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Currents At our Sept. 26 communications meeting two panels took part in a second contest focusing upon JCAHO-related questions. The contest, modeled after a combination of the television games shows Family Feud and Jeopardy, served to highlight typical questions we can expect with the JCAHO survey as listed below. Ideally we strive to maintain operations in a “JCAHO survey readiness” status as all times. But, the standards gradually change and the JCAHO tends to shift area(s) of emphasis based upon its observations and evolving issues in the healthcare industry.  As we approach the final phase of preparation for the survey scheduled for the week of Nov. 6, new interpretations of how certain standards and trends apply to our internal operations seem to surface with little or no advance notice. Many of us are having to get into high gear to ensure records and documentation are in order. Understandably this causes much anxiety. Thanks to everyone involved for your support and cooperation during this very demanding period. W. Stuart Smith Vice President for Clinical Operations and Executive Director, MUSC Medical Center Another edition of “JCAHO Feud” A work team consisting of Effie Amerson, 7 East, 8 East; Anne Benton, Occupational Therapy; Warren Bradley, Respiratory Therapy; Cindy Brown, Radiology; Phyllis Malpas, DDC and Endoscopy; and Erica Rouvalis, Physical Therapy; created the “JCAHO Feud” contest. Examples of questions and answers are outlined below. Anyone interested in the “JCAHO Feud” PowerPoint presentation can contact Warren Bradley at 792-4014 or through e-mail at bradleyw@musc.edu. Once again, David Hutto (the “Host with the Most”), Main and Ambulatory ORs and Sterile Processing, served as the master of ceremonies while two teams went head-to-head over JCAHO questions and answers (outlined below). The two teams consisted of: Team A-Jodell Johnson, Infection Control; Rick Welch, SICU/Burn Unit; Laurie Zone-Smith, Clinical Services; Terry Wilson, Pastoral Services; and Joan Herbert, IOP; Team B-Betts Ellis, Institutional Relations; Fred Miles, Hospital Maintenance; Irene Thomas, 10W/6E; Al Nesmith, Safety and Security; and Cindy Williams, Patient Access Services. (Team A came away with the Gold in a close contest—but Team B filed a protest and requested a rematch.) JCAHO Questions and Answers Name three of the six processes that JCAHO standards address for Information Management: Identifying information needs; Designing the structure of the information management system; Defining and capturing data and information; Analyzing data and transforming it into information; Transmitting and reporting information; Integrating and using information How often should medical records be reviewed and what are four items that MUST be checked when doing so? Medical Records are reviewed on an ongoing basis. They must be reviewed for timeliness, completeness, legibility, and appropriate authentication. How is operative and anesthesia information documented thoroughly in the medical record? Recording a preoperative diagnosis before surgery; Immediate brief op note and dictated operative report; Postoperative documentation of OR events Can you name a comparative report used by the Hospital? UHC benchmarks including HBSI trend data; ORYX performance indicators for JCAHO; State data (patient billing data); AAMC Financial Data (COTH survey); Health Care Advisory Board comparative information; Numerous internal performance improvement initiatives. True or False Security and confidentiality are maintained when you leave your computer screen up and go to lunch. False What is the performance improvement model we use and who can make suggestions for PI projects? FOCUS-PDCA and anyone can make a suggestion for a project. What is included in MUSC’s Performance Improvement Plan? Quality Network structure; Committee objectives; Organizational performance indicators; Performance improvement approach; Key organization-wide performance improvement initiatives  How do you report an adverse drug reaction (ADR)? The person identifying the reaction will notify the physician of the ADR and encourage documentation of the reaction and management in the patient’s medical record; Contact the pharmacy or pharmacist covering the service to report the ADR; Complete the ADR form and forward it to the Department of Pharmacy Services How often must a physician write an order for restraints? Physical restraint requires a physician order which must specify a defined time limit. Time limits are not to exceed 24 hours for nonbehavioral health patients. A new order for restraints must be written by a physician at least every 24 hours following a face-to-face assessment. Do staff who perform waived testing have adequate, specific training and orientation to perform the tests and demonstrate satisfactory levels of competency?  Yes. Training and competency skills checklists have been developed for all waived tests. Training and annual competency assessments are completed for concerned staff. All documentation is maintained in the personnel file. Name the seven components in the Environment of Care: Safety; Security; Fire and Life Safety; Hazardous Materials and Waste; Emergency Preparedness; Biomedical Equipment; Utility Systems Where are the Environment of Care Management Plans located? The EOC plans are located in the Environment of Care Manual in each unit or department. These plans are reviewed annually by the safety director and the EOC committee. Name three of the many ways the EOC plans are (in effect) implemented: Fire Drills are conducted quarterly on inpatient units and at least once a year in free standing clinics. Fire alarm systems are maintained; Disaster drills are conducted twice a year; Surveys (Hazardous surveillance and Infection Control surveys) are conducted regularly to identify risks in the environment; Security assistance is available 24 hours each day. Special security measures are in place around entrances, exits, nurseries, behavioral health units and emergency care areas; Biomedical Engineering checks and maintains medical equipment; Utilities such as generators, electrical, water, sewer, heating/air conditioning and medical oxygen and air are maintained. Procedures are in place for action during emergency disruption of utilities; An EOC Committee meets regularly to monitor and resolve safety issues. How do you provide a comfortable social environment for the patient? Patient privacy and confidentiality are respected at all times; Outside areas are available for relaxation if their medical condition permits; An inside atrium playroom is available for children and adolescents; Telephones are available for patient and family use.; Grooming articles are available on admission and from the gift shop; Inpatient rooms and clinics are attractively furnished and comfortable; Patients are provided with furnishings for placement of personal items. What orientation and education do staff have concerning the Environment of Care (EOC)? All new employees receive EOC/safety training at orientation and at least annually as required by their work categories. De’Medici provides EOC competency updates. What personal protective equipment would you wear in your area of work? Employees should wear all the equipment needed to protect them. This may include gloves, masks, gowns, safety glasses or other specialized equipment. Do you have access to Material Safety Data Sheets (MSDS)? MSDS information sheets which list chemicals found in the service area may be in a department-based notebook, accessible via the MUSC home page or by calling Occupational Safety at 792-3604 or the Physical Plant help desk at 792-4119. What are the five steps to the fire plan? Remove the patient; Close the door; Pull the fire alarm; Call the operator using the emergency number 792-3333; Fight the fire What should staff do if notified of a disaster? Staff should finish their work and await new instructions; Managers should report to 2 West Amphitheater or as requested on their pager. Who has the authority to turn the oxygen shut off valves off in a fire or other emergency? The person in charge of the area may order oxygen shut off in an emergency. This could be the physician, charge nurse, unit manager or respiratory therapist. They should request assistance from facilities staff for valve shut off. What aspects in the EOC are being monitored for Performance Improvement? Recent PI in the environment of care has been to improve employee care in the event of a bloodborne pathogen (BBP) exposure especially during nights, weekends and holidays; Employees are monitored to see they receive BBP care within two hours of exposure as recommended by the Center for Disease Control (CDC); Employee injury reporting is monitored using the ACORD form (Worker’s Compensation First Report of Injury) How do you insure patient safety in the event of a power failure? Emergency generators are checked and maintained monthly; Emergency lighting is in place; All life support equipment is plugged into red emergency outlets; Units have emergency flashlights and lanterns; Utility assistance is available by calling 792-4119. What type of waste is disposed of in red bags? Items heavily soiled with blood and certain body fluids. If you have had a positive TB test, do you need to give additional information to Employee Health about your status and what may be  symptoms of active TB? Yes, you must still complete a “Signs and Symptoms Form.” Symptoms may be coughing, fever, night sweats. How do department directors participate in your hospital’s ongoing decision making? Weekly communications meetings; Planning retreats; Participation in tactical planning workgroups; Weekly administrators’ meetings. How does your organization promote recruitment, retention and development of staff members? Recruitment—national ads, job fairs, MUSC employment website, Dial-A-Job; Retention—exit questionnaires, salary surveys, training opportunities, staff satisfaction surveys; Development—performance appraisal planning stage, tuition assistance, attendance in training programs. Describe the department director’s role in developing your organization’s Code of Ethical Behavior The statement was developed by an interdisciplinary committee and reviewed by the Ethics Committee; The draft organization ethics statement was shared with the management team for comments prior to the Board of Trustees approval; It has been reviewed since the origination date and submitted to the Board of Trustees for information. How is staff oriented to their organization and performance expectations? Our orientation policy sets forth the general and service-area specific information for orientation of employees. The general orientation focuses on mission, vision, values, performance improvement priorities, EOC and a variety of key policies such as restraint and seclusion, patient confidentiality, patient rights and responsibilities, customer service and compliance (code of conduct).  The service area orientation focuses on specific skills and knowledge needed within the service area.  Departments use checklists to ensure employees demonstrate competencies and understand their job descriptions and performance expectations. The performance appraisal planning stage serves to ensure for proper understanding and documentation of expectations. What are the five tactical planning areas of the Clinical Enterprise Strategic Plan? Reducing Cost of care; Management Effectiveness; Medical staff involvement; Customer service; Information-based decision making. What two criteria have been identified as priorities for process improvement? Cost Reduction plus Customer service improvement . . . known as C2.  