CurrentsTo Medical Center Employees: At the Jan. 24 communications meeting Lois Kerr, JCAHO manager, briefed the management team on the “Unannounced JCAHO Survey Response Plan.” Details are outlined in this newsletter. All Medical Center employees need to understand their roles and responsibilities. Unlike years past, the 2006 JCAHO survey will be unannounced. We will not know in advance when the survey team will arrive. This underscores our need for “continuous readiness” and an orderly response. On another matter, one of our major goals is to achieve our financial targets, including a 4 percent margin or better for fiscal year 05/06. Ralph Greene, director of accounting, reported to the management team that we are on target for the first six months of the year with an operating margin of approximately $14.6 million or 4.3 percent. We need to achieve our financial target to fulfill our debt service obligations for the new Phase I hospital facility and to meet operating needs (e.g. capital improvements, equipment and payroll). We know that activity and expenses are greater in the second half of the fiscal year. This means that we need to be diligent in monitoring our expenses. Everyone needs to look for performance improvement opportunities to achieve operational efficiencies and cost savings. All business managers need to ensure that invoices are processed timely to enable monitoring of accurate reports. Sometimes we do not feel comfortable in talking about our financial targets in the context of providing excellence in patient care. But, the reality is we have to meet our targets to be successful as an organization and fulfill our mission. Sincerely, W. Stuart Smith Vice President for Clinical Operations and Executive Director, MUSC Medical Center JCAHO Response Plan, financial goals updatedPoint of Care testing manager Nina Epps reviewed details from a December 2005 Abbott Laboratories announcement confirming a medical device correction with their Precision Pcx Point-of-Care Glucose Monitoring System.If the glucose meter is dropped or exposed to excess fluid, the monitor may possibly display incorrect date and time information. Analytic glucose results using this device will display accurately. Results in the hospital information system will reflect an incorrect date and time. Therefore, if a meter is dropped or wet, staff are encouraged to notify their floor care testing team immediately and a replacement will be substituted. Finally, Epps reminded staff that it would be a good practice to continually monitor a meter’s date and time display each time they conduct a glucose test. JCAHO Response Plan Lois Kerr provided an update to the JCAHO Response Plan. Kerr announced that Georgetown Memorial Hospital underwent an unannounced survey beginning on Jan. 23—about four months earlier than expected at their facility. The hospital was last surveyed by JCAHO in May 2003. Kerr’s presentation reviewed MUHA’s 2006 JCAHO Survey Response Plan. To help manage the anticipated confusion that may be connected with an unannounced JCAHO visit, Kerr stressed team readiness and use of a centerwide response plan as key. Confirmation of designated coverage among staff members is critical. Staff who plan to be away from the facility for a full day/shift or longer must provide appropriate designated coverage via Simon Pager, Audix and e-mail. Once JCAHO surveyors are confirmed on site, a pre-prepared page alerting all MUHA personnel will be issued. Employees and staff should not call hospital administration. Any survey updates will be communicated to staff via e-mail. Directors, managers, and supervisors are advised to: place pagers to silent mode; inform staff of survey details as available; prepare area and staff for survey; use Environment of Care (EOC) checklist to ensure area compliance (Appendix A); use frequently called numbers as reference (Appendix B); review generic JCAHO Survey Agenda Info (Appendix C); remind staff of new survey process; be visible and available in your unit/area; remind staff to be prepared to answer questions; ensure unit based staff competency files are accessible; take requested staff competency files to Command Center (Room 224T); monitor e-mail for survey updates; address questions or concerns to Survey Command Center, 792-1845; and develop mechanism to notify department’s interdisciplinary team members regarding surveyor’s visit MUHA staff should: wear MUHA identification badges always; keep area/unit clean; keep hallways clear; doors should not be propped open; keep Walaroos closed; do not leave COWs unattended; remove all staff food and drinks from patient care areas; maintain refrigerator temperature logs; report any environmental issues requiring attention, 792-4571, (identify as JCAHO survey-related request); report any maintenance issues, 792-4119, (identify as JCAHO survey-related request); and be prepared to answer any questions from surveyors. Finally, Kerr encouraged staff to keep up the spirit of partnership and teamwork throughout this time of readiness and preparation. It is important for all MUHA employees to strive to remain compliant to JCAHO standards. The full JCAHO Response Plan will be posted on MUHA’s intranet Web site by Feb. 1. Financial Goals Update Hospital Fiscal Services’ Ralph Greene and Vicki Marsi, chair for the Tactical Plan committee, updated managers on the tactical plan (financial goal) and MUHA’s interim financial statement through December 2005. Greene reviewed the status of MUHA’s move towards achieving direct deposit. As of Jan. 23, only five MUHA employees have not registered for direct deposit. The launch of electronic pay stub information has been delayed until further notice. In his financial statement overview, Greene confirmed that MUHA’s operating revenue had grown. MUHA’s bottom line reflects a positive change in net assets of more than $4 million as compared to the previous year. Operating expenses remain under budget and responsible for driving the bottom line. Interest income and interest expenses have also increased dramatically. Last year, MUHA had only $102 million worth of bonds payable outstanding. As a result of the new hospital’s phase one construction plan, MUHA borrowed approximately $483 million since December 2004. But while we possess the bulk of that money, it is being spent down rapidly each day as construction progresses. Greene reminded the audience that although MUHA may be gaining in income, they are also paying a higher interest expense for borrowing that money. Regarding the Tactical Plan, the operating margin or profitability goal for FY 2006 is currently at 4.3 percent halfway through the fiscal year. The Tactical Plan’s 2006 goal is to achieve a 4 percent operating margin. Greene congratulated managers for their hard work and diligence in helping to meet these positive financial goals. Announcements
Friday, Jan. 27, 2006 |
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