In an individual tracer, Joint Commission surveyors ask staff about hand-offs, patient flow, the National Patient Safety Goals, patient education, staff competency and the information systems they use. They also ask clinicians about coordination and patients about their care, so every answer should be one a member of staff can show in the record.
Who surveyors talk to
Joint Commission's ambulatory Survey Activity Guide sets out three groups a surveyor interviews in an individual tracer. Staff, physicians and other licensed practitioners, and patients and their families.1 The tracer starts in the program where the patient's record of care is, by reviewing it with the staff member responsible.1 Tracers identify issues in one step of care or in the interface between steps.2
Questions for staff
| Topic in the Survey Activity Guide | A question you can expect |
|---|---|
| Communication and hand-offs | How did this patient's care pass from one person to the next? |
| Use of data | Which improvement project are you part of, and what has it changed? |
| Patient flow | Walk me through a patient's day here. |
| National Patient Safety Goals | How do you identify a patient before giving care? |
| Patient education | What did you teach this patient, and how did you check they understood? |
| Orientation and competency | How were you trained for this task? |
| Information systems | How do you protect this information, and what do you do if the system is down? |
| Cyber emergencies | How would you notice and respond to a cyber incident? |
Where the services apply, staff are also asked about pain assessment, safe opioid prescribing and access to the Prescription Drug Monitoring Database, and about the organisation's antimicrobial stewardship goal.1
Questions for clinicians and patients
Physicians and other licensed practitioners are asked about processes that support or block care, coordination with other practitioners, discharge planning and their role in the environment of care.1 Patients and families are asked about coordination and timeliness, education and discharge instructions, their perception of care, whether staff washed hands and verified their identity, their understanding of instructions and their rights.1 On an ASC deemed status survey, patients are asked whether they received patient rights, financial disclosure and advance directive information before their procedure.1
- Pick real patients. Choose patients who moved between services, recently started care or were recently discharged.
- Ask from the record. Have a colleague ask each question with the patient's record open, the way a surveyor does.
- Check the identity steps. Ask staff to show the two identifiers they use on a real record.
- Check the medication answer. Ask what the patient was taking, what changed and what the patient was given in writing.
- Ask the downtime question. Every member of staff should know the backup procedure for the record system.
- Close each gap. Write down each question staff could not answer from the record, and fix the process behind it.
- Patient selected because ______
- Staff interviewed, role ______
- Questions asked ______
- Answered from the record, yes or no ______
- Gap and owner ______
- Retest date ______
The continuity of care tracer
For medical and dental organisations, a program-specific tracer evaluates the process from ordering a diagnostic study to following up with the patient, and looks for causes of missed follow-up.1 The surveyor reviews the record and the organisation's tracking methods, such as referral logs.1 Patient identification and medication questions trace back to the National Patient Safety Goals for ambulatory care.3 The Joint Commission hub sets out how wai answers each one.
Questions
What is a Joint Commission individual tracer?
The survey method that evaluates compliance through one patient's care. The surveyor reviews the record with the responsible staff member and traces the care from entry to the end of the episode.
What are system tracers in ambulatory care?
Tracers of a process across the organisation. The ambulatory guide includes data management, and in its appendix infection control and medication management.
Do surveyors talk to patients?
Yes. They ask patients and families about coordination, education, their understanding of instructions, hand washing and identity checks, and their rights.
Sources
- 1Joint Commission, 2026Ambulatory Care Accreditation Organization Survey Activity Guide, September 2026Read source
- 2Joint Commission, 2026What is the Tracer Methodology?Read source
- 3Joint Commission, 2026National Patient Safety Goals, effective January 2026, Ambulatory Health Care ProgramRead source
Written by the wai team from Joint Commission guidance, checked on 15 October 2026. This is guidance, not legal advice. Joint Commission does not endorse wai or any software.