TracerMethodologyTIPS AND STRATEGIES FOR

CONTINUOUSSYSTEMS IMPROVEMENT

Frontline Strategies to Prepare for JCI Accreditation

Col. Dr. jamal HommadiCQI&PS Ditrector SR

Objectives

O Understanding Tracer Methodology

O Evolution of tracer methodology

O Tracer Methodology and the Survey Process

O Tracer Methodology and its Role in Continuous Systems Improvement

O Types of tracer methodology process

The hypothesis is:

If we look at health care as a series of systems and

subsystems, and identify the “defects” within the

system(s), errors causing patients harm

will be reduced

The method is:

Method of identifying “broken” systems

is through the use of tracers

IntroductionO The Joint Commission’s accreditation

process focuses on operational systems critical to the safety and quality of care received by those navigating the health care system.

O The goal is to ensure that an organization is always meeting the requirements of accreditation by providing ongoing, high-quality care at all times—not just during an on-site survey period.

IntroductionO This represents a shift in how health

care standards are assessed.O In the past the goal was to “ramp up”

for a survey, and got a periodic “snapshot” picture of an organization.

O Now the focus is on continuous systems improvement through an unannounced survey* and Periodic Performance Review, that incorporates tracer methodology as its primary evaluation tool.

TRACERMETHODOLOGY

O Tracer methodology is an evaluation method in which surveyors select a patient, resident or client and use that individual’s record as a roadmap to move through an organization to assess and evaluate the organization’s compliance with selected standards and the organization’s systems of providing care and services.

TRACERMETHODOLOGY: An

EvolutionO Roots in science- emerged in the early

twentieth century: Used by scientific researchers.

O The tracer methodology or tracer approach in Healthcare was introduced in the early 1970’s by Kessener and Kalk (1973)

O In January 2004, JCAHO redesigned their accreditation process by implementing Tracer Methodology Shared Visions –New Pathways ®

TRACER KEYO Flexibility is the key to the tracer

process, which typically allows the tracer to “observe”, “walk”, “talk”, “survey”, “analyze” and “report” that provides a “multi-dimensional” picture of an organization’s processes and services; rather than a “snapshot” picture, and a “dynamic” survey rather than a “ramp up” survey.

Types of Tracers:

Within this methodology, surveyors conduct the following types of tracers:O Individual tracersO System tracers (data use, medication management, and infection control)O Program-specific tracersO Environment of care tracer (emergency management), (for hospitals only)

Tracer Methodology

Individual Tracer

System Tracer

Program Specific Tracer

Environment Tracer

MMS Tracer

ICS Tracer

DUS Tracer

Ambulatory care

Behavioral care

Critical access

Home care

Hospital

Laboratory

Long Term

Individual tracers: patient tracers, resident tracers, client tracers)

Environment of care tracer (emergency

management), (for hospitals

only)

INDIVIDUAL TRACERS

OIndividual tracers (also called patient tracers, resident tracers, or client tracers).

OTo select individuals to trace, surveyors consider the CSGs and at least the top four priority focus areas (PFAs) for an organization.

Tracer Conduction To conduct the tracer, the surveyor might do the following:O Interview staff delivering care, treatment, and services to the tracer individual, as needed.O Evaluate PFAsO Evaluate the environment, if applicableOReview the record for clarification and confirmation of informationOInterview the care recipient and family, if appropriate or applicable

SYSTEM TRACERSO The system tracer activity focuses on

high-risk processes across organizations.O The concept behind the system tracer

methodology is to review processes at the organization; by examining a set of components that work together toward a common goal.

O The surveyor can evaluate how and how well the organization’s systems function.

SYSTEM TRACERS TYYPES

There are currently three types of individual-based system tracers:O Medication management system tracer.O infection control system tracer.O Data use system tracer.

Note: Only organizations with surveys of three days’ length or longer will have the medication management and infection control system tracers. For organizations with surveys of shorter duration (such as one- or two-day surveys in ambulatory care or behavioral health care settings),

A system tracer generally includes an interactive discussion between a surveyor and relevant staff members. Points of discussion can include the following:O The flow of the process across the organization, including identification and management of risk points, integration of key activities, and communication among staff and units involved in the processO Strengths in the process and possible actions to be taken in areas needing improvementO Issues requiring further exploration in other survey activitiesO A baseline assessment of standards complianceO Education by the surveyor, as appropriate

Data UseO The focus of the data use system

tracer is straightforward: How does the organization use data to improve safety and quality of care?

O To determine the answer to this question, organizations can expect to discuss with surveyors how leadership uses data to prioritize decision making to improve quality of care and patient safety.

Within that context, surveyors talk with organizations about the following topics:

O Current and past performance improvement activityO Type of analysis conductedO Data reporting—when it occurs and to whomO Actions taken as a result of using dataO Dissemination of findings and involvement of affected staffO Reporting to leadership for prioritization and decision makingO Performance issues O Approach to assessing staffing effectiveness and use of these data and information

Médication Management

O The objective of the medication management system tracer is to evaluate the continuity of medication management processes and complete a high-level analysis of the medication management system.

