Joint Commission

International
Tracer Methodology

Objectives
Upon completion of this presentation, participants
should be able to:
Understand the role of tracers in the accreditation
process
Identify how to use tracers as a method of improving
quality and patient safety within the organization.
Understand method for performing tracers
Understand method for analyzing tracer findings to
improve processes and standard compliance

Module 1: Introduction to
Tracer Methodology

What is a Tracer?
An evaluation method that is an effective way
to assess a healthcare organizations
performance of care, treatment, and services
provided as viewed or experienced by frontline
staff and the patient.

What is the Tracer Methodology?

Tracing the patients course of care is a
methodology to assess an organizations
systems and processes of care.
Follows the treatment path an individual patient
has taken in the healthcare delivery system and
involves:
Following a process from beginning to an endpoint
Identifying performance gaps
Identifying opportunities for improvement

What Do Tracers Accomplish

Tracers assess how care processes and the
care environment impact quality and patient
safety

You can learn more in 8 hours of

tracing than in 20 hours of
chart review!

Role of Tracers in Performance

Improvement Process
Four steps of PI:
Problem
Identify gaps in performance = tracer
Identification
findings
Identify primary root causes for gaps
Analysis
Identify the most important causes
Action
Identify, implement, and sustain corrective
Planning
actions for most important causes
7

Performance Gaps
Actual versus Expected Performance in JCI
Standards

Tracer Method and Lean-Six Sigma

Tracers require staff to assess frontline
processes by walking the gemba
Tracers are an evaluation method which
measures current state of performance

Six Sigma DMAIC model: Define-Measure-Analyze-Improve-Control

Three Types of Tracers

Individual Patient Tracer
System Tracer:
Infection control
Medication Management
Data Management
Focused Tracer
Facility Management and Safety
Disinfection, Sterilization
Pain Management
10

?What is a Patient Tracer

A unique case review
Opportunity to evaluate compliance with standards,
policies, procedures, guidelines, pathways
Observe elements of the system in operation

11

A Patient Tracer
Identify the patient
Locate the patient
Review the patient record
Interview the staff
Visit other areas the patient received care
Observe care in these areas
Interview the staff in these areas
12

13

Patient Tracer
An individual patient tracer:
Follows the experience of a patient as relates to
multiple care systems.
And always thinking about the patient care
processes as relates to standard compliance

14

A System Tracer
Identify the issue
Identify where the process begins
Identify the process
Interview the staff
Follow the route of the process
Observe the process in these areas
Interview the staff in these areas
15

System Based Tracer

Heparin IV

Lab
Results
MD Order

Order to Pharmacy

Pharmacy
Prepares

Nurse Administers
Medication

Nurse Checks
Order
Storage in the Unit

Delivery to the Unit

16

System Tracers
A system tracer follows one complex system and
related processes throughout the healthcare
system
For examples:
Medication Management System
Infection Control Management System
Data Management System

17

Focused Tracer
Focus on processes related to a specific set of related
standards:
Pain Assessment
Medication ordering
Disinfection/Sterilization
Diagnostic test process
A single patient safety goal

18

Module 2: Organizing for Tracer

Activity

19

Steps to Performing Tracers

1.
2.
3.
4.
5.
6.
7.

Get organized
Educate staff
Perform tracers
Document findings
Analyze findings
Develop corrective actions
Implement and sustain improvements
20

Step 1: Get Organized

Leadership Commitment
Set a start date (training), timeline and reporting schedule
Dont expect to be experts at first
Be willing to modify your process, tools, and focus
Frame all communication around patient safety and
quality improvement not JCI (But remember you are
assessing standards compliance)
Trace the sequential care, treatment, and service process
flow
Entry-to-discharge
Trace each major service area

21

Step 1: Get Organizedcont.

Select participants

Accreditation chapter-specific team members

Quality improvement staff
Risk managers
Physician and nurse champions
Pharmacy managers
Senior leaders and department managers

2-3 members per team, with interdisciplinary

participation
Eventually try to involve all mangers
in the organization
22

Step 1: Get Organizedcont.

