When Garrett Doering started at Westchester Medical Center in Valhalla, New York, he reviewed the hospital’s rounds process. As the System Director for Emergency Management, Safety & Security Doering found numerous weaknesses in the system. One weakness was a lack of data. For instance,
there was no data for the percentage of missed follow-up actions. “We knew it was high,” Doering says, “because when we revisited areas we kept finding the same problems.”
In addition to the lack of data, Doering was not convinced that the rounds team was covering the entire facility. “I handed out floor plans to the hospital,” Doering says. “I asked my reviewers to highlight the areas they covered as they conducted rounds. If there were missed areas, we could easily see it.” The result was numerous coverage gaps. Doering explains that as services and facilities moved within the hospital the rounds scheduling system was not updated to reflect those changes.
The existing rounds system also made compliance surveys stressful. “Our rounds team wasn’t very engaged,” Doering says. “People would walk around,but they were not consistently making notes and submitting work orders.” When surveyors visited Doering showed them his team’s attendance sheet to prove they did rounds and that there were some findings, but he had little documentation beyond that.
To address these weaknesses Doering implemented EoScene’s eCMS™ Compliance Management Solution, a suite of cloud-based tools enabling organizations to manage their patient care environment easily and efficiently. Implementing eCMS™ moved Westchester to a rounds system with standardized questionnaires, preset scheduling that automatically generated email reminders for follow-up actions. Doering now has the ability to track in real-time the hospital’s percentage of missed follow-up actions.
After his team performs rounds, eCMS™ emails a summary report to each area’s owner. Email reminders continue until every issue is resolved. “We now have a documented audit trail,” Doering says. “It begins when a finding is entered into the system and tracks all of the follow-up actions.”
Switching to eCMS™ not only provided Westchester with the data they had lacked, but the new system increased engagement from everyone involved in the rounds process. Doering says, “Area owners became more engaged in the whole process as they saw the data tracking their performance.” The ability to quantify performance at Westchester has also impacted the environment of care committee. “In the past it was seen as a chore to be on the committee,” Doering says. “But eCMS™ provides real-time data to everyone in the organization about each unit’s performance. The data shows all the hard work folks are doing, which has elevated the importance of the committee’s role in those positive outcomes.”
After implementing eCMS™ Westchester switched from the Joint Commission to DNV for its compliance surveys. Doering explains that the transition was very easy. “Because eCMS™ accommodates both The Joint Commission and DNV switching to DNV was totally seamless.” And, because of the data compiled by eCMS™, compliance surveys are no longer stressful. Doering describes a recent visit from DNV, “They asked for our latest rounds. We produced them and the follow-up corrective items within just a few minutes.” Prior to using eCMS™ Doering didn’t have much data to show surveyors. Now, if a surveyor asks about a specific issue in a specific room at a specific time, he has that data. “Our surveyors are always impressed at the thoroughness of our data and that we can get it to them so quickly.” “We’ve really benefited from eCMS™,” Doering says. “Everyone at Westchester can see something has changed. The value placed on the environment of care has never been higher and now we have the numbers to prove it.”
Hospital administrators, compliance officers, the Environment of Care team leaders, facilities managers, safety directors or heads of clinical engineering can test drive eCMS™ to see how it will make compliance at your hospital easier and better while helping improve the quality of care.
