Once, watching an episode of "ER," a surgeon of my acquaintance remarked that all of those things do happen in emergency departments, only not, in his experience, all on the same shift. Reading the patient's account of his hospital experience reminded me of this comment, although dramatic catastrophes were not reported. So many things that could go wrong did. Fortunately, the ultimate clinical outcome was good.

Frankly, it looks as if this hospital's organizational culture needs an overhaul. The patient's experience suggests that the hospital's administration and clinical staff have forgotten that patients are people, rather than "cases."

The whole sequence of events, some related to clinical services (both medical and nursing), some to environmental and housekeeping services, and others to communication, provides this hospital with an excellent opportunity to assess itself and make improvements. The past 40 years have seen the development of 4 approaches to health care quality assessment and improvement. The first was implicit review, with criteria and judgments that varied from one expert assessor to another. Patient care audits represented the second phase, involving the use of preestablished objective criteria, a clear improvement. The next recognizable phase was the adoption of ongoing monitoring techniques, with the use of clinical outcomes criteria. Now the field is in a fourth phase-tracing. There is nothing startlingly new about tracing as an evaluation process: it could be described as a modified offshoot of both the old patient care audit and critical path analysis. One major difference, of course, is that contemporary hospital survey tracing involves the study of the care provided to patients who are in the hospital at the time of survey.

Now tracing has become institutionalized as the current mode of the Joint Commission's survey process. Tracing methodology is well suited to the analysis of the quality problems confronting the hospital described by this patient. The hospital's quality assessment people would be well advised to develop a tracing model for performing their own assessment, using preestablished objective performance criteria. In designing their evaluation model, they should not limit the coverage to the specific types of poor performance that are reported in the present instance but to the entire system of care of bypass patients. Their tracing studies should involve every service and department, clinical and nonclinical, that is involved in the care of the patients. Far too often, well-intentioned, but badly designed, assessment efforts focus on the various professional disciplines separately, rather than on the patient and what happens to him or her between admission and discharge. In the tracing process, the focus is on the patient and the system as he or she experiences it.