated data for the current lot of quality control
material, the limits were established using the criteria that
had been established for the previous lot of quality control
product.

In the blood bank, the surveyor observed that the lab had a
completely manual information system. She noted that gel
technology was used for antibody screens. The documenta-
tion was on cards and in logs. The quality control was well
documented. There was only one rack of reagents, and it was
controlled each day without fail. Temperature monitoring
and alarm checks were well documented.

The surveyor took time to meet with the laboratory director,

laboratory managers, infection control staff, and other quality
staff to discuss how the laboratory and its component depart-
ments effectively integrate and communicate with each other.
She asked them to describe how they communicate key infor-
mation, such as test results and so forth. The laboratory
director explained that they have been reviewing their policy

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 Section 6. Tracer Exercises for Laboratories

Sample Tracer Questions

Questions for Laboratory Leadership:

• What is your process to ensure continuity of communication and interaction between laboratory departments?
• How do you communicate critical information in a timely manner?
– Please walk me through the process.
• What participation do you have on organizationwide committees, especially the infection control committee or the per-
formance improvement committee?

Questions for Laboratory Staff:

• How do you interact with the other laboratory departments?
• Please describe your process for communicating and documenting a test result.
• How do you document that communication? What happens when you are ready to share that information?
• Describe your proficiency testing process to me.
• What is your process for reporting a critical test result? Can you walk me through it?
• How do you ensure safety in the lab?

Questions for the Unit Staff:

• What is your process for ordering tests for a patient?
• How do you communicate test results?
• How are test results communicated to you?
• How do you receive information from different laboratory departments?
• What is your process to document test results?

Questions for Education Staff:

• Please describe your process for ordering tests for a patient.
– If different laboratory departments have different ordering policies, can you please describe those differences to me?
• How do you document and communicate those results?

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Exercise 6-5. Laboratory Integration
Program-Specific Tracer for a Laboratory
in a Large, Complex Teaching Hospital
Summary: In the following scenario, a surveyor conducts a
laboratory integration program-specific tracer for a laboratory
in a large, complex teaching hospital, where he explores issues
relating to the Priority Focus Areas of
• Communication
• Orientation and Training
• Analytic Procedure
• Equipment Use
Scenario
The surveyor conducted this survey and its representative
tracers at the satellite laboratories in a large, complex teach-
ing hospital. The laboratories were in surrounding cities in
addition to the ancillary laboratories in the main hospital.
During the opening conference he met with representatives
of administration, the point-of-care supervisor for the areas
he would survey, the performance improvement person, and
laboratory manager. The surveyor selected the patient tracer
while on site at one of the satellite laboratories. The surveyor
traced a patient at the satellite laboratory and then returned
back to the main hospital during the course of the survey.
The surveyor queried staff at the satellite laboratory about
patient identification while he observed phlebotomy. The
phlebotomist explained the organization policy to provide
identifiers. The patient specimens were also properly identi-
fied as per policy.
At the main hospital the surveyor began a tracer at the ancil-
lary laboratories. The emergency department had a satellite
laboratory where it performed some waived and moderately
complex tests. As the nurses performed the tests, the surveyor
selected a patient tracer from the laboratory log. The patient
selected had multiple waived laboratory tests performed by
the emergency department staff. All of the laboratory docu-
ments reviewed seemed to be in order, with the appropriate
quality controls documented. The surveyor interviewed the
nursing staff present on their procedures, quality control, and
how their competency had been maintained and
documented.
While the surveyor was conversing with the emergency
department staff, another staff member walked in with
124
several tubes of blood. This person placed the specimens on
the laboratory counter and proceeded to label the samples.
The surveyor asked the staff member what her name was, if
she had drawn the patient samples that she was labeling, who
the patient was, and where the patient was located. She
explained that she was a patient care technician. She said that
the nurse she was assigned to be with had drawn the samples
and had sent her to label the samples and then to send the
samples to the main laboratory for stat testing. The surveyor
asked her if this was the standard procedure and she said she
was only doing what she had been told to do. She said that
the nurse was too busy, so she was helping. As a result of this
observation, the surveyor decided to select other patients in
the emergency department and observe the nursing staff draw
the patient specimens. The other nurses that he observed fol-
lowed the hospital procedure for identifying the patient using
two identifiers. They asked the patients their names and dates
of birth, looked at the wrist bands, and labeled the samples
in the presence of the patients.
The surveyor then traced a patient in the ICU who had been
given tests from multiple laboratory departments in the hos-
pital. In the case of one test, there had been a delay in
reporting the critical test result back to the ICU.
The surveyor then visited the laboratory departments in the
hospital, asking the laboratory managers what their processes
were for communicating results and providing information to
departments and units, as well as to the other laboratory
departments. The surveyor also invited the laboratory direc-
tor, quality improvement director, and infection prevention
and control director to join the discussion. The surveyor
wanted to know what kind of involvement and integration
laboratory had with the rest of the hospital. The quality
improvement director explained that the hospital had identi-
fied laboratory integration and waived testing as two areas for
quality improvement initiatives, and as a result, the labora-
tory director was now participating on the infection
prevention and control committee and the performance
improvement teams for laboratory integration and waived
testing. The surveyor asked the staff what kind of compe-
tency assessment and training are provided for nurses
conducting waived testing. He also asked what the hospital’s
policy was on waived testing and how that was communi-
cated to the staff, along with whether there were training and
in-house sessions on the topic for nurses.
 Section 6. Tracer Exercises for Laboratories

