Currents
At the July 27 communication meeting Joan Herbert, Administrator, Institute
of Psychiatry, discussed the updated 2004 - 2006 tactical plan and methods
to be used to kick off the plan. Since 1995 the Medical Center has used
the tactical planning process as the vehicle for achieving our broader-based
strategic goals.
The updated tactical plan embraces key issues identified at last year's
management retreat, suggestions for improvements brought forward through
the customer service and leadership training sessions and various performance
indicators. The plan focuses on five major objectives (referred to as critical
issues) including: financial performance; provider of choice; employer
of choice; quality and safety; and information management.
For each critical issue there are multiple objectives or initiatives
that are being assigned to work groups. Ms. Herbert explained that to the
extent possible the initiatives will be assigned to previously existing
work groups or committees. The intent is to generate interest and enthusiasm
and to involve a wide range of individuals.
The complete updated version of the tactical plan will soon be posted
on the Medical Center's Intranet and the work group objectives may be viewed
at the end of this article (2003- 2006 Tactical Plan Work Group Objectives).
Periodic updates on progress will be given by the work groups at the communications
meetings and in other forums.
Thank you very much.
Sincerely,
W. Stuart Smith
Vice President for Clinical Operations and
Executive Director, MUSC Medical Center
Compliance alert, JCAHO, tactical plan update
dominate meeting
Reece Smith notified those attending the Medical Center communications
meeting Tuesday that an updated Compliance Alert poster has been issued
to replace the ones currently in use. The new posters are white with a
red border and should replace the current posters that have been in place
since 2001. She recommended that the posters be displayed in staff areas
rather than patient areas when possible. Managers who did not get
replacement posters at the meeting can contact Reece at 792-6128 to get
them.
“We are in our fifth and final year of the hospital’s Institutional
Compliance Agreement,” Smith said to some cheers and applause. “What we’ll
be doing this year is a repeat of last year. It’s the same CATTS format
again, with the exception of five departments: Radiology, Lab, Respiratory
Therapy, Hospital Patient Accounting and Patient Access Service, who will
have department-specific CATTS billing modules.”
She said that with the exception of those five areas, the training topics
will be identical to last year’s. “You’re going to have a HIPAA module,
a billing module and a general compliance module. We expect those to be
up and ready by the middle of August.” She said that an e-mail will be
sent to let the managers know when the modules are ready to be accessed
by employees.
JCAHO
Lois Kerr discussed both the National Patient Safety Goals for 2005
and a new scoring system for self assessment and periodic performance review.
To begin with, two 2004 National Patient Safety Goals have been moved
from goal status to standards. The clinical alarm system is now a standard
and the timeout is now a universal protocol.
National Patient Safety Goals updated:
-
Improve the accuracy of patient identification—no change
-
Improve the effectiveness of communication among caregivers—add, “Measure,
assess and, if appropriate, take action to improve the timeliness of reporting,
and the timeliness of receipt by the responsible licensed caregiver, of
critical test results and values.”
-
Improve the safety of using medications—add, “Identify and, at a minimum,
annually review a list of look-alike/sound-alike drugs used in the organization,
and take action to prevent errors involving the interchange of these drugs.”
-
Improve the safety of infusion pumps —no change
-
Reduce the risk of health care-associated infections—no change
-
Accurately and completely reconcile medications across the continuum of
care —add, “During 2005, for full implementation by January 2006, develop
a process for obtaining and documenting a complete list of the patient’s
current medications upon the patient’s admission to the organization and
with the involvement of the patient. This process includes a comparison
of the medications the organization provides to those on the list.
-
Reduce the risk of patient harm resulting from falls—“Assess and periodically
reassess each patient’s risk for falling, including the potential risk
associated with the patient’s medication regimen, and take action to address
any identified risks.
How to Score Standards
Kerr said that in the Joint Commission Steering Committee meeting last
month they divided up all of the functional chapters and will have teams
working in all of the self assessment areas. She said that the scoring
system for self assessment is available online at the Joint Commission
icon.
2003- 2006 Tactical Plan Work Group Objectives
I. Reduce Costs/ Improve Financial Performance
CRVC – Improve Clinical Efficiencies
1. Identify opportunities for clinical pathway development, facilitate
pathway creation and implementation
2. Identify and pursue opportunities to decrease waste
3. Sustain product/ equipment standardization gains
Utilization Management System
1. Identify best practices
2. Evaluate capabilities of existing and anticipated information systems
3. Determine optimum system components, design, and processes
4. Complete comparative analysis of current versus optimum system
Managerial Controls – (e.g. supply formularies, centralized supply/
equipment purchasing, monitoring of vendor compliance with contractual
pricing, expanded utilization of PYXIS units, “return to work” timeline
management for Workers’ Comp claims, etc.)
