August 20, 1998

At the recent MUSC Board of Trustees meeting, Thomas C. Rowland Jr., M.D., of Columbia, was elected chairman for a two-year term. Dr. Rowland has served on the MUSC board since 1982 and served as chairman in previous years. Charles B. Thomas Jr., M.D., of Greenville, was elected vice chairman. Committee members will be named in October.

The Finance Committee heard a report on the OR expansion project. This project’s original budget of $6.4 million proved to be insufficient once architectural and engineering reports came in. The board approved a new budget of $10 million for the project. In other finance news, Radiology received approval to purchase two major items, a linear accelerator and a CT scanner.

The board also heard a proposal from the Medical Center to change the organ procurement organization it works with from the South Carolina Organ Procurement Agency to LifeLink of Georgia. The goal of the Medical Center is to maximize organ donation efforts for the benefit of patients, and LifeLink has a strong track record in this area.

It was reported to the board that Joanne M. Conroy, M.D., professor and chair of Anesthesia and Perioperative Medicine, has been appointed to the newly created position of associate vice president for medical affairs. She will work with department and division heads in facilitating the clinical activities of faculty members of the College of Medicine. She also will be working with health care professionals in the Medical Center’s expanded clinical enterprise, with Medical Center and University Medical Associates administration, and with deans and faculty members in other colleges. Dr. Conroy also will continue to serve as the chair of Anesthesia and Perioperative Medicine.

W. Stuart Smith, Interim Vice President for Clinical Operations Interim CEO, MUSC Medical Center

Performance Improvement Update

• At the Aug. 18 communications meeting, Karen Pellegrin, Ph.D., director of Quality Management, gave the management team an update on the Performance Improvement Annual Report, PI training and PI forms. The PI Annual Report, which includes an overview of PI activities and trends, was presented to the MUSC Board of Trustees at its recent meeting.

• The PI Annual Report’s section on infrastructure included the following information:
• The Medical Center’s sentinel event policy was revised.
• University HealthSystem Consortium was selected by the Medical Center as its measurement system to meet the Joint Commission on Accreditation of Healthcare Organization’s new ORYX requirement. This standard requires hospitals to send their performance data on several indicators to the JCAHO quarterly. Of the 86 UHC measures that are JCAHO-approved to meet ORYX, the Medical Center chose the following indicators for reporting: length of stay for cardiology services; repeat Cesarean section rate; and psychiatric patients leaving against medical advice.
• The indicator review process has been streamlined to improve data collection and to make the reporting process less time consuming.
• The Trident Area Community of Excellence, or TACE, award was submitted for the organization.
• The trauma interdisciplinary team, or IDT, became the 17th such team in the Quality Network.
• A JCAHO program coordinator was hired (Vivian Gettys), and a JCAHO steering committee was launched.
• Pellegrin said many performance indicators are tracked through the Quality Network. Those with significant trends were reported to the board. For example, improvements have been seen in the number of insufficient biopsy samples sent to the lab, adverse anesthesia events, blood borne pathogen exposures and some infection control indicators.
• The PI training program includes a video shown at every Medical Center orientation, a PI guide available to anyone needing one, and two classes. One class covers the FOCUS-PDCA process used at the Medical Center. The other is about measurement and control charts. Pellegrin said training was designed to be cost-effective by allowing managers to send people when specific training is needed. In follow-up surveys, 61 percent of those participating reported they were involved in PI within three months of the training. Of the 39 percent who are not involved, most said it was because they had no time or that no one asked them to participate. Pellegrin asked that managers send staff members to training with the expectation that they will be encouraged to immediately put into action what they have learned and will be given the time to do so.
• PI forms: PI teams, or FOCUS-PDCA teams, are required to complete two forms that are used to track projects throughout the Medical Center. One is a project proposal form to be completed at the beginning of the project, and the other is the documentation form showing what was accomplished after the project is completed. The purpose of these forms is to enhance communication, documentation and coordination of PI projects. The information from these forms is entered into a database and used to generate reports to meet a variety of needs. These include identifying the projects with representation from a particular department, identifying the individuals involved in projects (for physicians, this information is included on performance profiles at reappointment), and providing information on completed projects to report to the MUSC Board of Trustees.
• As a reminder, Pellegrin said that the definition of a PI project includes two essential parts. The project must have an intervention (it must involve a change in the way work is done), and data must be collected before and after the intervention to evaluate whether it worked.

Bye-bye MECON, Hello HBSI