Sample Tracer Questions

Questions for the Laboratory Director:

• Can you tell me the process for coordinating the ordering and reporting of test results from multiple sources in the
hospital?
• How do you report results, and what is your time frame?
• What laboratory staff involvement do you have on hospitalwide committees?
• What improvement strategies are you involved in?
– What data collection and analysis led you to these improvements?
– Have you done any proactive risk assessment activity in the laboratory?

Questions for Quality Improvement Leadership:

• How are you monitoring for effective integration of the laboratory in the hospital?
• How are you involving laboratory staff in improvement work and on hospitalwide improvement- and patient
safety–related committees?

Questions for Nursing Staff Conducting Waived Testing:

• What is the process for conducting waived testing?
• How do you verify a patient’s identity before taking a blood or glucose sample, for example?

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Tips for Conducting Tracers

in a Laboratory Setting

Consider the following tips and strategies for conducting tracers in a laboratory:

• Use these scenarios as a starting point. To gain familiarity with tracers, consider using these example
tracers as a guide, and select patients or systems to trace based on a similar background or a similar situa-
tion. The sample questions can be used to help you become familiar with asking questions.

• Use closed records. The help start the process of tracers or to gain familiarity with it, use a closed record as
a training approach. In the same vein as an individual tracer, you can “walk through” the record as a way to
trace that patient’s experience and make notes of any variations from policy and procedure or other questions
that emerge. This kind of tracer can be done with those staff who were involved in providing laboratory serv-
ices for that particular patient.

• Focus on issues of particular concern for laboratory settings. Consider those issues that are of particular
concern to laboratories (including, but not limited to, patient identification, quality control, and communicating
critical test results), and use those to plan specialized tracers. Use some of the sample questions included in
these tracer scenarios to frame initial questions.

• Involve multiple staff. Encourage and involve as many staff as possible in tracer activity. By engaging more
staff in the process, staff better understand how tracers can work and can lend important insight and perspec-
tive into improvement efforts.

• Consider the issues related to laboratory integration, for laboratories that are part of a hospital. An
organization conducting a program-specific laboratory integration tracer should do the following to assess how
well laboratory integration is taking place at the organization and then use tracer methodology to assess how
effective it is:

• Evaluate the inclusion of laboratory personnel in key hospital committees, such as infection preven-
tion and control.

• Select a patient who received multiple laboratory tests, including tests performed at point-of-care
sites. Trace the testing from the time of the order to the action taken, if indicated.

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Tracer Exercises for Facility Management and Safety
T
his section contains several environment of care
tracer exercises based on the six functional categories:
environmental safety, security, hazardous materials,
fire safety, medical equipment, and interim life safety meas-
ures. In the Joint Commission International standards, this
area is known as facility management and safety. These
tracers are written a little differently than the other exercises
in this workbook because they involve examining an organi-
zation’s systems or processes as they relate to the six
functional areas to find trends or problems and may not
involve direct contact with patients. These tracers also are
Section 7
written so the general concept of each functional area exam-
ined can apply to all health care settings.
Please keep in mind that each tracer is unique. There is no
way to know all of the questions that might be asked during
a tracer, because the possibilities are limitless, depending on
the organization’s circumstances and the functional area
chosen for review. Use these tracer scenarios and sample
questions as an educational or training tool for yourself and
your staff.
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Exercise 7-1. Tracer for Security addressed only inpatient activities and failed to include out-
patients and visitors. Staff added that the nursing personnel
Summary: In the following example, surveyors conduct a had the primary responsibility for implementing these secu-
tracer relating to security in a health care organization, where rity activities.
they explore issues relating to the Priority Focus Areas of
• Physical Environment This risk was identified through document review and dis-
• Patient Safety cussions with safety personnel and staff in various units.
• Communication

Scenario
An organization was having a triennial survey with a full
team in place the first day of a three-day survey. During the
initial document review, surveyors reviewed various recent
documents, such as board meetings, medical staff meetings,
environment of care or facility management and safety meet-
ings, and annual environment of care plan reviews. All
documents indicated that there was concern regarding the
potential abduction of either infant or pediatric patients and
the potential of wandering geriatric patients.

The Life Safety Code® specialist, physician, and nurses began

their individual tracer activities and soon determined that
staff also had concerns regarding potential abductions and or
wandering patients. The concerns ranged from outpatient
settings, through the emergency department, and into inpa-
tient units. The surveyor noticed a security sensing system in
the obstetrics/nursery area. However, a monitoring system
was not present in any other inpatient unit or any of the out-
patient areas such as the emergency department. The
organization also did not use any other system to monitor
pediatric or geriatric patients.

