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Currents March 6

To Medical Center Employees:
On Feb. 27 and 28, the management team, including nearly all Medical Center supervisors with responsibility for hiring and performance evaluations, took part in our fifth Leadership Development Institute (LDI). The LDIs involve off-campus exercises designed to train managers to be better leaders and to focus upon our organizational goals. The LDI Team has done a super job of planning, organizing and conducting the LDIs since March 2006. 
 
At the February LDI five leaders were given Pillar Awards for their exceptional accomplishments in exceeding our pillar-based goals. The following individuals received Pillar Awards:
 
Sonja Muckenfuss, director, Children’s Services—substantially increasing patient satisfaction scores for the Children’s Hospital and exceeding the Service Goal;  Angela Raney, manager, Women’s Health Services—substantially increasing patient satisfaction scores for the Prenatal Wellness and OB/GYN clinics and exceeding the Service Goal; Michael Hartley, nurse manager, IOP, 1North & BICU—substantially reducing seclusion and restraints and exceeding the Quality Goal;  Bambi Miller, IDX registration application coordinator—significantly improving collection and denial rates and exceeding the Finance Goal; Debbie Browning, nurse manager, Peds ED & PICU, interim nurse manager, 8D—significantly increasing the Pediatric Emergency Department visits and exceeding the Growth Goal. 
 
Also, clinical and support departments were given quarterly department awards for exceptional patient satisfaction results or for supporting the award winning clinical departments in an exemplary fashion. These departments received banners to recognize their exceptional performance.
 
Departments and respective managers included: Children’s Services & Perinatal Services – 8D – Debbie Browning, interim nurse manager; Support Department – Children’s Hospital Volunteer Services, Christine Messick, coordinator; Adult Hospital – 10E – Kristen Wachsmuth, nurse manager; Support Department – Clinical Effectiveness & Patient Safety, Glenn Richmond, manager; IOP – Behavioral Intensive Care Unit (BICU) – Michael Hartley, nurse manager; Support Department – Dietary – Brad Mastellar, general manager; IOP Outpatient Services – Geriatric (GERO) – Cynthia Dominick, manager; Outpatient Services & Clinics  (On Campus – Pediatrics) – Pediatric Transfusion Clinic, Kathy Sellers, manager; Support Department – Rutledge Tower Ambulatory Pharmacy, Heather Kokko, manager; Outpatient Services & Clinics (On Campus – Adult ) – Hollings Cancer Center Thoracic Surgery Clinic, Rhonda Breland, manager; Support Department – Laboratory Services – Hollings Cancer Center Blood Draw, Pat Wanstreet, manager; Outpatient Services & Clinics (On Campus – Adult) – Gazes Rehab Clinic, Judi Buckman, manager; Support Department – Biomedical Engineering, Stan Trojanowski, manager; Outpatient Services & Clinics (Off Campus) – West Ashley ENT, Dr. David White; Most Improved Service Area  (Overall) – 8D – Children’s Hospital, Debbie Browning, interim nurse manager.
 
Congratulations to all staff and managers of departments that received the awards. See the MUSC Excellence Web site (http://mcintranet.musc.edu/muscexcellence/serviceteams/focus/rewardfocus.htm) for additional information concerning the awards. Next week’s The Catalyst will include additional details.
    
At the LDI we also heard presentations from our Press Ganey representative, Marty Lebbin, and our Studer Group account leader, Don Dean, concerning our Employee Perspectives Survey. Plans were made for managers to roll out the survey results to all departments and to involve everyone in preparation of action plans focusing on areas for improvement.
   
 The administrative team expressed appreciation for the excellent participation rate in the survey. While there are some high performing areas in regards to employee satisfaction, overall we were disappointed in the scores for the administrative team and we are committed to improving employee satisfaction. Improved employee satisfaction will help improve our patient satisfaction and reduce turnover. Plans are to conduct a follow up survey in the future to measure progress after action plans have been implemented.
 
Thank you very much.

W. Stuart Smith
Vice President for Clinical Operations
and Executive Director, MUSC Medical Center

Quality—Providing quality patient care in a safe environment

  • JCAHO/JC update
As of January, the Joint Commission on Accreditation of Hospital Organizations (JCAHO) unveiled a new title change and logo. Now known simply as the Joint Commission (JC), the organization’s new tagline is “Helping Health Care Organizations Help Patients.”
   
The new logo, featuring four triangles, represents the organization’s commit-ment and renewed emphasis to quality performance improvement. Following last fall’s survey, the JC expects the Medical Center to be practicing evidence-based outcomes.
    
Changes to the 2007 National Patient Safety Goals (NPSG) include an addition to medication reconciliation, two new goals and a scoring change to help demonstrate compliance.
    
The 2007 NPSG changes include: Goal 8: Accurately and completely reconcile medications across the continuum of care. (8B) A complete list of the patient's medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete list of medications is also provided to the patient on discharge from the facility; Goal 13: Encourage patients' active involvement in their own care as a patient safety strategy. (13A) Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so; Goal 15: The organization identifies safety risks inherent in its patient population. (15A) The organization identifies patients at risk for suicide (Behavioral Health Care, Hospital [applicable to psychiatric hospitals and patients being treated for emotional or behavioral
disorders in general hospitals]).
 
For more information about NPSG http://www.jointcommission.org/PatientSafety/NationalPatientSafety Goals/.

  • Patient Safety Week, March 4-10
 The 2007 National Patient Safety Week theme, Patient Safety: A road taken together,  relates to medication safety. To commemorate the recognition, a variety of educational displays will be displayed around midday throughout the week at locations including the Main Hospital, Children’s Hospital and Charleston Memorial Hospital. Displays will focus on various medication safety topics related to pain management, resuscita-tion, DVT-deep vein thrombosis prevention, NPSG and infection prevention.
  • Safety culture survey
A new hospital survey on patient safety culture was conducted with staff March 7.
    
