Return to Main Menu

Currents At our March 28 communications meeting, Vivian Gettys,  JCAHO program manager, gave an update on the JCAHO survey process, areas of particular focus and trends. She also announced that the survey of the Medical Center and CMH will be delayed until October. While this delay will give us a little more time for preparation, we must not ease up in our preparation, because there is much work to be done  Recently, the bill to make the technical amendments to the Authority Act was passed by the General Assembly, and it is now awaiting the governor’s signature. The technical amendments strengthen the act by clarifying our exemption from the state permanent improvement regulations, and by stipulating our ability to issue bonds and borrow money. The authority work teams continue to make progress, and we remain on course for the July 1 implementation date. Some changes, although not dramatic, will be made to core human resources policies such as compensation and performance management (including the combined position description/EPMS). We expect the changes will be well received. We also are finalizing a new paid-time-off (PTO) policy, which combines annual leave and holidays while providing for extended sick leave. No one will lose any accrued annual leave, sick leave or holidays. All leave “on the books” can convert to the new PTO plan. The new accrual rates will be based on years of service. Managers will be trained on the new policy beginning April 18 through April 25, and a communication campaign will begin on April 26.  The Me Issues Committee has devoted a great deal of effort in preparing recommendations for the PTO policy. They sought to ensure fairness and employees’ well-being while incorporating key PTO plan elements successfully used by other hospitals, to promote productivity, to reduce unscheduled absences and to offer incentives. I believe the new PTO plan will be well received by many employees. Thank you very much. W. Stuart Smith Vice President for Clinical Operations and Executive Director, MUSC Medical Center Medical Center scheduled for triennial survey by JCAHO in October Vivian Gettys announced that the Medical Center will be scheduled for its triennial survey by the Joint Commission in early October. Charleston Memorial Hospital also will be included in the survey if MUSC and CMH continue to move forward with the integration process. Gettys will send out detailed summaries of experiences from hospitals surveyed this year to all managers and directors. Gettys said to expect the following changes to this year’s JCAHO survey process: Streamlined interview process. More time in patient care areas, observing care, interviewing staff and patients. Medical record review: 2-4 open records per unit; 10 closed records. ORYX data: Interviewers will have MUSC ORYX measures data in hand during the survey process and will want to see how this information is integrated in the performance improvement programs.  Peer review process: Medical staff has responsibility for conducting peer review activities when issues related to an individual’s performance are raised. The survey process will assess how well the peer review process is designed and how well it functions. Type 1 trends for the second half of 1999:  38 percent of hospitals scored below 90 43 percent of hospitals received at least four Type 1s 9 percent of hospitals received no Type 1s Percentage of hospitals that received the following Type 1 recommendations: Initial assessment—40 percent Credentialing—40 percent Assessing competence—37 percent Patient-specific data and information—35 percent Medication use—35 percent Special procedures—restraints— 27 percent Environment of care implementation—24 percent Leadership planning—19 percent Orientation—16 percent Medical staff bylaws, rules and regulations —10 percent The following activities are planned for MUSC survey preparation: Resolve deficiencies from mock survey findings—a list of items with responsible staff has been distributed. Revise documents and policies — managers and directors should update their scope of services documents, including performance improvement and planning information, by May 12. MUSC policies currently are undergoing review and revision. Reinforce staff knowledge—several activities are planned to educate staff about JCAHO-related topics. Alpa Vyas, administrative resident, presented the performance improvement and planning documentation template, which should be added to the scope of services document. Managers and directors should list departmental performance improvement and planning initiatives and goals, and indicate which performance improvement and planning areas each initiative addresses The template will be distributed to managers and directors when it is finalized.