The surveyor questioned the availability of emergency power

for the security system. The facility security officials could
not recall when the last inpatient drill occurred. They also
said the organization never addressed outpatient disappear-
ances. The organization has many outpatient activities,
including office practices, ambulatory surgery, nonemergent
treatment areas, and other various activities. As a result, exer-
cise critiques were reviewed and the surveyor discovered that
some deficiencies had been identified with little or no correc-
tive action taken. The majority of deficiencies centered on
both hospital and medical staff members’ inability to carry
out assigned duties during the exercise.

Late during the first day, the surveyor reviewed the facility’s
security procedures for patients who had disappeared. The
surveyor discovered that the organization’s procedures

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 Section 7. Tracer Exercises for Facility Management and Safety

Sample Tracer Questions

Questions for Safety Staff:

• Has a risk assessment been conducted regarding the potential abduction of an infant? If so, what were the results of this
risk assessment?
• Has a risk assessment been conducted for a potential abduction case involving a pediatric patient? If so, what were the
results of this risk assessment?
• Has a risk assessment been conducted regarding the potential for a geriatric patient wandering from the facility? What
were the results of this risk assessment?
• What areas have been identified as security sensitive?
• What has been done to address the concern of the board and medical staff regarding the potential abduction of an
infant?
• What has been done to address the concerns of the board and medical staff regarding the potential abduction of a pedi-
atric patient?
• What has been done to address the concerns of the board and medical staff regarding the case of a geriatric patient
wandering from the facility?
• Which departments have a security monitoring system?
• Is this system connected to emergency power?
• When was the last abduction drill held?
• What were the identified deficiencies?

Questions for Unit Personnel:

Obstetrics
• What are your responsibilities when the abduction system alarms?
• Is this system connected to emergency power?
• When was your last drill?
• What were the results?
• Were the results satisfactory? Why or why not?
Emergency Department
• Is there a system to monitor patients who are at risk of either abduction or wandering off?
• What would be your response if a child disappeared?
• Would your response be the same if an adult disappeared?
• Have you ever had an abducted patient exercise? If so, tell me about it.

Questions for Leaders:

• Has this organization addressed the potential situation of an outpatient abduction or a disappearing patient?
• What needs to be done to ensure that all staff members are trained to respond to either a suspected abduction and or a
wandering patient?
• What has your security staff done to take the lead to address these two potential situations instead of it being a nursing
responsibility?

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Exercise 7-2. Tracer for Utility Systems
Summary: In the following example, surveyors conduct a
tracer for utility systems at a health care organization, where
they explore issues relating to the Priority Focus Areas of
• Equipment Use
• Physical Environment
• Quality Improvement and Expertise/Activities
Scenario
After the initial document review, the surveyors noted that
the organization had not accomplished the necessary genera-
tor test runs within the required 20–40 day time frame as
established by EC.02.05.07 (see NFPA 110–2005) for 2 of
12 months. This document review also showed that the
annual required load test was not accomplished appropriately.
Prior to the survey, department personnel determined that
this deficiency was not of sufficient risk to justify increased
monitoring and therefore did not cause any increased risk.
These issues were further discussed during the group inter-
view. Staff said that policies existed regarding the inspection,
testing, and maintenance of emergency power systems. The
organization staff also said that current policies met estab-
lished standards. NOTE: This organization had generators and
limited battery-powered lights and no stored emergency power
supply system (SEPSS). The tracer only addressed systems cur-
rently available in the organization; however, for some
organizations, this may be battery backup only.
After more discussion between the surveyor and the appropri-
ate facility personnel, it was determined that this testing
failure of emergency power equipment was indeed of
increased risk to the organization and that compliance should
be more closely monitored for the near future.

Sample Tracer Questions

Questions for Physical Plant Personnel:

• How are generator test runs initiated?
• What process is in effect to ensure that all test runs are accomplished in a timely manner?
• Why was the annual load test not accomplished according to established standards?
• What processes have been changed to ensure that in the future all runs and load tests are accomplished in a timely and
appropriate manner?
• Why did the department personnel decide that this deficiency was not of sufficient risk to justify increased monitoring,
and therefore did not generate any increased risk?

Questions for Environment of Care or Facility Management and Safety Group Members:
• What is your basis for evaluating test completions?
• How did you determine that the annual load test did not meet established standards?
• Has a review of policy and procedures been accomplished? Do they meet established standards?
• How did you decide that no further action is required?

Questions for Later in the Survey:

• With further thought, how do you think that a risk assessment should be accomplished?
• What added oversight requirements should be initiated?

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 Section 7. Tracer Exercises for Facility Management and Safety

• Do you think that additional staff education should be initiated to ensure that all staff members realize the importance
for timely testing of emergency power systems?
• What were the identified deficiencies?

