Tracer university: Preparing staff to maintain continual survey readiness

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Tracer university: Preparing staff to maintain continual survey readiness

After reading this article, you will be able to:

  • Identify "generalist" areas where the observations of non-clinical tracer team members can be best utilized
  • Discuss challenges with all-day tracer training programs
  • Identify why civilian tracer team members may better serve in a military hospital or clinic
  • Describe timing and its effect on tracer effectiveness

You can have all the survey prep knowledge in the world, but if it doesn't get into the right hands, your organization is still at risk. For this reason, education is always at the forefront of every survey coordinator's job-and it's why the Joint Commission Sustainment Office at Evans Army Community Hospital, Fort Carson, CO, developed its concept of tracer university.

"We started from nothing," says Christine Levy, RD, MBA, MHA, FACHE, CSHA, a retired Army lieutenant colonel who has served as the Joint Commission sustainment officer (JCSO) for the 78-bed hospital for the past three and a half years. The accreditation section started with one person, the JCSO, and then added a tracer coordinator and three health system assistants who conduct and support sustainment activities.

The quality support division was doing tracers, of course, but active involvement of the rest of the hospital staff was still in its infancy four years ago. To better reach out to staff, the department developed the concept of a "tracer university"-in-depth training to get staff up to speed on their role and build their competence conducting surveys.

The original concept was perhaps too ambitious-an all-day training session with subject matter experts providing in-depth information and education on their area of expertise.

"It's hard to pull them from their patient care or assigned duty for a day's worth of training," says Levy. "Our first priority is to make sure all staff attend newcomer orientation and complete all mandatory training dictated by their position; that can take days. It's hard to attract people to voluntarily attend more training and be committed to an additional duty."

Surprisingly, though, the organization has new volunteers every month. That can be attributed to its hospital commander, Col. Jimmie O. Keenan, who is known throughout the hospital and the community for her sincerity and dedication to the hospital population.

"These wounded, ill, and injured whom we care for every day rely on us to get it right," Keenan says.

She supports the organization's Joint Commission sustainment (JCS) program not because of the seal on the wall but ­because "at the end of the day, it's all about taking care of patients and their families," a statement she closes most leadership briefings with. Keenan recognizes the value of continuously doing tracers to identify issues before they impact patient safety and the organization's quality of care.

To attract and retain more tracer team members, the university training program is much more flexible and less time-consuming.

"The new methodology is to train people to do specific tracers. They come to training-in a regular year that would be monthly-and get an hour-long, focused presentation on a specific topic, like HIPAA or infection control or environment of care [EOC]," says Levy.

Attendees would then go out and focus specifically on that topic in their own tracer practices to give them immediate, firsthand, and practical experience tracing the topic. "We can then say, ‘Okay, we did 18 tracers and these are the trends related to HIPAA,' for example," says Levy.

This often yields immediate results with implementable fixes, she notes. For example, even if staff members are trained to look for HIPAA violations, they will also review other employees' competency folders or credentials files, thus potentially identifying a missing competency or incomplete training requirement.

With a rapidly increasing staff and high turnover of military personnel, having an extra review of the organization's competency folders assists its education and training division by ensuring ongoing staff competency.

For people working in the JCS section, Levy says, spotting EOC or medication management issues is second nature. The trick is to enlist other staff who have the potential, such as clerks or licensed practical nurses, to spot those deficiencies..

"We found that if we gave them focused training over time, they start to retain the knowledge-they'll go into an area looking for expired meds, but then also spot infection control issues or EOC issues," says Levy. "We always encourage people to list everything they see."

The problem, as is often the case, is accountability.


Building accountability

You can spot an issue time and time again, but if no lasting change occurs to put an end to it, even the best intentions won't make a difference, Levy explains. "Holding everyone accountable is the most challenging part of the job," she says, noting that she relies on Keenan's support with this endeavor.

"We promote a culture of trust here and we are all on the same team," Keenan says. "We encourage input from patients and staff so that we can make continuous improvements to processes that aren't working."

For Levy's organization, tracers provide objective documentation on opportunities for improvement and jobs well done. The tracer team members are tiered by expertise and experience level.

For example, record documentation tracers are not a generalist activity. The staff who are trained to conduct those tracers work primarily in patient administration, risk management, and patient safety-in other words, they are competent in reviewing medical records.

