Providing healthcare to a patient involves multiple departments, professionals and functions. This increases the operational complexity and leads to a variety of problems such as errors, inefficiencies, and even harm to patients. To address such problems, hospitals often follow best practices and standards, recommended by national/international bodies and accreditation programmes. While these standards and practices are well researched, whether or not it improves operational efficiency, depends upon how well have they been implemented or the level of compliance. There are various methods of assessing compliance; such as audits, reviews, surveillance, patients' feedback, indicators and gemba walk. However, one problem with these compliance assessment methods, is that most of them assess each specific function independent of others and fail to assess, how is it translating into actual patient care.
Tracer survey is a unique methodology as it is an integrated assessment of compliance to standards and practices that were required to be followed during care of a particular patient. It gives a comprehensive understanding of hospital’s operational performance and effectiveness in translating standards into actual patient care. Tracer survey is one of the prime survey method used by The Joint Commission in their on-site survey for accreditation.
So how can hospital managers can make good use of this method in achieving operational excellence for their organization? Here is a step by step guide for using Tracer methodology.
Types of tracers
There are two types of tracer methods, individual patient’s tracer and system’s tracer. Individual tracer traces the care process of a real patient and assesses the compliance at each and every point of care process. System’s tracer traces one particular system of the hospital from its beginning till end and assesses every transaction points in the system. In practice, system’s tracer can be done along-with individual tracer, as and when the specific system comes into picture while tracing the patient.
Who should do the tracer survey?
The tracer survey shall ideally be done by a team of 2-3 people who as a team has a comprehensive and in-depth understanding of hospital’s systems, policies, standards and practices for patient care as well as non-patient care activities. At-least one of them shall be competent in understanding medical care and nursing care part. The team shall be trained in interviewing and auditing skills.
Which and how many patients shall be traced?
Ideally, patient selected for tracer shall be one whose condition, diagnosis or type of services received will enable best in-depth evaluation of hospital’s policies and practices. Critical care patient, vulnerable patient, emergency admission, high risk surgery patients etc. are suitable for tracer survey. Secondly the patient shall be a current or recently discharged patient so that the tracer finding reflects the current status. A mix of patients can be taken that should cover majority of the departments and functions of the hospital.
How is it performed?
Following steps explains how to perform a tracer survey
1. Select the patients for tracing as described above. Get their medical records.
2. Only one patient’s care shall be traced at one time.
3. From the medical record chart out the movement of patient from entry till exit (or current place). Note each point of care that patient went through in his/her care process
4. Track movement in exact sequence (as much as possible).
5. At each point of care, evaluate how the care was provided, what were the applicable standards/practices that were required to be followed and whether it was complied with. For this, interview the staff who were involved at that point of care. Document any non-compliance observed. For example, if the patient was given I.V. medication at a point of care, ask if the staff who administered I.V. washed his/her hand, followed medication safety checks and monitored the patient post-administration.
6. While evaluating, do not restrict to the core care part, but expand the assessment to include support systems also. For example, if at a point of care patient’s image was taken through CT-scan, check if the machine has a preventive maintenance schedule, is scattered radiation monitored, effectiveness of housekeeping, quality control mechanism of imaging, whether consent was taken etc.
7. Prevent from going tangential on some different system. This can be done by connecting back every question to the patient being traced. The staff shall be questioned with respect to the care provided to the particular patient.
8. Plan and prioritize your time. Spend more time on critical care points such as anaesthesia administration, intubation, blood transfusion and informed consent.
9. Avoid redundant question. Also, if a particular process seems to be well in place same can be avoided from further questioning.
10. In case some important points are missed, same shall be noted and covered at the end of the tracer survey
11. At the end of the tracer survey a report shall be prepared on all non-compliances observed during the care of the patient. The surveyors shall also record their subjective assessment of the way care was delivered to the patient.
An example
Let’s take a hypothetical example of a road traffic accident patient brought to emergency through hospital’s ambulance, who was sent for MRI scan and later admitted to ICU for head injury.
The surveyor must start with Ambulance and interview the driver and staff in ambulance. The assessment shall focus on whether or not ambulance staff reach the accident spot on time, how did they shift patient and manage within ambulance, availability of medicine and instrument in ambulance and system to manage it, condition and maintenance of ambulance, communication system etc.
Next point will be emergency care, where the nurses and doctor who received patient shall be interviewed on whether emergency treatment protocol was followed, how much time it took for initiating treatment of patient, whether MLC policy was followed, whether patient was triaged, whether referral was sent or not, how did they identify patients etc.
In MRI room the focus can be on safety practices while shifting patient, safety from magnetic field, calibration and maintenance of equipment, reporting process, communication of critical findings etc.
In ICU the focus can be on what admission criteria was followed for admitting the patient, infection control practices being followed, equipment maintenance and calibration, care bundle, monitoring and assessment of patient, housekeeping practices etc.
Suggested read - 11 Conditions that a hospital must fulfil in-order to participate in JCI accreditation process
Suggested read - 11 Conditions that a hospital must fulfil in-order to participate in JCI accreditation process
