Accreditation 2023 - Accreditation Methodology

Mock Tracers are Coming by Danielle Rae and the Accreditation Team

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Pembroke Regional Hospitals (PRH)’s Accreditation Canada survey is scheduled for April 3-6, 2023. During their onsite visit, 3-4 peer surveyors will use a methodology called “tracer” to assess how well our compliance to standards and key processes have been implemented throughout the hospital against their standards of excellence. During a tracer, the surveyors engage with staff at all levels throughout the organization. They will follow the organizational path of a patient or an administrative process while assessing and validating their findings by asking questions, reviewing records, and making observations.

To familiarize our team of staff and physicians with the tracer methodology, we will be conducting Mock Tracers as an opportunity to practice, simulate and prepare for the surveyors Tracer activities. 

Tracer Teams will meet with staff in their work areas to go over several questions related to the Accreditation standards. Similar to Accreditation Canada Surveyors, Tracer Teams will make observations about the behaviours they see and the physical environment of the area.

Our Tracer Teams are interested in celebrating what our PRH already staff know – it’s not a test of whether staff know the “right” answer. Tracer Teams are here to support our accreditation journey and enjoy meeting PRH team members they don’t typically work with and learning about other programs and Departments. Mock Tracers are also a great way to increase everyone’s awareness of Accreditation requirements.

Mock Tracer Goals:

1. PRH team members are comfortable with answering simulated accreditation survey questions
2. Engage with our teams to identify our strengths, as well as opportunities for improvement
3. Opportunity to evaluate effectiveness of PRHs policies and procedures

How Mock Tracers will work

• Every area will be offered a minimum of two Mock Tracer opportunities.
• Your Manager will schedule a Mock Tracer based on the best time for your team. Teams will know in advance when a Mock Tracer is scheduled in their area.
• Tracer Teams from across organization will conduct the Mock Tracers.
• On the day of the Mock Tracer, the Tracer Team will spend a total of 90 minutes in your area, with the first 20-30 minutes with your Manager.
• Tracer Teams will come to where you work and spend a few minutes with each person they encounter. Efforts will be made to engage and approach staff working in a variety of roles.
• Once the Mock Tracer is complete, the Tracer Team will connect briefly with the Manager to debrief and send a high-level summary that can be shared with all members of the team, even those that were not able to participate.

Mock Tracers will be scheduled from January to March 2023.

Preparing for the Mock Tracer

No preparation is needed for a Mock Tracer, but PRH Team members may want to review Accreditation 2023 Q-Tips in advance and have them to reference! Q-Tips are part of our Accreditation Education Campaign; they are rack cards that outline key information about a PRH process in a short, digestible format. You can also review the following Mock Tracer resources: 

• Mock Tracers Handout for Staff
• Frequently Asked Questions for Mock Tracers

If you have questions about Mock Tracers, please contact danielle.rae@prh.email.