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The UPMC Health System maintains a culture of safety by performing internal mock surveys at its 35 hospitals in Pennsylvania, New York and Maryland. To do this consistently, they have adopted Joint Commission Resources’ Tracers with AMP® Mock Survey module. This tool allows users to collect and enter mock survey findings and create robust reports that help users determine trends and risk points across a system.

UPMC logoUPMC’s system accreditation team had a historically strong internal mock survey process that required manual compilation to collect and report data. The process involved typing up the findings and manually plotting them on the SAFER Matrix for the site at which the mock survey was conducted, as well as compiling the findings to analyze trends across the health system. In 2019, UPMC acquired JCR’s Tracers with AMP Mock Survey module as a more consistent and less time-consuming way to record and analyze the data the health system collects.

Since the adoption of the Mock Survey module in late 2019, UPMC has conducted internal mock surveys in approximately 20 of their hospitals. Every year, the system accreditation team conducts a data recap looking at their top requirements for improvement across the system. In addition, the team runs a report that includes all mock survey findings and now has the ability to compare those findings.

  • Concise and consistent reports across the system for easier comparison
  • Use of the same language in policies and tracers at all hospitals in the system
  • Ability of the team to identify issues that may be problematic systemwide
  • Sharing published reports to address identified issues of non-compliance and drive performance improvement initiatives at the system level

Accreditation professionals and clinicians participate in conducting internal mock surveys using the Mock Survey module. One of the health system’s next steps is to familiarize a core group of individuals at each UPMC hospital with the Mock Survey module so that the module can be utilized by each site’s designated mock survey team as well.

“Some of the reports that are able to be generated between the Mock Survey and Tracers are amazing,” says Phelicia Goshea, Patient Safety and Regulatory Specialist at UPMC. “The software makes it so much easier to compare and review data and analytics – much better than a spreadsheet.”

Such in-depth and consistent reporting helps the team pick up on system issues more easily. “For example, when the new National Patient Safety Goals® came out, we saw that we needed to move from our own suicide screening process to a more evidence-based screening tool. Tracers helped us identify the issue, then remedy and test it before our survey.”

“Our experience working with JCR has been very positive,” says Goshea. “They provide excellent resources, and their educational opportunities are great. For each hospital in our system, the experience varies – some use a lot of JCR resources, others aren’t quite as engaged or proficient.

“At first, after being introduced to JCR’s Tracers with AMP Mock Survey module, it can be a little overwhelming,” continues Goshea. “But it’s worth it to stick with it because it facilitates a much smoother process overall.”

The Tracers with AMP Mock Survey module has given UPMC the ability to more efficiently and effectively identify and analyze opportunities for improvement and implement initiatives to address those opportunities system-wide.

“The software makes it so much easier to compare and review data and analytics – much better than a spreadsheet.”