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How tracer rounds can support effective continuous improvement in healthcare

The increasing complexity that hospital organizations are facing requires healthcare professionals to use innovative approaches and new tools such as Tracer-based Continuous Improvement (TCI) to maximize the outcomes. Our quest to understand the value of healthcare tracers has resulted in a new innovative tool to help hospitals prevent or minimize nonconformance and improve their quality and safety of care.

These days, there are so many methods for improving quality and safety of hospital care, it’s hard to see the forest for the trees. But which improvement method is the best fit for your organization and team? The ongoing cycle of assessing, prioritizing, resolving and repeating is what continuous improvement is all about. It’s not complicated, it should not be tedious, it should not be labour-intensive, and most importantly, the process should never complete. You may ask: “If continuous improvement is so easy, why is it so hard to build into my organization’s culture?

Not all methods are created equal. For certain types of processes and organizations, some methods simply work better than others. For the best results, you can combine multiple methods when necessary. This is the case with tracers, but I think in terms of philosophy and method it is the closest to Kaizen. By documenting the current best practice, standardized work forms the baseline for kaizen or continuous improvement. By improving standardized programs and processes, kaizen aims to eliminate waste and redundancies. In healthcare, the approach enables continuous improvement in a structured, measurable way, to deliver the quality and safety of care according (and by conforming) to the highest standards.

It all starts by engaging people across the organization to identify problems or opportunities for improvement, and then also engaging them in the discussion towards finding potential solutions to these problems. It is, after all, the people on the frontlines of the organization that battle with these challenges every day, whereas management isn’t typically even aware of most of them, let alone realize how common or important a specific issue actually is.

Not only will this help you improve the right issues, but by engaging the entire organization in the process, you’ll be able to fight resistance to change and actually create a culture that values change, improvement, and innovation.

It is also an activity with a goal that goes beyond improvement. It is also a process that, when done correctly, makes the workplace more human (when using appropriate standard goals).

A number of Kaizen basic elements can also be found in tracers:

- teamwork (it is always working with people from the process)

- self-discipline and accountability (the ultimate success of any change initiative lies in holding everyone accountable for doing their part in implementing the improvement)

- improved morale (focuses on improving processes as a means to improve the organization rather than blaming workers for sources of nonconformance and inefficiency)

- Quality cycles (and encouraging your employees to embrace the improvement cycle)

- Suggestions for improvement (and implement improvements quickly, don't keep looking for the perfect solution, keep pace).

For those unfamiliar, tracers can be used to check the extent to which day-to-day practice complies with the organization-wide quality policy and standards. The main goal is to stimulate the quality cycle of continuous improvement in departments and to provide healthcare professionals with feedback on their implementation of practice. Tracing is the foundation for safe patient care and as its importance continues to grow it is without doubt that it is a vital tool for the success of a hospital organization.

It’s originates from accreditation bodies Joint Commission International (JCI) and Accreditation Canada International (ACI), among others. Their auditors use it as a survey method to assess a health care organization’s compliance with the accreditation and certification standards. It follows the path of a patient or process, asking questions and making observations to determine whether the standards are being met. Some tracers address other aspects of health care organizations, such as systems for medication management or infection control. While the main focus of JCI and ACI tracers is on assessment and judgment, the hospital tracer is aimed at supporting the departments in their improvement and the monitoring of their progress.

Tracers carried out by healthcare institutions

Tracers carried out by the healthcare institutions take a much broader view than the “old” audit approach and tracers done by accreditation bodies. They have a much more learning and stimulating than a judgmental intent.

You don't have to be an auditor to do a tracer. On the contrary, they are carried out by professionals (doctors, nurses, managers, policy officers), who have been trained for this. These so-called tracer-contributors visit (unannounced) departments in teams in different compositions. They score the extent to which policy is followed in practice and whether the physical environment comply with the policy and the standard. They aim to collect good practices and opportunities for improvement and question employees about their knowledge of the relevant policy. Where necessary, the contributors refer to or explain the policy. When looked at in its entirety, it is evident that the scope of tracer process is usually more complex than one might initially think.

Today, in the context of patient participation, tracers are no longer only started from the standard (and appropriate policy), but also from the patient experience. Experience and feedback from patients are collected and checked in the electronic patient record. Tracer-contributors then link these back to the relevant professionals. This includes compliments (for good practice) as well as points for attention (due to less good practice). This is educational for the employees in the department as well as for the contributors. They learn from the experiences outside their own department / division.