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 Mock Tracer Workbook

Exercise 7-3. Tracer for Environmental
Safety
Summary: In the following example, surveyors conduct a
tracer for environmental safety in a health care organization,
where they explore issues relating to the Priority Focus Areas of
• Equipment Use
• Patient Safety
• Quality Improvement and Expertise/Activities
Scenario
During the initial document review, the surveyors read the
annual environmental safety management plan, the corre-
sponding annual plan review, and the environment-of-care
management team minutes. There was no indication that the
product recall process was at risk.
Staff members were asked about the organization’s product
recall process during several patient tracers that included
inpatients and outpatients. Staff showed no indications that
they understood the process for products or supplies to be
recalled, if required.
During interviews, no evidence was provided that the organi-
zation participated in product and equipment recalls. No
individual or department had been designated to be responsi-
ble for any portion of the recall oversight. The surveyors
noted that policies and procedures did not exist. It was dis-
covered that the organization received recall notices and little
was done to follow up on any of the issues. Recalls were
addressed only when biomedical equipment and warehousing
departments received recall notices, but those departments
checked only their own inventories for recalls; there was no
interdepartmental collaboration. Inventories for inpatient
care units were not checked.

Sample Tracer Questions

Questions for Patient Care Staff:

[Note: These questions can be used in all patient care locations.]
• What is the process for checking the unit patient inventories for recalled products and supplies?
• What type of items could be recalled?
• What kind of responsibilities do you have for product recalls?
• What is the process or policy that you follow when an item, medication, or supply is recalled?

Questions for Biomedical Equipment, Supply, or Purchasing Personnel:

• Has anyone been designated to provide oversight to the recall program?
• Who receives recall notices?
• What is done with these recall notices?
• How do you follow up on potential issues?
• What policies and procedures govern the recall program?
• Does any leadership-level group monitor recall activities?
• What inventories do you check when you receive a recall notice?
• Are inventories in care units ever checked or followed up on?

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 Section 7. Tracer Exercises for Facility Management and Safety

Exercise 7-4. Tracer for Fire Safety
Summary: In the following example, surveyors conduct a
tracer for fire safety at a health care organization, where they
explore issues relating to the Priority Focus Areas of
• Infection Control
• Orientation and Training
• Quality Improvement and Expertise/Activities
When surveyors conducted various tracers, the staff members
interviewed could not describe their responsibilities during a
fire drill. They also were not able to describe their responsi-
bilities if a fire emergency occurred while they were in a
specific area of the building, such as in surgical and delivery
suites where cesarean sections were performed. Medical staff
members and volunteers also could not describe their roles
during a fire regardless of where they might be in the build-
ing when the emergency occurred, nor could they describe
when or how they were trained.

Scenario
Appropriate surveyors reviewed the environment of care
management plans, annual plan reviews, and environment of
care management minutes. This material indicated that all
fire drills were done as required. However, the exercise cri-
tiques indicated that staff did not respond as expected. The
corridors should have been clear but were not for inpatient
units, and staff in the behavioral and obstetrics/nursery units
did not unlock the exit doors quickly. Also, staff in business
occupancies did not exit the building. No trends had been
established. In addition, the organization conducted little or
no follow-up after the exercise critiques showed some
problems.
During the most recent fire safety inspection, the local fire
authority also expressed concern about staff members’ lack of
response during fire drills, even though records indicated that
staff had been trained. Fire safety staff had not yet addressed
any of these concerns.
Surveyors identified this risk issue after reviewing documents
containing statistical analysis and interviewing safety
personnel.

Sample Tracer Questions

Questions for Fire Safety Personnel:

• Explain the disparity among the minutes, critiques, and annual evaluations.
• What type of deficiencies did the fire drill critiques identify?
• What kinds of responsibilities are assigned to individual staff members?
• What type of fire response training do individual staff members receive? Please describe it for me.
• How are deficiencies trended? By whom?
• What kind of corrective action was taken?
• What type of action was taken regarding the findings of the most recent fire authority inspection? Who followed
through on those actions?

Questions for Patient Care Unit Personnel:

[Note: These types of questions might also be asked in a geriatric unit with wandering patients.]
For a Locked Behavioral Health Unit:
• What is your procedure for unlocking secured doors during a fire drill or fire emergency?

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 Mock Tracer Workbook

• Where do you keep the key to unlock the secured exit doors?
• Which staff members are issued a key?
• How much time do you have to get to the door during a fire drill or other emergency?

For an Obstetrics Unit:

• Does the exit door unlock when the fire alarm sound?
• How much time do you have to get to the exit door?
• How do you evacuate newborns from the unit?
• When was the last time this evacuation was practiced?
• How often are fire drills practiced so you can practice evacuating the newborns?

Questions for Surgical Suites That Include Cesarean Section Suites:

• Who is responsible for responding to a surgical fire?
• How have these individuals been trained?
• When was the last time this special fire response was exercised?
• For physicians and anesthesiologists in the area:
1. What are your particular responsibilities during a surgical-site fire?
2. What kind of training do you receive? Please describe it.
3. How often do you receive ongoing training? Please describe it.
4. When did you last drill for this?

