H
ealth care organizations conduct mock tracers for a variety of reasons. These include maintaining
survey readiness, performance improvement, as part of a risk assessment, or to identify potential patient safety risk points in their processes, among others. Tracer teams must take care to ensure that the mock tracer they’ve designed is effective. Equally important is the need for appropriate
follow-up—applying the lessons learned during the tracer to improve quality and patient safety.
Critical steps that follow a mock tracer include a debriefing by the tracer team, additional work to organize and analyze the tracer results, and finally disseminating those results to stakeholders throughout your health care organization.
After each mock tracer, the tracer team should meet as soon as possible to evaluate and document how it went. (Note: This debriefing session should focus on the mock tracer process, not on what the mock tracer revealed about your organization’s problems or issues. That comes later in the process.) The team should consider using one of the following approaches:
Hold an open forum: An open forum should allow all team members to discuss anything about the tracer, such as methods, logistics, and conflict resolution. For a broader perspective, invite interview subjects from the mock tracer to participate.
Let each member present: In a direct, focused approach, team members can present their feedback to the rest of the team, one at a time. Each person playing the role of a surveyor can be given a set amount of time to present, with questions to follow at the end of each presentation.
Complete a feedback form: Team members and mock tracer participants can complete a feedback form in which they record their impressions of the mock tracer and suggestions for improvement of the process. These can be vetted and then discussed at the next team meeting to plan for the next mock tracer.
Organize and Analyze the Results of the Mock Tracer
Conducting a mock tracer is not enough; the information gained from it must be organized and analyzed. The
The work your tracer team does after the tracer is as important as their work during the tracer.
problems and issues revealed in the mock tracer must be reviewed, ranked, and prioritized. The following strategies can help tracer teams accomplish this:
File the forms: If the mock tracer team used forms— either electronic or paper, those can be categorized for review. The forms might be categorized by types of problems/issues or by unit/department/program/ service.
Preview the data: Those who played the roles of surveyors should be the first to review the data (notes) they collected during the mock tracer. They should check for and correct errors in the recording of information and highlight what they consider to be issues of special concern.
Rank and prioritize the problems: The team, led
by the team leader, must carefully evaluate all of the team’s data.
Critical issues or trends can be identified and then ranked by severity/urgency with regard to threats to health or safety, standards noncompliance, and violations of
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Tracer Methodology 101
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other policies. Prioritizing is the next step and will require considerations such as the following:
What is the threat to health or safety? What is the degree of threat posed by the problem—immediate, possible, or remote?
What is the compliance level? Is the problem completely out of compliance? That is, does the problem relate to a standard that always requires full compliance (that is, Category A elements of performance [EPs]) or one for which you may be
scored partially compliant or insufficiently compliant (that is, Category C EPs)?
What resources are required? How much staff time and resources will likely be needed to correct the problem?
Depending on the degree of threat to health or safety and compliance level, there may be a time frame imposed on how soon the problem must be corrected (for example, immediately or within 45 or 60 days).
An organization’s response to a mock tracer will depend largely on the results of the mock tracer, including how— and how well—the results are reported. In all reports, avoid having the tracer appear punitive or like an inspection, so do not include staff names or other identifying information.
Following are several ways to report results effectively:
Publish a formal report: Compile all documents and carefully edit them. Determine which documents most clearly summarize the issues. Submit a copy of the report to the appropriate leaders at the organization.
Present as a panel: Invite leaders to a panel presentation in which team members present the results of the tracer—by unit/department/program/ service or by other arrangement (for example, problems with staffing, infection control, handoff communication, or transitions in care, treatment, or services).
Call a conference: Set up an internal conference event in which you present the results. They could be presented on paper, delivered by speakers from a podium, and/or delivered using audiovisual formats.
Invite leaders and everyone who participated in the mock tracer. Keep the conference brief (no more than two hours), being considerate of attendees’ time. Make the content easier to digest by color-coding the level
of priority and using other keys to signal the types of problems and their severity. Open up the conference to
feedback with breakout brainstorming sessions on how to address the problems.
Post for feedback: Post the results on a secure organization intranet and ask for feedback and suggestions from participants and others in your organization. A bulletin board in the lunchroom works, too. After a week, remove the report and incorporate any new information to present to organization leaders.
Report in a timely way: One goal of a mock tracer is survey preparedness via standards compliance, so
addressing problems before a survey is vital. All reports should therefore be made within one month after completion of a mock tracer to allow plenty of time to correct any compliance problems.
Accentuate the positive: Remember to forward any positive feedback that comes to light during the mock tracer and data analysis. To encourage continued success as well as future positive interactions with
the mock tracer process, reward or acknowledge departments and individuals that participate or are particularly cooperative and responsive.
Your reports should indicate which problems must be addressed immediately and which can wait, which require minimal effort to correct and which require extensive effort.
Employ one or more of the following improvement plan approaches to help address corrective actions:
Hand off to managers: Hand off any easily addressed corrective actions that are particular to one department or program to the relevant managers. Inform them
of your estimates of time and resources necessary to address the problem. Offer to work with them on more complex corrective actions. Offer to repeat mock tracers to confirm findings.
Work with performance Improvement (PI) Staff: Most of what will need to be done will require integration into your organization’s PI program. Follow the required approach in addressing corrective actions.
Check your compliance measures: Be sure to check which EPs for a Joint Commission standard require a Measure of Success (MOS). At least one measure demonstrating the effectiveness of recommended changes should be included in the Plans of Action addressing compliance for those EPs with an MOS, and it must be included in the findings that will be integrated into a Focused Standards Assessment.
Share the plans: Ensure that the entire organization is aware of the corrective actions proposed as a result of the mock tracer. Cooperation and support during
future mock tracers depend on awareness of their value and follow-through. Activities and results can be shared in internal newsletters or staff meetings.
Monitor the plans: The mock tracer team is not responsible for completing all the corrective actions, but it is responsible for working toward that
goal by monitoring any plans based on findings from the mock tracer. Give deadlines to heads of units/departments/programs/services and others involved in corrective actions (in accordance with any PI policies). Check
regularly on progress and make reports to leadership and the PI program on progress and cooperation.
Prepare for the next round: After a few mock tracers, most organizations discover the exponential value of such exercises. They then develop a mock tracer program that allows for periodic mock tracers, sometimes with several running at one time.
Editor’s Note: This article was adapted from: The Joint Commission. Mock Tracers for Home Care. Oak Brook, IL: Joint Commission Resources, 2015.