All results of the tracers are transparent in a central dashboard. In this way professionals see whether policy is being complied with or whether there are problems with implementation or compliance with policy. This dashboard is accessible to everyone in the organization. Employees can thus learn from good practices. To support the quality cycle, quality and patient safety managers regularly check all results and see if there are any trends. If there is reason to do so, departments are asked which measures they implement on the feedback given.

Many hospitals have discovered the great added value of tracers for the improvement process compared to traditional audits. It contributes to a dialogue in which you do not judge each other, but jointly focus on what can be improved. And not only in the context of hospital accreditation, but also in the pursuit of standardization of work processes in general. The tracer process allows you, as an organization, to evaluate the success of your organizational policies, focus on how care is being delivered to your patients, provide a constructive system of immediate feedback, and help you to maintain a constant state of survey readiness.

A good reason for us as a software development company, to delve deeper into this matter. After all, standardization is still the best way to ensure quality and patient safety while keeping costs as low as possible.

We closely followed the developments regarding the application of tracers and soon discovered that the tracer has great potential to form the basis of an continuous improvement tool. An improvement tool based on dialogue and feedback (suggestions), set up on the basis of improvement objectives.

Software to support the tracer workflow

I think we were the first company to take the step to develop a dedicated software solution to support the tracer workflow. At the time, we were confident that our investment would pay off. To answer the support question more comprehensively, an action module to convert issues into improvement actions was recently added to the application.

During the evolution of the tracer, improvement based on own insights, responsibility and initiative power had become a necessity in modern organizations. A necessity to cope with the increasing complexity that hospital organizations are facing. Tracers are an effective way to study these complex systems. Finding the system imperfections or flaws is critical. That makes it possible to correct them and prevent potential harm to patients, staff, or visitors.

Attention was paid in the development to place the responsibility for compliance in the primary process. There is the only place in the organization where it can be stated with certainty that the care provided corresponds to the quality and safety standards and policy as agreed with each other. That is actually the core of compliance. The employee who understands that he or she is the only one who knows exactly how the care has been provided and is an unmistakable link in demonstrating that the care has been provided in the correct way. Promoting transparency in the process of tracing and providing feedback in our software application became essential. We kept pace with the increasing demand in healthcare for a transparent culture where continuous improvement is central.

Tracer-based Continuous Improvement

Now, years later, we dare to speak of a new improvement model with a prominent basic place for the tracer in the improvement cycle. This new style of continuous improvement creates a dynamic and we like to call “Tracer-based Continuous Improvement”, or TCI for short. TCI provides a continuous stream of real life actionable insights that encourage frontline employees to keep working on their quality improvement. Responsibility is taken more quickly for improving compliance.

Providing transparent positive feedback that focuses specifically on effort and/or improvement, rather than specific outcomes, will encourage employees to act

We define TCI as an improvement instrument applied by healthcare institutes that utilizes 1) frontline professionals existing knowledge and expertise, 2) the tracer methodology and 3) well-established standards related to quality and patient safety goals to identify possible problems and risks and act on them before errors, incidents or other unwanted movements occur. The concept place a priority on tracking and sharing performance, encouraging (team) communication, engagement, and (team) participation for all of the stakeholders affected by the quality improvement process.

TCI has become the most effective hospital quality improvement method of our time. It has a strong preventive and stimulating effect and makes a major contribution to a Continuous Improvement culture. The preventive nature of the method - early identification in the workplace and focusing on what can be improved - makes you less dependent on big data, patient surveys and incident reports in the pursuit of meeting the highest standards of quality care and patient safety.

In order to achieve a sustainable improvement cycle with TCI, technological support is indispensable in addition to good leadership. Focus in implementation on simplicity, effectiveness and fun is the starting point for success. That's why we make it easy and enjoyable to work with our QTRACER TCI sostware.

Essential components of TCI software

A good TCI software system should contain at least the following 4 essential components:

Component #1: A Question set creator, a tool to create tracer themes related to the measurable elements of your quality and patient safety goals (policie, standards maintained in the system) for use during performing tracers.

Component #2 A Tracer app, an app to automate your tracer workflow, to support the process of compliance scoring and collecting and reporting evidence through interviews, observations (photo’s), record viewing, etcetera

Component #3 A Dashboard, an uncluttered dashboard for transparent sharing of tracer results and reports and monitoring improvement progress.

Component #4 An Action planner. Scores are recorded, but the real work to make patients safer is closing the loop between issues and action.

William Sommer,, +31 (0)6 2144 8283,

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