Fifth in our series on TJC Survey Management Strategies

You’re coming down the home stretch of your survey. Now it’s time for the TJC System Tracer on Data Management.

So, what’s this tracer all about these days? And how best to prepare? Let’s take a look at the current focus for this session and what surveyors are looking for.

TJC System Tracer on Data Management: Surveyor Focus

This session has changed quite a bit over the years. It used to be the organization would present a PI project. Sort of a “dog and pony show.”

These days, the surveyors really want to see how you use data to evaluate the safety and quality of care you provide. Consequently, there are specific, high focus topics they want to explore.

Psychiatric Hospitals

Here’s the topics we see surveyors pursue during the TJC System Tracer on Data Management in psychiatric hospitals:

• Medical staff involvement in PI projects
• Use of clinical outcomes data
• Data on pain management and safe opioid prescribing
• Antimicrobial stewardship
• PI data re compliance with the hospital’s suicide risk assessment process
• Data on medication errors and adverse drug reactions
• Flu vaccination rates (with improvement toward 2020 90% target)
• Hand hygiene compliance data
• Failure Mode and Effects Analysis in last 18 months
• Monitoring of contracted clinical services
• Evaluation of the culture of safety and improvement actions

Behavioral Health Organizations

For BH organizations, the following topics are high on surveyor radar during this Data Management session:

• Outcomes Measurement (CTS.03.01.09)
  • Use of a standardized tool
  • How clinicians use the data for treatment planning
  • How the data is aggregated to evaluate organizational performance
• PI data re compliance with the organization’s suicide risk assessment process (LINK)
• Data on medication errors (if med management is within organization’s scope)
• Flu vaccination rates (with improvement toward 2020 90% target)
• Monitoring of contracted clinical services
• Client satisfaction data re how the organization can improve the safety of services it provides (PI.01.01.01 E 16)

TJC System Tracer on Data Management: Compliance Challenges

A frequent finding we see is that the organization is collecting large amounts of data but not taking action based on the results of that data. For example, here’s a recent survey finding:

“The hospital Quality Department does not review and analyze the data on Altercations/Threats according to the monthly trending reports. The Corporate data reflected an increase from the 4th Quarter 2018 to the 1st Quarter 2019 in Altercations/Threats. However, there was no documentation in the hospital’s quality data of analysis and/or action on this issue.”

Clearly, the take-away here is you need to show you’re analyzing the data and taking action – when needed – to improve performance.

For BH organizations, a common finding is not using outcome data to monitor the client’s progress on achieving the goals and objectives in their treatment plan. For example, here’s a finding from a recent BH survey report:

“The organization uses a standardized tool to measure outcomes.  However, there was no documentation to show how they analyzed and used the results of the tool to inform the plan of care and services.  The tools were completed and scored.  But there were no notes from the providers as to what the score meant for the individual, etc.  In addition, the Clinical Director and therapist confirmed this lack of documentation.”

For a look at how one of our clients tackled this challenge, see our post How One Organization is Meeting the New Outcomes Measurement Requirements.

Barrins & Associates Mock Survey

Our Mock Survey includes a robust System Tracer on Data Management. We coach your team on what to present and how to put their best foot forward during this session. As a result, you avoid Requirements for Improvement (RFIs) in the Performance Improvement chapter.  Always a welcome outcome!