How do the leaders of your organization collaboratively make decisions affecting the hospital? Administrators' operations meetings; Communications meetings; Medical Executive Committee; Quality Council  How can patients and staff be informed of patient rights and responsibilities? Recorded message on Health Information library; Brochures available in ambulatory care; Posters in hospital public areas; Clinical and Patient Education website; Patient care area welcome packets; Preadmission packages; Staff may review policies on patient rights.  Recruitment and Retention Plan Susan Carullo, manager, Employment, Compensation and Employee Relations, presented elements of  the Recruitment/Retention Plan for the Medical Center. The plan will be available for the JCAHO survey.  The purpose of the Recruitment/Retention Plan is to recruit, motivate, develop and retain competent staff to provide excellent care for patients and efficient support services.  In recruiting qualified staff, a number of mediums are used to enhance recruitment efforts including: career opportunities announcements (job list is posted on bulletin boards and the Internet), Dial-A-Job, advertisements, outside recruiters and a specialized healthcare internet service (www.healthcareerweb.com).  Recruiters also attend conferences and job fairs and the career opportunities announcement is mailed weekly to numerous outside organizations. Human Resources reviews hire rates regularly and, as needed, adjusts pay rates to respond to market needs. Relocation assistance is provided when needed to recruit for key positions. The Medical Center maintains contact with the MUSC colleges and other schools to enhance recruitment activities. Retention tactics are based upon information obtained through separation notices, turnover analyses, exit interviews, and benchmarking (with other institutions). In order to retain employees, the Medical Center offers training and development opportunities, the clinical advancement program and other career ladders, promotion and upward reclassification, performance pay, premium pay, and bonus and incentive pay. You can contact Carullo at 792-1684 for further information on the Recruitment/Retention Plan or with any ideas or suggestions that may assist in recruitment or retention efforts.  2001 Annual Enrollment (for Benefits) Janet Browning, manager, Benefits, Records and Training, announced the 2001 Annual Enrollment for benefits and insurance would take place during the month of October. A benefits fair for Hospital Authority employees will be held on Oct. 18 and 19 in room 100 of the Administration/Library Building from 10 a.m. to 3 p.m. Benefit changes may be made at the fair or throughout the month of October in the Medical Center Office of Human Resources, room 109, Clinical Sciences Building. The Benefits Section's hours are 8 a.m. to 5 p.m. During this enrollment period, you can change plans (switch to another insurance carrier) but you cannot add or drop dependents. If you are enrolled in MoneyPlus or Dependent Day Care, you must reenroll if you wish to continue for 2001.  Major changes to the Optional Term Life (OTL) plan are in store for 2001. Premiums are going down and coverage is going up. Dependent Life coverage and premiums will no longer be combined with dependent life coverage for children. Life coverage for a spouse will change from a flat amount to an age rated premium based on level of coverage and the age of the employee. Premiums for covered children under dependent life will be a flat rate of $1.50 per month for the $10,000 benefit level. Current OTL subscribers (active employees) can increase their coverage level by up to $50,000 without medical evidence of good health. Current OTL subscribers can increase their coverage up to a maximum of $300,000 with medical evidence of good health. Active employees can insure their spouses for $10,000 or $20,000 without providing medical evidence of good health, or up to one half of the value of the employee’s insurance up to $100,000 maximum (on the spouse) by providing evidence of good health. Monthly premium increases for the State Health Plans (Economy and Standard), MUSC Options and HMO Blue are all effective Jan. 1, 2001, and deductions will begin in December. Annual deductibles for the State Health Plans will increase by $50 per person and  by $100 per family. Changes in copayments for prescription drugs and other services will change. Be sure to review the booklets and handouts carefully.  All changes are effective Jan. 1, 2001 with payroll deductions beginning in December. Remember you cannot add or delete dependents from health or dental until October 2001.  Enrollment in Dependent Day Care or Out-of-Pocket Medical Spending Accounts is not automatic. You must reenroll for 2001 during the month of October. If you have questions, call the Medical Center Benefits Office at 792-0826 or 792-0859. Announcements Robin Hardin, director, Student Programs and Activities, announced the annual Symphony in the Horseshoe will be held on Tuesday, Oct. 3, from 11:30 a.m. to 1:15 p.m. The full Charleston Symphony Orchestra will be performing and eight local restaurants will have food for sale. This event is cosponsored with the MUSC Cultural Projects Council. Dave Northrup, director, CCIT Healthcare Computing Services, announced that support for the Oacis system is in the transition process from the parent company, Science Applications International Corporation (SAIC), to another company. The impact to MUSC is unknown at this time, but this change is being closely monitored by Medical Center and CCIT leadership.