Maintain Team Motivation
Integrate tracer status and findings into
management meeting agenda
Include tracer findings in:
staff meeting discussions
quality meetings
leadership meetings

Recognize/reward participants
Reward performance improvement
23

Step 2: Educate Staff

Introduce methodology to all staff including medical
staff
Provide staff resources and time for tracer activities

Training process

Use a train-the-trainer approach

Use internal experts or external consultants to train teams
Understand JCI standards
Understand document review and staff interview
techniques
24

Skills Needed to Trace

Ask
Questions

Observe
Practices

Do Not
Assume

Respectful
of the Staff

Ask
Questions
25

Step 3: Perform Tracers

Tracer Selection Criteria
Patients who use services in several programs
and care areas or sites
Patients with complex medical problems
Patients using high risk medications
Patients who are vulnerable and at risk for abuse
Patients receiving invasive procedures
Patients with communicable or infectious disease
Patients receiving highly specialized services
26

Step 3: Perform Tracers

Method for Selecting Patients
For inpatients, tracer team should review:

Patient admission date,

Service location,
Diagnosis, invasive procedures, operating room schedules
Sedation services

For ambulatory, tracer team should review:

Clinic schedules,
Specialty referrals
Recent hospital discharges

For system tracers, tracer team should review:

Patients with specific infections
Prescribed high risk medications
27

Step 3: Perform Tracers

Preparation Guidelines
Let the patient be the focus of the process
Focus on a system-oriented process .
Take all standards with you ! Keep them in a reference
document which is easily accessible
Be systematic and develop your plan about issues or
standards you need to cover in a specific tracer
Use the patient health care story or journey to lead you
to another question or other area of interest.
Follow prompts but avoid overuse of same questions
Let observations and findings guide your inquiry
28

Step 3: Perform Tracers

Preparation Guidelines
Standardize Information Gathering Methods

Check list for document reviews

Standard-specific reference sheets
Scripted or opening questions for interviews
Focused observations
e.g. Medication storage and labeling

Use tool for Documenting findings or performance

gaps
Incorporate information into chapter-specific action plan
29

Step 3: Perform Tracers

How to Assess Care Processes
Identify the patient and location
Go to location and introduce yourself to nurse
manager
Interview patients primary nurse and physician while
reviewing the medical record
Review related policies and procedures as necessary
30

Step 3: Perform Tracers

How to Assess Care Processes
Initial review of record to determine:
Care experience of the patient being traced
(nursing care, diagnostic testing, treatments, etc.)
Staff caring for the patient
Medications ordered
Referrals and consultations

Process
Interview staff delivering care, treatment and
services
Evaluate the environment
Interview patient and family, if appropriate

31

Step 3: Perform Tracers

How to Assess Care Processes
Interview multiple disciplines, not just nurse, e.g.

Dietician
Physician
Therapist
Pharmacist; Clerk

Create a centralized process for follow-up

monitoring
HR and competency files
Medical staff and allied health files
Equipment model/serial numbers
Be sure all necessary information is captured & reported
32

Step 3: Perform Tracers

How to Assess Care Processes
Ask staff to show you documents and policies
Ask to demonstrate a procedure or process
Validate
discrepancies from policy
good practice
system gaps
Include clinical unit manager as an observer
If answers are incorrect, leader can go back and
coach or clarify in private

33

Step 3: Perform Tracers

Document Review
Review JCI required policies and procedures
Use policy document to ensure practice is
consistent with written requirements
Use policy documents to train staff on
appropriate procedures
Ensure documents are accessible to staff and are
used as reference source

34

Step 3: Perform Tracers

Staff Interviewing Strategies
Attempt to put staff and patient at ease
Explain purpose of tracer
Professional attire
Serious but approachable style
Be educative as well as evaluative
35

Step 3: Perform Tracers

Staff Interviewing Strategies
Use active listening.
Drill down until issues are fully
developed
Dont pursue one standard; focus on
several standards related to a process
Avoid hypothetical situationspose
questions around patient being traced
Base questions and findings on standards
Interview staff, not management
Interview patients when feasible

