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Currents To Medical Center Employees: At the July 23 communications meeting Pamela Marek of Decision Support Services asked that departments return to her right away the Healthcare Benchmarking Systems Inc. (HBSI) Action reports. Decision Support Services generates most of the data for the reports but department managers are relied upon to review the reports to ensure for comparison of “apples to apples” and to enter certain information (i.e., defined work load units applicable to the respective service areas).  The HBSI Action reports provide quarterly comparative data to enable benchmarking with other hospitals. The University HealthSystem Consortium, of which we are a member, contracts with HBSI Action (owned by Solucieng) for this service.  HBSI collects data from approximately 450 hospitals including over 50 UHC members. UHC replaced the previous benchmarking system with HBSI Action in 1998. Decision Support Services provides HBSI Action with our data from various sources including the general ledger (revenue and expenses), payroll system (worked and paid hours) and the patient accounting/registration system (discharges, patient days and transfers). The reports enable internal and external trend analysis and provide information to help with identification of best practices and performance improvement.  It’s our goal for the management team and employees to make full use of this valuable information as we seek to continually improve our operations and services.  Thanks to everyone for your attention to our efforts for continuous improvement. W. Stuart Smith Vice President for Clinical Operations and Executive Director, MUSC Medical Center   Graduate Medical Education update “An integral part of being a good physician is exhibiting professionalism in all that one does,” stated Franklin Medio, Ph.D., associate dean for Graduate Medical Education, in his comments to the management team.  “During the last two to three years, the Office of Graduate Medical Education has been diligent in teaching our residents about this serious issue.” The GME Committee, continually reviews mechanisms for assessing residents’ professional behavior and addressing any concerns in this regard.  The current procedure to address any concern regarding a resident’s professionalism consists of the following steps: Speak with the resident directly.  If there is no resolution, discuss the concern with the chief resident and attending physician. Should further attention be required, notify the residency program director and copy the Office of Graduate Medical Education. Final resources for the resolution of the concern would be the department chair and George Arana, M.D., associate dean for Graduate Medical Education and Medio. In order to give residents feedback regarding their work performance, the GME Committee is drafting an evaluation tool. This tool will assist residency program directors and chief residents in providing helpful, objective information to a resident about his/her performance as a health care professional.  These efforts exemplify why the Office of Graduate Medical Education has received two commendations for outstanding efforts in graduate medical education during recent institutional reviews by the Accreditation Commission for Graduate Medical Education (ACGME.) “We are committed to ensuring that any graduate of our program is a welcome addition to any medical staff,” concluded Medio.  Further information regarding the GME program can be found at http://www.musc.edu/gme.  Environment of Care (EOC) Update: Environment of Care/Infection Control Performance Improvement Measures In the Medical Center’s ongoing effort to ensure JCAHO readiness, the management team has been charged with continuous monitoring of the environment in which we provide patient care.  During the last year, directors, managers or their designees have completed a monthly checklist to promote compliance with JCAHO standards. Since its implementation, usage of the EOC/IC checklist has increased from 65 percent to 90+ percent thus yielding better overall compliance and survey preparedness in all areas. Environmental hazard surveillance is performed in a number of ways: Occupational Safety and Health provides a report to EOC committee every one to two months; Security, facility and Environmental services staff assist with identification and resolution of environmental safety issues, the EOC/IC check list is performed monthly by clinical and administrative personnel; JCAHO Mock surveys and other regulatory agency surveys, such as DHEC, JCAHO, CMS, are performed periodically. Results from these survey methods reveal areas where we should continue to focus our efforts. These include: Wall-a-roos—Close wall desks when unattended. Do not “weigh open” with charts or equipment. Corridor obstructions—keep hallways and exits free and clear Compressed gas cylinders—secure at all times. Needle boxes—lowered to comply with NIOSH standards. Avoid placing glove boxes on top of needle boxes, this could result in bloodborne exposure. Extension cords—these are for emergency use only. Food separation—label and separate employee foods from patient foods. Patient Food—date and remove after 3 days.  Refrigerators—keep clean and orderly. Record temperatures and take the appropriate action if the temperature is out of range.  To build on the success of the monthly reporting, the EOC/IC check list will become automated, eliminating the inefficiencies of the paper/scan cards process previously used, while providing an Intranet-based system which will allow for real time recording and reports.  Monthly e-mail reminders will continue to be sent to each department’s EOC liaison.  Managers need to give the name of their staff members who are completing the EOC/IC checklist to Mary Hughes to ensure their access to the EOC/IC report information. If further assistance is needed, contact Mary Hughes at 792-0086 or Mary Allen at 792-5176 Fall Prevention Policy Rosemary Ellis, director of Quality, announced that in keeping with our patient safety efforts a Medical Center Fall Prevention Policy has been developed and is under consideration by the Medical Executive Committee. The policy calls for all inpatients to be assessed at time of admission and on a daily basis for potential risk for falls. Patients determined to be at risk for falls will be given orange identification bands and orange strips will be placed on their doors.  Patients registered in Ambulatory Care clinics (not including diagnostic only visits) will be assessed at the time of their first visit and annually thereafter.     Catalyst Online is published weekly, updated as needed and improved from time to time by the MUSC Office of Public Relations for the faculty, employees and students of the Medical University of South Carolina. Catalyst Online editor, Kim Draughn, can be reached at 792-4107 or by email, catalyst@musc.edu. Editorial copy can be submitted to Catalyst Online and to The Catalyst in print by fax, 792-6723, or by email to petersnd@musc.edu or catalyst@musc.edu. To place an ad in The Catalyst hardcopy, call Community Press at 849-1778.