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Currents Preparation continues for the JCAHO survey scheduled for the week of Nov. 6. We have been advised that JCAHO surveyors have shifted their focus more to staff interviews than in previous years. The surveyors will be looking for some form of consistency with information obtained in the leadership interview and responses from other employees throughout the organization.  The survey team will be looking for evidence of how we all understand and apply within our respective areas the tactical plan, goals, policies and performance improvement program and priorities.  Listed below are examples of questions which could be asked of any staff member. Although these issues will be formally addressed in the leadership interview, it is the expectation of the survey team that knowledge of these items is not limited to our management team. Most recently we have been informed by the JCAHO that the survey will include an off-hours visit for a period of four hours. This underscores the need for everyone to be prepared. On another matter, our Board of Trustees will be meeting on Oct. 12 and 13. I will share the highlights of the Board's me W. Stuart Smith Vice President for Clinical Operations and Executive Director, MUSC Medical Center Information Management Survey Results Christine Lewis, manager, Coding and Record Processing, and Dave Northrup, director, Healthcare Computing Services, CCIT, highlighted the JCAHO standards for information management and presented the results from the Information Management Survey conducted recently. Lewis outlined the four types of information included in our Information Management Plan including: patient specific data, aggregate data, knowledge-based data and comparative data. This information is used to make decisions and improve patient care and operations.  Northrup shared a summary of the recent information management survey which served to assess information needs. Based upon 153 responses received, the electronic medical record remains as the top priority, followed by decision support services (Trendstar), integration of systems, research capabilities, outcomes management, and stability of systems. The survey results indicated the overall effectiveness of management of information has improved. The survey results are a part of the Information Management Plan. The plan is accessible through the MUSC Intranet site <http://www.musc.edu/medcenter/policy/implan/imindex.html> If you have any questions or need further information about the survey or the Information Management Plan, you may contact Northrup at 792-6675.  Conscious Sedation Policy Update Marilyn Schaffner, director, Digestive Disease, Medicine and Oncology, presented the updated Conscious Sedation/Analgesia by Non-Anesthesiologist policy (MUSC Medical Center Policy No. C-44). The purpose of the policy is to ensure that moderate sedation/analgesia (conscious sedation) is administered by qualified practitioners, under the supervision of medically licensed members of the Medical or House Staff appropriately privileged to do so, and to ensure provision of a uniform standard of care. Updates to the policy include: Adopting the JCAHO definitions; Credentialing: M.D.s and APNs; Guidelines for dosing Review of: Nursing competency; Requirements for moderate conscious sedation/analgesia (nurses—responsibility unless noted): consent (M.D. responsibility), documented assessment of patient using the Conscious Sedation/Analgesia Documentation Tool, history and physical (M.D. responsibility), Aldrete score, and monitoring of patient; Reporting adverse events associated with conscious sedation (updated form) The policy can be accessed through the MUSC Medical Center Policy Manual which is available through the MUSC Medical Center Intranet Web site. You may contact Marilyn Schaffner at 792-7821 if you need further information. JCAHO Leadership Questions and Answers Lois Kerr of Wilson, Cunningham, and Kerr Associates, reviewed the following general leadership questions that can be asked of any Medical Center employee: Describe your hospital's planning process and its relationship to the mission statement. The mission statement serves as the starting point for the Medical Center's two-tiered planning process including: Clinical Enterprise Strategic Plan; Tactical Planning Cycle How do you coordinate administrative and clinical decisions for patients under legal or correctional restrictions?  Policy A-53: Prisoner Security; Policy A-52: Medical Center-Wide Security; Policy A-54: Provision of Special Security for a Patient How do you communicate the hospital's mission, vision, and plans to all hospital and medical staff? Tactical planning groups; Management retreats; General orientation presentation by Executive Director; Name badge attachment; Posted in clinical and support areas How do you ensure that patient care services relate to the identified needs of your patients? Trident United Way Community Needs Assessment (Tri-County); Environmental assessment How do you establish priorities for performance improvement?  Functional/organization-wide priorities (“C2”) are established through tactical planning initiatives, which are linked directly to the strategic plan. The Medical Center also focuses on several care management/clinical priorities:  Customer service Cost reduction Medication processes Cesarean section rates Medical records OR efficiency Discharge planning Pneumonia Obstetrical care in the ED Pain management Adult ventilator days If clinical practice guidelines are used, how do hospital leaders identify or set criteria to guide the selection and implementation of the guidelines? Patient case types with high volume, or low volume but high risk or high variability with LOS or charges may be selected as populations for development of clinical pathways. Other considerations for pathway development may include recently developed evidence-based guidelines, HCFA or JCAHO priorities, or data related to benchmarking studies with other organizations. What structures exist to support patient rights?  How are staff made aware of them? Policy C-9: Customer Satisfaction and Grievance; Policy C-1: Patient Rights and Responsibilities; Ethics consultation service; Ethics committee; Patient information booklet; MUSC Medical Center New Employee Orientation Information booklet (Policy C-1 included); Patient rights information placed in key areas; Admissions process How are you involved in ensuring that billing, marketing, admission, transfer, and discharge practices are conducted in an ethical manner?  Policy A-67: Compliance; Compliance Training; Policy A-62: Code of Ethical Behavior  How do you address the issue of conflict of interest? Policy A-62: Code of Ethical Behavior  What types of aggregate data do you have available to support patient care and operations decisions? Examples include: UHC Data; HBSI Data; Daily HSC reports; Monthly budget reports How do you ensure that the competence of all staff members is assessed, maintained, demonstrated and improved on an ongoing basis?  Annual competency assessment; Human Resources file audits; Human Resources Policy 5: Competency Assessment and Maintenance; Human Resources Policy 16: Performance Management What is your approach to measuring, assessing, and improving the performance of important functions? FOCUS-PDCA: Find a process to improve; Organize a team; Clarify the process; Understand the process; Select improvements; Plan the study to test improvements; Do/implement the plan; Check/study the results; Act on the findings How do you determine the organization's approach to the use of restraints in the care of nonpsychiatric patients? Policy C-22:  Restraint and Seclusion  Describe your organizationwide performance improvement initiatives. “C2”— Customer Service and Cost Reduction