Questions for Independent Practitioners and Volunteers:

• What do you do when the fire alarm rings?
• What type of training did you receive for fire response? Please describe it.
• How often do you practice for a fire or other emergency?

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 Section 7. Tracer Exercises for Facility Management and Safety

Exercise 7-5. Tracer for Interim Life were well thought out, and several aspects appeared to exceed
Safety Measures requirements.

Summary: In the following example, surveyors conduct a
tracer for interim life safety measures, where they explore issues
relating to the Priority Focus Areas of
• Infection Control
• Equipment Use
• Physical Environment
Scenario
During the initial document review, the survey team and, in
particular, the Life Safety Code®* specialist reviewed the
Interim Life Safety Measures (ILSMs) policies and proce-
dures. The documents were complete and quite
comprehensive. These policies and procedures were closely
linked to the preconstruction risk assessment process. It
appeared that one process could not function without the
other. Reference was made to other facility policies, which
were required to be enforced.
Several ILSMs and preconstruction risk assessments were
reviewed for three current projects, one major construction
project and two minor construction projects. The processes
During the building tour, the Life Safety Code® specialist
asked to see all three projects. During the tour of these proj-
ects, several items were noted. The organization was using a
fire exit through the construction site, and the route was
blocked by a pallet of supplies in the construction site. The
fire-detection system had no operational detectors in one
area. Fire-watch procedures were not implemented, and the
local fire authority was not notified. In addition, the fire
extinguishers at all three sites had not been inspected on a
monthly basis. When questioned, the facility’s fire safety staff
said they thought that sufficient fire drills per shift per
quarter were held. The surveyor also noted a positive air flow
was present on one construction site, but the other two sites
were properly vented directly to the outside. Staff also indi-
cated that asbestos was discovered in one site after
construction began. The current preconstruction risk assess-
ment had not addressed the presence of asbestos or the need
to remove it. At the end of the first day, other surveyors
noted that they had observed what was perceived to be con-
struction dust near two sites.

Sample Tracer Questions

[Note: Much of this tracer could occur during the life safety tour and/or during a conference session, which would include all per-
tinent individuals. Most of the questions would center on implementation issues.]
Questions for Fire Safety Personnel:
• What is your organization’s policy regarding blocked exits?
• What procedures do you follow if you discover that an exit is blocked?
• Is the exit route on emergency power?
• Why are the fire/smoke detectors covered?
• Is the detection system compromised?
• What fire watch procedures have been implemented?
• How do you notify the local fire authority that the detection system is down?
• What is the process to ensure that all fire extinguishers are properly checked?
• How often do you conduct fire drills? Why are fire drills not accomplished twice per shift per quarter?
• Are revised exit routes posted? How are staff educated about the changes?

* Life Safety Code® is a registered trademark of the National Fire Protection Association (NFPA), Quincy, MA.

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Question for Construction Managers and Infection Control Personnel:

• Why is there positive air pressure rather then negative air pressure at one construction site? What is your procedure for
handling this?
• It appears that asbestos was discovered after construction began on site. What is your organization’s policy for managing
the discovery and removal of asbestos?
• How is the tracking of dust being minimized in patient care areas?
• Who provides construction oversight to ensure compliance with ILSM and preconstruction risk assessment require-
ments?
• How are these individuals trained? Please describe.
• What inspection process is in effect to ensure that the contractor complies with ILSM and preconstruction risk assess-
ment requirements?
• Who implements ILSMs?
Note: As the answers to these questions are reviewed and analyzed, one might come to one of two conclusions. Preconstruction
activities regarding the ILSMs and the preconstruction risk assessment may have been properly developed and implemented.
Inspection requirements may be lacking because the inspectors are not properly trained. The organization may also be relying on
the contractor to solely ensure compliance with ILSMs and the preconstruction risk assessment issues, which could be creating sur-
veillance issues. As a result, the ILSMs and infection control risk assessment project review process prior to construction may have
to be reviewed to ensure that it was properly completed.

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 Section 7. Tracer Exercises for Facility Management and Safety

Exercise 7-6. Tracer for Hazardous
Materials and Waste
Summary: In the following example, surveyors conduct a
tracer for hazardous materials and waste, where they explore
issues relating to the Priority Focus Areas of
• Infection Control
• Equipment Use
• Physical Environment
Scenario
During the initial document review, surveyors found that
there was no reason to perceive an increased level of risk
regarding hazardous material use within the organization.
Management plans and the annual performance review
regarding the handling of hazardous material identified
no issues.
During the initial day of patient care tracers, surveyors
observed what was perceived as improper handling of haz-
ardous material on patient care units, such as hazardous
waste bags being dragged on the floor, sharps being placed in
unapproved containers, and waste containers left uncovered
in soiled utility rooms. When staff members were inter-
viewed, they did not think these were problems and also
could not describe facility procedures for the handling of
these materials.
During the building tour, another surveyor witnessed
improper handling of hazardous waste in the loading dock
area. Supervisors present said that the observed actions did
not comply with established procedures. However, the indi-
vidual observed could not describe how training was
conducted.
These concerns were discussed with the staff during the envi-
ronment of care session. The staff said they thought the
policies and procedures met established standards. They were
reviewed and determined to meet standards. Disposal records
were reviewed along with state Environmental Protection
Agency inspection reports. These records were appropriately
completed and maintained. It also was determined that haz-
ardous material was properly handled and accounted for up
to the time of use on patient care units. However, supervi-
sory personnel were not able to describe the orientation and
ongoing training required for individuals handling hazardous
materials.

