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Currents As indicated in the last Currents newsletter, we need to make preparation for the JCAHO survey expected in October (or sooner) a top priority. It is very important that everyone is familiar with the JCAHO standards that are relevant to our respective duties and service areas. By understanding the intent of the standards, we will be better prepared to articulate how various Medical Center policies, patient care practices, performance improvement initiatives and governance mechanisms serve to fulfill the standards.  Numerous resources are available to promote understanding of JCAHO standards. Medical Center policies and the JCAHO standards manual can be accessed through the Medical Center intranet.  An updated Employee Information Handbook (“blue book”) that highlights topics addressed by the JCAHO survey process  was recently distributed to managers. The New Employee Orientation Information booklet (including the competency assessment checklist) includes important information. Managers and others are encouraged to contact Vivian Gettys, JCAHO program manager, for other resource information and guidance to prepare for the survey. Our communications meetings over the next few months will include JCAHO-related presentations, and we will share this information. We need everyone's cooperation to ensure we are prepared for the JCAHO survey. Thank you. W. Stuart Smith Vice President for Clinical Operations and Executive Director, MUSC Medical Center Management survey shows managers praise, discipline employees for job performance employees Karen Pellegrin, Ph.D., director of Quality Management, reviewed the results of the management survey taken in March. Managers were asked to rate their employees, as well as Medical Center employees as a whole, on core competencies, organizational values and job tasks. Managers tended to rate their employees more favorably than the Medical Center as a whole.  Survey results indicated that managers tend to praise employees for great performance for job-related tasks, as well as discipline employees for poor performance for job-related tasks. Pellegrin encouraged managers to also praise and take disciplinary action for behaviors related to the Medical Center's organizational values and core competencies.  The survey contained one open-ended question: What suggestions do you have for improving customer service at the Medical Center? The top five responses included the following: customer service training, leadership commitment to and focus on customer service, accountability for customer service behaviors, leadership modeling customer service behavior  and staff morale. The customer service task force has directly addressed the top three responses with the development of the new customer service policy, a video and web-based training. JCAHO: Environment of Care Mary Allen, R.N., coordinator of Environment of Care, reminded managers that maintaining environment of care standards is a collaborative effort.  She reviewed the following points: Halls and exits must be free of obstruction at all times. Wall-mounted, self-closing desks must be kept closed when not attended.  Patient information must be kept secure to protect patient confidentiality. Items should be kept at least 30 inches away from electrical panels. Items should be stored at least 18 inches away from ceiling-mounted sprinklers. Medications, needles and syringes must be secured at all times. Remove gloves from the top of needle boxes to avoid potential needle stick injury. When needle boxes are full, empty them promptly and place in red carts. Life support equipment must be plugged into red emergency outlets. Chemicals should be labeled with content name, concentration and hazards. The oxygen tanks on mayday carts should be kept uncovered, according to DHEC rules. Oxygen tanks should be stored upright in tank holders. Eyewash stations and emergency showers are checked quarterly by maintenance staff. Contact Allen at 792-5176 or the facilities desk at 792-4119 if tags go unchecked.  Departments that have toys in their areas should refer to the Infection Control manual to determine how frequently the toys should be cleaned. Red bags that contain infectious waste should be stored separately from regular trash. Keep lids closed on bins containing soiled linen; avoid overfilling the bins and dispose of promptly. Compliance Billing Training Reece Smith, compliance officer, said seven weeks of compliance billing training will begin the week of Aug.14 and will take place on Tuesdays, Wednesdays and Thursdays. Two hours of compliance billing training is required for all Office of the Inspector General (OIG)-mandated employees and agents.  Departmental compliance billing training that has taken place or will take place must be approved by the Compliance Office and include sign-in sheets. Compliance billing training tapes will be available in late August.  General compliance training is required within 30 days of the hire date. New Medical Center employees receive this training during orientation.  Employees returning from FMLA need to have general compliance training within 30 days of their return. Billing training is required within 30 days of the hire date. Clinical Services orientation meets billing training requirements. Some administrative departmental orientation sessions meet billing training requirements. Every manager should be certain that each new employee who meets the OIG's criteria has a departmental orientation that is approved by the Compliance Office as billing training. (The Compliance Office is investigating billing training for new patient care techs.) It also is the manager's responsibility to supply compliance training—both general and billing—to new non-Medical Center employees who meet the OIG's criteria. Please contact the Compliance Office if you have questions.  Managers Recognized  Pam Cipriano, Ph.D., administrator for Clinical Services, thanked Pamela Allison, R.N., manager of the CCU, CTICU, PCICU, ACU, and Joan Janes, manager of Pediatric Cardiology, for their years of service and dedication. Allison and Janes are leaving MUSC to pursue other opportunities. Test Your JCAHO Knowledge Q: What are three Environment of Care items you would check for in the handling of patient linens? A: You should check for the following: The linens are covered and neatly stored. Clean and dirty linens are not mixed. The soiled linen bags are clearly marked and tightly closed. Linen storage rooms are neat and clean. Q: What is the “official” MUSC name used to describe quality enhancement initiatives? A: Performance improvement. Q: What are three Environment of Care items you would check for in the storage and handling of medical supplies? A: You should check for the following: Storage is at least 18 inches from the ceiling and six inches off the floor. Expiration and potency dates have not passed. Storage areas are neat, clean and locked, if appropriate. General awareness of the recall and complaint process for damaged supply items. Q:  What are the various types of emergency disaster responses? A:  Code blue is for regular disasters (crashes, fire); code yellow is for radiation exposure; code green is for weather emergency. Q:  If I wanted to initiate a performance improvement project in my department, what form should I fill out, and where should I send it?  A:  The form you fill out is the FOCUS-PDCA Performance Improvement Project Kick-Off Form. The form is available on the Internet at: <http://www.musc.edu/qn> You may be fill it out and submit it electronically, or send a hard copy to Karen Pellegrin, 246 North Tower. Q:  How do department directors participate in your hospital's ongoing decision-making? A:  Discussion periods in Tuesday communications meetings; management retreats; development of tactical plans; Thursday administrators' meeting.