"It's very hard to teach, and not everyone has access to the electronic medical record," says Levy. "So those focused tracers are conducted by a small, specialized group of individuals."

More general topics, however, are taught across the board to all staff conducting tracers. For these topics, it's possible to rely on cheat sheets and lists of appropriate answers rather than intuition, deep research, years of experience, or skill level.

"The staff knows what the answers should be," explains Levy.

For example, when assessing the use of two patient identifiers, tracer team members can be provided with a list of the appropriate identifiers and can perform on-the-spot education if they come across a situation where the organization is out of compliance, explaining the facility's policy as necessary.

"If you have a clinic which has decided to ask additional identifiers besides the two mandatory identifiers, you can discourage that-because sometimes you miss the nonnegotiable ones in those situations," Levy says.

The tactic of telling staff members what to look for also gives the organization an opportunity to examine its existing policies-are they reasonable, rational, and functional? Are there workarounds or common informal changes that need to be either discouraged or potentially built into the policy itself?


Examples and opportunities

Properly trained staff can use tracers to spot changes as they happen and help keep the relevant policies up to date and accurate. More generalist topics are often the canary in the coal mine for accreditation ­compliance-early signs where things require updating.

For example, Levy's organization recently moved its tissue storage area. The organization as a whole has a significant amount of construction and facilities changes, so staff have been trained to look for modifications in layout or process when a unit or area is moved.

"We shouldn't have the same locations listed in our policies, and these need to be updated. We'll pick up different things based on what happens in a given day in the new location," says Levy. These observations are made through tracers and can then be implemented in policy as well. "We're really doing well at planning for these things prior to our construction-related moves."

Sentinel event follow-ups are another opportunity for training. Tracers and root cause analyses (RCA) go hand in hand by their very nature. As such, the lessons and training learned through tracer university education come into play when following up on RCAs.

"It's a list of things to go back and check on," says Levy. "I might have a list of 46 items to go back and review following an incident."


Team development

The tracer team consists of approximately 20 staff members. As the team has evolved over the years, the organization has come to rely on civilian staff more and more, despite being a military institution.

"We try to have more civilians-they stay in one place longer," says Levy.

Military personnel can be redeployed at a moment's notice, and when they leave, all of that training leaves with them. Using civilian staff for the tracer team adds some stability to the overall process.

The military leadership is also trained and will participate in the tracers when they are available. They support the tracer methodology, and many participate in groups called functional management teams.

All tracer team members are volunteers. "Nobody's told that they have to be a part of the team," says Levy, noting that when someone steps forward, it's a good sign. "Many people tend to see anything inspection-related as a negative-we try to promote it as a positive and an opportunity for us to identify potential problems early."

The organization allows a great deal of flexibility for its team members. They go through an hour or two of training every month and spend several hours performing tracers when it's convenient for them to do so.

"They are told we need their information by a certain day of the month, so they can do the tracers at their pace," says Levy.

Team members are instructed on where to conduct their tracers among the various units and clinics that fall under the system's purview.

The staff are also told to use common sense when conducting the tracers-if a clinic is overwhelmed or shorthanded on a given day, it's not the ideal time for a tracer to get an accurate look at the clinic's compliance. Poorly timed tracers can also foster a negative relationship between the tracer team and the clinic or unit.

This does not mean team members should always turn around when they encounter a busy unit, though. "If that were the case, the emergency department would never get traced!" says Levy. "It's a matter of finding the right balance."

And speaking of balance, it's important to note that an all-volunteer team needs to have the right combination of knowledge and skills for maximum effectiveness. For ­example, the current makeup of the team could benefit from additional clinical nurses or physicians. This way they would be able to make use of those skills to maximize the effectiveness of the tracers.

"I'm a dietitian by training, so my comfort zone is not the [operating room]," Levy says. "I will ask physicians, nurses, or specialized technicians to assist with tracers for areas requiring their specialized skills and expertise. It's easier for those folks to know what ‘right' looks like when they have the skills, knowledge, and abilities."

Accurate, valid documentation of tracer findings instills confidence in the process as well as commitment, from the hospital commander to the most junior employee on the staff. Through the use of this documentation, improvements can be made across departments and units to better prepare for future surveys, keep staff up to date, and improve future Joint Commission visit outcomes.