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Currents To Medical Center employees: At our recent communications meeting the management team heard updates from various teams of the Medical Center’s Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Steering Committee. The reports focused upon initiatives related to human resource competency measurement, Medical Center policy management, and patient acuity measurement. Highlights of the reports are outlined below. As mentioned in an August 2001 Currents newsletter, the JCAHO Steering Committee was restructured earlier this fiscal year to place greater emphasis upon ongoing survey readiness across the organization. Our goals, among other things, are to eliminate fragmentation of the JCAHO readiness process, decrease the crisis approach to preparation for meeting the standards, and to maximize knowledge and resources available across the organization.  Stated another way, our intent is to make JCAHO standards preparation a “way of life” and to ultimately enhance patient care and service. Thank you very much. W. Stuart Smith Vice President for Clinical Operations and Executive Director, MUSC Medical Center Joint Commission charter teams established to improve continuous readiness The MUSC Medical Center has cleared a Type I recommendation from the Joint Commission of Accreditation of Healthcare Organizations (JCAHO) outstanding from the general function lab survey conducted in 2000, consultant Lois Kerr told the management team at the Nov. 27 communications meeting. This recent survey is a follow-up to the accreditation survey of MUSC’s Medical Center Laboratory held last November that evaluated the organ-ization’s compliance with nationally established JCAHO standards on organizational quality-of-care issues and the safety of the environment in which care is provided. JCAHO performed an extension survey at the Medical Center for the laboratory for the specific purpose of reviewing  i-STAT point of care testing in the Neonatal Intensive Care Unit and Pediatric Intensive Care Unit. This survey “went well and produced positive outcomes,” according to Kerr, who has consulted with the Medical Center since 1997. In August, a continuous readiness effort was launched through the formation of a task force and Terri Ellis was named as new JCAHO coordinator. Several charter teams now have been established to focus on readiness and to identify and remove barriers to the process of continuous readiness, including Human Resources Competency Team, Pain Management Team, Patient Acuity Measurement Team and Restraint and Seclusion Team. In addition, a standing Policy Management committee has been established to coordinate the review and approval for all Medical Center wide policies.  A steering committee was created to help with this process. Committee members will also serve as liaisons to management to help in removing barriers to the readiness process. Human Resources Competency Team The Human Resources Competency Team was chartered on Sept. 27 to assess the organization-wide competency process and to develop an efficient, cost-effective managerial and information technology infrastructure that supports the hiring, development and retention of competent employees. The Human Resources Competency Team determined that this was a two component task: 1) To identify the needs of the organization in obtaining a system that will manage/aggregate employee education records as well as provide web-based training 2) To assess the organization’s competency process as a whole and identify improvement opportunities.  Team Members include Julie Acker, UMA Compliance; Mary Allen, Safety and Security; Helena Bastian, Medical Center Human Resources; Amy Boehm, Hospital Administration; Cindy Brown, Radiology; Jeff Burdick, CCIT; M.E. Canaday, Ambulatory Care Services; Harriet Cooney, Institute of Psychiatry; Allen Coulter, Patient Access Services; Terri Ellis, JCAHO Coordinator; Rosemary Ellis, Quality; Tanis Koester, UMA Human Resources; Katy Kuder, Medical Center Human Resources; Carol McDougall, Clinical Services Education; Sherry Miller, Ambulatory Care Services; Nancy Powers, UMA Human Resources; Reece Smith, Compliance; Laurie Zone-Smith, Clinical Services Administration; Betts Ellis (liaison), Hospital Administration To date, the Human Resources Competency Team has identified the needs for an education system and is in the process of setting up demonstrations. Requests for proposals (RFP) are expected to be sent out by the end of December.  The second phase, which began in November, includes assessing the organi-zationwide competency process. The team will be adding ad hoc members and may be contacting Medical Center staff to participate.  The work expected in the upcoming months includes: Phase I—Continue with the RFP process, develop and execute an implementation plan for the new system. Phase II—Asses and identify opportunities for improvement of the organization-wide competency process beginning with preemployment and continuing throughout employment. Policy Management Committee The Policy Management Committee has several primary goals. The first is to assure the timely flow of policies through the approval process.  