Transcript Tracer Methodology - KHA Accreditation Committee

Tracer Methodology
Presented by the
Accreditation Matrix
Universal Tracer Tips
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Don’t forget to introduce yourself.
“Hello, I am William Deming and I work as the
Director of Engineering at Norton Dixie Hospital. I
am with you today for your hospital’s tracer survey.
It is great that I get to visit you today because I look
forward to learning a lot from this experience.”
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Involve as many people as possible
“Do we have everyone here we want to include in
this exercise? I do not mind having more people.”
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Universal Tracer Tips
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“Act the part. Be the surveyor.”
“Today, we are going to pretend that we are going
through a survey. I am going to be the surveyor, and
you will be lucky person that they picked. We will
learn this process together. And by the end of the
process, you can be our survey expert.”
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Focus on staff members and not management
“During many surveys, you, the frontline staff
become one of the most critical players during the
tracer process. Why? Because you spend the most
time with our patients.”
Universal Tracer Tips
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Ask open-ended questions
“What do you think? Is this a good practice? Is
there anything that you suggest we can do better?”
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Teach as you go
“We find the same thing at our hospital and this is
how we improved our process. (Explain) Do you
think this will work here too?”
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Universal Tracer Tips
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Address inappropriate practice/behavior that is
observed with staff and manager.
“Do you agree that this medication expired last
month. I know I can count on you to remove this
immediately.”
“We probably should label that specimen here so
that the patient will know for sure that we have
tagged it correctly.”
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Universal Tracer Tips
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Ask staff to show you data, policies and/or
procedures
“Can you show me your performance improvement data that
supports what you did? Is it working? If so, how did you do
it? If not, what are you going to do differently to get the
results you want?”
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Build staff confidence in you.
“It is so important that we have the a true picture of our
processes so we can have a better understanding for how we
can improve. Therefore, your honesty is key and we will
agree on what parts of your assessment will be shared, if
any.”
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Universal Tracer Tips
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Hold staff members and management
accountable – but don’t forget to reward and
acknowledge good compliance.
“You did a great job in the medication administration. You
introduced yourself to the patient, you washed your hands
before and after, and you used BMV to ensure that you gave
the right drug to the right patient. The only suggestion I
would have is to make sure you take the time to explain to the
patients the drug they are taking and the possible side effects.
Educate the patient on the drug so they can partner with you
in their care, in the event something does go wrong? It will
save you time in the long run…. Oh don’t forget to
document.”
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Universal Tracer Tips
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Use findings to reinforce good practice
“My, I am very impressed that all your records
include the proper and timely documentation for
pain assessment and reassessment. I am having a
difficult time with that at my hospital, and I want to
learn how you did this?”
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The Summation – Preparing and
Presenting Your Findings
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The Summation and Follow-Up Process
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The Summation – Preparing and
Presenting Your Findings
The Form
• How to Use It.
• Presenting the Positive.
• Dust Bunnies, Temps and Inches.
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Top Five
Joint Commission Tracer Activity Summary 2011
Surveyor:______________________________________________________
Units/Depts Surveyed:____________________________________________
List your top five areas of concern below – use this summary to focus your report at Summation.
Example:
1. Medication Security - Unsecured meds were found on units X, Y and Z and in department A. Unlabeled
medications were found in department B and therapeutic duplications were found on units L and M.
2. Medication Orders – blanket order on unit X, incomplete order on unit Y.
3. Patient Identification – incomplete patient ID check on unit P and in department C.
4. Fire Safety – There was equipment in the hallways on unit N and a door was blocked in department C.
5. Assessments – Missing pain reassessments in unit L and M. One H&P greater than 30 days for surgical patient on
unit N and one H&P w/in 30 days with no update for surgical patient on unit P. No immediate pre-anesthesia
assessment for patient in department C.
Turn in this summary and your tracer forms at the end of the summation.
Top Five Findings
Five Positive Findings:
1.
2.
3.
4.
5.
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The Summation – Preparing and
Presenting Your Findings
Delivering the Message
• Can You Hear Me?
• Introductions.
• Professional Presentation.
• How the Message is Received.
• What to Say.
• What Not to Say.
• Delivery.
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The Summation – Preparing and
Presenting Your Findings
Wrap it Up!
• Time Constraints
• The Signal
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Hot Topics and Commonly Cited
Standards
Joint Commission Perspectives –
Top Standards Compliance Issues for 2010
65%
RC.01.01.01
51%
49%
LS.02.01.20
LS.02.01.10
42%
EC.02.03.05
40%
LS.02.01.30
33%
MM.03.01.01
33%
31%
RC.02.03.07
PC.01.02.03
29%
IC.02.02.01
28%
MM.04.01.01
**The hospital maintains complete & accurate medical records
for each individual patient (date/time/sign).
**The hospital maintains the integrity of the means of egress.
**Building and Fire protection features are designed and
maintained to minimize the effects of fire, smoke, and heat.
**The hospital maintains fire safety equipment and fire safety
building features.
The hospital provides and maintains building features to
protect individuals from the hazards of fire and smoke
The hospital safely stores medications.
** Qualified staff receive and record verbal orders.
** The hospital assesses and reassesses the patient and his or
her condition according to defined time frames.
The hospital reduces the risk of infections associated with
medical equipment, devices, and supplies.
** Medication orders are clear and accurate.
** NHC was cited against these standards during the 2010 survey.
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Hot Topics and Commonly Cited
Standards
High Risk Topics That Surveyors Might Explore In
More Detail (2nd Generation Tracer Methodology)
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Cleaning, disinfecting, and sterilization.
Patient flow across the care continuum.
Contracted services
Diagnostic imaging
Ongoing professional practice evaluation (OPPE) and focused
professional practice evaluation FPPE
Any areas covered in the NPSGs
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Hot Topics and Commonly Cited
Standards
National Patient Safety Goals (NPSG) 2011
2010 NPSG
Goal Text
% Not Compliant 2010
NPSG 03.04.01
Labeling of
Medications
Timeout Performed
24%
8%
NPSG 01.01.01
Reporting Critical
Tests
Suicide Risk
Assessments
Patient Identification
NPSG 07.01.01
Hand Hygiene
4%
UP 01.03.01
NPSG 02.03.01
NPSG 15.01.01
19%
7%
5%
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Hot Topics and Commonly Cited
Standards
.....and…..
Anything related to Medication Management
• Sedation
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Hot Topics and Commonly Cited
Standards
Top Ten Technology Hazards 2011
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Radiation Overdose and other dose errors during radiation
therapy
Alarm Hazards
Cross Contamination from Flexible Endoscopes
High Radiation dose from CT
Data Loss, System Incompatibilities-IT Complications
Luer Misconnections
Over sedation and PCA Pumps
Needle stick, sharps injuries
Surgical Fires
Defibrillator Failures in Resuscitation Attempts
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