Tracer

Methodology
Patient Flow Tracer in a Level I Trauma Center

B reakdowns in effective patient flow can impact patient

safety and the quality of care, treatment, and services.
When a hospital effectively manages its systemwide processes
for patient flow it can minimize delays. During an on-site
accreditation survey, surveyors will conduct patient flow
tracers to understand and follow a hospital’s own processes
and to learn if there are any vulnerabilities in the system.
They will also check to see if the hospital has built in
processes to monitor and mitigate any patient flow problems.
“The patient flow standard applies to all types of
hospital settings—all hospitals need to ensure their
patient flow processes are effective,” emphasizes Cynthia
Leslie, APRN, BC, MSN, associate director in The Joint
Commission’s Standard Interpretation Group.
The patient flow standard (Leadership [LD] Standard
LD.04.03.11) has a three-fold goal:
1. Hospital leadership ensures that it relies on data and
measures to effectively manage patient flow.
2. Any flow issues that present in the emergency
department (ED) are managed throughout the
hospital.
3. The safety risks presented by issues such as patient
boarding are suitably managed.
Patient flow is covered in the leadership standards
because of the impact that leadership has on the culture,
expectations, and successful performance of the hospital
itself. Leaders’ active support and oversight are critical to
effective patient flow, as so many areas of the hospital need
to be involved, stresses Leslie.
A team approach can help achieve effective patient
flow, Leslie says. She recommends using a broad approach
to selecting members of the team. EDs have often been
viewed as causing the bulk of patient flow problems. And
yet, while the ED may be where a patient flow problem
manifests itself, the problems do not always originate there.
For example, delays in discharge planning or housekeeping
problems could impact admission rates from the ED.
Having a team approach to studying and responding to such
issues takes patient flow beyond the ED alone to focus on
hospitalwide risk factors. As a result, a patient flow response
team should be comprised of more than ED staff alone,
Poor patient flow can lead to delays in treatment and to patient
harm.
Leslie emphasizes. While clinical staff such as patient safety,
nursing, and medical staff are often critical to the team,
nonclinical hospital services have a role to play as well.
Facilities, cleaning, or transport staff should participate, she
notes, to ensure that critical details such as bed availability,
staffing issues, or facilities vulnerabilities are taken into
consideration. Discharge planning and case management
staff should also be represented on the team to provide input
into communication issues and possible delays caused by
external factors and agencies.
Leslie recommends that hospitals also look at the flow
of patients based on data from across the entire organisation.
“Not only should you look at data from the emergency
department, but also at surgical procedures, readmission
rates, discharge planning, case management, physician
involvement, and so on—any data which can potentially
impact patient care,” she adds.
In 2012 The Joint Commission undertook a review
of its patient flow standard and added new elements of
performance (EPs), primarily aimed at ensuring that there
is a process in place to manage and mitigate any patient
boarding in the ED (EP 6) and to ensure that effective

