JCAHO 2005 Tracer Methodology and Ongoing Record Review

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JCAHO 2005Tracer MethodologyandOngoing Record
Review

• Ray Pinder, MS, RHIA
• May 19, 2005

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WHY CHANGE?
The Primary Goal Shift the paradigm from survey
prep to a continuous operational improvement
model. Survey not as an event, but as
validation of change
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KEY COMPONENTS OF 2005 PROCESS

• Tracer Methodology- follow patients through care
  processes in sequence to evaluate how well
  systems function,
• 50-60 of time in tracer activity visits

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KEY COMPONENTS OF 2005 PROCESS

• Tracer Activity visits
• (1½ hours)
• Utilizing tracer methodology will begin and end
  in the patients current unit
• Medical Record review at the end of visit to
  validate processes and documentation

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TRACER METHODOLOGY DOCUMENTS

• Surveyors will use Primary Focus Tool (PFT) to
  map out tracer visits
• Based on Primary Focus Areas (PFA)
• Facilitates planning by the survey team to assure
  focus areas are addressed while limiting
  duplication of visits

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• Systems Tracer 60 minute sessions for
• Medication Management
• Infection Control
• Use of Data

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Human Resource May request files from
employee, physician, etc. rosters or may request
files of staff involved in tracer activities
sessions will not be interview-based, but
surveyors may ask about processes
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END OF SURVEY!

• Evidence of Standards Compliance
• ESC report must be sent to JCAHO within 90 days
  after the close of the survey
• Final accreditation decision will be made after
  JCAHO reviews accepts the ESC report

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TRACER ACTIVITY EXAMPLE

• St. Elsewhere Health System has a
  top 10 diagnosis of hip fracture repair
• Surveyors choose the following patient to do a
  tracer visit
• 72 year-old admitted 15 days ago through ER with
  R/O fractured hip. Had surgical repair of hip
  fracture. Postop spent 4 days in the orthopedics
  unit, then transferred to TCU and then to skilled
  nursing unit at Lafayette. Anticipate return to
  apartment with home care in 2 days.

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J.D.s TRACER VISITS

• Brief interview of staff or charge nurse to
  discuss JDs care and condition.
• Develop a tracer plan and identify focus areas
  for unit visits.
• Ask staff or unit manager to have care team and
  record available at specific time for return
  visit in about 1 hour.

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J.D.s TRACER VISIT PLAN

• Site 1 Emergency Department
• Site 2 Radiology
• Site 3 Operating Room and PACU
• Site 4 Orthopedics unit
• Site 5 TCU
• Site 6 Lafayette SNF unit

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J.D.s TRACER VISITS Site 1 Emergency
Department
Tour the area where EMS arrived, review pre
arrival communication, security, access and
patient flow Discuss triage, patient
confidentiality, admitting and registration
process for ambulance patient. How is medical
history info obtained?
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J.D.s TRACER VISITS Site 1 Emergency
Department
Discuss advanced directives and consent
processes, what if the patient is unable to
communicate?
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J.D.s TRACER VISITS Site 1 Emergency Department
Discuss patient initial assessment process, pain
management, and psychosocial assessments Is
emergency medication accessible, secure? How
is medication safety addressed in this case?
What is verbal order process? How are critical
results handled?
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J.D.s TRACER VISITS Site 2 Radiology
Department
How is privacy maintained in Radiology? Discuss
process for communicating critical results?
To the ED? How is consent handled? Discuss
process for handling radioactive materials
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J.D.s TRACER VISITS Site 2 Radiology
Department
Discuss sedation procedure for interventional
radiologic procedures Describe PI monitoring
process in department
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J.D.s TRACER VISITS Site 3 OR/PACU

• Discuss consent process with staff. What is
  required in an emergency? Did he need to have
  an HP? How would these be documented?
• Discuss advance directive process
• Discuss continuum and communication How do you
  interact with the Orthopedic Surgeon, ED, Patient
  family?

Anesthesia pre-op assessment, airway, immediate
pre-induction re-assessment
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J.D.s TRACER VISITS Site 3 OR/PACU (cont.)

• Request physicians file for credentialing and
  competencies
• HP, pre-and post op documentation
• Is there a time out before surgery to check
  correct patient/procedure?
• EOC fire safety and drills in the area?
• How is the equipment monitored? What about safety
  goals? (pumps and alarms)

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J.D.s TRACER VISITS Site 3 OR/PACU (cont.)

