1. Tracer Methodology Presented by the Accreditation Matrix

2. Universal Tracer Tips Don’t forget to introduce yourself. “Hello, I am William Deming and I work as the Director of Engineering at Norton Dixie Hospital. I am with you today for your hospital’s tracer survey. It is great that I get to visit you today because I look forward to learning a lot from this experience.” Involve as many people as possible “Do we have everyone here we want to include in this exercise? I do not mind having more people.” 2

3. Universal Tracer Tips “Act the part. Be the surveyor.” “Today, we are going to pretend that we are going through a survey. I am going to be the surveyor, and you will be lucky person that they picked. We will learn this process together. And by the end of the process, you can be our survey expert.” Focus on staff members and not management “During many surveys, you, the frontline staff become one of the most critical players during the tracer process. Why? Because you spend the most time with our patients.”

4. Universal Tracer Tips Ask open-ended questions “What do you think? Is this a good practice? Is there anything that you suggest we can do better?” Teach as you go “We find the same thing at our hospital and this is how we improved our process. (Explain) Do you think this will work here too?” 4

5. Universal Tracer Tips Address inappropriate practice/behavior that is observed with staff and manager. “Do you agree that this medication expired last month. I know I can count on you to remove this immediately.” “We probably should label that specimen here so that the patient will know for sure that we have tagged it correctly.” 5

6. Universal Tracer Tips Ask staff to show you data, policies and/or procedures “ Can you show me your performance improvement data that supports what you did? Is it working? If so, how did you do it? If not, what are you going to do differently to get the results you want?” Build staff confidence in you. “It is so important that we have the a true picture of our processes so we can have a better understanding for how we can improve. Therefore, your honesty is key and we will agree on what parts of your assessment will be shared, if any.” 6

7. Universal Tracer Tips Hold staff members and management accountable – but don’t forget to reward and acknowledge good compliance. “ You did a great job in the medication administration. You introduced yourself to the patient, you washed your hands before and after, and you used BMV to ensure that you gave the right drug to the right patient. The only suggestion I would have is to make sure you take the time to explain to the patients the drug they are taking and the possible side effects. Educate the patient on the drug so they can partner with you in their care, in the event something does go wrong? It will save you time in the long run…. Oh don’t forget to document.” 7

8. Universal Tracer Tips Use findings to reinforce good practice “My, I am very impressed that all your records include the proper and timely documentation for pain assessment and reassessment. I am having a difficult time with that at my hospital, and I want to learn how you did this?” 8

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10. The Summation – Preparing and Presenting Your Findings The Summation and Follow-Up Process 10

11. The Summation – Preparing and Presenting Your Findings The Form How to Use It. Presenting the Positive. Dust Bunnies, Temps and Inches. 11

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13. The Summation – Preparing and Presenting Your Findings Delivering the Message Can You Hear Me? Introductions. Professional Presentation. How the Message is Received. What to Say. What Not to Say. Delivery. 13

14. The Summation – Preparing and Presenting Your Findings Wrap it Up! Time Constraints The Signal 14

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16. Hot Topics and Commonly Cited Standards Joint Commission Perspectives – Top Standards Compliance Issues for 2010 16 65%RC.01.01.01**The hospital maintains complete & accurate medical records for each individual patient (date/time/sign). 51%LS.02.01.20**The hospital maintains the integrity of the means of egress. 49%LS.02.01.10**Building and Fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. 42%EC.02.03.05**The hospital maintains fire safety equipment and fire safety building features. 40%LS.02.01.30The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke 33%MM.03.01.01The hospital safely stores medications. 33%RC.02.03.07** Qualified staff receive and record verbal orders. 31%PC.01.02.03** The hospital assesses and reassesses the patient and his or her condition according to defined time frames. 29%IC.02.02.01The hospital reduces the risk of infections associated with medical equipment, devices, and supplies. 28%MM.04.01.01** Medication orders are clear and accurate. ** NHC was cited against these standards during the 2010 survey.

17. Hot Topics and Commonly Cited Standards High Risk Topics That Surveyors Might Explore In More Detail (2 nd Generation Tracer Methodology) Cleaning, disinfecting, and sterilization. Patient flow across the care continuum. Contracted services Diagnostic imaging Ongoing professional practice evaluation (OPPE) and focused professional practice evaluation FPPE Any areas covered in the NPSGs 17

18. Hot Topics and Commonly Cited Standards National Patient Safety Goals (NPSG) 2011 18 2010 NPSGGoal Text% Not Compliant 2010 NPSG 03.04.01Labeling of Medications 24% UP 01.03.01Timeout Performed19% NPSG 02.03.01Reporting Critical Tests 8% NPSG 15.01.01Suicide Risk Assessments 7% NPSG 01.01.01Patient Identification5% NPSG 07.01.01Hand Hygiene4%

19. Hot Topics and Commonly Cited Standards.....and….. Anything related to Medication Management Sedation 19

20. Hot Topics and Commonly Cited Standards Top Ten Technology Hazards 2011 Radiation Overdose and other dose errors during radiation therapy Alarm Hazards Cross Contamination from Flexible Endoscopes High Radiation dose from CT Data Loss, System Incompatibilities-IT Complications Luer Misconnections Over sedation and PCA Pumps Needle stick, sharps injuries Surgical Fires Defibrillator Failures in Resuscitation Attempts 20

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