36

Step 3: Perform Tracers

Staff Interviewing Strategies
Review standards based on patients experience
of care
Keep asking questions until issues are fully
developed before moving to another issue
Observe patient care, procedures, and processes
Maintain patient confidentiality
37

Step 3: Perform Tracers

Staff Interviewing Strategies
Dont pursue one specific standard, but focus on
several related to the patients processes
Consider pre-determining types of questions until
proficient at free-flowing interview
Pose questions around patient being traced, not
hypothetical situations
Seize the moments, but dont interrupt patient care
Question staff, not management
38

Step 3: Perform Tracers

How to Ask Questions
Use opening question, followed by drilldowns.
The same question, asked slightly different, may
deepen understanding of compliance

Avoid a confrontational tone. Goal is to gather

information, not catch someone
Use I statements to characterize care
I see that the patient was given Aspirin
Not, You gave the patient Aspirin.

39

Step 3: Perform Tracers

How to Ask Questions
Do not use leading Questions which suggest
the correct answer
Do you always wash your hands before
interacting with a patient? right?
You keep this door locked, right?
I assume you would put this type of
patient in a negative-pressure room.right?
Whenever possible, avoid this type of question.

40

Step 3: Perform Tracers

How to Ask Questions
Do not use Closed Questions which only allow a choice
of two options, typically yes or no.
Have you been trained to operate this
equipment?...Yes of course
Did you follow your organizations policy when
admitting this patient?... Yes of course
Did you educate patient on her treatment?

The respondent supplies a very limited amount of

information to the questioner.
41

Step 3: Perform Tracers

How to Ask Questions
Use neutral questions which do not suggest the
correct answer.
What kind of hand-washing protocols have you
adopted?
How effective have hand-washing protocols
been implemented on your unit?
There are many different ways to treat this type
of patient. How would you handle this case?
42

Step 3: Perform Tracers

How to Ask Questions
Use Open questions which allows a variety
of responses:
How do you know the correct way to operate
this equipment?
How did you admit this patient? What is your
organizations admission policy?

43

Step 3: Perform Tracers

How to Ask Questions
Make sure the question was understood.
Restate answers for clarification.
Pause after an answer to encourage more
information.
Give positive feedback for well-thought
out answers.
Ask for more information if you need it to
understand the answer.
44

Step 3: Perform Tracers

Assess the process
Think about asking questions that will help you understand
the process:

Is this step standardized? If not, why?

Does the step occur consistently?
Does it need improvement?
Is it an unnecessary or impractical step?
Is something absent that should be present?
What are the risk points for quality and patient safety?
How can risk points be eliminated?
45

Module 3: Design and Conduct

Tracers: Individual Patient Tracer

46

Map of Individual Tracer

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

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

3. Radiology: Patient Had

X-ray
Assessment and reassessment
Communication with
laboratory and radiology
Medication process, especially
high-risk IVs
Hand-off process

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

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

4. Laboratory
CBC
Data collection and trending
Chemistry profile
Critical test results

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

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
47

Example of an individual
Patient Tracer

48

Tracer Team Reviews Medical

Record
72-year old man presented to ER with chest pain
An electrocardiogram showed signs of sinus
tachycardia
Staff administered aspirin and drew blood
Patient:

Treated for diabetes and hypertension

Recently quit smoking after 33 years
Sent to cardiac catheterization lab for an angiogram, which
revealed 5 blockages
Put on IV heparin, nitroglycerin and beta-blocker
Transferred to ICU
Hypertension was an issue. So medications were adjusted to
lower his blood pressure
Surgery for a coronary artery bypass graft was scheduled for
the next morning
49

Tracer Team Reviews Medical

Record

Antibiotics were begun at the time of surgery

Sent to ICU with ventilator which was removed 5 hours later
Developed pneumonia within 2 days
IV antibiotic was changed, but history of smoking has
weakened his lungs
Placed on ventilator
Wean from ventilator within 6 days
Received Pulmonary treatment regimen of nebulizer
treatments, incentive spirometry, and assisted cough
Transferred to a general medical unit with telemetry after 3
days
Scheduled to be discharged for continued outpatient
rehabilitation
50

Tracer Team Visits Emergency Department

After reviewing the medical record, tracer staff
visits ED...
Step 1

Speaks with ED Staff

Discussions cover communication,
assessment, performance improvement, and
medication management issues.

