Evaluating the levels of patient quality and safety can take many different forms in healthcare organizations. Medical record audits can show deficiencies in timeliness and thoroughness of documentation. Leadership rounding provides an on-the-spot opportunity to assess compliance with processes such as patient monitoring, infection control like hand hygiene, and staff knowledge of mitigation strategies of the environmental risk assessment. Culture of Safety Surveys, created by organizations such as the Agency for Healthcare Research and Quality (AHRQ), are used to glean insights into teamwork, staffing, and staff support. Along with these evaluation methods, we strongly recommend using a tracer methodology to ascertain the quality and safety of a patient’s care, as well as any gaps that may be present in processes and systems.
A healthcare team can effectively trace a patient’s care in the following way:
- Select a medical record that shows the complexities of care. For example, choose a patient encounter in which a medical condition like diabetes existed along with an incident such as a fall. Patients who needed interpreter services and enhanced assistance with discharge planning can be helpful in examining multidisciplinary involvement.
- Starting with entry into the organization, trace the various processes such as admission assessments, provider orders, and consultations through to the discharge process.
- Look for variations from designed processes. For example, take note of deficiencies in admission assessments. If a patient was assessed as a high fall risk, was this risk communicated to the other staff? With diabetes care, was a nutritional consultation ordered and completed per policy? At what point did the process break down? Ask staff what should happen in caring for the patient compared to what happened as documented.
- Once deficiencies are noted, take those insights and findings through the Quality Assurance -Performance Improvement (QAPI) process. Use the Plan-Do-Check-Act (PDCA) and Failure Mode and Effects Analysis (FMEA) to uncover the process steps that need to be redesigned. Assess areas for staff training and retraining while discerning any accountability issues. Share results in committee meetings to inform leaders and ensure a proactive approach to quality and safety.
Using tracer methodology can be instrumental in looking deeply into those process issues that can adversely affect patient care at large. Engaging direct care staff and leaders is critical to gain their insights and foster a collaborative quality effort.
Is your organization taking full advantage of patient tracers?
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Courtemanche & Associates specializes in Healthcare Accreditation and Regulatory Compliance Consulting Services. With over 29 years of being in business and 100+ years of healthcare experience amongst our consulting team, we are ready to assist with your accreditation and regulatory compliance needs.
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