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Nursing Excellence

The Online Newsletter for Children's Nurses
e-Edition, Issue 11 

Susan Wisniewski Chrsitina Costello


Management and leadership programs and
resources that support the provision of patient
care and a professional practice environment.

By Susan Wisniewski, MPA, CPHQ and
Christina Costello, M.Ed.

Tracer Methodology - Tracing the Way to Excellence


With the advent of the tracer methodology in 2005, The Joint Commission updated the method it used to conduct accreditation surveys. Surveyors began to look at hospitals in a manner that was more meaningful by making the patient central. This paved the way for Children’s Hospital Central California to shift as well.

Under the direction of Beverly Hayden-Pugh, MOB, BSN, RN, NE-BC, vice president and chief nursing officer, and with the support of leaders throughout the Hospital, the tracer program was introduced at Children’s Hospital. It has evolved into a strong foundation for understanding and implementing regulations and standards in all areas. Active support for the tracer program was demonstrated through participation by 1) the patient care division leadership team, made up of all patient care area executive directors and directors; 2) Directors Forum with membership composed of an interdisciplinary group of directors; and 3) the patient care division management team which includes all managers, supervisors and charge nurses as well as executive directors and directors from the patient care division.

To meet the challenges of the ever-changing healthcare environment and the numerous regulations and standards that come our way, Children’s Hospital made a commitment to implement a system of “patient tracers” that mirrored The Joint Commission’s accreditation process. The purpose of the tracer program is to evaluate the effectiveness of the provision of care, identify noncompliant issues, provide “just-in-time” education, prepare staff for interactions with mock-surveyors, and promote a “just culture” that incorporates safety and quality in daily performance.

The tracer methodology is a systems approach to the evaluation of patient care and service. A patient is randomly selected and a mock-surveyor will follow the course of care and services experienced by the patient. While conducting evaluations, the mock-surveyor examines the components of a system (such as care within each department), and how those components work together (such as the “hand-off communication” between departments or areas). The mock-surveyor may identify performance issues or trends in one or more steps of the process – or in the interfaces between processes. The mock-surveyor may also provide education to Hospital staff and leaders, as well as share best practices from other departments.

In actual practice, once a patient is selected, the tracer team traces the patient’s location and services throughout the Hospital stay. If a patient was admitted through the emergency department and had laboratory tests and diagnostic images prior to surgery, the tracer team will visit each of these areas.  Beginning at the patient’s current location, the tracer team will observe staff in action providing services and determine if practices match policy and if both ensure safe patient care.

To measure compliance to standards and regulations, process-oriented indicators are identified based on specified requirements. The compliance with these indicators is what guides our practice. For example, with the indicator “Patient screened for the presence of pain,” the tracer team can determine if staff can articulate the process of documenting the pain scale, intensity and location of the patient’s pain, as well as assessing the medical record documentation for completion of the pain assessment and reassessment according to policy.

Once the tracer has been completed, the compliance data collected from each location is entered into a database. Unit-based reports are compiled and distributed to leaders of the locations traced for the development of action plans. Monthly tracer reports are compiled indicating the type and number of findings identified across the organization. These reports are posted on the George Page and available to all staff. Lastly, data is aggregated quarterly into organizational and department-specific compliance charts and shared with the nursing leadership team.

The tracer program is a source of continuous systems improvement for nursing practice at the point-of-care. The bedside nurse plays an integral role in the identification of opportunities for improvement. The process of looking at care across the continuum allows for the observation and assessment of the delivery of care at a variety of locations. It has proven to be an excellent way to validate patient safety and confirm practice of care throughout the organization.

Consistent use of patient tracers helps increase staff confidence, enabling nurses to describe nursing practice and demonstrate how policies and standards are met. The value in the tracer program lies with the continuous development of the knowledge base for staff and charge nurses and their increased comfort-level when talking about how they provide care. This program has provided an opportunity for staff to gain a better understanding of how what they do every day has a direct impact on patient safety and quality. Tracers have led to improving our environment by identifying issues, facilitating training, and ensuring patient/visitor/staff safety. Tracers also assist human resources and medical staff services by identifying individuals for a thorough record review to determine the competencies and privileging.

With five years of experience, the tracer program has expanded its value and influence. In addition to patient tracers, system tracers are now conducted with a goal of evaluating all parts or steps of a system or process. These tracers allow for a more detailed exploration of high-risk processes that have significant potential for impacting patient safety. Examples of our system tracers include medication management, safety and security, cleaning, disinfection and sterilization, and radiation safety. System tracers help our clinical leaders see the impact of high-risk processes in their area, which provides a better understanding of the organization’s overall plan for these processes and helps to identify any areas needing improvement.

The tracer program is a supportive safety tool that helps leaders assess and monitor compliance, identify opportunities for improvement, provide “just-in-time” education and develop communication skills. This program fosters a “just culture” that optimizes teamwork, respect, integrity, compassion and excellence in patient care.


In This Issue

Professional Practice

Professional Values

Theoretical Framework

Professional Practice


Collaborative Relationships

Care Delivery


Research / Evidence-Based Practice

Professional Development

Reward and Recognition