A little over 2 weeks ago, patient came into the ED

with chest pains and a history of hypertension and
diabetes. What processes were followed for
triaging and treating him?
I see that a cardiac catheterization was necessary;
how was informed consent obtained from patient?
You have said that like many heart attack victims,
the patient delayed seeking help after experiencing
the first symptoms. Has your ED conducted any
performance improvement projects to decrease
the to begin treatment?

51

Emergency Dept points of discussion

Triage process
Patient assessment
Communication prior to patient transfer
Medication process, including for high risk
concentrated medications and IV solutions
Communication needs for elderly patients
Competency of medical and nursing staff in
emergency care
52

At Cardiac Cath Lab

Step 2

Tracer staff talks with Staff Nurse and Cardiologist

Talks about verbal orders, assessment and
Emergency Care issues

What communication took place between the

catheterization lab and the ED before patient
arrived for his procedure?
How did you make certain patient had no allergies
to the contrast medium being used for the
procedure?
What process was used for ensuring medical
equipment safety?
53

Cath Lab points of discussion

Pre-procedural patient assessment

Patient identification process
Informed consent
Patient privacy and confidentiality
Infection control
Patient monitoring during and after procedure
Use and maintenance of equipment
Sedation and anesthesia use and safety
Frequency of cancellation of procedures and
reasons (Quality Improvement project)
54

At Operating Room
Step 3

Surveyor talks to the

Staff, Circulating Nurse,
Anesthesiologist

What assessments had been

performed and what information did
you receive before patient arrived in
the OR?

Discussion focuses on
medication use, anesthesia care,
informed consent, site
verification, Emergency Care
issues, infection control, patient
safety goals.
Patients undergoing bypass
surgery are at increased risk of
developing a surgical site infection.
What preventive measures did
you take to help reduce that risk
for the patient?

Can you explain the process to

obtain informed consent for patient
for this surgery?
What processes do you follow to
verify that you had the correct
patient and procedure before you
started patient surgery?
During open-heart surgery,
concentrated potassium was used.
How is access to this undiluted
concentrated electrolyte
controlled?

How was the placement of

patients pulmonary artery catheter
confirmed?
How do you maintain this
equipment? How were you
trained to use it?

* Surveyor also request

credentialing files for the
anesthesiologist and
cardiac surgeon.

What do you do in the event of

fire?

55

At Recovery Room
Step 4

At OR Recovery Area
Talks about verbal orders, clinical
practice guidelines and equipment
management.

Following the patients surgery, the patient was

started on an IV infusion pump for pain
management. What checks did you perform on
the equipment before starting him on the pump?
Who made the decision to discharge the patient
from the Recovery, OT?
What guidelines did you follow for postanesthesia monitoring of the patient
56

At Cardiac ICU
Step 5

Tracer staff talks with attending Physician, ICU Nurse,

Respiratory Therapist, Infection Control Practitioner
Topics include communication, assessment,
clinical practice guidelines, credentialing,
infection control, equipment
management and medication management

Was patient restrained while on ventilator? How was

the decision made to remove patient from the
ventilator?
How did the OR communicate what procedures took
place when the patient was transferred to the ICU?
The patient was receiving IV pain medication
following surgery. Can you show me where you
documented his pain assessment, treatment and
reassessment?

