Documentation Matters with Tracer Methodology

Tracer and HIM Professionals

While the Joint Commission survey process focuses less on paperwork and documentation, the HIM professional still plays a significant role as the organization strives to be in continuous compliance with standards that support safe, quality care. HIM professionals who understand the tracer methodology will be better able to see how their actions support the organization’s overall goals, including achieving accreditation.

In the tracer methodology, the surveyor selects a patient and uses that patient’s care record as a roadmap to assess and evaluate the services the health care organization provides. This includes not only the individual services, but the interaction of departments, services and functions throughout the organization.

Surveyors begin the patient tracer by starting where the patient is currently located. They then move to where the patient first entered the organization, and to any areas in the organization where the patient received care. Each tracer takes from 1-3 hours to complete and a 3-day survey includes an average of 11 individual tracers.

For example, a surveyor might select a patient seen in a hospital’s emergency department with pain from a pressure ulcer. The surveyor would look at the patient’s care in the emergency, radiology and surgery departments, along with any nutritional/dietary consultation and specialized wound care services.

The surveyor might focus on how each of these departments assessed the patient, obtained a medical history, eased pain and provided treatment. The surveyor also would return to the nursing unit where the patient resides to discuss the findings as they are exploring the care processes.

It may be that a new theme or area of focus such as infection control emerges from this tracer process. The surveyor would then explore this new area thoroughly and ask other surveyors at the hospital to explore infection control in their tracers to determine if similar findings exist in other tracer patients.

Connection to Patient Safety Goals

Surveyors also may use the tracer methodology to examine how National Patient Safety Goals are being addressed. On the surgical unit, a surveyor may observe a nurse changing a dressing or giving medications. The surveyor would spend time talking with the nurse about the patient selected for the tracer, asking for the unique identifiers used for the patient. What is the patient’s diagnosis? How is the nurse caring for this patient? What was the admission date?

The surveyor would note whether any of the “do not use” abbreviations related to medications are used. How are health care-acquired infections addressed? How is pain measured? By whom? The surveyor may ask the nurse to explain how the patient’s vital signs are being tracked, starting today and going back in time, and ask to see similar documentation for pain assessment and management. Looking at the interdisciplinary treatment plan, the surveyor may ask whether each discipline updates this plan and what serves as the update.

Medical Record Vital to Process

The tracer process takes surveyors across a wide variety of departments and shows the importance of the medical record. The quality of the documentation, timeliness of entries and legibility of the entire medical record are important because it will help guide surveyors as they trace a patient’s progress through the organization. The quality of the documentation, timeliness of entries and legibility of the entire medical record is also crucial to safe, effective care because providers rely on it to communicate with each other about treatment needs and decisions.

The tracer methodology’s use of face-to-face discussions with caregivers, staff and patients, combined with review of clinical charts and the observations of surveyors, make for a dynamic survey process that provides a complete picture of an organization’s practices and services. In other words, the tracers allow surveyors to “see” care or services through the eyes of patients and staff and then analyze the systems for providing that care, treatment or services.

Just as surveyors use the tracer methodology to assess standards compliance related to care delivered to individual patients, they evaluate organizational systems by conducting system tracers. The concept behind this methodology, which focuses on high-risk processes across an organization, is to test the strength of the “chain” of operations and processes.

By examining a set of components that work together toward a common goal, surveyors evaluate how, and how well, the organization’s systems function. This approach addresses the interrelationships of the many elements that go into delivering safe, high-quality care and translates standards compliance issues into potential organization-wide vulnerabilities.

While some of the system tracer activities consist of formal interviews, an interactive session, involving a surveyor and relevant staff members, is an important component of the process. Discussions in this interactive session with staff include:

Improving Care

The tracer methodology places the focus of the on-site survey on the actual execution of the delivery of care, not design or potential. Organizations as a whole and disciplines such as health information can use the resulting systems analysis that connects the dots between actions and outcomes to further improve care.

To get the most out of the tracer methodology and to use this process internally on a departmental basis to determine how well performance matches process design, HIM professionals should expect to work with organizational leaders who conduct internal tracer rounds.

For example, a performance improvement professional may perform a mock tracer by selecting a patient, examining that patient’s record, and developing sample questions that will allow for the tracing of that patient’s experience in the organization.

Conducting mock tracers is not a Joint Commission requirement, but can be useful in determining the effectiveness of process design in delivering safe, high-quality care, identifying potential areas of noncompliance with standards, and spurring new ideas for process improvements. These exercises can also help caregivers, along with support staff such as HIM professionals, better understand how their actions have an impact on safety and quality, even away from a patient’s bedside.

The following five steps can be used to evaluate performance and make necessary improvements:¹

1. When performing the Periodic Performance Review, review the top clinical service groups (CSGs) and priority focus areas (PFAs) identified in the priority focus tool outputs to determine which patients and which systems should be selected for tracer activities.

2. Select a sample of open patient records. The records should be chosen based on CSGs. It also will be useful to select records for patients who have received care in different areas of the organization so that organization-wide processes and continuity of care can be examined.

3. Plan the tracers. This process involves listing all of the disciplines and areas involved in the patient’s care, applicable Joint Commission standards, National Patient Safety Goals and relevant staff.

4. Conduct tracers. A designated person familiar with Joint Commission standards should visit the areas involved in the mock tracers, review records, interview staff and conduct any follow-up.

5. Analyze results to identify areas for improvement. Information gleaned from the mock tracers can be used to identify trends and prioritize improvement efforts.

Document, Document

HIM professionals can contribute to the success of the survey process by ensuring that caregivers understand the reasons behind the needs for timely and accurate documentation. The entire HIM department, not just its leaders, also should examine how medical records are maintained in a manner that accurately documents all the necessary information about a patient’s condition, care and needs.

Documentation created on a daily basis, which is used in the Joint Commission tracer process, is a powerful tool in organization efforts to identify and improve system weaknesses such as communication failures, documentation gaps and faults in hand-offs in care.

Reference

1.Joint Commission on Accreditation of Healthcare Organizations, The Source, January 2004, Volume 2, Issue 1.

Linda Murphy-Knoll is interim executive vice president of operations, division of accreditation and certification operations at The Joint Commission.