• Medication use control and security of
  anesthesia meds, verbal order read-back process
• Infection control sterilization processes and
  infection rates.
• Ethics disclosure of unanticipated outcomes.
• PI initiatives and outcomes

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J.D.s TRACER VISITS Site 4 Orthopedic unit

• When is J.D.s assessment finished,
  including nutrition and functional screens?
  How are other disciplines involved in his care?
• Patient rights confidentiality, pain management,
  advance directives, restraint use

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J.D.s TRACER VISITS Site 4 Orthopedic unit

• Medication use protocols in place (heparin),
  verbal orders read-back and signed,
  abbreviations, range orders, control of narcotic
  wastage

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J.D.s TRACER VISITS Site 5 Transitional Care
Unit
What is involved in J.D.s assessment? How are
other disciplines involved in his care? Patient
rights confidentiality, pain management, advance
directives, restraint use
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J.D.s TRACER VISITS Site 5 Transitional Care
Unit
Medication use protocols in place (heparin),
verbal orders read-back and signed,
abbreviations, range orders, control of narcotic
wastage
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J.D.s TRACER VISITS Site 5 Transitional Care
Unit

• NPSGs IV pumps, alarm testing, verbal orders,
  patient id
• HR staff qualifications and training, staffing
  levels
• Multi-disciplinary education and placement process

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J.D.s TRACER VISITS Site 6 LR SNF unit (base
unit)

• Closing visit on patients current unit
• Assemble team to discuss interdisciplinary care
  planning and communication
• Review the medical record and validate processes
  discussed in the tracer visits.

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J.D.s TRACER VISITS Site 6 LR SNF unit (base
unit)

• What kind of education has been done for J.D.s
  family?
• Have education needs been assessed including
  barriers, preferences and readiness to learn?

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J.D.s TRACER VISITS Site 6 LR SNF unit (base
unit)

• Is education interdisciplinary? (diet, exercise,
  meds)
• Continuum of care How is discharge planning
  being done? (rehab, counseling, community
  resources)
• Infection Control nosocomial infections and
  post-op infection rates? How are infections
  reported post-discharge?

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TRACER Methodology Everyone needs to be
survey ready and be able to answer questions
regarding any standard! Will
YOU SURVIVE?!
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Tracer Methodology for ORR

• Selecting Cast Members
• Selecting a Director
• Printing the Playbill
• Tryouts
• Your Scores
• Open Auditions
• Administrative Champion
• Medical Staff Champion

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ORR..The Cast

• Medical Record Staff
• Medical Staff
• Nursing Staff
• Quality Management
• Risk Management
• Ancillary Departments
• Laboratory
• Radiology
• Pharmacy

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ORR..The Cast

• Ancillary Departments (cont.)
• Physical Medicine and Rehabilitation
• Respiratory
• Nutrition Services
• Other departments that have documentation
  requirements in the Medical Record

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ORR Selecting a Director

• A Medical Record Manager should be the Team
  Leader
• Director
• Assistant Director
• Medical Record Manager or Supervisor
• The Right Person is the one who can effect change
  in current and future documentation practices

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ORR.Schedule

• Playbill Schedule
• Set Date (same day each month)
• Set Time (same time each month)
• Set Location (try for same meeting area)
• Send out Meeting Notices (Memo or Email)
• Attendance Requirements
• Mandatory, if unable to attend, send replacement
  or fill-in

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ORR.Tryouts

• An Annual Orientation for Record Review Team is a
  Must
• Review the purpose of Record Reviews
• Review attendance requirements
• Review documentation standards
• Review open vs. closed record reviews
• Prepare a dummy record with key documents
• Practice a record review with documentation tool

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ORR.Producers

• Appoint a Administration Champion
• This person will assist in making sure all
  ancillary departments understand the importance
  and time commitment
• Appoint a Medical Staff Champion
• This physician will be your Champion to the
  entire medical staff. He/She should be viewed as
  a shaker and mover among the medical staff

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ORR.Sets

• Ongoing Reviews
• Criteria, Monitors, JCAHO requirements
• Conducting the Review
• Collecting the Data
• Analyzing the Data
• Reporting the Findings
• Making Recommendation
• Follow-Up/ Action Plans

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ORR.Sets

• Regardless what you call it, you must have a
  process to identify criteria, monitors or JCAHO
  elements that meet the Standards
• Criteria, Monitors or Elements should be
  identified by Medical Staff, Medical Records,
  Various Hospital Departments that feel there is a
  documentation deficiency.

