Use of Tracers as a Leadership Tool

Creating the Opportunity for Excellence in Patient Care

Objectives Upon completion of this presentation, the participant should be able to: Articulate an overview of the process used when tracing the care of a patient Identify how to use tracers as a method of improving quality and patient safety within the organization Articulate how to use tracers as a leadership tool in this organization

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

Systems The new way of thinking

Accreditation and Systems Consensus definition of system: A group of interacting, interrelated, or interdependent components that form a complex, unified whole

Accreditation and Systems (cont.) The accreditation process is a system Overall quality and safety of patient care and the patient environment are measured by: Standards and measurable elements International Patient Safety Goals International indicators

What is a Tracer?

An individual patient tracer follows the experiences of a patient throughout the health care system. An individual-based system tracer examines high-risk processes (medication management, infection control, data) across the organization

Using Tracer Methodology in the Survey Process

Tracers in the Survey Process Gradual introduction into the survey process in 2006; official part of survey and accreditation decision process in 2007 Comments are positive – focus on the process of caring for the patient and their environment Changes in survey process are not significant

Changes include: New Patient system focus Patient is the center of activity – visits focus on the contacts the patient has or will have Standards compliance based on review of systems and process – unified, relationship to the whole Old Department function focus The departments is the focus – scheduled visits to each department Standards compliance based on department functions without examining the relationship to the whole

Changes continued: New Patient system focus Interviews focus on systems and processes (medication management, infection control, data/ quality, and competency) Bottom line is how you care for your patients and their environment each day Old Department function focus Interviews focus on questions and answers

You can learn more in 8 hours of tracing than in 20 hours of Bottom-line Focus How the care is delivered to the patients, and how their environment is maintained each day You can learn more in 8 hours of tracing than in 20 hours of chart review!

Performing Successful Tracers

Tracer Varieties Individual patient tracer Performed by those who have a broad organizational perspective

Tracer Varieties (cont.) Individual-based system tracer Theme-based tracer Hospitalwide issues, such as medication management, infection control, or data Typically performed by chapter teams or key organizational personnel Unit-based tracer Tracing or monitoring issues at the unit – pain assessment, advance directives, medication administration, etc.

Getting Started Don’t expect it to go perfectly at first Be willing to modify your process Frame all communication around patient safety and quality improvement

Selecting a Patient to Trace Use patient census – as an organization you will be asked to provide census with patient admission date, location, diagnosis For focused tracers such as a patient with an infection, you may be asked to compile a list – this usually will not be the first tracer Consider using the top diagnosis or top procedures performed

Approach Initial review of the record to determine: Process Care experience of the patient being traced (nursing care, diagnostic testing, treatments, etc.) The staff caring for the patient The medications ordered Process Interview staff delivering care, treatment and services Evaluate the environment Interview the patient and family, if appropriate

Area of Focus/Presenting Symptoms Start the process 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

Departments Visited: Discussion Points 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

Departments Visited: Discussion Points 2. Emergency Room / Preadmission Triage Process Assessment and reassessment Communication with laboratory and radiology Medication process, especially high-risk IVs Hand-off process

Departments Visited: Discussion Points 3. Radiology: Patient Had X-ray Assessment and reassessment Communication with laboratory and radiology Medication process, especially high-risk IVs Hand-off process

Departments Visited: Discussion Points 4. Laboratory CBC Data collection and trending Chemistry profile Critical test results

Departments Visited: Discussion Points 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

Departments Visited: Discussion Points 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

Departments Visited: Discussion Points 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

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

Tips for Tracing Trace the patient, not the department Ask open-ended questions Listen…the answer you’re expecting may not be the answer you get! Be ready to show documents and policies or to demonstrate a process Validate discrepancies from policy, good practice, or system failures Include more people than just the nurse (dieticians, physicians, therapists, clerks, etc.) Stay staff-focused, not leadership-focused

Tips for Tracing Survey for environmental compliance Go into patient rooms, medication rooms, supply rooms Scan for unsafe situations in the environment Include a facilities or safety person on teams Note equipment models and serial numbers Do a competence assessment Check human resources, competency, medical staff, and allied health files

Benefits Patients – Safety, Quality, Systems flow, Interest Staff – Team building, Systems thinkers, Understanding of each others jobs Organization – Happy patients, Systems improvement, Team focus among staff

Therefore, as leaders, let’s focus on systems and processes as we continually strive for quality and safe care for our patients.