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Quality pros see opportunity to identify system, process problems
Any time the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) adds a new requirement to the survey process, quality professionals are obligated to become conversant with it to ramp up for their next survey. But if that’s all the new tools are used for, they may be missing significant opportunities for improvement, experts argue.
Such is the case with tracer methodology. Likened by some to a safety walk around, a tracer follows a selected patient through the entire continuum of care. It may seem at first glance that little can be learned from a single patient that could be of benefit to the entire organization, or even a unit, but that’s not really the case.
"It’s a good way of learning where you have opportunities to improve," says Indun Whetsell, RN, CPHQ, director of quality management at The Medical Center in Orangeburg, SC. The 86-bed acute-care facility is preparing for a review in 2006, and for Whetsell, as for all quality managers, tracer is "a brand-new methodology."
Although the facility just now is beginning to learn about tracer methodology, Whetsell already sees value in it. "It will push you to a more concurrent review, rather than a retrospective one," she observes.
"The tracer methodology used by JCAHO surveyors to evaluate hospital compliance to standards is a valuable internal audit tool," adds Patrice L. Spath, RHIT, a consultant with Brown-Spath & Associates in Forest Grove, OR.
"Many organizations are conducting tracers to prepare for an on-site survey; however, the value of this methodology goes well beyond survey preparation. The tracer methodology is similar to other observational hazard identification techniques. The goal is to uncover process or system problems that increase the likelihood of undesirable outcomes," she explains.
When the tracer methodology is used for survey preparation, Spath adds, the goal is to find and eliminate areas that are out of compliance with JCAHO standards.
"When used for internal auditing purposes, the tracer methodology can help the organization discover a whole host of problematic practices, e.g., fragmented care, communication failures, ineffective hand-offs, documentation deficiencies, and so on," she adds.
What’s more, the nature of the process also will point you in a direction that is geared to improvement potential, notes Judy Homa-Lowry, RN, MS, president of Homa-Lowry Healthcare Consulting in Canton, MI.
"The selection process will gear you to high-volume, high-risk patients, anyway," she says.
Know your systems, processes
Being up to speed on your hospital’s policies and standards, as well as its processes, is a critical part of preparation for tracer, be it for a survey or something much more broad.
"It’s overwhelming, initially, because it crosses all boundaries [of patient care]; you have to follow a case all the way through the system," Whetsell explains.
"To be able to do it, there has to be some training involved for your people. You have to know your book of standards, and you also have to know your current hospital policies and procedures. You have to be very knowledgeable to try to implement tracer methodology," she adds.
"If tracer methodology is to be useful for internal auditing purposes, the process must be systematic," Spath advises. "Like any observational survey, the investigation must be conducted consistently and valid results gathered."
A central issue in conducting a tracer is completeness, she continues. "That means assuring all important aspects of patient care and services are evaluated.
"One way to address this completeness is by putting together a multidisciplinary evaluation team. The combined experience of the team will help to assure that no important activities are overlooked. The review process should be formalized and led by a knowledgeable team leader and an experienced review team," Spath explains.
Using the tracer methodology, the team then reviews the care provided to an individual patient systematically, from beginning to end (or to the boundary defined by the scope of the analysis), she says.
"The team leader can guide the analysis in any appropriate, logical way, although the objective is to be as comprehensive as possible, while economizing on time and effort. Oversight of the review is important for ensuring that all team members perceive situations in the same way and consistently apply the same criteria," Spath says.
Keep your eyes open
One way to optimize the value of tracer methodology is to observe everything that occurs in a unit — and not just those processes directly tied to the specific tracer patient.
"We’ll look at medication, environment of care, and infection control," says Homa-Lowry. "We’ve been cross-trained to look at those issues. If any one of us sees anything out of whack, we’ll meet in the morning or after lunch, and ask if anyone else has seen the same activity."
She maintains that if organizations identify their truly unique populations, each discipline service on that unit must look at the processes it provides to that special population.
"You have to make sure on the units that people pay attention, not just to their discipline, but to what other services are doing," Homa-Lowry asserts.
"You can’t just say, Oh, infection control takes care of that.’ People on the unit should have a general understanding of those processes that affect the patient; these things directly impact patients on your unit, and you need to be aware of them — whether you provide the service or someone else does," she says.
Homa-Lowry offers this simple but significant example: "I once asked staff who was responsible for cleaning the ice machine," she recalls. "The nurse thought engineering did it, and dietary and engineering each thought the other did it. They all realized they did not have a policy, and they decided to implement one."
The point, she notes, is that tracer methodology can help point out inconsistent processes.
"This raises the issue of organizational processes," Homa-Lowry says. "You have to make sure that the units are all aligned as well; that’s when you get into the issue of having a system for your organization."
The bottom line, Whetsell notes, is that the tracer methodology can have significant value beyond the Joint Commission survey.
"I’m a strong believer in the principle that everything you do should be done to improve care," she says. "That should be your motivating rationale for doing something. Tracer methodology is time-consuming, yet through it, you can find opportunities to make some important changes."
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