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 organization

• 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

quality

◦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

organization Clinical Service Groups and Priority Focus

areas

◦Select tracer patient Use active patient list LOS 4-7 days nearing discharge Considerations

Complex situations ICU ED Anesthesia services Surgery

Use Multiple approaches and sources

Interview Read Observe

Interview◦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

NPSG

◦Tell me your two patient identifiers

Observe the process of using patient identifiers

Medication administration

Specimens Testing

Pain assessment and reassessment

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 reassessed

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

Compliance Issue

Standard Action 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 record?

Which staff members would you speak to on the unit?

Which departments might you visit as you continue the tracer?

Start in ICU and track to ED and surgeryH&P – done prior to surgery or a note indicating it

is an emergencyAll surgery related paperwork complete?Consult with dietitian?Consideration of DTs?Restraints used? Documentation?Speak with RT, PT, DietitianIs 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 Spanish.

What would you look for on the patient’s medical record?

Which staff members would you speak to on the unit?

Which departments might you visit as you continue the tracer?

Start in telemetry and visit MICU, ED, cath lab and OR

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

appropriateness• 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 Questions Every level of the organization is involved

Questions