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Currents To Medical Center Employees: Recent news articles have focused upon patient safety as a state and national concern. We have seen patient safety emerge as a major JCAHO issue. Moreover, the Medical Center has adopted patient safety as an organizational priority, and, as a result, a number of patient safety-related initiatives have been undertaken as described below.   Our commitment is to anticipate potential problems before they arise. One key advancement to help accomplish this has been the establishment of the MUSC Center for Clinical Effectiveness and Patient Safety.    As members of the Medical Center staff, you all are central to making the process work on behalf of the many families who entrust us with their care. If you are caring for a patient and see a problem, don’t hesitate to call an attending or whomever you need to address the concern. We encourage you to be proactive in what you do and to help us identify ways we can, as a system, and as individuals, provide the very best possible care to our patients. I thank you all for your commitment and dedication. W. Stuart Smith Vice President for Clinical Operations and Executive Director, MUSC Medical Center   MUSC: Partnering for patient safety The MUSC Medical Center, in its on going efforts to improve patient safety, has joined other national leaders in developing system solutions to decrease medical errors.    “Patient safety and risk reduction strategies are an ongoing critical focus of the MUSC Medical Center,” said Stuart Smith, vice president for clinical operations and executive director of the Medical Center   The Patient Safety Committee will soon release 10,000 copies of the new patient safety brochure that details the rights of patients and family members to partner with their care providers in assuring the safety of their own care. Patients will be asked to report any episodes of care that fall short of what they expect and to ask questions of their providers whenever they are uncertain about the appropriateness of care.   The MUSC Center for Clinical Effectiveness and Patient Safety works actively to anticipate system problems before they manifest, and also adapts processes from other industries to identify and eliminate problems, Smith said.   Stuart Smith indicated that this applies to health care providers as well. “If you are taking care of a patient and see a problem,” he said, “never hesitate to call an attending or whomever you need to address the concern.”   Rosemary Ellis, director of Quality, also speaking at the June 18 communications meeting, urged managers to play a proactive role in safety improvement and enforcement efforts    Ellis gave an example of the proactive approach she is advocating. A reminder was recently issued to appropriate departments regarding the hazard of ferromagnetic pellets in sandbags that come within range of MRI machines. The pellets can become projectiles and can cause serious damage to equipment and humans alike. The Radiology Department responded by investigating the potential use of metal detectors as a part of its protocol.   MUSC is moving forward with plans to implement a computerized physician order entry system to reduce prescription errors, and is also working with national organizations to report errors at other institutions that help to ensure similar problems don’t occur here. MUSC is also partnering with other health care providers and institutions to lower error rates overall.  Organizational Assessment The organizational assessment survey will be circulated in the coming weeks to all employees through their respective departments. “We’re asking for people’s help to fill out this survey,” Ellis said. The survey will focus on several domains to include quality of supervision, work expectations, and clarity of communication.   Ellis pointed to the 1998 MUSC organizational assessment survey that launched a number of improvement initiatives, including: Increased physician representation in key decision-making groups, such as Quality Council and strategic planning retreats. Implementation of an improved performance evaluation system Implementation of a new nursing care delivery model Customer service focus Leadership training Please assist us in getting employees to complete this important organizational survey, as critical elements of the survey will be used to determine the success of our training efforts being performed by the McNair Group. Variance Reports  As part of JCAHO June highlight, Helena Bastian, director of Human Resources reviewed the Medical Center’s full-time equivalent (FTE) variance report. She indicated that each month, directors receive variance reports for which justification must be documented for any variances that fall +/- 10 percent for clinical departments and +/- 15 percent for non-clinical departments.  This report is used to document our staffing effectiveness as well as to serve as a budgeting tool.    A work group is currently involved in making improvements to the FTE variance report and more details will be issued in the near future.   Also, Bastian reviewed the JCAHO’s Competence Assessment Process Review Request Form 2002 which includes a listing of documents that will be reviewed during a survey of personnel files. The listing included the following: Job description Verification of current licensure, registration/certification, when applicable Initial assessment of competency including any skill/competency list(s)  Record of training/education in patient safety, error reporting, and team dynamics Most recent performance evaluation including any skill /competency list(s); age specific competence when appropriate; performance specific skill/competency   Bastian stated that temporary employees need to be evaluated.  She also indicated that the policy and reporting system for temporary employees’ upcoming evaluations will be reviewed for improvements.   If you have questions or comments about the policy, please e-mail Bastian at bastianh@musc.edu.