O Surveyors track medication processes and handoff points, asking staff to explain, “Where does the medication ‘go’?” “Why do we do what we do?” and “What systems touch a care recipient?”

To get a better understanding of an organization’s medication management system, surveyors might discuss the following topics:O Medication processes, O International Patient Safety Goals and the organization’s medication use systemO Reporting of errors, system breakdowns, or near missesO Medication education for patients and staffO Information management related to medication managementO Data collection and analysis, O Review of risk points, symptoms, and related issuesO Care recipient involvement as part of a medication management team

Infection ControlO In examining how an organization

addresses its infection control and prevention, surveyors trace a broad range of activities to assess compliance with relevant infection control standards.

Possible discussion topics can include the following:

O How patients with infections are identified by the organizationO How patients with infections are considered within the context of the infection control systemO Current and past surveillance activity—taking place in the past 12 monthsO Actions taken as a result of surveillance and the outcomes of those actionsO Type of analysis conducted on infection control data, including comparisonsO Reporting of infection control data—when it occurs and to whom?O Observation of infection control techniques (aseptic, sterile, surgical, and so forth)

O Prevention and control activitiesO Infection control data aggregation and

analyses trendingO Physical facility changes that have an

impact on infection control, if applicableO International Patient Safety Goal

complianceO Sterilization, disinfection, food sanitation,

housekeeping, …etc.O Role and activities of the organization’s

infection control officerO Written infection control planO How organization functions are integrated

into the infection control plan

PROGRAM-SPECIFIC TRACERS

O As of January 1, 2007, surveyors began conducting program-specific tracers during on-site surveys.

O This was specifically implemented for the ambulatory care, behavioral health care, critical access hospital, home care, hospital, laboratory, and long term care settings

Program-specific tracers bring a targeted focus on important issues relevant to the following information:

O Types of services offered by the organizationO Programs being surveyedO The organization’s PFAsO Centers for Medicare & Medicaid Services deemed status/recognition requirements

TRACING THE ENVIRONMENT OF

CAREO The EC session of the on-site survey

is often divided between group discussion on managing risk in the organization’s environment (30%) and surveyor observation and evaluation of the organization’s performance in managing EC risk (70%).

Tracer Data Form

Map of Tracer – Example on a Cardiac Stent Patient Date: __5/19/014__________ Medical Record Number:_123456____ Hospital: _General Hospital, AZ___ Surveyor:__John

Doe________Clinical Service Group:__Cardiology__________ Rationale for Tracer Selection: _PFP identified 2 points for this

CSG______________

Survey Methods

- Interviews- Medical Record Entries

Survey Methods

- Interviews- Assessment Forms

Start & End at same site to recap & validate findings with several other records

Site (START)

Participants Activity

Cardiac Care Unit

Charge NurseAttending MD

Review open medical record to map-out tracer

Site # 1

Participants Standards Interface

EmergencyDept.

Nurse supervisor

Advance directivesAssessmentPI initiatives, ORYXMed UseLeadershipEC issues

Site # 2

Participants Standards Interface

CathLab

Verbal ordersInformed consentAssessmentPI initiativeMed UseEC issues

Staff nurseAttending MD

Site (END)

Survey Methods

Cardiac Care Unit

Participants

Staff nursePatient educatorCase managerCardiac Rehab RNAttending MD

Standards Interface

EducationRightsContinuumPain managementMedication useAssessmentEC issues

- Staff interviews- Patient interviews- Medical Records- Review of educational materials

Map of Individual Tracer

2. Emergency Room/Preadmission Triage ProcessAssessment and reassessmentCommunication with laboratory and radiologyMedication process, especially high-risk IVsHand-off process

1. Current Location of the Patient

Assessment and careMedication processVerbal ordersScreening for nutrition,

rehabilitation, fall, and skin

Pain assessment and controlPatient educationDischarge planningStaff competency

3. Radiology: Patient Had X-rayAssessment and reassessmentCommunication with laboratory and radiologyMedication process, especially high-risk IVsHand-off process

5. Intensive Care Unit (ICU)Communication from emergency departmentEmergency department admission delaysAssessment and reassessmentMedication processVerbal ordersCritical equipment alarmsInformed consent and education on procedure

6. PharmacyIdentification of high-risk drugs and safety measuresReconciliation processData regarding the use of these drugsEducation regarding medicationsInvolvement in discharge planning

7. Physical Therapy (Patient Rehabilitation)Referral processAssessment and reassessmentGoal setting (long-term, short-term, and patient goals)Patient and family educationPain assessment and documentationDischarge planning

4. LaboratoryCBCData collection and trendingChemistry profileCritical test results

Patient Information

Area of Focus/Presenting SymptomsMoist lungs, Decreased activity tolerance,

Fatigue, Shortness of breath

HistoryCongestive heart failure, Coronary artery disease,

Cardiac catheterization, Stent placement

AdmissionTo Emergency department, Intensive care unit

ConclusionO Flexible and adaptiveO Interactive and dynamic instead of

ramp up survey.O Multi-dimensional picture instead of

snapshot picture for the organization.

References: