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Tracing the care experience

By Jane R. Schetter, RN, MSN, CNS, System Director Accreditation, Certification, and Regulatory Compliance, Office of Patient Safety,
and Tina Scott, System Director of Clinical Performance
Have you ever walked into a hospital patient room and thought about what type of gloves or eye protection the staff used to clean the space before you walked in? Did you look at the empty trash bin and think to yourself, “I wonder if that was emptied before the sharps container, or after the staff disinfected the bed rails?” Thankfully for our patients, many EMHS employees do think about such seemingly minor details. The hospital environment is comprised of hundreds of thousands of processes, or systems—like cleaning patient rooms—which call for protocols and procedures in order to greatly reduce all types of risks to patients. When a process, like a catheter placement, is deconstructed into many smaller steps, to be performed in a particular sequence or method, it allows care teams to look back and retrace their steps to see where a process might have broken down. A method of identifying “broken” systems is through the use of the Tracer Methodology, an important tool in patient safety work. The tracer methodology follows the experience of care, treatment or services for patients through the organization’s entire healthcare delivery process. Tracers are designed to “trace” the care experiences that a patient had while at an organization or trace a system.

When performing a tracer, some of the primary questions and observations can be, “What is the process?” and “What are the risk points and how do I mitigate them?” Then, if a process changes, care teams need to take into consideration how the change might affect staff, equipment, information systems, sequencing of other steps, and location (where physical steps take place, where needed supplies or equipment are located, or where patient care is provided). The EMHS Patient Safety and Clinical Performance System Team is working to establish the tracer method as a tool to be used regularly at all EMHS organizations when reviewing policies, processes, and practices as a means to improve patient care, quality, and safety. Tracers allow us to identify performance risks in one or more steps in a patient care delivery process, or among the interfaces between those processes.
Often seen as a way to prepare a hospital for certification and accreditation surveys, tracers improve the care and services provided to patients. Leadership and staff participation in this quality improvement and quality management method is essential and can include many ways of evaluating a process, including staff interviews and observations. Although The Joint Commission, the Healthcare Facilities Accreditation Program standards, and the Medicare Conditions of Participation may be used to review care within a healthcare facility, it is important that EMHS uses tracers to repeatedly examine patient care process design, and to look for risk points, opportunities for improvement, and processes that support safe practices. It’s about finding the holes in the swiss cheese. Tracers can reveal if a process has been designed well enough that it results in safe, effective, high quality care.
The Tracer Methodology also supports our path to becoming a high reliability organization. By repeating the same process several times throughout the organization, the Patient Safety and Clinical Performance System Team can more clearly identify and replicate the good demonstrations of patient care, and isolate what isn’t working so well, and explore why and how a process broke down. Possible applications for tracers can be a new process or a redesigned process, a complex process such as medication management, a high-risk process such as high level disinfection, or basic housekeeping process that is the foundation for all infection prevention and control throughout a healthcare facility. While some tracers may be flexible and allow for variation of a process, others may require specific steps to be traced based on manufacturer’s guidelines, law and regulation, and organizational policy where consistency of process is a must.  
Each person working within a healthcare organization has a responsibility for the care of the patient whether that is direct care or supporting the functions that make care possible. By using Tracer Methodology, you can improve any process—just think about the primary questions.