Inside Look: Supporting 20 projects & 300 staff at Penn State Hershey

Qualaris interviewed Marcy Gamble, MBA, MT (ASCP), Director of Quality Systems Improvement, at Penn State Hershey Medical Center (PSHMC). In her role, Marcy has oversight for organizational hospital quality initiatives, data reporting and outcomes. We talked with Marcy about how she and PSHMC use Qualaris.

Inside Look: Supporting 20 projects & 300 staff at Penn State Hershey 


Qualaris interviewed Marcy Gamble, MBA, MT (ASCP), Director of Quality Systems Improvement, at Penn State Hershey Medical Center (PSHMC). In her role, Marcy has oversight for organizational hospital quality initiatives, data reporting and outcomes. We talked with Marcy about how she and PSHMC use Qualaris.

Marcy and PSHMC have a great deal to celebrate about their work improving patient care:

  • They successfully piloted Qualaris getting buy-in while reducing their CLABSI rates
  • They expanded usage to +20 active projects and +300 staff 
  • They helped multiple departments take ownership of major projects using Qualaris
  • They achieved recent wins like low C. diff rates and a successful Safe Sleep initiative

The Qualaris team loves this great work being done! And, we’re eager to pass along helpful insights to others tackling healthcare quality improvement challenges.

Read on to learn about how PSHMC built the program and Marcy’s pro tips for achieving high-quality results.

Use a pilot project to build initial buy-in

“Using Qualaris for data collection and reporting enabled us to start small and create buy-in.”  Marcy Gamble, Director of Quality Systems Improvement

Marcy shared that PSHMC started with a CLABSI pilot to create buy-in. The organization was struggling with bundle compliance. The old tech they had was tedious to use. There was no way to provide everyone with shared visibility on the actual data. So, data collection was difficult. They struggled to get internal agreement on whether there even was a compliance problem. 

Marcy worked with a nurse leader from the CLABSI team to get 3 units on board for 3 months. They quickly configured the bundle as an audit in Qualaris and trained staff to collect data. Qualaris’ ease-of-use made it easier to get auditors to the tool. When the results came in they learned that they were only 30% compliant. This was a huge shock to the team. They used that information and engagement to get buy-in to take action.

Provided by Penn State Health Milton S. Hershey Medical Center

They spread the bundle audit tool across the organization. And, they worked with units to act on the data to improve compliance. The hard work paid off. In their Cancer Institute they saw a correlation between improved bundle compliance and reduced CLABSI rates. Learn more about this project in Marcy’s presentation at the Systems Process Improvement Conference

(CLABSI audit form included, Appendix 1)

Engage staff by addressing common QI project challenges

“At Milton S. Hershey Medical Center, everyone loves data. They’re hungry to get it. With Qualaris, they don’t have to put in a ticket to get a report built. The system enables them to do it themselves.” Marcy Gamble, Director of System Process Improvement

After the CLABSI pilot, Marcy and her team turned their focus to more topics like CAUTI, falls, and pressure ulcers. People started to hear about the progress the teams were making and the ease of use for auditing, and usage spread.

Here are some tips Marcy shared to help get more teams engaged and encourage spread of the software.

  • Show teams how quickly they can get the tools they need - Marcy shared that “At Milton S. Hershey Medical Center, everyone loves data, they’re hungry to get it. They don’t want to get a report built, or manage the data in a spreadsheet. Qualaris enables them to do it themselves, they are getting real-time visibility and results.” 
  • Highlight the reporting capabilities - Marcy shared that Qualaris provides bar charts, tables, and a variety of ways to view the data. This functionality makes it easier to get buy-in internally.
  • Give leaders visibility on key projects - Marcy shared how Qualaris supports projects where executives were seeking timely visibility such as accreditation-related work and priority patient safety issues. 
  • Eliminate cumbersome spreadsheets - Marcy shared how organizations struggled to manage projects out of manually updated spreadsheets. 
  • Not every project really needs to capture protected health information (PHI) - Marcy shared that many teams like to capture PHI, but in most cases they’ve been able to overcome this need with the inclusion of other fields like room number, time of day, etc.

Work with key departments to expand usage

Over time, many teams have taken up Qualaris at PSHMC. With the expansion, usage has grown to +3,000 audits collected each month providing critical compliance data across the organization.

Here’s how some of the teams use the product:

  • Performance Improvement Teams audit best practice bundles to reduce hospital acquired infections and conditions.
  • The Regulatory Team  performs audit tracers to ensure survey readiness. 
  • Environmental Health Services use audits to monitor high-touch surfaces. 
  • Patient Safety monitors the utilization of error prevention tools and has safety coaches that do audits and real time coaching. 

Here’s a comprehensive list of PSHMC’s ~80 audit projects that have been developed over the years.

