Rather than filling the survey agenda with formal interviews and unit tours, the new survey process allows surveyors to score standards by spontaneously following or "tracing" either a patient or system through the organization.
Surveyors select patients and systems to "trace" based on an organization's priority focus areas for the survey as well as areas identified in its most recent self-evaluation.
In a patient tracer, a surveyor will:
- Identify a particular patient
- Travel to the unit where the patient is located
- Review that patient’s record
- Visit other service locations where the patient received care
As the surveyor reviews the medical record, he or she will note the various staff, physicians, and units involved in the patient's care. The surveyor requests personnel and credentials files for selected caregivers and list the units and services he or she will visit. As the tracer begins and the surveyor speaks with those directly involved in the patient's care, he or she evaluates compliance with the accreditation standards.
A system tracer might focus on processes such medication use, infection control or use of data. These tracers begin with a formal interview and program review.
System tracers may then bring surveyors to a selected patient care unit, where they continue to focus only on the target process or evolve into a patient tracer. Surveyors interview staff, inquiring about how they complete tasks, their training and their orientation to new and revised policies related to that system.
Special session interviews include:
- Environment of care tour
- Environment of care interview
- Leadership session
- Competency assessment
- Medical staff credentialing