Healthcare Quality Beyond Accreditation Compliance

The value of interactive “Tracer Dialogue Questions” for Improving Quality of Care and Service Excellence

Why go Beyond Accreditation Compliance?

Accreditation essentially identifies the capability to deliver quality of care, but in reality it does not ensure that patients receive (higher) quality of care. Your hospital is already ISO, JCI or ACI certified, and yet you have the feeling the quality is still poor…. Important factors, which affect quality, are the unavoidable changes in personnel and loss of motivation and engagement when attention for quality improvement wanes. Come and go of leaders with different level of commitment and competence in the field of quality and performance also negatively affect this.

“Accreditation Compliance is not a one-time event, but an Ongoing Process”

Accreditation is just a beginning rather than an end to your quest for quality. After this new challenges come into play that I want to discuss below.

  • In the preparation of your initial accreditation process you have to transform your standards requirements (“measurable elements”) into question sets for performing tracers and demonstrating compliance. When you achieved your accreditation you have to continue developing new target question sets to enable you to shift to an every-day state of continuous compliance and to prevent progressive collapse. It’s an ongoing process, knowing your accreditation has limited validity: you will be always audit-ready for the accreditation of your certification body.
  • Within today’s health care market patients have more choices than ever before. Retaining patients by providing superior quality care and service excellence is becoming an increasing priority for health provider networks. It reinforces the need for vigilance in maintaining and improving quality and performance excellence. Patients are responsible for spreading the good image of the hospital and therefore patient satisfaction is important for hospital management and in this context feedbacks of patients are vital in quality improvement.

Tracers are an interactive process of gathering evidence about the organization’s quality and safety of care and services based on direct observation and dialogue questions feedback. It is used to demonstrate standards compliance and to identify areas of quality improvement during the tracer visit. Now let’s talk about how to upgrade tracers to go beyond normal accreditation tracers.

The value of “Tracer Dialogue Questions” from the Patient Perspective

For our partner University Medical Center Utrecht (UMCU) accreditation is a dedicated tool for continuous improvement of safety and quality. After achieving their JCI accreditation the hospital is aiming for a higher level of appreciation (The path to a patient safety and hostmanship culture). In order to achieve this they started developing tracers from the patient’s perspective to identify critical areas for further improvement and focussed on patient-provider interactions. However in many cases, these questions that are related to internal policy guidelines and procedures can be set up under the umbrella of the accreditation. That means these questions do not necessarily directly relate to ‘measurable elements’ but do go back to standards. Sometimes you just ask your patient a simple question and you will surprise yourself with the results, but do it in the right way. A sample question inspired by the book “Tabner’s Nursing care: Theory and Practice”: “I’m concerned that you don’t feel up to a shower; how are you feeling today?” instead of asking, “When did you last shower?”

Recently the UMCU developed a deliberately tracer question set (TQS) that will be implemented in all nursing wards during the year 2017, says Bas de Vries, Sr. Policy Officer. The TQS is focused on various aspects of assessing patient and practitioner’s feedback on satisfaction and experience, including malnutrition, pain assessment, identifying critically ill patients. The set exists of 31 questions (interview questions, observations and verifications) for patients (8), nurses (17) and physicians (6). “It is better to ask carefully designed and quite detailed questions about a few precisely defined issues than the same number on a very wide range of topics”, (Dyer 1995, from the book “Research in the Early Years: A Step-by-step Guide”).

“Is there a CLEAR care/treatment goal discussed with you?” is an initial sample question from the UMCU’s TQS that you can make a numerical data score to compare and measure progress, but whose function is also to continue a dialogue and break through the confines set by one set of questions by asking new questions depending on the answer and making use of the “Dialogue Education” approach. Link to Wikipedia. Such custom question can also be asked to members of the treatment team and caregivers to achieve mutual clarity. This particular question reminds me of my duties as project manager. The project failures are mostly due to ambiguity (dimensions like target controls, timeline, evaluation,..), uncertainty caused by the project – and how said project is managed. Economics call it “ambiguity aversion”, or the malaise that results from a lack of clarity. Dr. Deepa Bhide says about patient care from a project management perspective, “Physician-patient centric projects involve managing patients and their conditions as projects”. Providing clarity about the goals of treatment is important for the patient, the entire treatment team and the family to avoid ambiguity. Through dialogue questions you have the opportunity to increase the engagement and encouragement to pursue clear goals that leads to greater performance and will ensure that the work continues to be focused on the treatment goals. So if nurses and physicians want the treatment to be a success, they have to kill the ambiguity!

Why the implementation is important?

The accuracy and timeliness of the tracer data collection procedures will be influenced by a series of practical issues and the overall attitude of the performers. The best “control” systems are often the simplest and making the tracer data collection processes complex only increases the costs and the possibility of error, and inhibits the motivation of implementing tracers. A practical issue that needs to be addressed is how the execution of tracers – developing TQS’s, processing scores and evaluations, results and progress reporting – can be supported in an efficient and cost-effective manner. It is not my intention to write a technical article, but some clarification can be found at the end.

Of course it all starts with the capability of creating intelligent questions, because intelligent questions stimulate, provoke, inform and inspire. If patient experience data is to be used to improve quality of care in hospitals, it needs to be reliable.

“Intelligent questions stimulate, provoke, inform and inspire”

Because of the fact that healthcare providers and academics are raising strong objections to the use of patient-experience online surveys because of studies indicating that these measurements at best have no relation to the quality of delivered care and at worst are associated with poorer patient-outcomes, these interviews should take place face-to-face on the spot. Only then will you be able to extend dialogue and experience patient’s emotional expressions.

“Become aware of ‘how things are done’ and ‘why the things are done this way’”

Besides the quality of your TQS the implementation; the process of executing your TQS is of great importance. Although gaining standards compliance insights during the tracer is of great value, it must certainly not be seen as a conformity assessment process. Like the essence of Buddhism of how to gain insight, awareness is the key. Become aware of ‘how things are done’ and ‘why the things are done this way’.

Another important element is tracer results sharing. Hospitals should embrace transparency and openness by sharing their tracer results with all employees. The data should be available directly for the wards involved after the tracer has been performed to drive employee pro-active engagement. Sharing the collected data trough a dashboard on an enterprise level contributes to inspire staff from other wards and learning from each other. It will certainly contribute in developing and fostering a positive safety culture.

As a conclusion I want to share with you some practical thoughts based on our customer experiences shared vision on tracer implementations beyond accreditation compliance:

  • See questions as the starting point for dialogue and gaining deeper insights – Make sure that your employees can develop and manage TQS’s quick and easy and perform their tracers with confidence, so they can focus on the dialogue to ensure the accuracy of the obtained information.
  • Strive to achieve engaging and effective collaboration between employees – Facilitating employees with an appealing digital platform they love using will certainly help to make improving processes more transparent and collaborative.
  • Communicate timely feedback of your actionable findings to your employees in an open and transparent way – I believe that if you show people the opportunities for improvement they will be moved to act; a dashboard for data sharing is essential!

The mentioned UMCU TQS is adapted for QTracer implementation, but will be made available for others later this year. If you require any further information about QTracer’s value to support hospitals to effectively implement TQS’s, feel free to contact us.