Current Problems in Diagnostic Radiology ] (2017) ]]]–]]]

Current Problems in Diagnostic Radiology

journal homepage: www.cpdrjournal.com

The Joint Commission Ever-Readiness: Understanding Tracer

Methodology
Bettina Siewert, MDn
Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA

The Joint Commission (TJC) evaluates the consistent provision of appropriate and safe access to health care, treatment, and services. Currently, TJC uses
the tracer methodology to assess standards compliance and follows a number of patients through an organization’s entire health care delivery process.
The tracer methodology uses 3 different types of tracers as follows: individual or patient tracers, program-specific, and system tracers, to identify
performance issues in one or more steps of the care process or at interfaces between them. This review article describes the different types of tracers used
by TJC and provides examples of each tracer in radiology; it outlines how to achieve TJC ever-readiness with the use of mock tracers and provides
practical suggestions on how to ensure staff engagement.
& 2017 Elsevier Inc. All rights reserved.

Introduction organization. In the radiology department this starts at the time of

The Joint Commission (TJC)1 evaluates the consistent provision
of appropriate and safe access to care, treatment, and services. For
this purpose TJC has outlined 270 standards and approximately
2000 elements of performance for health care institutions to
follow. During an accreditation visit, TJC assesses the alignment
of an institution’s practices, policies, procedures, and documenta-
tion with its standards of performance.
For many years a TJC visit consisted of a detailed review of
hospital policies to ensure that an institution had all required
policies in place to guide their employees in the performance of
their daily work. In 2004, TJC introduced a new methodology to
assess standards compliance: the tracer methodology.2 With the
use of a variety of tracers TJC follows a number of patients through
the organization’s entire health care delivery process and eval-
uates their experience of care, treatment, or services. TJC thus
strives to ascertain not only that hospital policies and procedures
satisfy TJC standards, but moreover that frontline personnel
delivers health care according to those standards. A TJC visit aims
to identify performance issues in one or more steps of the care
process, and to uncover issues at interfaces between different
elements of the care process.
The tracer methodology uses 3 different types of tracers as follows:
individual or patient tracers, program-specific, and system tracers.
Individual Tracers
Individual tracers focus on “patient care at the point of care”
and assess the actual care experience of a patient while at the
n
Reprint requests: Bettina Siewert, MD, Department of Radiology, Beth Israel
Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02115.
E-mail address: bsiewert@bidmc.harvard.edu
the patients’ first telephone contact with the department when
scheduling an examination.3 It includes all encounters while
physically in radiology and extends to results communication by
a radiologist to either the referring physician or patient4 after a
diagnostic examination as well as discharge after an interventional
procedure.3 Individual tracers place an emphasis on performance
evaluation of frontline personnel and their compliance with
policies.
Individual tracers are a daily part of the TJC visit and last
between 60 and 120 minutes. They can be performed by the
surveyor in person interacting directly with staff, observing their
health care delivery or as chart review.
Patients are selected as an individual tracer if their diagnosis,
age, or services allow for an in depth evaluation of organizational
practices. The TJC targets areas or patients known to be vulner-
able: such as areas that take care of high-risk patients or perform
high-risk procedures where maintaining staff competency may be
challenging due to low volumes5; patients who move between
services or programs and go through multiple hand-off situations
where communication errors are common.6-9 Communication
errors are also known to occur at the transition of care in those
who are about to be discharged or are recently admitted.
Although the former is prone to lapses in result communication,
the latter can highlight issues in medication reconciliation.
Finally, individual tracers may be chosen based on information
gathered during a system tracer meeting (discussed later in this
article) and thus relate to infection control, data, or medication
management.
During an individual tracer the surveyor observes the care,
treatment, or services being provided to patients and focuses
particularly on 5 components: medication process, infection con-
trol issues, processes for planning and coordinating care, the
environment as it relates to the safety of patients or staff, and
laboratory testing. The medication process includes medication

http://dx.doi.org/10.1067/j.cpradiol.2017.05.002
0363-0188/& 2017 Elsevier Inc. All rights reserved.
2 B. Siewert / Current Problems in Diagnostic Radiology ] (2017) ]]]–]]]