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ORR.Sets

• Regardless what you call it, you must have a
  process to identify criteria, monitors or JCAHO
  elements that meet the Standards
• .
• JCAHO NO longer requires the 19 Data Elements
• JCAHO Part 1 and Part 2 Review Tool on their
  website at

http//www.jcaho.org
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ORR Conducting Auditions

• Monthly Review
• Sample Size Update this from Website
• JCAHO requires minimums based on the what you are
  reviewing/sampling.
• Sample size under 30 you must do 100
• Sample size 30-100 review 30 records
• Sample size 101-500 review 50 records
• Sample size larger than 500 review 70 records

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ORR Conducting Auditions

• Monthly Review
• Sample Selection
• 1st Month of each Quarter Point of Care Reviews
• 2nd Month of each Quarter-- Focused Reviews
• 3rd Month of each Quarter-- Tracer Record Reviews

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ORR Conducting Auditions

• Monthly Review ..
• Interpretation of Data Elements
• Review each element so all team members know what
  they are looking for and where it is documented

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ORRConducting Auditions

• Documentation Tool
• Dos and Donts
• Make the process easy, dont collect too much on
  one review
• Dont word questions in such a way that the
  review team is confused.
• Do use Yes, NO, N/A type questions
• Use a documentation tool for reviews that is easy
  to follow
• Use same documentation tool each month just
  different questions/reviews

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ORR.Conducting Auditions

• Data Analysis
• Review all worksheets from the review team prior
  to tabulating results
• Tabulate Results
• Set Threshold
• If an element falls below the threshold report it

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ORR.Conducting Auditions

• Data Analysis
• Prepare Draft Report on Findings
• Report the percentage of each data element
• Those above threshold--no action required
• Those below threshold--need a plan of action

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ORRConducting Auditions

• Make Your Report Easy to Read and Understand
• Presentation should be either in WORD Table or
  Excel format
• Bold the elements that fell below the threshold

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ORRConducting Auditions

• Make Your Report Easy to Read and Understand
• Have a narrative report to give an overall sense
  of what the study/review revealed.
• Ask for recommendations and who to forward each
  one to
• Ask for an Action Plan to include follow-up

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ORR.Conducting Auditions

• The draft report should go to
• Medial Record Committee
• Hospital Services/Quality Committee
• Medical Staff
• Departments of Medical Staff with deficiencies
• Ancillary Departments of the Hospital with
  deficiencies

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ORR.Final Cast

• Every Review should have a Plan of Action with
  Follow-up Addressed
• Action Plans should include
• Recognition of the deficiency
• How the deficiency will be address
• Time frame for addressing the deficiency
• Education of staff

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Automate

• Record Reviews that use Automation
• Microsoft WORD Worksheets and Programs
• Microsoft EXCEL Worksheets and Programs
• Scanning Worksheets and Programs
• AutoData Systems

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Automate

• Record Reviews that use Automation
• Automated Worksheets and Programs
• ORRA (Ongoing Record Review Assistant)
• PDA (Plato Data Analyzer)
• RRA (Record Review Assistant)

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Automate

• Automated Worksheets Programs
• What ORRA, PDA and RRA have to offer in their
  automation of ORR?
• Templates
• Customized features
• Tabulates results
• Trends results
• Graph results
• Form letters to physicians, nurses, other
  documenters
• And MORE

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ORR.Final Curtain Call

• Ideas/Suggestions for Ongoing Record Review
• Conduct reviews ongoing/continuous
• Random sample of service/department/unit
• Timeliness, completeness, accuracy, legibility,
  presence of documentation
• Multidisciplinary
• Trending reviews and outcomes
• Focus on problem areas
• Promote performance improvement activities

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Curtain Call

• Resources
• http//www.jcrinc.com/publications.asp?durki77ho
  splink (JCAHO Manuals 2005)
• Automating Ongoing Record Review-Enhanced
  Strategies for Success-2004 http//www.hcmarketpla
  ce.com/Listings.cfm?topicM1_HIM
• Ongoing Record Review A Guide to JCAHO
  Compliance and Best Practice, HCPro

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Continuing Ed Credit

• AHIMA self report 1 hour
• AAPC - Preapproved for 1 hour
• report DVAEES0505041119

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Questions/Comments/Concerns
Raymond.Pinder_at_med.va.gov Barbara.Millas_at_med.va.go
v