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Community hospital of monterey peninsula.

Safety, on its own, is a major responsibility for staff members, and added tasks like manual data reporting, analysis and follow-up with each department head can quickly become burden some. The safety team at the nonprofit Montage Health, located in Monterey, California, was no stranger to these challenges until the health system found a solution for its staff. Montage’s main campus, Community Hospital of the Monterey Peninsula (CHOMP), uses Joint Commission Resources Tracers with AMP platform for its EOC rounding and to drive standardization with other tracers. For the staff at CHOMP, Tracers with AMP didn’t just improve processes — the platform drove an entirely new culture around environment of care for its patients.

CHOMP's Clinical Quality Analyst and Safety Coordinator team oversee the management of their Environment of Care program. Natasha DiPretoro, Assistant Safety Coordinator, was an integral part of setting up their facility to use Tracers with AMP. Daniel McKernan, who is the Safety Coordinator from Montage Health observes how their Environment of Care rounds have benefitted from Tracers with AMP.


Improving Processes with EOC Tracers

The team uses the JCR Tracers mobile app when conducting EOC tours. For each non-compliant finding, the tracer directly assigns a task to the area’s Assistant Directors. This means that the safety team makes assignments to the correct party in real time during rounding.

When pointing out an area of non-compliance, the team can reference Joint Commission Elements of Performance (EPs). Connecting the EPs to the relevant standard removes ambiguity for department heads because they can see exactly what is expected of their staff.

The EOC tracer template also simplifies review and reporting. The team references the task report from the previous visit to an area, comparing past tracer findings to current findings. This process elevates the team’s EOC round reporting capabilities. The data gathered via the tracer enables department comparative analysis and a report similar to the SAFER® Matrix, all of which lets the team more easily report to the EOC Committee.

Streamlining Time-Consuming Environment of Care Rounds

Safety staff at CHOMP conduct EOC tours every other week to ensure the safety and quality of patient care.

Before using Tracers with AMP, the team relied on manual spreadsheets for EOC rounding. The spreadsheets tracked corrective action and documentation in Excel, then the team sent an email to inform department heads of their findings and how to proceed. The next steps for departments might include a work order, additional education or instructions on managing supplies and equipment.

This EOC rounds process carried some major problems. The manual documentation work was time-consuming, and leader follow-up involved sending hundreds of emails to ensure departments took corrective action. “It was very difficult to close the loop and very difficult to just document in general,” Daniel notes.

Noting these challenges, Natasha used Tracers with AMP to create a new tracer template for EOC rounding. The tool transformed rounds for the hospital and brought great results.

Transforming Meeting Minutes

The team at CHOMP found a creative use for Tracers with AMP: capturing  Environment of Care (EOC) Committee meetings minutes.

The EOC Committee created a tracer template which offers a standardized format for each meeting’s minutes. The template allows the minute taker to assign tasks and corrective action items based on the discussion.
The committee generates a task report for each meeting. Then, in future meetings, they can easily reference the task report to follow up and ensure all previous action items have been closed.

Improving Emergency Management

After adopting Tracers with AMP, the staff at CHOMP began to conduct After Action Reports (AARs) within the tracers. The result? “Our entire emergency management program improved,” Daniel says.

Staff completes the AAR in Tracers with AMP using the mobile app. The process was especially relevant during a recent wave of storms in Monterey, California. The mobile app offers features like talk-to-text, as well as note-taking and photos. Following each AAR debrief, the team creates a binder, assigns tasks for follow-up items and uses the task report to document actions taken as a result of the AAR debrief.

Having the AARs within the tracers allows the staff to reference emergency management (EM) standards and connect the standards to assigned tasks and corrective action plans after drills.

Gaining Standardization

In addition to using Tracers with AMP for EOC rounding, CHOMP has expanded how it uses the platform. Previously, the team at CHOMP didn’t have standardization with tracers, and they relied on a wide range of reports and spreadsheets. “Now we have a one-stop shop and standardization for all our reports,” Daniel explains.

Tools standardized within the program include:

  • Infection control risk assessments
  • Grounds inspection reports
  • Emergency management for drill critiques and fire drill critiques
  • Interim life safety measures (ILSM)
  • Construction life safety rounding

An New Culture of Accountability

For a large hospital like CHOMP, staying on top of EOC rounds and findings is no small task. The EOC tracer has brought new levels of accountability to help each department stay on top of standards and compliance.

The new process has even raised staff interest levels in improving the environment of care. Thanks to clearer connections to EPs and standards, senior management now acts as a steward of the tracer tool. Now, department heads better understand and support the essential corrective actions to improve as a team.

Natasha says that the visibility, ease of assigning corrective actions, simplified follow-ups and email reminders make a major difference. “It helps us do a better job with keeping our place the way we want it for our patients,” she says.

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