Make your next mock tracer more effective
Make your next mock tracer more effective
Tracers can make or break your next survey
Mock patient tracers probably are a key aspect of preparedness for unannounced JCAHO surveys at your organizations. But do yours really identify problem areas and help to prepare nervous or uninformed staff members?
Staff preparedness at Baptist Health in Jacksonville, FL, has improved dramatically as a result of mock tracers, reports Missi Halvorsen, RN, BSN, senior consultant for JCAHO/regulatory accreditation. "The more frequently you do them, the less anxious they will be during a real survey," she says. "I start off by telling staff, You can’t have a wrong answer; maybe there is a better answer, but we are here to help you.’"
Continual tracers make staff far more comfortable answering questions about processes and the care they deliver, says Wendy H. Solberg, CHE, director of quality resources at Gwinnett Hospital System in Lawrenceville, GA.
"The process also allows our leadership team to get a real’ sense of how we are doing with continual compliance," she says. "We are able to interact with staff and communicate with those delivering the care."
Patient tracers are done weekly, with smaller, more focused tracers being conducted on a unit level, such as tracing a congestive heart failure patient through his or her stay. "The concept has really been found to keep a handle on compliance as well as monitoring the care delivered to our patients every day," Solberg explains.
During a recent unannounced JCAHO survey at Long Island Jewish Medical Center in New Hyde Park, NY, mock surveys proved invaluable, says Kerri Anne Scanlon, RN, MSN, ANP, associate executive director of quality management. "By the time the JCAHO got here, no one was frightened to speak to them," she adds. "The staff actually came looking for the surveyors and came right up and welcomed them to their units."
"The primary nurses really knew their patients, and we didn’t have one nursing care-related issue," Scanlon reports. "I credit that to the tracers we’ve been doing. The staff felt so comfortable because they had been doing this in front of us for so long."
To make the most of mock surveys, do the following:
- Do system tracers.
System tracers routinely are done with Baptist Health’s leadership, including infection control and competency assessment, Halvorsen says.
"They need practice just like staff do," she says. "If the surveyor identifies an issue during the system tracer, they can follow up with a patient tracer activity to assess the impact of the process deficiency on patients and staff."
For example, if the surveyor has a concern about infection surveillance or prevention activities, the surveyor might ask to do a tracer on a patient diagnosed with a community-acquired infection.
- Focus on hot topics during tracers.
At Tifton (GA) Regional Medical Center, an employee handbook lists "hot point" JCAHO questions, and provides information on failure mode and effect analysis (FMEA) and the status of current patient safety initiatives, says Angie King, BSN, CPHQ, CPHRM, quality management director. "This is given to all employees in orientation and is updated approximately every six months," she says.
The JCAHO hot points are then covered during mock tracers, including life safety code compliance, the "first-dose" requirement, patient identification, timeout procedures, and strategies implemented as a result of FMEAs. "The confidence of the staff was evident in their ease with survey questions, chart review knowledge, and familiarity with patient issues," King says. "Staff who were previously afraid of making a mistake or blanking out are now more confident."
Solberg refers to a master list of areas that need to be covered during patient tracers, with patients picked randomly once the "surveyors" arrive on the floor, focusing on patients with complicated care and/or high-risk conditions or procedures, such as inpatients receiving chemotherapy.
- Conduct tracers on the unit level as well as organizationwide.
At Gwinnett Hospital System, each member of the 17-member leadership council must conduct at least one tracer monthly, with almost all departments visited within a year. "In addition, our leadership council members have passed on this expectation to managers of various units," Solberg explains. "The managers of the units can do tracers to better refine their processes internally and be more prepared for when we come through."
The importance of the tracers at a unit level is that the staff and the unit managers are more involved and use the tracer methodology as a continual improvement tool, she says. "The widespread use also has allowed staff to be a lot more comfortable when the blue suits come around to do their tracers."
Topics are based on a number of elements that need improvement or reinforcement, gleaned from open medical record audits, patient safety rounds, or the needs of the specific unit.
For example, one unit has focused on core measure data, with a tracer conducted for congestive heart failure and pneumonia patients; and a surgical unit has focused on looking at consents prior to procedures to be sure that they are complete, as well as other typical surgical tracer elements such as history and physical.