preparation, dispensing, administration, storage, and control of
medications. In radiology, dispensing of medication occurs mainly
in the context of moderate sedation provided during interven-
tional procedures. The preparation of medication is highly regu-
lated and in radiology may be evaluated during intra-arterial
chemoembolization. Infection control issues focus on hand
hygiene,10 sterilization of equipment, disinfection, food, sanitation,
and housekeeping. Hand hygiene is a National Patient Safety
Goal11 and compliance with guidelines is expected and needs to
be continuously audited. Processes for planning and coordinating
patient care in radiology include workflow around coordinating
interventional procedures and guidelines for communication of
critical results to referring physicians for diagnostic imaging.12,13
An example of environment as it relates to safety of patients
and staff is the governance of access to magnetic resonance
imaging safety zones. Laboratory testing encompasses
quality control, maintenance, and testing performance, important
issues for radiology departments that include nuclear medicine.
Additional topics a surveyor may ask frontline staff about are:
institutional processes relating to TJC standards and National
Patient Safety Goals,11 patient education, the use of data and the
orientation, education, and competency of staff. In preparation for
a TJC visit, it is helpful to develop written material on National
Patient Safety Goals and how they are reflected in daily practice in
radiology (Table 1). Patient education includes preprocedure and
postprocedure instructions for interventional radiology, as well as
pretest instructions, and information provided after intravenous
contrast reactions. Staff will need to be able to speak to processes
around how and when the information is distributed and by
whom. Staff’s familiarity with the use of data has recently received
more attention by surveyors. Staff can demonstrate familiarity
with and involvement in QA processes by being able to speak to
what data is collected (example hand hygiene audits) and
how processes are changed to achieve improvements. Staff may
be asked to describe their job orientation, how they were trained
to perform a certain task, and how their competency was
established. Written documentation of individual staff members’
competency needs to be available to be presented to a TJC surveyor
if requested.
The number of individual tracers that a surveyor will perform
during their visit at an institution or in a specific department
varies by size of the organization, observed practice compliance,
and information gathered during discussions of system tracers as
described later. Individual tracers can be added to further explore
an observed vulnerability in other departments of the institution
as needed.
Example of an Individual Tracer in Radiology
Table 2 provides an example of an individual tracer and
summarizes how the TJC surveyor establishes that frontline
clinical care is concordant with hospital policies.
Program-Specific Tracers
Program-specific tracers focus on assessing continuity of care,
laboratory integration, patient flow, violence, and suicide preven-
tion. The most relevant program-specific tracer for radiology is
continuity of care. The integration of the patient’s diagnostic
evaluation into overall care will be evaluated including follow-
through from ordering of an examination to discussion of test
results with the patient and referring provider. Patient flow may
investigate admissions from the emergency department, who go
directly to interventional radiology and from there to the intensive
care unit. Violence and suicide prevention do not apply to
radiology department and are limited to institutions with mental
health programs. Program-specific tracers are not discussed during
a dedicated time interval, but are discussed during individual
tracers.
Example of a Program-Specific Tracers in Radiology
Continuity of care in radiology focuses on hand-off communi-
cations with referring physicians and the patient. In the outpatient
setting, this may center on recommendation for follow-up imaging
studies and systems that are in place to ensure that imaging
recommendations are followed to avoid a delay in diagnosis.14 At
our institution, we require immediate physician to physician
communication on critical results such as ischemic bowel or
pneumothorax. The communication is documented in the radiol-
ogy report including the name of the person spoken to, the
method of communication (in person, by telephone), the date
and time of the communication, and the time interval between the
discovery of the abnormality and the communication. The sur-
veyor may ask to see audit data on how often the process is
followed and documentation of all elements is complete. For
nonurgent abnormal results that require follow-up, we have
developed a result communication dashboard where all patients
are entered by the reporting radiologist. An administrative assis-
tant will then personally contact the referring physician by email
or phone to relay the follow-up recommendation and document
the communication (including date, time, and person spoken to) in

Table 1
National Patient Safety Goals 2017 in Radiology

National Patient Safety Goal (NPSG) Initiatives in radiology

(1) Improve the accuracy of patient identification Universal Protocol

Accurate specimen labeling

(2) Improve the effectiveness of communication Critical result communication policy

among care givers

(3) Improve the safety of using medications Medication labeling on and off the sterile field
Guidelines for recommencing anticoagulation held for interventional procedure

(4) Reduce the harm associated with clinical alarm Analysis of alarm signals in department
systems
Development of policies around appropriate settings, when alarms can be changed or silenced and by whom
(example fluoroscopy alarm)