The second goal is to develop a standardized communication plan that assures individuals know key points of new and revised policies.  Committee members include Cindy Brown, Radiology Services; Annette Drachman, Legal Affairs; Terri Ellis, JCAHO Coordinator; Sherry Miller, Ambulatory Care Services; Chris Malanuk, Hospital Administration; and Phyllis Malpas, DDC and Endoscopy. Pain Management Team Betsy Batemen, coordinator of Pain Management and chair of the Pain Management Team will be leaving the Medical Center and will be greatly missed.  Karen Rankine, Clinical Services Education and Hazel Huff, Outcomes Management, have accepted appointments as co-chairs of the team. Patient Acuity Measurement Team The Patient Acuity Measurement Team, a nursing committee established several years ago, was chartered by the JCAHO Steering Committee in the fall of 2000. The group was formed to examine the current acuity system in all nursing units and revise the tool in order to provide prospective and retrospective data for staffing pattern decision making. The intent is to assure that accurate and pertinent data reports are available to schedulers and Hospital Services Coordinators to assist with staff assignment and floating decisions in a timely manner. This project initiative addresses the question, “How do we know if we have enough nursing staff to provide care to the volume and severity of patients admitted on the patient care units?”  The Patient Acuity Measurement Team members are co-chairs, June Stovall, Newborn Nursery and Postpartum; and Laurie Zone-Smith, Clinical Services Administration; Donna Padgette, Clinical Services Administration; Sonja Muckenfuss, 7B; Stephanie Bonnette, 9 PCU ; Bonnie Foulois, 8 East; John Welton, College of Nursing; Michelle Drummond, 9 PCU; Terry Bola, student, College of Nursing; Gail Sealey, 9 PCU; Mary Hughes, Outcomes Management; Tammy Steplight, Burn Unit; Tammy Sawyer, SEI Observation Unit; Suzanne Cole, 8 West Hematology/Oncology; Donna Sheppard, CT/PCICU; Traci Cain-Ray, 8 East General Medicine; Lauren Weich, 8 East General Medicine. During the past year, the group modified a current commercial acuity tool. The first-phase pilot for the revised instrument was completed in July 2001. An expert review panel evaluation was completed and the revisions were incorporated.  The second phase revised acuity tool was formatted in an Access database. The team made several revisions to the database and invited staff nurses to participate in the software adjustments to assure reports were designed that would be helpful to the nurse. The Acuity tool was made available to the pilot unit nurses on patient care units by computer ICON. An application was submitted to the MUSC IRB for exempt status with intent to publish the project work and findings. Training of pilot nurse users and charge nurse inter-raters occurred on Nov. 19 and the pilot began on Nov. 26 and will continue Dec. 14. Pilot feedback meeting is scheduled for Dec. 18 to examine data collected, incorporate feedback from the expert review panel and make final revisions.  The team anticipates roll out of the revised acuity tool to the Medical Surgical patient care units in early spring of 2002. The goal is to assure an organizational acuity system for all inpatient care units. The team plans to pilot and test the use of the tool in the Pediatrics and Intensive Care Units in the spring. Restraint and Seclusion Team The Restraint and Seclusion Team was established by the JCAHO Steering Committee in January 2001.  The work of the group was to make any necessary revisions in the restraint and seclusion policy, documentation process and staff education based on recent changes in the JCAHO standards on restraint and seclusion.  Team members are Susan Beason, Outcomes Management, Nancy David-son, 6 East and Dialysis; Maureen Decker, Hospital Services Coordinators; Barbara Hiott, TCU/7 West Orthopedics/Trauma; Mercedes Mayebe, Quality Management; Celeste Phillips, Clinical Services Education; Nancy Pope, Compliance; Peggy Simmons, Therapeutic Services. The team revised Policy C-22 on Restraint and Seclusion including reorganization of content, statement of purpose, format and increased clarity regarding use with psychiatric patients. Revisions also include policy changes regarding training/education, orientees, current employees, along with data collection and analysis, committee responsibility, and Appendix C: Process. Other work included revisions in Restraint and Seclusion Physician’s Order and Documentation Form and the establishment of data collection and analysis process. Staff will be informed of the changes beginning in January 2002. As soon as education and training is complete, the new forms will be implemented. Pediatric patients have designated elevator In an effort to improve services to patients, Children’s Services has designed elevator 54 for patient use only, according to Carol Dobos, Ph.D., director of Children’s Services. The interior of the elevator has been upgraded “and looks very nice,” Dobos said. The designated elevator is not to be used by employees unless they are transporting a patient. The elevator does not stop on the first floor.