Surrey Memorial Hospital NICU staff review medication practices as part of 2018 accreditation
Written by Joanne Longson, Managing Consultant, Accreditation

A NICU team shares their mock tracer accreditation experience.

In this photo: Braden Davie, former manager clinical operations, NICU, and NICU patient care coordinators, Fatemeh and Theresa review their medication practices to prepare for their site's Accreditation Canada visit.

As many of our sites and programs work hard to prepare for the October 21-26 Accreditation Canada visit, staff in the Neonatal Intensive Care Unit (NICU) at Surrey Memorial Hospital share their mock tracer experience which boosted the team’s confidence going into the hospital’s upcoming accreditation visit. 

A mock tracer exercise is a ‘practice’ session that simulates, or mirrors, an Accreditation Canada tracer visit to a unit or team. In the case of a real Accreditation Canada visit, a surveyor would arrive at a unit or program at a pre-planned time. They would meet with staff and review several patients’ charts to understand the different types of care journeys for patients on that unit. The surveyor would ask questions of staff, physicians, patients and family members and observe how well the team incorporates the Required Organizational Practices and other standards into their care activities. The surveyor provides the unit with feedback and results after the exercise.

The Surrey NICU team’s mock tracer exercise involved a Fraser Health Accreditation Team member and a manager trained in the mock tracer methodology. The two visited the Surrey Memorial Hospital NICU at a pre-scheduled time and spoke with the care team, including physicians, nurses, unit clerk and pharmacy staff, about their medication practices. The surveyors observed the unit’s medication administration practices and spoke with family members about their involvement and understanding of their baby’s medications. 

“Our biggest learning from the mock tracer exercise was how well our NICU team was already incorporating the accreditation standards into our day to day work,” said Trish Tinkham, Director Clinical Operations, Maternal, Infant, Child and Youth Program.

“The training helps care providers to keep best practice and accreditation top of mind so it’s not just something that occurs every four years," she said. "We also use the exercise as a springboard for ongoing quality improvement to see what we are doing well and how we can track our progress for further improvements over time." 

Learn more about Required Organizational Practices and our upcoming Accreditation visit.

Fraser Health is fully accredited by Accreditation Canada until the end of the cycle in 2018. 


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