Free Accreditation Resource: Infection Control System Tracer for a Hospital

The tracer is the essential component of the Joint Commission International on-site accreditation survey. In the book excerpt below, from the 2009 JCI publication, Mock Tracer Workbook, one way a surveyor can conduct an infection control system tracer is explored, providing organizations with advice not only on how to be ready for a survey, but how to perform surveys year-round as a performance-improvement tool.

Scenario
The surveyor conducted this infection control system tracer in a 250-bed hospital. She started the session by meeting with the infection prevention and control (IC) director and with representative members of the infection prevention and control committee. She asked them to explain the committee’s mission and focus, and asked each to explain his or her role on the committee and in the infection prevention and control program.

The IC director explained that she was a nurse with Association for Professionals in Infection Control and Epidemiology (APIC) certification and that she had coordinated the IC program in this hospital for about five years. She led the program with a physician who was an epidemiologist. Committee members included representatives from the laboratory, pharmacy, environmental service, nurses from several areas in the hospital, and an administrator. The committee met every other month, but was involved in the program on a daily basis.

The surveyor asked the committee representatives to identify the greatest infection control risks that they currently deal with. She also asked them to identify any studies in which they currently collect data. They explained that they monitored for hand hygiene, and that this was a main focus for the committee. They also focused on potential exposures to needle sticks and other potentially infectious body fluids. In addition, they worked with staff regarding compliance with isolation requirements. They described how they worked with staff regarding identification of and interventions for preventing the spread of health care–associated infections, such as Clostridium difficile and hospital-acquired vancomycin resistance. They believed that the incidence of health care–associated methicillin-resistant Staphylococcus aureus (MRSA) was actually diminishing, though they saw an increase in community-acquired MRSA infections.

The surveyor asked the staff to present their studies and to identify how they addressed the identified challenges. The IC director and medical IC coordinator described how they accessed the Centers for Disease Prevention and Control data and information on a daily basis, and how they disseminated the relevant information to staff through the hospital’s intranet. They also provided periodic education programs for staff.

The surveyor asked the staff to present data regarding staff compliance with hand hygiene requirements. She asked how they measured compliance, if they believed that their measurement strategies were reliable, and if the interventions were effective.

The surveyor then asked the staff to explain the organization’s requirements for isolation and when it was used. She also asked how they monitored compliance and if they collected data to identify the potential risk points in this process.

After the formal meeting and review, the surveyor chose a patient with an infection for the tracer. The surveyor observed a nurse entering the tracer patient’s room and providing care. She also observed a laboratory technician entering the room and performing a blood draw. She noticed that some family member visitors did not follow the guideline requirements posted outside the patient’s room for the use of personal protective equipment. Staff said that they educated the family members, but sometimes it was difficult to hold them in compliance, so they generally did not stop them. The laboratory technician fully followed the guidelines. However, the surveyor witnessed that a nurse left the room, went to the medication room, and returned to the patient’s room wearing the same protective garb. Afterward, she was asked if her conduct was acceptable and safe practice. The nurse responded that she knew she should have removed the garb when leaving the patient’s room and worn new protective garb upon re-entering, but it was often difficult to follow all of the procedures because of her heavy caseload—due to staffing shortages—and the number of times she needed to leave the room for supplies. The surveyor asked her how she prepared for each entry to the patient room and if she could plan the visits to include all of the equipment and supplies that would be needed. She also asked staff how they could assist one another through handoffs of equipment and supplies to ensure full compliance with requirements

Sample Tracer Questions
Questions for the Infection Prevention and Control Director and Medical Coordinator of Infection Prevention and Control
► How do you obtain needed and current information regarding infection prevention and control?
► How do you disseminate this information to other staff at all levels?
► What are the greatest infection control risks facing your organization?
► What are you doing to diminish the risks and impact on outcomes of care?
► How do you monitor compliance with infection control requirements such as hand hygiene and contact precautions or isolation room
requirements?
► How do you intervene when you observe noncompliance?
► How do you collect and analyze data regarding risky or problematic trends and patterns?

Questions for Members of the Infection Prevention and Control Committee
► What is your involvement on the committee?
► Why were you selected to be on this committee?
► What data are being studied?
► How are the data communicated to you?
► Do you compare and benchmark your data and outcomes with others? Describe this process. How do you compare?
► What improvements have you implemented?
   – Are they effective?
   – How do you know?
► How is your staff performing regarding hand hygiene requirements?
► How is hand hygiene monitored?
   – Have you identified risk areas? If so, how do you address these identified risks?
   – Has compliance improved?
   – Is improvement sustained and is it sustainable?
   – How do you know?

Questions for the Nurse
► How do you monitor hand hygiene compliance in staff, visitors, and patients?
► Do you intervene if you believe the required guidelines for infection prevention and control are not being complied with? How?
► How do you educate patients and families regarding hand hygiene and infection prevention and control principles and requirements?
► How do you document this education?
► Are you aware of the requirements for the use of personal protective equipment for entering the rooms of patients on contact
precautions or isolation?