Sample Tracer Questions

Questions for Staff Members on Patient Care Units:

• There was an individual dragging a bag of hazardous waste across the floor to a trash cart. What is your organization’s
established procedure for handling a bag of hazardous waste in a patient care unit? Please show me.
• What type of training did you receive on handling hazardous waste in a patient care unit? How often do you receive
ongoing training?
• How are used sharps supposed to be disposed of?
• An observation was made of a syringe being disposed of in a trash can rather than in a sharps container. What is your
organization’s established procedure for disposing of syringes?
• The red waste container was uncovered in a soiled utility room. What is your organization’s policy for handling waste
containers in soiled utility rooms?
• How are staff trained for handling waste containers in soiled utility rooms?

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Questions for Individuals Observed on Loading Dock:

• An observation was made of red bags stored in an unsecured location on the loading dock. What is your organization’s
established procedure for handing hazardous material red bags on the loading dock?
• How is hazardous materials waste prepared for pickup by the waste contractor?
• Do you routinely handle this waste?
• What special precautions do you take while handling red bag waste and sharps containers?
• Who has access to this storage area?
• How often are you trained for handling hazardous waste in the loading dock area? Please describe the training.

Questions for Supervisory Personnel:

• How are personnel trained to handle hazardous waste?
• How do you insure that those individuals are properly trained prior to handling hazardous waste?
• What type of information is reviewed or presented during orientation training for individuals transporting hazardous
waste?
• What kind of annual refresher training is required for these individuals?
• What kind of orientation training is required for all assigned staff, including members of the medical staff?
• What kind of refresher training is required for all assigned staff, including the medical staff?

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 Section 7. Tracer Exercises for Facility Management and Safety

Exercise 7-7. Tracer for Medical incidents and determined they occurred when commercial
Equipment power was transferred to emergency power.

Summary: In the following example, surveyors conduct a
tracer for medical equipment in a health care organization,
where they explore issues relating to the Priority Focus Areas of
• Equipment Use
• Physical Environment
• Communication
• Quality Improvement and Expertise/Activities
The organization conducted a risk assessment and deter-
mined that the equipment failed because it had no battery
backup. Leaders decided to order battery backups, which
were due to arrive within the week. The organization deter-
mined that this corrective action was sufficient. Leaders just
hoped that a power outage would not occur before the
backups were installed. Clinical personnel were not involved
in this risk assessment.

Scenario It also appeared that emergency procedures and the corre-

During patient tracers, surveyors questioned nursing person-
nel, laboratory and radiology personnel, and anesthesia
personnel regarding maintenance of medical equipment. The
interviews indicated that biomedical equipment technicians
routinely performed preventive maintenance on individual
pieces of equipment. When asked about the emergency repair
of equipment, numerous staff said the biomedical equipment
technicians were responsive to the units’ requests for repair.
During the environment of care session, staff said a number
of instances recently occurred in which critical equipment
failed. Biomedical equipment technicians researched these
sponding clinical interventions had not been addressed for
these particular pieces of equipment. Staff in several patient
care units was not able to describe emergency procedures for
patient treatments if the electrical power failed.
Two issues were traced in this instance:
1. Why there was no clinical involvement in the specific risk
assessment
2. Whether emergency procedures and the corresponding
clinical interventions had been established regarding emer-
gency equipment outages

Sample Tracer Questions

Questions for Unit Personnel:

[Note: These questions can be asked in a large number of care locations. You do not have to limit them to one location in your
organization. The intent is to gather information to determine a trend.]
• How do you know if equipment is maintained appropriately?
• Do you help biomedical equipment technicians find pieces of equipment requiring preventive maintenance?
• What do you do if this specific piece of medical equipment does not work?
• How do you report an equipment outage?
• How quickly do the technicians respond when the equipment fails?
• How quickly do technicians respond when equipment fails in the laboratory or radiology and anesthesia areas, where
some equipment is maintained by an outside company?
• What pieces of equipment are maintained by the biomedical equipment technicians?
• What equipment is maintained by outside companies?
• How do you notify the outside company that an individual piece of equipment is not working appropriately?

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Questions for Biomedical Equipment Technicians at the Environment-of-Care Session:

• Have you had any critical equipment failures occur during the past 12 months?
• If so, what did the staff do when this equipment failed?
• What was the cause of this equipment failure?
1. How was this determined?
2. Who was involved in the risk assessment?

Questions for Clinical Personnel from a Number of Care Locations and for the Biomedical Equipment Technicians:
• What kind of emergency procedures did the clinical staff initiate when the equipment failed?
• What policies and procedures have been developed to address this type of equipment failure?
• Who should be involved in the development of emergency procedures and all necessary clinical interventions when
there is an emergency medical equipment outage?