57

Cardiac ICU points of discussion

Communications received from Recovery Room

Patient assessment and monitoring
Patient privacy and confidentiality
Infection control
Use and maintenance of equipment, especially
clinical alarm systems
Staff competency based on patient populations cared
for in ICU
Process for advance directives; end-of-life issues
Medication management
Handling of verbal orders
58

Module 3: Design and Conduct

Tracers: System Tracers

59

A System Tracer
Identify the issue
Identify where the process begins
Identify the process
Interview the staff
Follow the route of the process
Observe the process in these areas
Interview the staff in these areas

60

System Tracer Methods

A system tracer follows a complex process
throughout the healthcare system
Such as
Medication Management System
Infection Control Management System
Data Management System

61

System Tracer Methods:

Medication Management Example
Includes:
Group discussion
Explore the 6 steps; identify concerns
Discuss medication occurrences or errors
Review International Pt. Safety Goals (IPSG 1, 2, 3,
5, and 6)

Focused Tracer
Explore the path of a selected high risk medication
based on the group discussion or previous
information identified through patient tracers
62

System Tracer Methods

Medication Management Systems
Selection,
Procurement

Monitoring

Storage

Administration

Ordering, and
Transcribing

Dispensing and
Preparing

63

System Tracer Methods

Medication Management Example

Selection of medications
Procurement of medications
Storage of medications
Medication ordering Policy & Procedure
Verifying prescriptions

Controlled substance storage, monitoring and use

High-risk therapy

Allergy reconciliation
IT support for verification

IV mixing, TPN prep, chemo agents prep

Concentrated electrolytes
Look alike, sound alike drugs

Preparation
Dispensing
Pharmacy role in discharge planning and patient/family education
64

System Tracer Methods

Infection Control Example
Group discussion
IC Program - Goals, surveillance data, analysis,
prevention & control strategies, areas of concern &
action, outbreaks
Focused tracer
Trace infection control processes across organization
Example 1: a TB patient admitted through Emergency to
Medical Unit to Radiology to Medical Unit to Rehab
Example 2: an immuno-compromised patient admitted
through Emergency to Oncology to Intensive Care Unit
to Medical Unit to End-of -Life care unit
65

Module 4: FMS System

Tracer

66

Facility Tour
Addresses issues related to

Physical facility
Security
Medical and other equipment
Hazardous waste
Fire safety
Utility systems
Patient and visitor safety
Infection control

67

Environmental Safety
Rounds
Observe for environmental compliance
Go into patient rooms, med rooms, supply
rooms
Observe for unsafe situations in environment
Include a facilities safety person and an
Infection Control staff on the tracer team

68

FMS
System
Tracer

69

FMS System Tracer: Guidelines

Group meeting with individuals responsible for
Facilities Management
Interactive assessment through discussion with
key personnel
Identify areas of concern and strengths
Assess actual degree of compliance to relevant
standards
70

FMS System Tracer: Guidelines

Occurs after surveyor(s) reviews:
Annual evaluations of 6 management plans
FMS multidisciplinary team meeting minutes
(previous 12 months)
FMS issues identified by other members of
the survey team (if applicable)
FMSrelated issues and information identified
from previous surveys
71

FMS System Tracer: Guidelines

Two parts:
Group discussion (approx 30% of allocated
time)
On site tracer (approx 70% of allocated time)

72

FMS System Tracer: Guidelines

Part 1
Discussion of management processes for 6
functional areas for managing risk
Assessment of compliance with Emergency
Management standards
Listen! This is not an interview
73

FMS System Tracer: Guidelines

Select risk process for Tracer

74

FMS System Tracer: Guidelines

Part 2 / Tracer
Visit source of risk
Interview staff about roles and responsibilities
for minimizing risk
Assess any physical controls for minimizing risk
Assess emergency plan in reference to
particular risk

75

FMS Risk
Management Cycle
IMPROVE

MONITOR

PLAN

FMS Risk
Management Cycle

RESPOND

TEACH

IMPLEMENT
76

Facilities Management and Safety

Matrix
Plan

Teach Implement

Monitor Improve

Safety/Sec
Haz Mat
Emer. Mgt.
Fire
Med Equip
Utilities
77

FMS System Tracers

Examples

78

Chemotherapy Waste
Pharmacy
Storage, preparation, disposal,
transportation, staff training / competencies
Patient Care Unit
Storage, preparation, disposal, staff
training / competencies
Waste Collection area(s)
Handling, training, storage, disposal,
manifest
79

Fire Detection / Suppression

Patient Care Areas
Detectors, extinguishers, sprinklers, hoses,
standpipes, access
Construction projects
Detectors, extinguishers, access