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The Source, December, Volume 12, Issue 12
systems are in place to support and manage boarded
psychiatric patients (EP 9). Both of these new EPs went into
effect on January 1, 2014.
Boarding can put patients at increased risk due to care
delays, and it can put added pressure on staff. It can also
point to a systemic hospitalwide problem with patient flow.
Patients presenting in the ED with psychiatric
emergencies can face particular vulnerabilities if boarded.
Ensuring that the needs of ED–boarded psychiatric patients
are appropriately and safely accommodated requires that
the ED has clear lines of communication with a hospital’s
psychiatric unit, explains Leslie. By ensuring that all of the
necessary services and staff are communicating, hospitals
can both speed up and ease the boarding process for
potentially vulnerable patients.
During a tracer focused on patient flow, surveyors
will consider what elements of the patient flow process
are in place and how well the hospital follows its own set
process, paying particular attention to issues of leadership
involvement, communication, staff training, and data
collection. Patient flow teams can conduct their own tracers
by conducting rounds or by tracing a boarded patient to
determine how effective their process is and where there
are vulnerabilities in their system. Conducting tracers at
particularly busy times of day can help reveal issues more
readily as well.
The Scenario
This tracer took place in a 300-bed Level 1 trauma center
in an urban community in the southwestern United States.
During the course of the survey, the surveyor noted long
wait times in the ED, including seven patients boarded
in the ED while waiting for inpatient beds to become
available. The surveyor also noted that three incoming
ambulances had been diverted to other hospitals. Two of the
seven patients boarded in the ED were psychiatric patients
reporting suicidal ideation. The surveyor began a tracer
focusing on patient flow in the hospital.
Exploring processes to manage patient flow. The
surveyor looked closely at the hospital’s process to manage
patient flow with members of its leadership team and with
staff identified as being involved in patient flow activities.
[1, 2, 3] During the tracer, the surveyor met with the ED
director, quality improvement director, ICU charge nurse,
and psychiatric department charge nurse. She also looked at
how staff were involved in the patient flow team, what data
they collect on patient flow, and how processes are put in
place, particularly for improvements to patient flow. [4, 5, 6]
Examining patient flow in relation to boarding and
psychiatric patients. The surveyor opted to further study
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The Source, December, Volume 12, Issue 12
Tips for Success from Other
Hospitals
In its work to improve patient flow, the Urgent
Matters Learning Network II (LNII) created a toolkit
for hospitals. The following are a few example
strategies from the toolkit:
• 
Bedside Triage and Registration: Patients are
placed in beds immediately and registered and
seen by providers as staff becomes available. This
eliminates bottlenecks within the ED and reduces
wait times for patients.
• 
Comprehensive Diversion Reduction Plan: One
hospitals developed a comprehensive plan to
improve efficiency of hospital discharges.
• 
ED Scribes: Scribes work with physicians as they
see patients to record information electronically in
real time, allowing physicians to spend their time
with patients rather than entering information.
• 
Emergency Department Follow-Up Office: A highly
specialized team of registered nurses and clerks
inform patients about diagnostic tests completed
after discharge, communicate with primary care
and other community providers, and field calls
from patients who have questions or concerns
after leaving the hospital.
• 
Improved Treatment of Asthma: One hospital
created a multidisciplinary team to develop an
improved protocol for asthma patients in the ED to
prevent return ED visits and reduce hospital length
of stay.
Source: George Washington University School of Medicine and Health
Sciences. Urgent Matters Toolkit. Accessed Nov 7, 2014. http://smhs
.gwu.edu/urgentmatters/toolkit/985888.
patient flow by visiting key areas of the hospital, including
the ED and the inpatient behavioral unit, to speak with staff
about their experiences with boarding, particularly in the
case of specific populations. [7, 8] She noted that although
the ED was boarding patients, processes were in place to
admit and move the patients at the earliest point available,
and specialist nurses from the psychiatric unit had been to
the ED to assess the two patients identified with suicide
ideation. She also saw that the hospital had set a four-hour
boarding time limit, during which the team collected data
to measure levels of success. She noted that the hospital had
(continued on page 6)
Tracer Methodology 101
(continued from page 5)
generally been successful since they began collecting data six
months earlier.
Moving forward. The surveyor asked if the team
had determined what hospitalwide factors were resulting
in increased numbers of boarded patients in the ED.
The quality improvement director noted that they had
determined delays in available inpatient beds were being
caused by the discharge and case management planning
processes. The director indicated that the team was already
discussing a project to improve the discharge planning
process, as well as a hospitalwide effort to reduce ED wait
times.
Sample Questions
The following represent some questions that could be asked
during a tracer. Use them as a starting point to plan your
own tracers.
1. Please describe your own process to manage patient
flow in the hospital.
2. Who is responsible for the patient flow function?
3. Which staff are involved in conferring on patient flow?
How do you train and educate staff on patient flow?
4. What oversight structure (such as a team or committee)
do you have in place? How is this monitored and
reported back to leadership?
5. What data collection processes do you have in place to
track and monitor patient flow?
6. If a modification needs to be made to your patient flow
process, how is that done? Who documents it?
7. What processes do you have in place to manage and
respond to boarding? Do your processes include a time
limit on boarding?
8. What is your process to handle patient flow regarding
psychiatric patients? TS

Mock Tracer Tracking Worksheet:

Patient Flow Tracer in a Level I Trauma Center
Use this worksheet to record notes and areas of concern that you identify while conducting your organization’s mock tracers. This information
can be used to highlight a good practice or to determine issues that may require further follow-up. Checking “yes” or “no” indicates whether
the staff member interviewed during the tracer answered the question correctly. An incorrect answer should always receive comments or
recommendations for follow-up.

Tracer Team Member: ___________________________ Tracer Patient or Medical Record: ____________________________

Staff Interviewed: ________________________________________________________________________________________
Unit or Department Where Tracer Was Conducted: _____________________________________________________________

CORRECT INCORRECT FOLLOW- COMMENTS

TRACER QUESTIONS ANSWER ANSWER UP NEEDED OR NOTES
1. Please describe your own process to manage patient flow in
the hospital.
2. Who is responsible for the patient flow function?
3. Which staff are involved in conferring on patient flow? How do
you train and educate staff on patient flow?
4. What oversight structure (such as a team or committee) do
you have in place? How is this monitored and reported back
to leadership?
5. What data collection processes do you have in place to track
and monitor patient flow?
6. If a modification needs to be made to your patient flow
process, how is that done? Who documents it?
7. What processes do you have in place to manage and respond
to boarding? Do your processess include a time limit on
boarding?
8. What is your process to handle patient flow regarding
psychiatric patients?

Page 6 Copyright 2014 The Joint Commission

The Source, December, Volume 12, Issue 12