With a new era on focus on accountability of quality and safety rapidly emerging compliance is a priority for most healthcare organizations. Reducing the risk of non-compliance and continuous improvement are driving the need for ongoing auditing. The last decade more and more accrediting bodies recommend the use of tracers as an instrument for demonstrating compliance and gaining meaningful insights in improvement opportunities. By leveraging technology, tracers are becoming increasingly attractive – apart from accreditation – because of all the new challenges and opportunities they can bring as an instrument to drive organizational change and performance improvement. In this white paper I discuss four ways how an effective tracer system can tackle important compliance concerns and help in the ongoing effort to improve quality and safety.
1. Respond more efficiently to the current compliance landscape
In today’s healthcare landscape, organizations are faced with a strong call for transparency and expectations towards accreditation. On average a hospital participates in 19 quality labels (e.g. NIAZ, JCI, ISO) and in addition, a plurality of mandatory outcome measurements, CQIs and PROMs*. Once achieved, accreditation is not permanent – it is renewed periodically to ensure that the quality of the educational program is maintained thus committing themselves to meet the ongoing standards requirements in order to remain compliant.
Healthcare organizations are facing countless challenges around accreditation and compliance in this complex and ever-changing compliance landscape. The execution of a comprehensive program for controlling tracers with hundreds of tracers a year for thousands to multiple standards and regulations related measurable elements can therefore be very complicated? They are fast realizing that point solutions and spreadsheet-based systems are no more suitable for managing tracers and to efficiently response to all quality issue driven standard requirements.
Today is the moment for quality executives to optimize and centralize the performance of tracer activities for responding constructively to the gap between expected standards and organizational reality. A tracer system, when effectively implemented, can arguably be considered the most important tool of the quality and safety system toolbox.
A tracer system is a system of collecting, storing and processing “real life” data on compliance and improvement opportunities used by healthcare organizations to improve the quality and safety of care. Tracer systems are designed to support all tracer activities including controlling assessment frameworks, conducting tracers and reporting and sharing of results and to make compliance much easier to achieve and maintain.
“From the start of the accreditation process in 2012 was heavily deployed on tracers to sensitize employees, but also to test the hospital policy on feasibility and consistency. It is a powerful instrument to show directors and executives at a glance the extent to which the organization is ready for the JCI audit and expose working points or priorities. “The “tracertool” not only helped us to achieve accreditation in August 2015 but it is an excellent means to keep abreast and absorb relapse.”**
A consistent, risk-based and technology driven approach to standardize, automate and track tracer activities will drive greater efficiency in the execution of the enterprise tracer program. Simplifying the routine tracer activities provides core tracer team members with additional time to focus on non-routine areas of the tracer that often require more analysis and professional judgment.
An user-friendly and easily accessible tracer system supports and encourages employees at all levels in the organization to expose non-compliance and identify potential opportunities for improvement; it will help implement changes as a part of an ongoing improvement process and to meet and maintain overall quality standards.
* KPMG study on the costs of quality measurements conducted in The Netherlands in 2015
**Abstract presentation “Tracers: a practical approach” presented by University Hospital Antwerpen at the seminar Continuous improvement with tracers, which was held in the University Medical Center Utrecht on 10 December 2015.
2 Collect quality improvement data in a cost-effective way
Data is the cornerstone of quality improvement. The volume of (big) data that hospitals create is astounding. These data is often in disparate systems, and the extent of the information captured may not always be widely understood within the organization. Because the data is retrospectively collected and represent a static view of what happened in the past, making sense of the information presented can be difficult. Although these data can be helpful in improvements efforts, without context they are less meaningful for quality and safety improvement. So we must not rely too much on the insights gained from these data.
To achieve relevant and meaningful insights for providing actionable information for frontline workers to improve, you have to go beyond this. Tracers can help collect data in real-life that is observable and about phenomena, which provide important information about patterns, relationships between systems, and thus can provide context for needed improvements.
“Our hospital achieved within two years at one time the JCI accreditation with the new academic accreditation standards, where only 5% of all hospitals succeed in the world. Thanks to our tracer app and dashboard with continuous quality measurements,” said Robert van Barneveld, Manager Care at University Medical Center Utrecht. “Since we use the tracer system we save around 50% of our time on reporting.”
University Medical Center Groningen has similar positive experiences using a tracer system. They also experience significant timesavings in reporting, according Emmy Hoevelaken, projectleader Quality App.
Tracing one guideline, not to mention hundreds of processes, a large variety of standards, across multiple departments take time and the scoring and reporting tasks can be very comprehensive and labor-intensive. With automation that process is simplified tenfold. An automated tracer system speeds the process of conducting the tracer and reporting activities.