Sponsored by the Quality Interagency Coordination Task Force (QuIC), the survey was funded by the Agency for Healthcare Research and Quality. The QuIC was established under a 1998 presidential directive collaborating federal agencies involved in health care services to work together to improve quality care.
 
Results from a previous safety culture survey showed that hospital employees agreed that teamwork contributed to a unit’s continuous improvement towards patient safety. They also affirmed that hospital management was supportive to a work environment that promotes patient safety. Employees also agreed that hospital procedures and systems were effective in the prevention of errors.
  • Miscellaneous
A recent S.C. DHEC report unveiled a recent rise of statewide influenza cases. MUSC still has available flu vaccine. Flu vaccine is a Joint Commission require-ment for health care workers.
 
Beginning this spring, staff will soon have the ability to verify the status of attending physicians and their credentials for providing their services and medical privileges at MUSC. Quality Management and Patient Safety have begun evaluating a15-physician pilot group and will expand to larger groups in coming weeks.

People—Fostering employee pride and loyalty

  • Linkage grid review
Follow up from the fifth Leadership Development Institute event (Feb. 27-28)
 
First assignment: Man-agers are asked to meet with staff to review generational differences. Work groups should work together to identify two techniques that can improve communications with staff. Areas should submit an activity summary using the Leadership Evaluation Management (LEM) tool by April 27.
 
Second assignment: Leaders should schedule staff time to review Employee Perspective Survey results. Individual Work Group Report CDs will be distributed to area directors who will share with managers. Managers are encouraged to use roll-out tools, including a survey tool kit, sample Power Point presentation and Press-Ganey Solution Starters (12 question dimensions/sections), which can also be found at the LDI Web site. Teams should prepare and complete an action plan by April 15 and submit details using the LEM by April 30.
 
Third assignment: MUSC Excellence’s AIDET (Acknowledge, Introduce, Duration, Explanation and Thank You) Managers should develop a department-specific AIDET program and establish a roll-out process by March 17. The complete AIDET Competency Assessment Tool should be entered via CATTS by April 15.
 
Hardwired Project: Staff rounding for outcomes should include rounding on patients, staff and internal customers. Managers are encouraged to continue writing at least two thank you notes monthly and manage up staff and faculty.
 
New leader/supervisor/manager/director informa-tion: All new leaders in the Medical Center are encouraged to attend any of the Medical Center Human Resources’ quarterly management training sessions. David McNair of McNair Associates, is expected to assist with MUHA new leader training.  Current leaders are asked to provide instruction to new leader staff on accessing the MUSC Excellence Web site and LDI reference information in preparation for the next scheduled LDI session.
 
The center’s LDI 6 is scheduled for June 6-7.
  • Education roll-out
March 1 meeting results featured revisions to test request cards and Medication Administration Record (MAR) changes. The request, submitted by Marilyn Jenkins, manager of the Fast Flow Lab/Laboratory Services, asked that the revised test (lab) request cards be used by medical staff in conjunction with the green lithium heparin tubes with gel now required by tests. However, Lab Services will continue to accept the yellow SST tubes until inventory is depleted.
 
Holly Griffin, PharmD, submitted a request to the MAR format. Changes relate to  proper use of bolding and font size of specific words on medications to ensure readability and support safety purposes.
  • HR update
HR policy 33—Hospital volunteers must be at least 14 years old to participate in volunteer programs (i.e. Candy Stripe Program).
 
HR policy 12—Amendment to the MUHA Standards of Behavior (MUSC Excellence) policy. Under the respect, employees should refrain from criticizing MUSC in the workplace, the community and in the presence of our customers.
 
Primary source verification of licensure and registration should be conducted at the time of renewal. Departments are reminded to enter the renewal information via CATTS.
 
Standards of Behavior should be discussed and signed off for all job applicants during the interview process.    
  • Employee news
Sharon Dunning, R.N., has joined the Transitional Care Unit staff as a nurse educator. Dunning comes to MUSC from Atlanta with lots of experience in teaching and nursing management. 
 
Dave Northrup, director of Clinical Systems, Office of CIO, reminded staff of Daylight-Saving Time (begins at 2 a.m., March 11) and how it will affect the GroupWise calendar system. The system will not automatically adjust appointment times. Users are reminded to review their system calendar by March 9 or prior to the change. For more information, visit http://www.musc.edu/infoservices/gw_dst.html.

Finance—Providing the highest value to patients while ensuring financial stability

  • Finance update
Stephen Hargett, MUSC Medical Center controller, updated the management team on the fiscal year financial performance of the Medical Center for the seven month period ending Jan. 31. 
 
Following are selected highlights: For the seven month period, the Medical Center had a net income of $20.6 million or 4.7 percent compared to the pillar goal of 5 percent; This 4.7 percent net income is down from 5.2 percent at the end of December due to a substantial increase in supplies during January; The Medical Center reported an unexpected increase in supplies (volume related). Hargett asked managers to review supply numbers for January.
 
Also, the Medical Center's days cash on hand increased from 35.2 days in December to 39.4 days in January.

MUHA Excellence pillar goal statements
Service—Serving the public with compassion, respect and excellence
People—Fostering employee pride and loyalty
Quality—Providing quality patient care in a safe environment
Finance—Providing the highest value to patients while ensuring financial stability
Growth—Growing to meet the needs of those we serve
   

Friday, March 9, 2007
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 catalyst@musc.edu. To place an ad in The Catalyst hardcopy, call Island Publications at 849-1778, ext. 201.