JC Tracer

Hello All,

Our past experience for a tracer is like this:

1. Show me an I-stat ABG run in NICU and OR in Feb. and Nov. of 2018.

2. Provide the documentation for the competency/education for the operators.

3. Provide the documentation for the competency/education for the validators of the I-stat.

4. Provide the documentation for the calibration verification for the I-stat.

5. Provide the documentation for the QC for the cartridge lot used for the patient testing.

6. Provide the documentation of the results in the patient's EMR.

That's what we experienced with all the lab departments.

Interestingly enough, we just transitioned from JC to CAP inspections.

Good Luck,

Tricia

Tricia Boyer MT(ASCP)

Point of Care Coordinator

Tower Health- Reading Hospital

Hi.

Not sure if your hospital has access to this system : https://softwaresolutions.jcrinc.com/Login.aspx?qs=1

We use it and it has tracer forms built in specifically related to the standards for different areas.

All my POC testing is waived, so I just use the one that identifies all the WT standards.

It is a great way to follow up and track items.

I can send you screen shots of some of it if you want. Just email me :)

Michelle

Michelle E. Wilcox, MT (ASCP)

Point of Care Coordinator

Department of Laboratory Services

Rutland Regional Medical Center

160 Allen Street, Rutland, VT 05701

Phone: 802.747.1781 Fax: 802.772.2682

mewilcox@rrmc.org, www.rrmc.org

Our lab switched from CAP to TJC last year.
I had previous experience with TJC because I used to monitor hospitals with POC Labs.
All accrediting agencies inspect based on CLIA regs with just a slight differences in interpretation.
TJC will ask for a patient medical record for a patient from 2 years ago, a year ago, 6 months ago and a week ago.
They may also say: “When is your birthday? “ ( month and day) and pick a patient record that day.
They go through the patient records and pick out a lab tests , e.g. fingerstick glucose, an i-STAT, an ABG, etc.
They look at the results and see if a QC was done that day ( if no IQCP ) or that week or month depending on what is stated on the policy and procedure.
Who did it? Then they ask for the tester’s competency record. If nonwaived test and the tester is new ( within the last 2 years),
they will ask for the orientation and training record, 6 month competency and the annual competency record.
Training is different from orientation.
They will also ask for the proof of academic attainment. They now accept nursing license,
if not a high school diploma or transcript, GED, agency verification record ON FILE is acceptable.
If it is a test that require calibration: calibration records, comparison records and statistical acceptable range.
You have to have it in the procedure what you accept as slope, mean SD and CV.
They do not require calibration on i-STAT ( EPOC ) anymore. Just comparison with the main lab.
Meter to meter is not required.

You are already doing TRACER even when you were CAP. It is just not called that.
The CAP standards asked the same questions.

Since this is your first time to get inspected by TJC,
it will be more an introduction, informational, more recommendations
rather than citation unless it is glaring deficiency, and only the records of the last 6 months will be inspected.
The more thorough inspection will be 2 years later. So you got 2 years to prepare for the real test.

Read the standards line by line and make sure you have documentation for everything that is asked for in the standards.
There are notes in the standards , read those very well.
If you pass CAP with flying colors before, you should ace this one also.

Pet Maniquis, MPA, MT(ASCP) POCS (AACC)
Laboratory Point-of Care Coordinator
Providence Medical Center/ Saint John Hospital
8929 Parallel Parkway, Kansas City, KS 66112
Ph: 913-596-4727; Fax: 913-596-4728
PManiquis@primehealthcare.com

From: Thais Cruz via POCT Listserv (Groupsite) [mailto:users+1193004@poct.groupsite.com]
Sent: Thursday, May 16, 2019 11:04 AM
To: Perpetua Maniquis (PMC)
Subject: [POCT Listserv] JC Tracer

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Cindy,

Email me (mewilcox@rrmc.org) and I can send you a .pdf of what my JC tracer looks like.

Michelle