1. Evaluate extent and consistency of utilization of current capabilities
2. Identify additional methods/ systems not currently consistently
used at MUHA
3. Evaluate the potential value and associated costs of additional
methods/ systems
4. Recommend additional methods for adoption at MUHA
Shared Services Agreement
1. Carefully review all aspects of shared services agreement with MUSC
2. Articulate performance criteria for functions purchased
3. Design regular performance monitoring and evaluation system
II. Provider of Choice
Customer Service (standing subcommittee of the Quality Council)
1. Monitor results of Patient Satisfaction survey activities and identify
opportunities for improvement
2. Assure that effective action plans are designed and implemented
in relation to identified opportunities
3. Evaluate effectiveness of customer service training programs and
recommend enhancements as indicated
4. Establish cost effective service recovery program
5. Monitor trends in patient complaints, critical events, and litigation
for issues related to customer service improvement opportunities
6. Identify and implement mechanisms to obtain consumer input in service
analysis and planning
Internal Awareness
1. Identify strengths and achievements that differentiate MUHA in the
market
2. Develop an internal communication campaign to raise employee awareness
of strengths and achievements
3. Create plan for developing MUHA employees into effective, positive
community ambassadors to potential patients, referrers and employees.
III. Employer of Choice
Professional/ Career Development
1. Investigate mechanisms utilized within and outside the healthcare
industry to support and provide for professional/ career development that
prepares individuals for expanded responsibilities and/or career advancement.
2. Identify best practices for developing a work force prepared for
career advancement and retention of ‘developed’ employees
3. Analyze costs and benefits of potential development programs and
prepare report of recommendations for administrative consideration
Education/ Competency (both clinical and non-clinical)
1. Review existing systems for orientation and competency verification
for new employees
2. Review existing systems for ongoing education and development for
personnel related to their responsibilities in positions they currently
occupy
3. Identify gaps in our current education/ competency development systems
and design recommended activities to close those gaps
Recruitment/ Retention
1. Define the “ideal employee experience”
2. Review available employee satisfaction assessment mechanisms and
recommend method for use by MUHA
3. Based on identified components of the “ideal employee experience”
identify the greatest gaps between our current employee experience and
the ideal
4. Prepare prioritized recommendations for closing the identified gaps
5. Review existing employee recognition and reward activities within
the organization, as well as externally identified best practices and develop
proposals for revamped internal systems as indicated
6. Identify and implement effective plans for increasing peer respect
and collegiality to foster a culture of “team collaboration”.
Parking
1. Work with Parking Management to assure availability of enough parking
space to accommodate all employees wishing to park
2. Clarify prioritization and assignment logic for current parking
facilities
3. Project parking access needed to accommodate all Medical Center
employees who wish to pay for proximal parking
4. Work with Parking Management to develop and implement a plan to
create sufficient proximal parking to accommodate identified need.
IV. Improve Care (Quality, Safety, Effectiveness)
Clinical Pathway – Development (CRVC)
1. Review comparative benchmark data and identify apparent opportunities
for improved care performance
2. Create teams to investigate identified areas for true improvement
opportunities, develop pathways to address the opportunities, including
ensuring that safety practices are incorporated into pathways and implement
the pathways into practice
3. Monitor initial phases of pathway implementation to assure consistent
practice and attainment of desired impact on patient outcome and cost.
Clinical Pathway – Variance Monitoring
1. Establish processes to monitor ongoing adherence to existing clinical
pathways
2. Aggregate and analyze monitoring data for pathway adherence and
associated patient and financial outcomes.
3. Work with relevant clinical teams to review data analysis, sustain
high performance, implement action plans when variance trends indicate,
and continually strengthen pathways and outcomes over time.
Improvement Processes
1. Identify and implement processes to reduce response time from problem/
opportunity identification to action implementation and evaluation
2. Create a dashboard of key quality and safety performance measures
3. Continue to develop a culture that supports “safety mindedness”
through planned interventions based on periodic assessment
4. Identify and act on opportunities to increase coordination of various
safety and quality improvement initiatives.
5. Evaluate effectiveness of current orientation and training processes
to build basic organizational competency in root causes and failure mode
effects analyses among management team members and ultimately front line
staff
Key Clinical Performance Indicators
1. Identify valid and reliable internal and external data sources
2. Create and disseminate comparative reports to clinical and administrative
leaders for opportunity identification and action
3. Provide resources to support data drill down and analysis
4. Create forums to share success stories and lessons learned
V. Information Management
Automated Systems
1. Evaluate responses to RFP for an advanced point of care clinical
system
2. Select Clinical information system vendor
3. Implement electronic physician order entry
4. Implement clinical documentation system
5. Increase accessibility of knowledge based and decision support on-line
resources
Internal Communication
1. Identify the “take home message”
2. Identify current and innovative mechanisms to disseminate information
3. Enhance use of inter- and intranets to improve hospital-wide communication
4. Provide access to kiosk-based PC’s for staff
5. Define a communication plan, including time lines and continually
evaluate effectiveness of the plan
Krispy Kreme Fundraiser for the
MUSC/MUHA/UMA Military Recognition Day
Glazed doughnuts are being sold to raise money for the MUSC/MUHA/UMA
Military Recognition Day Program (Nov. 10). Purchase a dozen doughnuts
($5 cash) from the committee members below or the MUSC Volunteer Office.
Gift certificates are also available. Sale ends Aug. 9.
Doughnut pick-up: 8 to 11 a.m., Aug. 11, Children’s Hospital lobby.
Call Latonia Allen, 792-1421; Donna Bouissey, 792-1004; Chad Chadwick,
876-8585; Tanis Koester, 852-7075; Katy Kuder, 792-0858; Holly Maben, 792-4674;
Archie Reid, 792-2938; Robert Waite , 792-1070.
The Catalyst, July 30, 2004
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