"We are able to give but also receive great feedback," Solberg notes. "On a recent tracer, a nurse on our orthopedic floor was questioned on cultural diversity and mentioned that we needed a vegetarian liquid diet on the menu for ordering. We are working to print new menus as we speak and to get this into the system. So the road does go two ways."
At Long Island Jewish, quality managers and nurse and physician leaders all are involved in mock tracers, Scanlon says. "About a year and a half ago, we put in a very different approach, with myself, the nurse executive, and the medical directors doing tracers and rounds on every patient care unit," she adds. Every week, a different area is chosen to focus on, such as the National Patient Safety Goals, emergency department throughput, open medical records, and communication.
- Address problems identified during tracers.
An effective communication structure is key to ensuring that, once identified, problem areas actually are addressed, Scanlon says. The organization’s "captains" responsible for each of the JCAHO standards follow up on any issues identified during tracers and mock surveys. These issues also are addressed in administrative leadership meetings with directors and at a weekly senior leadership meeting.
At Gwinnett, data captured from mock tracers are used to identify potential areas for improvement, Solberg says. "We have had several processes that we have identified through this methodology and have seen a dramatic change of events," she reports.
For example, tracers revealed a need to improve nursing documentation of patient comorbidities, both active and nonactive. "Once this was identified, our nursing leadership was able to direct very specific education to our units, and we have seen a dramatic improvement," Solberg says.
Another issue that came to light during tracers involved case managers lacking enough space to adequately document the discharge plan, particularly for lengthy admissions. "As a result, we are working with our medical records committee to create a discharge planning tab and document that ties to our clinical pathways and provides ample room to communicate this type of information," she says.
While walking through a unit during a mock tracer, if you see medications sitting on a cart that aren’t supposed to be accessible to the public or observe staff failing to follow hand-washing procedures, have staff address that immediately, Halvorsen advises.
The goal is to change staff behavior to improve patient care, she stresses. "I tell staff that we don’t use alcohol foam because it’s a JCAHO standard. We do what we do because we want to protect our patients from infection," she says.
- Connect patient tracers with process improvement activities.
In some organizations, there is a disconnect between tracer activity and clinical process improvement activities, notes Janet A. Brown, RN, BSN, BA, CPHQ, FNAHQ, president of Pasadena, CA-based JB Quality Solutions. Costly activities initiated to comply with accreditation requirements may involve the quality department but often are structured separately from other quality activities, she explains.
"With tracers, we are once again creating a compliance process that may be separate from, and in addition to, the other ongoing quality methods we use, such as performance measures, data collection and analysis, improvement teams, and monitoring effectiveness," Brown adds.
Tracers must have a purposeful, direct link to performance improvement, she emphasizes. "I assume most quality departments are receiving the tracer data and can aggregate it to look for needed process improvements. But if process is not the focus, then we may tend to fall back to looking at who was responsible for a problem, or go for a short-term fix, rather than seek how to improve the process for the long term," Brown points out.
She recommends utilizing tracers as one way to monitor effectiveness of a change whenever improvements are made to any clinical process, with relevant performance measures incorporated into the tracer review. "Looking at patient flow through the processes of care is a great way to monitor. I envision a tracer that checks against applicable standards but includes measures for the way things are supposed to flow, coordinating applicable clinical practice guidelines, known best practices, and the results of relevant root cause analyses, FMEAs, and other team quality improvements," Brown says.
[For more information, contact:
- Janet A. Brown, RN, BSN, BA, CPHQ, FNAHQ, President, JB Quality Solutions Inc., 2309 Paloma St., Pasadena, CA 91104-4926. Phone: (626) 797-3074. Fax: (626) 797-3864. E-mail: [email protected].
- Missi Halvorsen, RN, BSN, Senior Consultant, JCAHO/Regulatory Accreditation, Baptist Health, 800 Prudential Drive, Jacksonville, FL 32207. Phone: (904) 202-4966. Fax: (904) 202-2847. E-mail: [email protected].
- Angie King, BSN, CPHQ, Quality Management Director, Tift Regional Medical Center, 901 E. 18th St., Tifton, GA 31794. Phone: (229) 386-6119. Fax: (229) 556-6390. E-mail: [email protected].
- Wendy H. Solberg, CHE, Director, Quality Resources, Gwinnett Hospital System, 1000 Medical Center Blvd., Lawrenceville, GA 30045. Phone: (678) 442-3439. Fax: (770) 682-2247. E-mail: [email protected].]
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