Leadership Rounding: Shifting to a Tracer Approach for Regulatory Compliance

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"Tracers provide an opportunity to teach in the moment when human factors are identified as a contributory reason for failure as well as enhance the unit’s culture where it is ok to ask questions and problem solve for better solutions."

Are you a clinical leader, new accreditation professional or someone who is tired of performing the traditional “audit” to evaluate regulatory compliance? There has to be a better way, right? There is. You can shift from spending your time behind the computer sifting through emails and medical records, to engaging staff in a meaningful way to evaluate the care treatment and services being provided. Oh, and you will still be able to verify regulatory compliance and check the box on the audit form. Let me introduce you to leadership rounding and the tracer approach.

What is a leadership rounding tracer and how is it different than an audit?

Great question. An audit is simply a review to verify that something is documented correctly. A tracer, on the other hand, is an assessment of processes and systems. The intent of leadership rounding using the tracer approach is to evaluate the sum of the whole, subsequently validating that each part is working as intended, and the desired outcome is achieved. Both the audit and tracers provide data, but the tracer can add valuable insight into the process as well.

The advantage of leadership rounding via tracers is that they provide an opportunity for human interaction between leadership and staff. That interaction often results in not only evaluating the process, but also obtaining feedback from staff who are closest to the work who can readily identify underlying root cause(s) for system and process failures.

Tracers provide an opportunity to teach in the moment when human factors are identified as a contributory reason for failure. Tracers also provide an opportunity to enhance the unit’s culture where it is ok to ask questions and problem solve for better solutions.

Simply put, while audits may highlight a problem, they don’t provide real time information and rarely point to why the problem occurred. Audits don’t typically provide solutions; and most importantly, they don’t positively impact the culture through staff engagement.

I am committed to trying a leadership rounding tracer; how I do to prepare?

The great news is that anyone can do a tracer. Leaders don’t need to be the subject matter expert, but you do need an open mind and a willingness to ask questions in an attempt to understand.

Your job during a tracer is simple: ask questions to evaluate a process or a system against a policy or procedure with the intent to identify where breakdowns may be occurring and resulting in potential process failure, and ultimately patient care failure.

There are three main steps to prepare for a tracer:

1.  Identify the system/process for evaluation

2.  Research the source of truth to understand process metrics and anticipated outcomes (e.g., policy, evidence-based guidelines, manufacturer instructions for use, etc.)

3.  Define the where, what, how and when you will go on to the unit:

a. Where will you start?

b. What are some questions you want to ask?

c. How will you engage staff and reduce anxiety?

d. When is a good time that is least disruptive but still provides the desired outcome?

I have prepared and am ready to go out on the unit; now what?

Great. You have committed to and prepared for the tracer. Keep in mind that there are many ways to conduct a tracer. With practice, you will develop your own style. Below are a few examples that might help.

Take a tour of the unit—This can provide a wealth of information. For example, if you see a clean instrument/equipment room, what items are in the room? If you have the instruments/equipment then you probably use them, which may lead to a certain type of patient you’d like to trace. Or, if you see a dirty room, this may lead you to trace how you manage dirty instruments/equipment? Were any procedures done recently? Are there any related environment of care or infection control concerns? Are there any patients on the unit with procedures using these instruments?  Do any of them meet the specific criteria for the process you want to trace?

Zero in on a process/patient—Introduce yourself to the staff; and if appropriate, the patient. Explain the intent of the leadership rounding tracer. You can relay that it is like show and tell. You also can describe it as a review of the systems and processes (versus individual people) to better set up for success. It is very important to help staff feel at ease. Try asking them to talk about or do something that is familiar to them (e.g. can you give me report on your patient just like you would during handoff). If you are writing, be sure to tell them what/why you are writing, such as, you are making notes to use as a reference or tracking consistency in the process, etc.

Let the patient experience drive the tracer—Look for meaning during the report out; listen for key indicators that deserve follow up. You may deviate from your original intent, but that is ok. Ask to review the orders and check to see if they are being following. Can you show evidence that you are following the organization’s policy as it relates to the process you researched?

If you identify a gap in process, don’t worry. That is why you did the tracer. Ask yourself the following: Why did the gap occur (people or process)? Is it an educational moment? Does it require a larger systematic fix? Why does the staff think the process failed? Does the staff have plausible solutions that may help fix the problem?

Most importantly, have fun. This is a time for interaction, engagement and relationship building.

What about after the leadership rounding tracer?

There are only two things to do after the tracer is finished: say thank you and follow up on opportunities. A tracer is a disruption and many people get nervous talking about and showing what they do every day. Make every effort to leave the staff feeling good about the tracer and the impact that they can have on fixing potential issues. Ensure you follow up on opportunities you uncovered. It demonstrates to staff that you work with/for them and their feedback is valuable. It also helps fix system issues with the involvement of the staff who do the work. Finally, make sure you use examples (including positive deviance) to provide team education.

Challenge yourself to conduct leadership rounding using the tracer methodology. Pick a topic that is something that you have been working to improve. Commit to using the tracer methodology for a month. Remember to trace to understand, not to correct. Be sure to follow up. Practice these basics and staff may respond by initiating the conversation! You may even see a positive shift in your team’s culture of safety and transparency!

About the author: Mitch Gesinger, MSN, RN, CJCP is a Vizient accreditation advisor. In his role he serves members by delivering accreditation and regulatory services, including The Joint Commission (TJC) and Centers for Medicare & Medicaid Services (CMS) mock surveys/gap assessments, coaching during TJC surveys, faculty for educational presentations on accreditation and CMS compliance and strategies for effective change management.

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