Are You Ready for JCAHO?
Sometime in 2007, BWH will be the subject of unannounced JCAHO hospital and laboratory surveys, BWH’s second survey since the JCAHO began using its patient tracer methodology.
Tracers are an evaluation method in which surveyors select a patient and use that individual’s record as a roadmap to move through the hospital and evaluate compliance with selected standards as well as the hospital’s systems of providing care and services. BWH expects the JCAHO surveyors to conduct approximately 50 tracers during the five-day hospital survey.
Sample Tracer
A surveyor might trace a surgical patient admitted through the Emergency Department. The surveyor would begin by going to the ED to inquire about care the patient received. The surveyor may ask the following:
• What was your process for this patient’s assessment?
• Does the assessment include screening for abuse?
• What types of abuse did you look for?
• Can you explain the process to reconcile the patient’s medications?
The surveyor then would travel to the Operating Room and ask to speak with surgical staff involved with the patient. The surveyor may examine the OR’s scheduling process, review surgical prep procedures and verify that physicians are sufficiently privileged and credentialed.
From there, the surveyor would travel to the PACU and the inpatient floor the patient was transferred to following surgery and any other hospital areas where the patient subsequently received care.