(5) Reduce the risk of health care associated infections Hand hygiene guidelines
Cleaning and disinfecting equipment
 B. Siewert / Current Problems in Diagnostic Radiology ] (2017) ]]]–]]]
Table 2
Example of an individual tracer during a TJC visit in radiology
Patient care provided
A 35-year-old Russian speaking woman is referred to interventional radiology for
placement of a temporary line for dialysis as her AV fistula is nonfunctioning. She
has a decreased level of consciousness and there is a concern for sepsis. Her
medical history includes hypertension and diabetes mellitus, she is MRSA
positive.
During preprocedure assessment:
On evaluation by the interventional radiology service, the patient is not
consentable, her health care proxy is a brother who lives out of state and is
Russian speaking, a telephone consent is therefore necessary.
In interventional radiology procedure suite:
Before starting the procedure a preprocedure time-out is performed: The patient
identity is confirmed with 2 patient identifiers and the type of procedure is
verified by double checking the written procedure requisition.
Temporary dialysis line is placed.
Recovery room:
After successful temporary line placement the patient is brought to the recovery
area where postprocedure documentation is completed.
Relevant policies are mentioned in bold.
the dashboard so that we can ensure that the test result has
reached the referring provider.
System Tracers
System tracers refer to 6 topics that involve general procedure
in an entire institution in regards to data management, infection
3
Compliance with policies and NPSG as evaluated by TJC
Hospital policy on “Informed consent and decision making,” particularly:
(1) Consent is obtained with an interpreter.
(2) Telephone consent includes a witness who confirms the health care proxy
giving consent over the phone.
(3) Documentation of telephone consent includes signature of the witness on the
consent form.
“Nonoperative Universal Protocol Policy,” specifically:
(1) The entire team present in the procedure suite is engaged in the time-out
process.
(2) All clinical activities come to a full stop.
(3) A time-out script, if available, is followed.
(4) An interpreter is available throughout to answer the patient's question.
“Hand hygiene” policy
“Infection control” policy
“Medication and solution labeling for use in procedural settings on or off
the sterile field” including:
(1) All medications on the procedure table are labeled
(2) Moderate sedation medication is labeled
-“Moderate sedation provided by nonanesthesist” particularly:
(1) Moderate sedation is administered adhering to guidelines for dose range
(2) Regular pain assessment is performed throughout the procedure
Policy on “Cleaning and disinfection of equipment between patient use” is
followed during room turnover.
Patient recovery follows guidelines in policy on “Moderate sedation provided
by nonanesthesist.”
Procedure documentation, the story of care, is:
(1) legible
(2) complete including documentation of H&P, moderate sedation, and a separate
procedure note
(3) signed with date and time of the completion of the documentation
(4) timeline of the documentation is accurate, i.e., documentation has to occur in
this order: H&P, patient consent, preprocedure time-out, moderate sedation
documentation, procedure note
(5) Postprocedure orders are adequately documented.
Patient receives written discharge instructions including resuming medications
that have been discontinued, i.e., anticoagulation, in accordance with National
Patient Safety Goals on reconciliation of patient medication.
control, medication management, National Patient Safety goals,
contracted services performance monitoring, and incident or error
reporting. System tracers are organized as group meetings with
staff representatives from all departments involved in a specific
tracer and are performed after several initial individual tracers
have taken place. The meeting time is scheduled at a time
convenient for the organization and generally encompasses
4 B. Siewert / Current Problems in Diagnostic Radiology ] (2017) ]]]–]]]
60-90 minutes. Depending upon the size of the organization all
mandatory topics of system tracers can be discussed during a
single meeting; however, in large institutions several system tracer
meetings are required and dedicated to a single topic. Data
management, infection control, and medication management are
part of every TJC visit, whereas National Patient Safety goals,
contracted services performance monitoring, and incident or error
reporting may or may not necessarily require a dedicated meeting.
Example of a System Tracer in Radiology
Representatives from radiology participate in a dedicated
system tracer meeting to discuss medication management
together with staff from other departments such as pharmacy,
internal medicine, oncology, and health care quality. During this
meeting, TJC leads a discussion on processes for setting formula-
ries, use of dispensing units, controlled substances, administration,
storage, transport, and waste of medication. Following the
discussion the surveyor may ask to visit a clinical area to see the
described processes in practice. A visit to radiology may
focus on the storage and administration of contrast media and
policies around transport and administration of chemo-
therapy agents in interventional radiology during intra-arterial
chemoembolization.15,16
TJC and Radiology
The spotlight of TJC is expected to be on imaging services for at
least the next 3 years. Individual patient tracers will likely focus on
National Patient Safety Goals,11 imaging utilization, and training of
personnel. System tracers in radiology are completely aligned with
American College of Radiology (ACR) standards for accreditation as
a Diagnostic Imaging Center of Excellence17 and are therefore easy