The above figure is a representation to demonstrate how content can be structured in a tracer system, enabling organisations to easily perform tracers at organizational level while working with multiple standards, question sets (QS) and individual dashboard users. A question set is a collection of questions retrieved from selected standards. The use of individualised dashboards makes it possible to collect data on organizational or departmental level, or for specific standards or rounds. Users can easily navigate on a tablet, find content and conduct tracer themes and topics using score forms from question sets or standards. The collected data from tracer rounds are captured in the selected dashboard and accompanied by a report automatically archived in a central database. Filtering all of the data help you analyse a set of data and can bring forth powerful insights.
Healthcare leaders and staff should be able to record compliance data and improvement potentials while they are conducting the tracer so that they can assure accuracy and save time. Mobility makes this possible. Tablets are a widely used choice for conducting tracers, especially with web-based tracer software. Mobility allows people to enter each compliant data into their tablet in real-time and at any place.
3 Facilitates organizational learning
A learning organization is an organization skilled at creating, acquiring, and transferring knowledge, and at modifying its behavior to reflect 0new knowledge and insights. It all happens as a function of experience within the organization. A tracer system could provide a framework for action that will support leaders and frontline staff to improve their standard practices.
Health organizations have developed an extensive library of standard practices that bring efficiency and effectiveness in quality and safety. These policies, standards, guidelines and procedures are developed to reduce errors and improve patient safety, but hospitals must ensure that their standardized work benefits the patients and healthcare workers, and the hospital itself. Such standardization, however, leads to a countless number of guidelines and procedures that healthcare workers face in daily practice. But trying to comply with them would seem like an overwhelming challenge. Guidelines and procedures described in our manuals are by far not matching with what we do in our daily practice and what really matters.
“Tracers are an interactive form of auditing that takes place in the middle of practice (life world) and keeping direct connection with guidelines and procedures (system world),” notes Bas de Vries, Quality Advisor at University Medical Center Utrecht.
Healthcare workers meet ever-changing and increasingly stringent competency requirements. If organizations want to get grips with performance and especially with their intangible enablers, then they need to allow experimentation with measurements and encourage innovative ways of non-compliance and “workplace collaborative” learning.
“In the execution of a tracer both good practices in the implementation as well as points of attention and improvement are measured and evaluated. It thus provides feedback to the department being visited and shown in a central dashboard of the tracer system,” said Bas. “In addition, the performer of the tracer gets inspired and learns in a different way. On questioning and learning manner the conversation is conducted on proceedings, which may or may not be carried out in accordance with existing guidelines and protocols. The tracer methodology characterized by its interactive and stimulating process.”
A tracer system should not only report on areas of concern and non-compliance, but also highlight areas of good practice, allowing people to learn from each other to improve working practices and enhance quality and safety.
Facilitates frontline staff
A tracer system is potentially a powerful platform to drive learning and gain real-life experiences and performance improvement. Automating observation of employees and assess performance and process in real-time, on the job, and even at the bedsite as they provide care to patients is critical to maintaining competency and ensuring compliance throughout the care process. Identifying and sharing good practices and giving timely feedback of findings and constructive ideas for improvement crucial in addressing non-compliance are essential parts of the tracer activity and should be enabled by the tracer system.
Whilst not always required by management system standards, tracer checklists are essential tools for “conformity assessment” to standard requirements. Many organizations will use them to ensure that the tracer at a minimum will address the requirements as defined by the scope of the tracer. Although they contain relevant points of attention it isn’t working when “auditors” approach a tracer with checklist in hand and a compliance mindset. Focus on compliance alone will not make your organization safe. You should definitely focus on systems thinking, exploring situations for improvement and dialogue.
A tracer system contributes to fulfilment of a number of important conditions that facilitate learning towards the idea of a learning organization, which we appoint some:
- Facilitate the exchange of information, the basis of which a learning organization is built
- A tool that access the distance between where an organization is and where it would like to be (Empowering people toward a shared vision)
- Prior identification and recognition of capabilities and areas for improvement
- Promoting inquiry and dialogue
- Encourage collaboration
- A clear connection between the learning task and its potential consequences
- Performance feedback
- A climate that encourages, facilitates and rewards learning
4 Foster a culture of safety
Hospitals have already made an effort at standardizing, including hand hygiene, medication administration, communication with patients and proper cleaning and disinfection of patient rooms, but there will always be opportunities for improvement. If you are a “learning organization”, you are driven by a desire for quality and continuous improvement.
