The Tracer Methodology remains a primary tool for assessing compliance and it can also be a valid tool for assessing risk. An organized and ongoing continuous survey readiness process with integration of tracers throughout the triennial cycle is an excellent way to stay prepared for a survey as well as to identify and mitigate risk.
This process, introduced several years ago, is borrowed from the manufacturing industry, where a product is followed through from start to finish identifying process and system issues. In healthcare, the tracer involves the patient care process or a procedure or system used in the organization. Use the daily census lists, OR schedules, procedure schedules, and other data sources for a selection of patients to trace. Identify processes and systems that support patient care and operations and use existing procedures to develop a tracer or create a process map of the system and use the process map as a tracer guide.
The tracer process may include:
- Observation of care delivery
- Observation of medication-related processes
- Observation of planning care
- Patient or family interview
- Review of medical records as indicated
- Discussion with staff about performance improvement (PI) and patient safety activities, their daily duties and clinical practice, and their orientation and training
- Review of policies and procedures
It is worth the time to use the tracer process and involve front-line staff. They are the keys to the success of your organization in terms of patient care delivery.
-Jean S. Clark, RHIA, CSHA, and Jodie L. Eisenberg, MHA, CPHQ, CPMSM, CSHA