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 Section 7. Tracer Exercises for Facility Management and Safety

Tips for Conducting Environment of Care

(Facility Management and Safety) Tracers

Consider the following tips and strategies when conducting environment of care tracers:

• Use these scenarios as a starting point. The environment of care presents unique challenges for organiza-
tions to consider. Consider using these sample tracers as a thematic starting point, and use the sample
questions as a guide.

• Apply past experiences. If the organization has had a facility–related challenge—such as a recent natural
disaster that required the actual execution of a disaster plan—consider taking that challenge as a way to
develop a tracer or tracer scenario.

• Focus on issues of particular concern in your setting. Consider those issues that pose a particular threat
to your type of health care organization and patient safety, such as home fires in a home care setting, elope-
ment in a long term care setting, or infection control and other risks during construction in a hospital setting,
and use those to plan specialized tracers. Use some of the sample questions in these tracer scenarios to help
frame potential questions.

• Follow up on issues identified in safety minutes and patient care committee minutes at your organiza-
tion. The minutes will help you find specific environment of care issues that your organization or facility has
identified for improvement. Conducting tracers on these topics will help you assess if these issues have been
properly resolved or need additional work.

• Involve multiple staff. Encourage and involve as many staff as possible in tracer activity, particularly
staff that are impacted by environment of care issues. By engaging more staff in the process, staff better
understand how tracers can work and can lend important insight and perspective into improvement efforts.

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A
t the beginning of each tracer exercise in this work-
book is a brief summary that includes the priority
focus areas that are focused on in the tracer scenario
example. There are 14 priority focus areas (PFAs) that help
ensure safe, high-quality care and are generally universal
across health care settings. All Joint Commission standards
for U.S. health care organizations are related 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 from the
Priority Focus Process, form the foundation of the tracer
process. The PFAs are
summarized below.
Assessment and Care/Services
Assessment and Care/Services (not applicable to laboratories)
include the execution of a series of processes 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
discontinuation of services. Assessment and Care/Services are
fluid in nature to accommodate a patient, client, or resident’s
needs. Subprocesses of Assessment and Care/Services include
the following:
• Screening
• Assessment
• Reassessment
• Planning care, treatment, or services
• Provision of care, treatment, or services
• Discharge planning or discontinuation of services
Analytic Procedures (for laboratories only)
The laboratory’s main function is that of conducting pre-ana-
lytic, analytic, and post-analytic procedures. When effectively
executed, each aspect of the analytic procedures contributes
to the safety and quality of care for patients. Critical elements
of analytic procedures include, but are not limited to the
following:
• Request
• Transportation
• Processing
Appendix 1
Priority Focus Areas
• Interpreting results
• Specimen collection
• Receipt
• Testing
• Data report/dissemination
Communication
Communication is the process by which information is
exchanged between individuals, programs/services, or organi-
zations. Effective communication successfully permeates
every aspect of a health care organization, from the provision
of care to performance improvement, resulting in a marked
improvement in the quality of care delivery and functioning.
Subprocesses of Communication include the following:
• Provider and/or staff–patient/client/resident
communication
• Resident, patient, or client and family education
• Staff communication and collaboration
• Information dissemination
• Multidisciplinary teamwork
Credentialed Practitioners
Credentialed Practitioners are health care professionals whose
qualifications to provide resident, patient, or client care serv-
ices have been verified and assessed, resulting in the
assignment of clinical responsibilities. The category varies
from organization to organization and from state to state.
Equipment Use
Equipment Use incorporates the selection, delivery, setup,
and maintenance of equipment and supplies to meet resident,
patient, and staff needs. It generally includes movable equip-
ment, as well as management of supplies that staff members
use (for example, gloves, syringes). Subprocesses of
Equipment Use include the following:
• Selection
• Maintenance strategies
• Periodic evaluation
• Orientation and training
• Risk prevention
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Infection Control
Infection Control includes the surveillance/identification,
prevention, and control of infections among patients, clients,
or residents, employees, physicians, and other licensed inde-
pendent practitioners, contract service workers, volunteers,
students, and visitors. This is a systemwide, integrated
process that is applied to all programs, services, and settings.
Subprocesses of Infection Control include the following:
• Surveillance/identification
• Prevention and control
• Reporting
• Measurement
Information Management
Information Management is the interdisciplinary field con-
cerning the timely and accurate creation, collection, storage,
retrieval, transmission, analysis, control, dissemination, and
use of data or information, both within an organization and
externally, as allowed by law and regulation. Subprocesses of
Information Management include the following:
• Planning
• Procurement
• Implementation
• Collection
• Recording
• Protection
• Interpretation
• Storage and Retrieval
• Data integrity
• Information dissemination
Medication Management
Medication Management (not applicable to laboratories)
encompasses the systems and processes to provide medication
to individuals served by the organization. This is usually a
multidisciplinary, coordinated effort of health care staff,
implementing, evaluating, and constantly improving the
processes of selecting, procuring, storing, ordering, transcrib-
ing, preparing, dispensing, administering (including
self-administering), and monitoring the effects of medica-
tions throughout the patients’/residents’/clients’ continuum
of care.
Organizational Structure
Organizational Structure is the framework for an organiza-
tion to carry out its vision and mission. The implementation
is accomplished through corporate bylaws and governing
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body policies, organization management, compliance, plan-
ning, integration and coordination, and performance
improvement. Included are the organization’s governance, as
well as business ethics, contracted services, and management
requirements.
Orientation & Training
Orientation and Training is the process of educating newly
hired staff in health care organizations to organizationwide,
departmental, and job-specific competencies before they
provide resident care, treatment, or services. Training entails
providing opportunities for staff to develop enhanced skills
related to revised processes that may have been addressed
during orientation, new resident care techniques, 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 is a systems-based approach that examines all
activities within an organization that contribute to the main-
tenance and improvement of patient safety, such as
performance improvement and risk management, to ensure
that all disciplines work together, not independently, to
improve care and safety. Subprocesses of Patient Safety
include the following:
• Planning and designing services
• Directing services
• Integrating and coordinating services
• Error reduction and prevention
• The use of Sentinel Event Alerts
• Joint Commission National Patient Safety Goals
• Clinical practice guidelines
• Active patient involvement in their care
Physical Environment
Physical Environment refers to a safe, accessible, functional,
supportive, and effective physical environment for patients,
staff members, workers, and other individuals by managing
physical design; construction and redesign; maintenance and
testing; planning and improvement; and risk prevention,
defined in terms of utilities, fire protection, security, privacy,
storage, and hazardous materials and waste.
 Appendix 1. Priority Focus Areas

