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

3. 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

4. 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

5. 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

6. 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.

7. 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.

8. 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.

9. 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 ®

10. 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.

11. 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)

12. 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

13. 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.

14. 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

15. 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.

16. 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),

17. 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

18. 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.

19. 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

20. 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?”

21. 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

22. 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.

23. 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)

24. 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

25. 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

26. 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

27. 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%).

28. Tracer Data Form

29. 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

30. 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

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

32. References: