Joint Commission Survey Tracers

InAHQ Annual Conference May 2011
Identify techniques for developing tracer
Identify how to use tracers to improve
organizational readiness
Demonstrate how to conduct a tracer
◦ To provide an accurate assessment of the
systems and processes for the delivery of
care, treatment, and services
◦ Identify gaps or risk points that could affect
quality or safety of care
◦ Link to TJC elements of performance
◦ Learn from individuals directly involved in
providing/receiving services about how the
process work
• Retrospective-learn more about why a process
didn’t work or was successful
• Prospective-evaluate process identified as
problematic, determine current practice around
new regulatory standards, evaluate high risk
populations or processes with poor outcomes
What would you like to know more about in your
What do you worry about
What keeps you awake at night
Systems Tracers – process focused
◦ Infection Control
◦ Medication Management
◦ Use of Data
Patient Tracers - patient-focused
(PPR and Priority Focus Areas)
Program Specific Tracer – Hospital
• Hospital – lab integration is topic – consistent
application of critical value, specimen collection and
handling, etc.
• Hospitals with psych – Suicide prevention to include
effectiveness of HCO suicide prevention strategy.
• Patient flow tracer
• Relates to specific types of services offered or
programs being accredited
• Ambulatory
• Behavior Health
• Lab integration
• Home Health
Tracers provide
◦ Unique opportunity to see the care and
services on a daily basis
◦ Better understand relevancy of process
◦ Detect problems that could increase
risk/compromise patient safety
◦ Cost effective approach to improve safety and
◦ Team approach-who should be on team
◦ Team leader-suggest co-leaders
◦ Provide Guidance and training for tracer team
◦ Channel information to leadership
Who should be on the team?
◦ Performance Improvement
◦ Nursing leaders
◦ Pharmacy
◦ Infection control
◦ Facilities
◦ Determine Goals
 PI data
 Sentinel event
 Sentinel event alerts
 Confirm practices of key policies
 Confirm practices of NPSG and UP
 What unique situations exist in your
 Clinical Service Groups and Priority Focus
◦ Select tracer patient
 Use active patient list
 LOS 4-7 days nearing discharge
 Considerations
 Complex situations
 ED
 Anesthesia services
 Surgery
Use Multiple approaches and sources
◦ Choose opening, welcoming tone
◦ Listen attentively
◦ Restate or clarify responses
◦ Ask open ended questions
Interview questions
◦ Use PPR chapter elements of performance as
a guide
◦ Use national survey questions
◦ Ask multiple staff the same question
◦ Have staff answer questions not managers
◦ Tell me your two
patient identifiers
Observe the process
of using patient
Pain assessment and
Is there evidence in
the medical record
the patient has been
reassessed for pain
per policy
What is the process
for pain assessment
and reassessment
How often is pain
assessed or
Data collection
◦ Develop tools
 Standardize check list
 Department relevant standards
 Measure of success measures
 Tools need to help organize findings
◦ Aggregate data
• Share data with leadership
• Develop action plans
• Set a timeline and reporting dates
Date Completed
Tracer Activity Visits
For selected patients – visits are focused
around the patient’s care and identified priority
focus areas
Utilizing tracer methodology will begin and end
in the patient’s current unit
Medical Record review at the end of visit to
validate processes and documentation
Classic Tracer Activity:
Visit the current unit to get a brief history of the
patient and identify what services were involved
in their care
Trace back to units or services who cared for the
patient, discussing various processes with unit
staff. (may include lab, radiology, ED, Cath Lab,
pharmacy, PT, etc.)
Notify the manager or charge nurse of the
patient you have chosen to trace
Request patient record
◦ Be sure to get bedside record if appropriate
and current MAR
Ask to have the patient’s nurse assist you with
chart review
◦ To decrease time staff is away from their
patients you may wish to review part of the
record alone.
◦ Also allows time to formulate questions
Focus on high risk processes
◦ What is the process
◦ Trace the process
◦ Look for risk points
Process changes
◦ People, equipment
◦ IT, sequence of procedures, locations
Reports or data will indicate an issue
Reviewing the process not an individual patient
Where does the process touch
Who does the process touch
Infection control
◦ Learn about planning, implementing,
evaluating infection control program
◦ What is the process used to reduce infections
 Proper hand washing
 Standard precautions
 Transmission based precautions
 Sterilization processes
Identify safety concerns within different levels
and types of care
Ambulatory-continuity of care
Behavior Health-elopement, suicide prevention
Home Health-falls, equipment
26 year old male admitted to ICU via ED after
MVA. Patient has been to surgery for repair of
orthopedic injuries and is on a vent. The
patient’s history includes diabetes and he drinks
a 6 pack of beer per day. Plan is to move the
patient to a surgical floor tomorrow.
What would you look for on the patient’s medical
Which staff members would you speak to on the
Which departments might you visit as you
continue the tracer?
Start in ICU and track to ED and surgery
H&P – done prior to surgery or a note indicating it
is an emergency
All surgery related paperwork complete?
Consult with dietitian?
Consideration of DTs?
Restraints used? Documentation?
Speak with RT, PT, Dietitian
Is care plan customized to the patient?
56 year old female post 3 vessel open heart
procedure. Patient was admitted via the ED and
went to cath lab and subsequently on to OR.
Patient is now in a telemetry unit but was in
MICU prior to that transfer. Nursing assessment
indicates the patient’s faith is very important to
her in her recovery. The patient only speaks
What would you look for on the patient’s medical
Which staff members would you speak to on the
Which departments might you visit as you
continue the tracer?
Start in telemetry and visit MICU, ED, cath lab and
Interpreter available? Written material such as
consent available in Spanish? Staff know how
access to interpreter
Chaplain or priest notified if patient requests?
Cath lab and OR documentation indicate timeout?
• Don’t trace your own department
• Trace processes of care not clinical
• Failure to take notes
• Failing to summarize findings
• Lack of validation
• Lack of feedback to staff
Understand Tracer Methods
Have a plan
Follow through using your PI model
Incorporate into annual PPR plan
Every level of the organization is involved