You can build a culture of safety through continuous improvement. According to studies a culture of continuous improvement is built upon three critical elements: engaged leadership, a consistent improvement methodology, and enabling technology. More and more organizations choose to use tracers as a new method for bolstering or even replacing current quality improvement activities.
“We tested our tracer audit system on several wards on the usability to perform so-called quality rounds. The process in the pilot fits in well with the vision of UMCG to use quality rounds accurately and efficiently as a means for continuous and measurable improvement of quality and safety of care,” said Emmy Hoevelaken, Project leader at University Medical Center Groningen. “Our quality staff became highly motivated and enthusiastic. Since we provision the system to facilitate quality rounds, we receive constant requests from all departments to implement their own theme or question set.”
All teach, All learn
According Institute for Healthcare Improvement (IHI) the ability to improve must not only resides within the quality department or with just a few people, but need to spread so that the entire organization has the ability to engage in improvement. “All teach, all learn,” as they say at IHI.
A sophisticated tracer system enhances employee’s engagement in continuous quality improvement by emphasizing collaboration and making tracers more appealing to all employees, included management. The system maintains a constant state of readiness for random tracers and regulatory processes, an innovative approach of constantly introducing small incremental changes in order to improve quality that is fundamental for continuous improvement. In this context the execution of a tracer should not take more than an hour, but has to be done on regular base. Health organizations that already implement such tracer system experience strong positive influence on the safety culture of the organization.
“Building improvement capability is not only about skill building; it also means creating an environment in which the frontline staff can identify and participate in needed improvements,” said David Munch, MD, Senior Vice President and Chief Clinical Officer for health Performance Partners.
This approach assumes that employees are the best people to identify room for improvement, since they see the processes in action all the time. User-friendly technology in this context is essential to enable standardized unified communication and help building confidence in conducting dialogue and providing constructive feedback. The tracer system as a whole enables collaborative knowledge sharing of practices and employees to be pro-active. It will help the organization to identify unrecognized compliance and patient safety issues and implement changes as part of an ongoing improvement process.
Considerations before selecting a tracer system
Your organisation maybe using manual, paper-based processes, spread sheets or a general audit tool. In either case, you need to answer several questions as you evaluate different tracer systems.
1. Is the system designed for healthcare?
Healthcare has unique challenges when it comes to measuring and improving compliance. The system should provide the ability for defining, customizing, and managing compliance frameworks, compliance standards, and compliance standards rules. In addition, the system is able to support the tracer process based on the three level structures of standards according the World Health Organization (WHO) and the tracer methodology as recommended by IsQua accredited accreditation organizations. The tracer system’s functionalities should be easily accessed and deployed through a user-friendly graphical interface to make performing tracers attractive for all employees, to encourage communication and increase employee’s engagement for quality improvement.
2. Does the system supports multiple dashboards, standards frameworks and question sets (to select themes or topics)?
It is becoming increasingly more challenging for health professionals to measure, manage and track a tremendous increase of requirements and compliance data related to multiple standards and regulations. The system must be able to aggregate and report these collected data at the organizational and individual level cross round types, standards and even departments using own reference frameworks to achieve greater efficiency.
3. Allow scoring on a range in compliance ratings.
For each requirement or recommendation tracer team members should reach a conclusion about the extent (compliance rating) to which an organization complies (or not) with the standard. A three-point scale scoring should be possible: (sufficient) compliant, partially compliant and non-compliant. In exceptional circumstances a requirement or recommendation may also be rated as not applicable (requirement does not apply). For conducting quantitative evaluation/monitoring of patients/employees the system can interpret a user-configurable end-result from the three-point scale.
4. Ability of sharing data supported insight
Evaluation and reporting is the last step of the tracer, but provides frontline workers with a basis for starting improvements. Timely availability of data supported insight is essential to get motivated to act. Therefore the data must be available trough a dashboard in an on-going manner and easily accessible and understandable by legitimate users (frontline health workers).
5. What type and level of client service and support is provided
It’s important to have a support team that’s knowledgeable in the needs of healthcare clients. Will the vendor be able to respond to questions about the implementation of certain standards frameworks within the clients organisation or questions that may arise when surveyors for JCI or other regulatory groups on site for an accreditation audit? It’s also essential to have support specialists who can work with people who have differing levels of technical skills.
Tracer systems are powerful solutions designed to standardize, automate and track your tracer activities. It helps you make measurable progress in meeting compliance challenges and quality & safety improvement in a practical, efficient and cost-effective way. Although the tracer system architecture and software are extremely important considerations, complementary components such as tracer and auditor education, the socio-technical environment of the organization and “tone at the top” are fundamental as well.