January 26, 1999

The KPMG consulting firm presented a report, “Strategic Policy Assessment of Restructuring Options for MUSC,” to the state’s Performance Audit Steering Committee, chaired by Lt. Governor Peeler, on Jan. 26. A number of MUSC Board of Trustees members attended the Jan. 26 meeting.

We shared the highlights of the KPMG report, as presented to our board in October, in an earlier issue of Currents. The report concluded that MUSC has four options to consider for the Medical Center’s organizational structure and governance, including: maintain the status quo; seek regulatory relief (i.e., target state regulations from which the Medical Center needs to be exempt); form a public benefit corporation (i.e., an independent public state entity); or become a nonprofit organization.

KPMG recommends that the Medical Center restructure into a public benefit corporation or pursue the regulatory relief option. These changes would help us achieve increased flexibility and autonomy to enable us to respond to the demands of our health care market and reduced federal funding.

The KPMG consultant explained that the various issues associated with the options presented need to be carefully considered to determine the best course of action. Lt. Governor Peeler appointed a subcommittee to examine the options and report back to the full Performance Audit Steering Committee.

We expect that our Board of Trustees will continue to evaluate the restructuring options as we move forward. The decision-making process will take time. Whatever the outcome, we intend to ensure the best results for all Medical Center employees while fulfilling our organizational goals.

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

Communications Meeting Canceled

• Lisa Montgomery, administrator of financial services, noted that there will not be a communications meeting on Feb. 2.

JCAHO Preparation: Clearing the Halls

• Mary Allen, R.N., environmental quality control coordinator for Safety and Security, stressed the importance of clearing all hallways and corridors in order to prepare for a possible JCAHO random visit. Please do not leave carts, monitoring equipment or beds in hallways or elevator lobbies. Mayday carts are allowed in hallways as long as they do not block fire exits or equipment.
• Since storage space is limited, all unused, broken, old or outdated equipment or furnishings should be sent to surplus. All items must be accompanied by a property and equipment activity form, also known as a PEA form. q Items without asset tags may be taken to the first floor of Children’s Hospital by 10 a.m. every Friday for automatic pick-up by movers. Please attach the PEA form.
• Items with asset tags need the following information:
• All items listed on the PEA form.
• Legible signature.
• Department name and cost center number.
• Room number where the equipment was housed.
• Contact phone number.
• Contact person to notify when the items are picked up.
• Call 747-0453 or fax the PEA form to the movers at 554-7222 to arrange for pick-up on the unit. Keep the original PEA form.
• PEA forms are forwarded to fixed assets so that items can be cleared from your inventory. Please contact Allen at 792-5176, on pager 1-1842 or e-mail (Allenmc) for additional assistance.

JCAHO Preparation: Staffing Needs

• Vivian Gettys, JCAHO program manager for the Medical Center, reviewed the JCAHO human resource standards associated with staffing. When planning for staffing needs, the Medical Center must provide an adequate number of staff members whose qualifications are consistent with their job responsibilities.
• Gettys outlined the following considerations in determining staffing needs:
• Medical Center mission—patient care.
• Case mix of patients and the degree of complexity of care.
• Care provided by the Medical Center.
• Technology used in patient care.
• Expectations of both internal and external customers/professional standards.
• Gettys reminded managers that department leadership is responsible for staffing. All departments must determine staffing needs. Gettys noted departments should regularly evaluate current staffing in order to project staffing needs. Each department conducts an annual review, which is tied to the budgeting process, to update staffing plans.
• Gettys presented the following information about the FTE budget variance report:
• Refers to actual staffing levels by occupational code versus budgeted levels.
• Established thresholds for variance: 10 percent clinical, 15 percent nonclinical.
• Justification/comments included when outside thresholds.
• Laurie Zone-Smith, R.N., MSN, manager of special projects for Clinical Services, and John Franklin, director of Support Services, shared examples of how clinical and nonclinical departments use staffing reports and other data to make adjustments in staffing levels as needed.
• Gettys led two teams of managers in a round of “JCAHO Trivial Pursuit” to review the following JCAHO random, unannounced survey focus areas: medical staff credentialing, patient assessment, medication use, environment of care, improving organizational performance and human resource planning. A flier has been distributed throughout the Medical Center that outlines the focus areas. If chosen, the Medical Center can expect a random, unannounced JCAHO survey sometime before mid-April 1999.
• Gettys offered the following compliance tips for the six focus areas:
• Medical staff credentialing: The surveyors want to see that information about previously successful or pending challenges to any licensure or registration, or the voluntary relinquishment of licensure or registration, is requested in the process for appointing or reappointing personnel and renewing and revising clinical privileges.
• Patient assessment: Surveyors want to see that history, physicals and other screening assessments are completed within 24 hours of inpatient admission. Additionally, it is important that pre-anesthesia assessments are documented in the patient’s medical record.
• Medication use: The Medical Center policy must address how medication and emergency medication is controlled. It is important to regularly spot check medication controls in units and remote locations to make sure medications are controlled, secure and follow established policies and procedures. For emergency medications, make sure crash carts and drug cabinets are secure. Keep records of inspections of medications in crash carts and drug cabinets.
• Environment of care:
• Waste and sharps containers shouldn’t be overfilled.
• Carts and equipment shouldn’t be stored in hallways or patient care areas.
• Doors shouldn’t be blocked or wedged open.
• All areas should be clean, clutter-free and smoke-free.
• Inspection stickers on equipment should be dated and current.
• Signage such as exit signs and evacuation routes should be visible.
• Clean and dirty linen should be separated and appropriately covered.
• Improving organizational performance: The surveyor will want to see how the Medical Center conducts intense analysis when a potential problem has been identified. The JCAHO standards require intense analysis of significant medication errors, all significant adverse drug reactions and all confirmed transfusion reactions. Intense analysis includes a root cause analysis of sentinel events, significant adverse events associated with anesthesia use, and major discrepancies, or patterns of discrepancies, between preoperative and postoperative diagnoses.
• Human resource planning: The surveyor will want to see how the Medical Center monitors staffing levels. Additionally, personnel files may be reviewed to assure that all appropriate regulatory licensing and legal requirements are met, including: education, training, licensing, certification or registration, and appropriate knowledge and experience for assigned responsibilities.