Engineering
Documentation, contractor oversight, staff training

Control Room
Fire alarm panel, trouble zone identification,
documentation, duty roster

Fire Pump
Maintenance, access

80

Security of Infants /Newborns

Delivery room
Identification, transportation, access

OB unit
Transportation, access, patient education, staff
roles / responsibilities, security features, drills

Nursery
Transportation, access, patient education, staff
roles / responsibilities, security features, drills

Security department
Role of security, communication mechanisms,
drills

81

Medical Equipment
Patient Care Unit

Select equipment, labeling, staff training, evidence

of PM, disinfection / cleaning, transport, storage

Purchasing department

Process, liaison with biomed

Biomedical department

Inventory, safety testing / PM records, staff

credentials, PPE, disinfection, recall policy,
contract oversight

Storage areas

Space, safety, plan for disposal

82

Safety Risks
Patient falls
visit area with high fall incidence, environmental
concerns, ask about staff training, incidence
reports

Needle stick injury

e.g. start in laundry, employee health, incident
reports

Behavioral health
suicide risk assessment, staff safety, elopement,
patient / family safety, abuse, incident reports,
security features, communication
83

Construction Site

Visit site
Review plans, risk assessments
Contractor education / training
Daily / weekly rounds documentation
Risk reduction strategies
Signage / barriers
Adjacent areas - Staff awareness
Fire alarm panel -trouble zones?
84

Emergency Power
Generator room

Condition / redundancy / activation

How tested- with load?
Fuel

Engineering

Documentation testing, PMs, emergency plan,

utilities plan, what areas served by generators or
UPS

Patient Care Unit

ID / availability of outlets?, staff knowledge

Emergency exits

Lighted / signage?
85

Module 5: Documenting Tracer

Findings

86

Sample Tool for Tracer Inquiry

and Finding Documentation

87

Sample Tool for Tracer Inquiry and

Finding Documentation

88

Sample Tool for Documenting Findings

Type of Patient:______________________________

Patient ID Number:__________________________

Date of Tracer:______________________________

Evaluators: ________________________________

Unit /
Department

Individuals
Providing
Care

Issues

Standards

Reported
to

89

Sample Tool for Documenting Findings

90

Step 4: Analyze Tracer Findings Validate Tracer Findings

When you notice a policy violation or an inconsistency in
clinical practice, you should:
- Drill down
Ask probing questions to more fully understand the
problem
- Validate
Look for examples of the problem in other settings
or with other practitioners. Is this an isolated
incident, or a trend?
91

May Validate Findings with Closed

Record Review
Review a sample of closed medical records for
required clinical documentation
Review record with staff member
Look for gaps in performance based on clinical
processes
92

Step 4: Analyze Tracer Findings Document Findings

Summarize and document tracer findings by chapter,
reference standard, and measurable element
Incorporate periodic tracer findings into a master
chapter-specific action planning tool
Using Action Planning tool, create a feedback
process of tracer findings and proposed corrective
actions:
To Leadership
To Appropriate Quality/Chapter Teams
To staff and physicians

93

Evaluate During Tracers

Consistent compliance
to organization policies
and procedures

Compliance with
standards

The Physical
Environment

Communication within
and between
departments/programs
and services

Staff activities and

behaviors

94

Step 5. Analyzing Tracer Findings Create a Feedback Plan

Create a plan to communicate feedback from
tracer findings
Plan should include:
Who needs feedback information? (Leaders,
PI / Quality / Chapter Teams, staff &
physicians)
What information do they need?
How will the information be delivered?
Who will deliver the information?
95

Effective Use of Tracers

Determine the goals
Train the tracer team
Create tools to standardize findings
Establish a schedule
Assign the tracer activities
96

Effective Use of Tracers

Preview the findings
Review the findings
Aggregate the data
Prioritize the issues
Share the results
Develop and implement the improvement plans

97

Summary - Steps to Performing

Tracers
1.
2.
3.
4.
5.
6.
7.

Get organized
Educate staff
Perform tracers
Document findings
Analyze findings
Develop corrective actions
Implement and sustain improvements

98

THANK YOU

99