Quality Improvement Expertise/Activities

Quality Improvement Expertise/Activities identifies the col-
laborative 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 involves identifying, measuring, imple-
menting, monitoring, analyzing, planning, and maintaining
processes to ensure they function effectively. 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 and Ethics includes patient rights and organizational
ethics as they pertain to patient care. Rights & Ethics
addresses issues such as resident privacy, confidentiality and
protection of health information, advance directives (as
appropriate), organ procurement, use of restraints, informed
consent for various procedures, and the right to participate in
care decisions. Subprocesses of Rights & Ethics include the
following:
• Resident rights
• Organizational ethics pertaining to resident care
• Organizational responsibility
• Consideration of the resident
• Care sensitivity
• Informing residents and/or family

Staffing
Staffing includes assessing those defined competencies and
allocating the human resources necessary for patient safety
and improved patient outcomes. Subprocesses of staffing
include the following:
• Competency
• Skill mix
• Number of staff

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 Appendix 2
Tracer Development Worksheet Template

T
he goal of this workbook is to provide a multitude of
tracer scenarios in a variety of health care settings
with sample tracer questions so readers can become
familiar with tracers and practice conducting their own. A
worksheet template is provided on page 148 to help you or
your staff members develop and brainstorm your own organi-
zation tracers and potential questions. Although you can use
the worksheet template as many times as you like to suit your
improvement efforts, consider the following suggestions for
ways to get the best use out of it:
• Considering the kinds of patients, residents, or clients that
your organization serves, develop a scenario that could
take place in your organization, and write up sample ques-
tions that could fit the scenario; then use those questions
as a guide for a similar kind of individual tracer.
• Take a discharged client, patient, or resident medical or
clinical record, and develop a scenario and sample ques-
tions based on the record and demonstrate that scenario
for staff in a training session.
• Rather than using the worksheet to develop an individual
or systems tracer scenario, consider developing a scenario
based on a specific policy and procedure, develop ques-
tions related to that policy and procedure, and then take
that scenario and the related policy and procedure to
“walk through” a tracer of the policy and procedure.

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Figure 1. Tracer Scenario Development Worksheet Template

Tracer Scenario Worksheet

Type of Tracer

Setting
(type of organization)

❑ Assessment and Care/Services ❑ Organizational Structure

PFAs
(Mark the priority focus
areas to be highlighted
in this tracer. For U.S.
organizations only.)
❑ Analytic Procedures
❑ Communication
❑ Credentialed Practitioners
❑ Equipment Use
❑ Infection Control
❑ Information Management
❑ Medication Management
❑ Orientation & Training
❑ Patient Safety
❑ Physical Environment
❑ Quality Improvement Expertise
❑ Rights and Ethics
❑ Staffing

Scenario Details (Include

main details about the indi-
vidual or system chosen for
the tracer. This will help you
create a road map of what
units or departments to visit
as part of the tracer.)

Sample Tracer Questions

(Write down some questions
you want to make sure to
ask staff or the patient. This
can be a starting point for
the interview, but make sure
to listen to the recipient and
base additional questions on
what you hear.)

Staff Members to Question

for this Tracer
• Physician
• Nursing director
• Medical director
• Administrator
• Nurse
• Pharmacist
• Other
_______________________
_______________________

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