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Currents Pam Cipriano, Ph.D., R.N., FAAN, administrator, Clinical Services, recently announced her resignation. She has accepted an offer to join the University of Virginia Health System as their chief clinical officer effective Nov. 17. The selection of Dr. Cipriano for this key leadership position with a prestigious academic health center is testimony to her professionalism and outstanding contributions to MUSC and the health care field. While we are very happy for Dr. Cipriano, she will be greatly missed. In the near future plans will be announced for a search process and interim appointment. The Special Function Lab was surveyed by JCAHO the week of Sept. 11. This survey provided good insight into what we can expect with the week-long Medical Center-wide survey (including Ambulatory Care and CMH) scheduled for the week of Nov. 6. The preliminary findings from the Special Function Lab are very good, however, it was clear that very detailed documentation for competency assessment and other records is needed. We hope to receive our score soon. Thank you very much. W. Stuart Smith Vice President for Clinical Operations and Executive Director, MUSC Medical Center Wood, Cook receive AREA awards for exceptional job Alpa Vyas, program coordinator, Hospital Administration, presented this past quarter’s AREA Award Winners.  Congratulations to Susan Wood from Hospital Patient Accounting and Susan Cook from 5 East.  Wood was recognized by staff and patients for “working your heart out” as Ida the Clown at the “Big Free Show” on May 21. The children loved her. Cook was recognized by fellow staff members.  She used her personal funds to purchase 30 knobs and 30 handles for some bedside stands which were inaccessible to patients. Thanks to Ms. Cook’s generosity and thoughtfulness, the patients are able to utilize the bedside stands as designed. Competency Report Carullo informed the group that mock personnel file audits are being conducted in preparation for the upcoming JCAHO accreditation survey. Based upon the audit findings, particular attention is needed to ensure that all BLS and other certifications are properly updated and included in the files. Also, the age specific competencies need to be properly updated and included in the files. (The age specific competency grid(s), which are available through the intranet website, must be attached to the performance appraisal documents.) All documents related to competency a The report includes employee separation data. The primary reasons for separation during FY 1999-2000 were: career development, relocation, personal, retirement, better pay and other. To improve the accuracy of separation reports in the future, our goal is to minimize the number of separation notices sent to Human Resources with separation reasons coded as “personal” or “other.” Carullo asked that managers and business officers ensure for good communication in order to report separation reasons as accurately as possible. Human Resources stands prepared to assist departments, upon request, in determining the most suitable separation codes. Carullo highlighted the exit interview results from the questionnaires which were voluntarily completed by employees leaving during FY 1999-2000. Of those completed, the primary reasons for leaving MUSC were: 1) relocation and, 2) better job opportunity.  File Audits Carullo informed the group that mock  personnel file audits are being conducted in preparation for the upcoming JCAHO accreditation survey. Based upon the audit findings, particular attention is needed to ensure that all BLS and other certifications are properly updated and included in the files. Also, the age specific competencies need to be properly updated and included in the files.  (The age specific competency grid(s), which are available through the intranet website, must be attached to the performance appraisal documents.) All documents related to competency assessment need to be properly dated and signed. Carullo commended Susan Beason, nurse manager, PICU and 8D, for having “model” travel nurse files. All travel nurse files must include the same key documentation as files for regular employees. Carullo emphasized to the management team the need to document service area orientation and age specific competencies for travel nurse and other contracted staff.  Mock audits on travel nurse files will be done soon. If you have any questions or need information concerning personnel files, please contact Carullo at 792-1684 or Eric Frisch at 792-7908. Per Diem (“Agency Nurse”)Charts Dolores Reynolds, coordinator, Hospital Options Pool, discussed the mock personnel file audits recently conducted on per diem nurse files. Reynolds stated that there will be an increase in the documentation requirements for service area orientation and clinical competency checklists. These required items must be included in the per diem agency nurse files located in the HOP office. Approval for employment of per diem nurses  will not be granted until the agency provides the appropriate documentation. Please contact Reynolds at 792-5126 before scheduling a per diem nurse to determine if credentials are on file and for further details. Medical Record Review Christine Lewis, manager, Coding and Record Processing, presented findings from her ongoing review of open medical records. In preparation for the upcoming JCAHO survey, Lewis and her focus team have been reviewing records and advising the nurse managers, residents, and attending physicians of any deficiencies which need to be corrected.  Medical records being reviewed are from the Institute of Psychiatry, Ambulatory Care Services, Charleston Memorial Hospital, and MUSC inpatient units.  Lewis advised the group of some of the top deficiencies found which include:  lack of patient/family education documentation incomplete treatment plans history and physicals not signed or dated verbal orders not signed or dated general consent forms not signed assessment/screening incomplete entries to the medical record not signed Announcements Dave Northrup, director, Healthcare Computing Services, CCIT, introduced Dave Moses as the new  manager for Healthcare Network Services. Moses will be managing the ClinLan team. If you need to talk to Moses, he can be reached at 792-9814.