to navigate for departments holding that accreditation. A new
focus of TJC has been a rising interest in quality assurance
activities. Radiology will therefore need to show increased involve-
ment of staff members in QA activities and staff awareness of local
QA efforts will be most beneficial.
Hot Topics in Radiology
Several areas in radiology will undergo careful evaluation by
TJC such as maintenance of equipment, credentialing, radiation
safety, result communication, and procedural areas (Table 3).
Maintenance of equipment needs to be performed as indicated
according to manufacturer’s instruction including time intervals.
For high-level disinfection such as transvaginal probes, the clean-
ing process has to be demonstrated to a surveyor including proper
storage of cleaned probes.
Credentialing in general has become a major focus. Physician
staff’s ongoing practice performance evaluation18 has to address all
areas the physician is credentialed for. The scope of practice for
technical staff has to be defined, training has to be provided and
competency documented. The documentation of competency of
personnel has to be available to the surveyor including annual in-
service and observational competency. Vendors need to undergo
institution specific safety training and wear institutional identity
badges.
Departmental policies for computed tomography (CT), mag-
netic resonance imaging, and nuclear medicine will be reviewed
including the dates of last policy review. Radiation safety will
verify radiation doses in CT and nuclear medicine. Proper storage
of lead aprons needs to be demonstrated and staff needs to be
educated around which aprons are safe to use. Communication
between providers and patients has become increasingly
Table 3
TJC hot topics in radiology checklist
Procedural areas Universal time-out protocol
Medication labeling on and off sterile field
Conscious sedation dosing
Code cart and tackle box inspection
Maintenance of According to manufacturer's specification
equipment
Including time intervals
Radiation safety Departmental policies up-to-date
Radiation doses for CT, nuclear medicine
Proper lead apron storage
Training on lead apron quality control
Result Critical result communication policy
communication
Credentialing Physicians: OPPE in accordance with clinical practice
Technical staff: define scope of practice, provide training,
and document competency
important including direct communication by the radiologist to
the patient.4 Keeping patients informed with written information
material prior or after examination; and proper documentation in
the electronic medical record including date, time, and signature of
a radiologist involvement in the patient’s care. In addition, TJC
emphasizes closed loop communication between all staff members
in a specific service line as well as between services.8 For example
CT workflow from technologists requesting and receiving a study
protocol from a radiologist to sending images to a picture archiving
and communication system and ensuring that an urgent prelimi-
nary interpretation is performed in a timely fashion have to be
established. In procedural areas, documentation of American Society
of Anesthesiologists scores and consistent airway classification
across service lines are confirmed. The universal time-out protocol19
will be observed and needs to show that all staff in the procedure
suite participate in the process and fully stop all clinical activities
during this time. Medication management will be reviewed includ-
ing medication storage or dispersal and conscious sedation dosing.
Code carts and tackle boxes are inspected for proper emergency
medication content and expired medications.
Achieving TJC Ever-Readiness
Until recently, TJC visits were scheduled on a specific date with
the institution and could be meticulously prepared. Currently, TJC
informs the institution about a 3-month time window during
which the visit can occur at any time without further notice. Ever-
readiness has thus become a major focus of preparation.
To maintain a high level of preparedness over the 3 month
period of a possible TJC visit, it is critical to maintain continuous
staff engagement. Daily emails with test questions a surveyor
could ask can be most helpful. A jeopardy game using an audience
response system with prizes for the most successful team provides
an opportunity to foster team building and memorization of
otherwise challenging material.
Mock surveys using the tracer methodology20 performed
jointly by hospital and radiology department health care quality
personnel are most helpful to uncover specific vulnerabilities. The
use of individual patient tracers is helpful to pinpoint critical areas
and develop a specific action plan. A resurvey after the action plan
has been put in place can determine whether the issue has been
satisfactorily addressed or further work is needed on the topic.
As much of a TJC visit will be spent with individual tracers
observing frontline staff, this gives staff the unique opportunity to
 B. Siewert / Current Problems in Diagnostic Radiology ] (2017) ]]]–]]]
showcase their excellent patient care, awareness of departmental
QA activities and active involvement therein. If staff can speak to
how the department addresses and integrates National Patient
Safety Goals into daily practice, this will underscore the high safety
standard of the institution.
Conclusion
In summary, the tracer methodology evaluates patient care at the
point of care from hospital admission to discharge. It allows for
analysis of systems throughout institutions as well as system
interfaces. In helping to uncover vulnerabilities during mock
surveys, the tracer methodology is a cornerstone for achieving TJC
ever-readiness.
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