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Are you ready for accreditation?

Perkins, Jeannette MHA, BSN, RN; Tulod, Marilou BSN, RN, CCRN

doi: 10.1097/
Department: Team Concepts

At the Department of Veterans Affairs Medical Center at Northport (N.Y.), Jeannette Perkins is a performance improvement specialist and Marilou Tulod is a utilization manager.

The authors have disclosed that they have no financial relationships related to this article.



The tracer methodology was introduced into the survey process by The Joint Commission in 2004 as an evaluation tool used by surveyors to help assess a facility's standards and compliance in providing care and services. This focus approach is started by selecting a patient, resident, or client and utilizes the individual's medical records as a roadmap to follow that patient throughout the facility. The tracer path enables the surveyor to identify compliance issues and any breakdown in processes by the healthcare organization. By tracing the path of one patient, the healthcare organization is assessed as a team in its day-to-day delivery of care, allowing for a more accurate assessment by the surveyors. During tracer activities, the surveyor observes and talks to staff members and patients (with permission). The surveyor also provides education to staff members and leaders, and shares best practices in similar healthcare organizations. Through this process, the healthcare organization can identify improvement processes and prioritize system redesign efforts.1

Mock tracers, as part of an organization's continuous readiness program, allow for consistent, real-time examination of policies and processes in terms of meeting accreditation standards, organizational goals, or healthcare system strategic goals. Tracers provide the framework to prepare staff members for accreditation, as well as supporting their endeavors to provide high-quality care on a daily basis.

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Why seek accreditation?

Hospitals seek Joint Commission accreditation for a variety of reasons, including:

  • organizing and strengthening patient safety efforts
  • strengthening community confidence in the quality and safety of care, treatment, and services
  • providing a competitive edge in the marketplace
  • improving risk management and risk reduction
  • reducing liability insurance cost
  • improving business operation
  • enhancing staff education
  • receiving reimbursements from Medicare and Medicaid as third-party payers.2

Joint Commission accreditation is recognized nationwide as a symbol of quality that reflects an organization's commitment to meeting certain performance standards. Governed by a 32-member board of commissioners that includes physician, administrators, nurses, employers, a labor representative, health plan leaders, quality experts, ethicists, a consumer advocate, and educators, The Joint Commission evaluates and accredits more than 19,000 healthcare organizations and programs in the United States.3

The seven program areas for Joint Commission accreditation are:

  • ambulatory healthcare
  • behavioral healthcare
  • critical access hospitals
  • home care
  • hospital lab services
  • long-term care
  • hospitals.
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The survey process

The Joint Commission onsite survey team includes a physician, a nurse, a life safety code specialist, and a hospital administrator who has senior management experience. Most visits by The Joint Commission are unannounced and occur between 18 and 36 months after the healthcare organization's last survey. During the survey process, The Joint Commission evaluates an organization's performance of functions and processes aimed at continuously improving patient outcomes.

The organization's compliance with applicable standards is evaluated based on the following:

  • tracing the care delivered to patients
  • verbal and written information provided to The Joint Commission
  • onsite observations and interviews by Joint Commission surveyors
  • documents provided by the organization.4

Your facility's performance improvement/quality management specialists are responsible for helping your staff members understand and implement the regulations needed to comply with The Joint Commission standards. One of the first steps in getting your staff members ready for The Joint Commission survey is to ensure they're well-versed on the National Patient Safety Goals (NPSGs). As stated by The Joint Commission, NPSGs are a series of specific actions that accredited organizations are required to take to prevent medical errors, such as miscommunication among caregivers, unsafe use of infusion pumps, and medication mix-ups.3

One way to accomplish the goal of continuous readiness is to strategically place NPSG posters on each unit of your facility. Information technology staff can also create a pop-up screen highlighting the NPSGs on each desktop, along with other performance standards. Another strategy is to develop and provide pocket guides with questions and answers that staff members can use as a quick reference.

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Conducting mock tracers

If the mere mention of The Joint Commission strikes fear in your staff, the best way to overcome it is by doing weekly mock tracers. (See Figure 1.) This will help alleviate anxiety, change misconception, promote education on the survey process, and increase staff member confidence when answering questions. It's important to let staff know that tracers are a learning process and not meant to be punitive in any way. Tracers can provide the opportunity to identify breakdowns in processes and come up with a resolution to the problem. This is also a perfect time for staff members to share their best practices with other areas of the hospital.

Figure 1

Figure 1

The most effective way to conduct a mock tracer is through a team approach, which more accurately resembles The Joint Commission survey. The ideal team consists of a representative from management, nursing education, the nursing department, performance improvement/quality management, engineering, and housekeeping. In the beginning, it's best to do mock tracers once a month and progress to weekly as your survey window approaches. The team should establish a set of questions based on patient priority focus areas. A major focus of the mock tracers should be NPSGs and the environment. For example, during the first mock tracer, focus on the NPSGs and priority focus areas; during the next tracer, focus on environmental rounding.

We've found that the best way to perform environmental rounds is to develop a checklist for inspection that includes checking:

  • equipment for outdated bio-med stickers
  • expired medication and supplies
  • open medication vials not labeled with a 28-day expiration
  • refrigerator temperature logs
  • crash cart logs
  • uncluttered corridors
  • outdated fire extinguishers
  • separate medication and food refrigerators
  • staff wearing employee identification badges
  • computers turned off when an employee isn't in the room
  • Health Insurance Portability and Accountability Act materials aren't left unattended
  • medication carts are locked when not in use.

Staff members must be able to speak about their roles, responsibilities, training, and orientation necessary to prepare them to perform their duties. They should be able to speak to any policies and procedures that guide their practice. It's also expected that staff members will be able to speak about their patient's medical condition and care plan when queried.

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Always be prepared

Constant awareness and practice of the survey process can build confidence toward a successful Joint Commission survey. An organizational program of continuous readiness that includes ongoing mock tracers builds staff confidence and ensures a positive survey outcome.

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1. The Joint Commission. Facts about the tracer methodology.
2. The Joint Commission. Facts about The Joint Commission.
3. The Joint Commission. Facts about hospital accreditation.
4. Clark JS, Eisenberg JL. The Joint Commission Survey Coordinator's Handbook. 13th ed. Danvers, MA: HCPro, Inc.; 2011.
© 2012 by Lippincott Williams & Wilkins, Inc.