November 12, 1998

During the week of November 16 we will be issuing to Medical Center employees an organizational assessment survey. The purpose of the survey will be to identify strengths and weaknesses of our organization based upon employees’ perceptions. The results of the survey will be widely communicated and will be used to determine priorities for improvement. We will also be able to use the survey findings to compare the Medical Center to other organizations since it has proven reliability and validity. The survey will require approximately 20 minutes to complete. It is very important that everyone complete the survey and return it promptly in accordance with the instructions which will be provided.

Recently, Shirley Wilson and Lois Kerr of Wilson, Cunningham, and Kerr Associates visited with us and conducted a mock JCAHO survey. Ms. Wilson and Ms. Kerr have been consulting with us concerning the JCAHO accreditation process since February 1997 and are knowledgeable about MUSC Medical Center operations.

In general, the mock survey went well, and I commend everyone involved for your continuing efforts to fulfill the JCAHO standards. As Ms. Wilson and Ms. Kerr reminded us, the likelihood of a random JCAHO survey is greater since we achieved accreditation with commendation in August 1997. We must revitalize our efforts to keep abreast with changes to the standards and to take measures to ensure that we are prepared to demonstrate at any time how we ensure the standards are met.

W. Stuart Smith, Interim Vice President for Clinical Operations Interim CEO, MUSC Medical Center

Recognition

• Carol Dobos, director, Children’s Services, recognized Susan Beason, nurse manager for Pediatric ICU and 8D, and her staff for winning poster awards at the “Partnerships for Quality Health Care in the New Millennium—Challenges for Pediatric Nurses” conference in Atlanta recently.
• The poster entitled, “Beliefs and Perceptions About Children in Pain” submitted by Karen Rankine, MSN, RN; Francine R. Margolius, EdD, RN; and Yvonne Michel, PhD, won first place in the research poster category.
• The poster, “BEAR” (Baby and Child Education, Awareness, and Resource program) submitted by Susan Beason, MSN, R.N.; Jodie Denemark, BSN, R.N.; Lynn Hadley, M.A., Med; Stephanie Lamy, Med, CCLS; and Karen Rankine, MSN, R.N., won second place in the clinical poster category.

JCAHO Mock Survey

• A JCAHO Mock Survey of the Medical Center was conducted Nov. 5-6 and 9-10 by Shirley Wilson and Lois Kerr of Wilson, Cunningham, & Kerr Associates. The mock survey focused on the areas that would be targeted for a possible JCAHO random, unannounced survey in early 1999.
• Kerr reported that major improvements have been made since her initial visit in February 1997. But, it is easy to become complacent and we must continually focus upon ensuring the JCAHO standards are routinely communicated, monitored and fulfilled.
• Kerr noted that the widespread understanding and involvement in performance improvement is impressive. People seem eager to respond to questions related to performance improvement and to give examples of various initiatives underway. Kerr emphasized a recent update to the JCAHO performance improvement standards which include demonstrated ability to sustain improvements once implemented. She mentioned that our Information Management survey was conducted in a timely fashion, and it is anticipated the Information Management Plan will be updated as needed based upon the findings.
• Kerr and Wilson discussed in detail specific areas where continuous monitoring is needed to ensure compliance to standards. For example, areas which need ongoing attention include: advance directives, nutritional risk assessment, medication use, patient/family education, continuum of care, medical records documentation including verbal orders and restraint orders, medical staff credentialling, infection control and patient rights and responsibilities.
• Other areas which need continuous attention include the exhaustive Environment of Care standards which involve safety (bloodborne pathogen exposures, needle sticks, injuries, etc.), security (criminal activity and security, etc.), hazardous materials and waste, emergency/disaster preparedness, life safety (fire procedures, etc.), medical equipment management, utility systems and the physical facilities in general.
• Wilson urged that all managers keep attuned to the human resources competency assessment requirements. Among other things, she emphasized that any documents missing from personnel files could result in a Type I recommendation. All job descriptions and performance evaluations must be up-to-date and properly signed. (The performance appraisals should reflect the same duties as the job description.) General and service area-specific orientation as well as the initial assessment of competencies must be documented. All licenses and/or certifications required (according to the job description) must be current and on file. Age specific competencies must be documented for employees involved in care or regular contact with patients. Staffing variance reports must be maintained on a monthly and current basis with appropriate comments affixed to the reports.
• It was noted that hospitals which have been distinguished by accreditation with commendation are more likely to be targeted for a random survey around 18 months following the regular survey. This suggests a random survey would be more likely to occur sometime in early 1999.