Revised survey process for system tracers for hospitals and critical access hospitals

Effective May 1, 2024, The Joint Commission is updating the System Tracers – Data, Infection Control, and Medication Management session that occurs during critical access hospital and hospital surveys. These changes were prompted by organization and surveyor feedback and the U.S. Centers for Medicare & Medicaid Services (CMS) March 2023 release of QSO-23-09-Hospital, Revision to State Operations Manual, Hospital Appendix A – Interpretive Guidelines for 42 CFR 482.21, Quality Assessment and Performance Improvement (QAPI) Program.

Infection prevention and control (IC) and medication management systems will no longer be evaluated in a meeting format. Instead, surveyors will evaluate these two systems in depth during individual tracers. During tracers, surveyors will observe processes, interview key staff, and visit areas of the organization that are integral to the day-to-day functioning of these systems. Surveyors will identify a block of tracer time during which the organization’s medication management system will be the primary focus of their evaluation; IC–related systems will be evaluated throughout the survey by all surveyors. If a group discussion is needed, surveyors will coordinate with the organization to identify participants, time, and location; these discussions will be limited with a targeted focus.

The data use/management segment of the System Tracers session will stay in a meeting format and be renamed Organization Quality and Performance Improvement (OQPI) session. This name better reflects the scope of what the surveyors are evaluating—the hospital’s processes for monitoring and improving the safety and quality of its care. Surveyors will continue to evaluate the same aspects of the organization’s data use/management program, including the following:

• Program structure
• Program scope
• Leadership direction and priority setting
• Leadership reporting
• Chosen improvement methodology
• Culture of safety
• Patient safety-related data collection, analysis, and monitoring
• Integration of infection prevention and control and medication safety data into the quality and performance improvement program
• Monitoring of contracted services

This scheduling allows the surveyors to learn about the quality monitoring and performance improvement throughout the organization during individual tracers. Surveyors will identify the ongoing performance monitoring, distinct quality indicators, and improvement projects that will be the focus of the OQPI session. Surveyors will inform the organization contact about their selections so that the appropriate information and staff can be available for the discussion.

The Survey Activity Guide for hospitals and critical access hospitals will be updated to reflect the changes to the system tracers session, including a description of the OQPI activity. The updated Survey Activity Guide will be available in April on The Joint Commission’s website and organizations’ Joint Commission Connect^® extranet site. Contact your Joint Commission account executive with any questions about these updated survey processes.