Tracer Methodology TIPS AND STRATEGIES FOR CONTINUOUS SYSTEMS IMPROVEMENT Frontline Strategies to Prepare for JCI Accreditation Col. Dr. jamal Hommadi CQI&PS Ditrector SR

Objectives Understanding Tracer Methodology Evolution of tracer methodology Tracer Methodology and the Survey Process Tracer Methodology and its Role in Continuous Systems Improvement 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

Method of identifying “broken” systems is through the use of tracers The method is: Method of identifying “broken” systems is through the use of tracers

Introduction 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. 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.

Introduction This represents a shift in how health care standards are assessed. In the past the goal was to “ramp up” for a survey, and got a periodic “snapshot” picture of an organization. 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.

TRACER METHODOLOGY 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.

TRACER METHODOLOGY: An Evolution Roots in science- emerged in the early twentieth century: Used by scientific researchers. The tracer methodology or tracer approach in Healthcare was introduced in the early 1970’s by Kessener and Kalk (1973) In January 2004, JCAHO redesigned their accreditation process by implementing Tracer Methodology Shared Visions –New Pathways ®

TRACER KEY 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: Individual tracers System tracers (data use, medication management, and infection control) Program-specific tracers Environment of care tracer (emergency management), (for hospitals only)

Tracer Methodology Individual Tracer System Tracer Program Specific Tracer Environment Tracer Individual tracers: patient tracers, resident tracers, client tracers) Environment of care tracer (emergency management), (for hospitals only) MMS Tracer Ambulatory care ICS Tracer Behavioral care DUS Tracer Critical access Home care Hospital Laboratory Long Term

INDIVIDUAL TRACERS Individual tracers (also called patient tracers, resident tracers, or client tracers). To 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: Interview staff delivering care, treatment, and services to the tracer individual, as needed. Evaluate PFAs Evaluate the environment, if applicable Review the record for clarification and confirmation of information Interview the care recipient and family, if appropriate or applicable

SYSTEM TRACERS The system tracer activity focuses on high-risk processes across organizations. 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. 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: Medication management system tracer. infection control system tracer. 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: 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 process Strengths in the process and possible actions to be taken in areas needing improvement Issues requiring further exploration in other survey activities A baseline assessment of standards compliance Education by the surveyor, as appropriate

Data Use The focus of the data use system tracer is straightforward: How does the organization use data to improve safety and quality of care? 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: Current and past performance improvement activity Type of analysis conducted Data reporting—when it occurs and to whom Actions taken as a result of using data Dissemination of findings and involvement of affected staff Reporting to leadership for prioritization and decision making Performance issues Approach to assessing staffing effectiveness and use of these data and information

Médication Management 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. 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: Medication processes, International Patient Safety Goals and the organization’s medication use system Reporting of errors, system breakdowns, or near misses Medication education for patients and staff Information management related to medication management Data collection and analysis, Review of risk points, symptoms, and related issues Care recipient involvement as part of a medication management team

Infection Control 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: How patients with infections are identified by the organization How patients with infections are considered within the context of the infection control system Current and past surveillance activity—taking place in the past 12 months Actions taken as a result of surveillance and the outcomes of those actions Type of analysis conducted on infection control data, including comparisons Reporting of infection control data—when it occurs and to whom? Observation of infection control techniques (aseptic, sterile, surgical, and so forth)

Prevention and control activities Infection control data aggregation and analyses trending Physical facility changes that have an impact on infection control, if applicable International Patient Safety Goal compliance Sterilization, disinfection, food sanitation, housekeeping, …etc. Role and activities of the organization’s infection control officer Written infection control plan How organization functions are integrated into the infection control plan

PROGRAM-SPECIFIC TRACERS As of January 1, 2007, surveyors began conducting program-specific tracers during on-site surveys. 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: Types of services offered by the organization Programs being surveyed The organization’s PFAs Centers for Medicare & Medicaid Services deemed status/recognition requirements

TRACING THE ENVIRONMENT OF CARE 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______________ Start & End at same site to recap & validate findings with several other records Site (START) Participants Activity Cardiac Care Unit Charge Nurse Attending MD Review open medical record to map-out tracer Site (END) Survey Methods Cardiac Care Unit Participants Staff nurse Patient educator Case manager Cardiac Rehab RN Attending MD Standards Interface Education Rights Continuum Pain management Medication use Assessment EC issues Staff interviews Patient interviews Medical Records Review of educational materials Site # 1 Participants Standards Interface Emergency Dept. Nurse supervisor Site # 2 Participants Standards Interface Cath Lab Verbal orders Informed consent Assessment PI initiative Med Use EC issues Staff nurse Attending MD Advance directives Assessment PI initiatives, ORYX Med Use Leadership EC issues Survey Methods Interviews Medical Record Entries Survey Methods Interviews Assessment Forms

Area of Focus/Presenting Symptoms Map of Individual Tracer 7. Physical Therapy (Patient Rehabilitation) Referral process Assessment and reassessment Goal setting (long-term, short-term, and patient goals) Patient and family education Pain assessment and documentation Discharge planning 1. Current Location of the Patient Assessment and care Medication process Verbal orders Screening for nutrition, rehabilitation, fall, and skin Pain assessment and control Patient education Discharge planning Staff competency Patient Information Area of Focus/Presenting Symptoms Moist lungs, Decreased activity tolerance, Fatigue, Shortness of breath History Congestive heart failure, Coronary artery disease, Cardiac catheterization, Stent placement Admission To Emergency department, Intensive care unit 6. Pharmacy Identification of high-risk drugs and safety measures Reconciliation process Data regarding the use of these drugs Education regarding medications Involvement in discharge planning 2. Emergency Room/Preadmission Triage Process Assessment and reassessment Communication with laboratory and radiology Medication process, especially high-risk IVs Hand-off process 5. Intensive Care Unit (ICU) Communication from emergency department Emergency department admission delays Assessment and reassessment Medication process Verbal orders Critical equipment alarms Informed consent and education on procedure 3. Radiology: Patient Had X-ray Assessment and reassessment Communication with laboratory and radiology Medication process, especially high-risk IVs Hand-off process 4. Laboratory CBC Data collection and trending Chemistry profile Critical test results

Conclusion Flexible and adaptive Interactive and dynamic instead of ramp up survey. Multi-dimensional picture instead of snapshot picture for the organization.

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