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Currents At our Oct. 19 communications meeting, Vivian Gettys, JCAHO program manager, gave an update on JCAHO issues.  The "hot topics" that we need to fully address and resolve are outlined below. We must have at least one year's documentation at the time of the survey to substantiate that we meet JCAHO standards.  Our next JCAHO survey is expected to be in August 2000.  Managers should focus on the hot topics related to their areas of responsibility, and all employees should be prepared to address questions frequently asked by JCAHO surveyors. In the Oct. 5 Currents newsletter, I shared some highlights from the most recent University HealthSystem Consortium (UHC) patient satisfaction survey. At our Oct. 19 communications meeting, Karen Pellegrin, Ph.D., director of Quality Management, shared additional information about the survey findings as explained below.  Finally, please remember that the Trident United Way campaign runs through the end of October, and time is running out. If you need a pledge form or other information, please contact Katie Gesenhues in the MUSC Development Office at 792-1973 or through e-mail (gesenhka).  Your support will be greatly appreciated.   W. Stuart Smith Vice President for Clinical Operations and Executive Director, MUSC Medical Center Chair, 1999 Trident United Way Campaign JCAHO Hot Topics Signed verbal orders Consent for treatment Advance directives documentation Entries in medical record dated and signed Documentation of restraint and seclusion Safe medication use Interdisciplinary care planning Patient rights and confidentiality Performance improvement process Monitoring and documentation of environment of care plans Staffing plans/variances Age-specific competency requirements Timely annual evaluations Frequently Asked Questions by JCAHO Surveyors  What makes you competent to do your job? What is the hospital's mission, and how do you contribute to it? How do you maintain patient confidentiality? Describe how patients are involved with care. How do your processes provide for coordination among health professionals, services or settings involved in patient care? Describe how your processes promote safe medication use.  Who is responsible for patient and family education, and how is it done? What have you done to improve the way things are done in your job during the last year? What resources are provided to meet your hospital's needs for knowledge-based information? How are ethical issues handled? How do you report patient care occurrences?  Safety-related issues? Infection control issues? What is your role in a fire? How do you handle a chemical spill? What is an example of a utility failure? Where are the oxygen valves located in your q  What is your role in a disaster?  Patient Satisfaction Update Karen Pellegrin reported that we recently received the results of our patient satisfaction survey.  The UHC, of which we are a member, contracts with the Picker Institute to conduct the survey. In both the percent of people rating MUSC "excellent" and the percent who would "definitely recommend" MUSC, the pediatric and adult inpatient ratings were significantly better than the UHC average. In the adult sample, inpatients rated us significantly better than the UHC average on the five dimensions and many amenity items. In addition, adult inpatients rated us significantly better than the non-academic health care organizations in several areas: information and education, childbirth-specific, privacy in room, noise level, temperature in room and meal temperature. Because academic health care organizations typically have lower patient satisfaction scores than non-academic organizations, and because we compete primarily with non-academic organizations, these comparisons are particularly important. The only weakness in the adult sample was that patients reported less satisfaction with the cost of parking relative to non-academic organizations. However, we were no different from the UHC average on this item. In the pediatric sample, we had many strengths and no weaknesses. We were rated significantly better than the UHC average and the Picker average on several dimensions: partnership between family and clinicians, coordination of care, information and education to parents, confidence and trust, and continuity and transition, as well as several amenity items. The Picker average includes academic health centers and non-academic health centers. Pellegrin explained that these results suggest we are doing relatively well in the area of patient satisfaction, but that doesn't mean we can't do better.  Based on high correlations with overall satisfaction, some dimensions can be considered "drivers" of patient satisfaction. We will focus our improvement efforts on these dimensions. For the adult sample, key dimensions include emotional support, information and education, and surgery-specific.  In the pediatric sample, key dimensions include confidence and trust, and partnership between family and clinicians. Because of some limitations of the Picker survey, over the past six months a committee has worked to evaluate other vendors and to make recommendations to the Quality Council. More updates will be provided when a decision has been made. Y2K Message The hospital coordinates its Y2K planning with the university.  Call 792-9526 for more information.