Joint Commission Revises Survey Process for System Tracers for Hospitals and Critical Access Hospitals

March 28, 2024
The organization announced on March 27 the change is effective May 1

According to a March 27 announcement from The Joint Commission, the organization has revised its survey process for system tracers for hospitals and critical access hospitals.

The announcement states, “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.”

Instead of infection prevention and control and medication management systems being evaluated in a meeting format, surveyors will evaluate the two systems during individual tracers.

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

The announcement adds, “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 Joint Commission has the announcement.