Anesthesia Consent - Audit

APD Medical Group Customer Service 2

Bedside Shift Report

Bundle Buddy Pilot

C diff Contact Precautions Bundle

Carotid Endarterectomy or Carotid Stenting Mock Template for NCCU, HVICCU, HVPCU, HVOU

CAUTI Prevention

Children's Hospital SPS Unplanned Extubation Bundle

CLABSI Line Maintenance

Code/ARRT Debrief

Contact Isolation Precautions

CPD Medical Group Customer Service 2

Discharge Instruction

ED Patient Rounding

EHS Clinical Quality Inspection

EHS Non-clinical Quality Inspection

EHS Patient Rounds

EHS Quality Inspection

EHS Validation Inspection

Fall Precautions

Falls Prevention Bundle

Infant Feeding Survey

Infant Security System Audit

Infection Control - Construction Compliance Monitor Form

Intraoperative Universal Protocol Audit

Intraoperative Universal Protocol Audit Tool

Leader Methods

Leadership Rounds

Locked Anesthesia Carts in Endoscopy Department - Audit

MD-RN Rounding in MIMCU

Medical Group Customer Service 2

Medical Group Mock Tracer 1

Medical Group Mock Tracer 2

Medical Group Mock Tracer 3

Medical Group Mock Tracer 4

Mock Tracer 1

Mock Tracer 2

Mock Tracer 3

Mock Tracer 4

Mock Tracer Week 1

Mock Tracer Week 2

Mock Tracer Week 3

Mock Tracer Week 4

NICU Respiratory Quality Rounds

Nursing Documentation

Nursing Facility Focused Regulatory Rounding Tool

Nursing focused - Infusion titrations

Nursing focused tracer - Plan of Care

Nursing Staff Focused Regulatory Rounding Tool


OR/ Peri-Anesthesia CLABSI Central Line Maintenance Audit

Pain Documentation

Pediatric ED and CH Perianesthesia specific Safe Sleep Audit

Pediatric Emergency Department Specific Safe Sleep Audit

Pediatric Surgical Site Infections Prevention Audit

Pediatric VAP/VAE Bundle

PO Pain Reassessment Audit

Postpartum Hemorrhage Team Debriefing Form

Pressure Injury Prevention


Respiratory Focused Regulatory Audit

RLM Assessment

RT Education Resource Tracking

S E A T Communication Competency Checklist

Safe Sleep Audit

Safety Coach Data Collection

Safety General Inspection Tool

Safety Inspection Tool

SEAT Communication Competency

Skin Round Audit


SPS PIVIE Audit-test

Stroke Mock Survey for 4 Acute

Stroke Mock Survey for ED

Stroke Mock Survey for ED Providers

Stroke Mock Survey for NCCU

Time Out for Sign Out

tPA & Thrombectomy Audit for NCCU

VAP/VAE Bundle

Whiteboard Audit

Sustain high quality projects with the right processes

Today, PSHMC’s usage is going strong. Here’s a breakdown of active projects so far for 2021.

Marcy shared some of the key tactics that have helped PSHMC sustainably support high quality auditing projects over time.

  • Designate a dedicated administrator who can specialize: At PSHMC, they have one main administrator for Qualaris in the Quality department. The person ensures that appropriate people have access, support needs are addressed, and that projects stay organized as they’re set up.
  • Take the time to construct a good quality audit: Marcy shares that it pays off to invest time up front by working with the group to develop their audit’s questions. Sometimes, even though questions seem straightforward they are interpreted differently by different team members. One tip is to add help text in the audit form to give people advice on how to think about their answers. Another tip is to make sure audits get tested and have the Quality team both do audits themselves and round with the auditors. Lastly, it is also important to train your auditors when you roll out an audit. Remember “garbage in, garbage out” when it comes to data. 
  • Incorporate Qualaris reports into your PI processes & documentation: At PSHMC, the PI team has developed a consistent format with a clear place for Qualaris data to be incorporated. Through standardization, each team’s work has the same look - showing outcomes, control charts, after action reviews, and the process metrics slide is generated from Qualaris.
  • Help other teams take ownership: These days, Marcy and her team have disseminated the responsibility for auditing and reporting to other teams. Nursing now owns CAUTI, CLABSI and nursing-centric things like Magnet. Regulatory reports their compliance through their channels. EHS reports up through their channels. This progression has allowed more high quality auditing and reporting to be sustained at PSHMC.

Some recent wins to celebrate!

Lastly, Marcy shared some great work recently completed by PSHMC teams. Great work, everyone!

  • C. diff team - Marcy shared that the team has used Qualaris to significantly reduce the hospital acquired C. diff rates with the use of audits for precaution compliance. She shared they are in control with an extremely low rate, excellent bundle compliance, and now each unit only has to do a very low amount of audits (4 each month). 
  • Safe sleep study - Marcy shared that work by the PI team was recently accepted for publication. The safe sleep project shows that a safe sleep bundle can be utilized to decrease the chances of sudden unexpected infant death that often results from unsafe sleep environments. They also showed that standardization of infant sleep environment education has been shown to impact such deaths.

Many thanks, Marcy! Congrats, and thank you for sharing.

About Penn State Health Milton S. Hershey Medical Center

Penn State Health’s flagship 628-bed medical center, Penn State Health Milton S. Hershey Medical Center is central Pennsylvania’s only locally based academic medical center. A Magnet-designated hospital since 2007, it provides high-level, patient-focused medical care. The Milton S. Hershey Medical Center is the only medical facility in Pennsylvania to be accredited as a Level 1 trauma center for both children and adults. Hershey Medical Center shares its Hershey campus with Penn State Health Children’s Hospital, Penn State Cancer Institute and Penn State College of Medicine. 

About Qualaris

Qualaris Healthcare Solutions, Inc. provides affordable, easy-to-use auditing and reporting software for quality improvement, infection prevention and patient safety. Common topics include hand hygiene, falls prevention, rounding, accreditation tracers and PPE checks. Visit  to learn more or sign up for a free trial.

Appendix 1 - CLABSI Audit Template

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