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Currents During the past few months this newsletter has included a great deal of JCAHO-related information in an effort to assist with the preparation process for the survey. The survey is scheduled for the week of Nov. 6. While everyone needs to be properly informed and educated to address questions, we need to “be natural” during interviews. As a surveyor asks questions, we should resist the temptation to interrupt. Let the surveyor finish the question. If a question is raised by a surveyor which relates to a project or work underway, it's alright to say “we are still working on those issues”. . . and then offer a summary of steps being taken. If a question is raised by a surveyor which you do not understand, then ask for clarification. Avoid saying “I don’t know” or “I’m not sure.” If a question involves something out of your area of expertise it’s alright to say that and give a general answer about where to go to find the information. As indicated in a previous Currents newsletter, we should strive for consistency in responses. Once the survey begins, managers, directors and administrators for each area should share information about the kinds of things they were asked so that responses are consistent from one interview to another. We will continue our intense preparation efforts over the next few weeks. Everyone's cooperation is needed. If anyone has questions or issues which remain unresolved, they should be brought forward to the respective manager or director or contact Vivian Gettys at 792-7688. Thank you very much. W. Stuart Smith Vice President for Clinical Operations and Executive Director, MUSC Medical Center JCAHO Preparation Mary Allen, coordinator, Environment of Care, reviewed several important Medical Center EOC policies and various items which are considered “hot topics” with the Joint Commission for Accreditation of Healthcare Organizations (JCAHO).  Policy A-36: Smoke-Free Policy—All Medical Center and Ambulatory Care areas are smoke-free facilities. Smoking is permitted outside in designated areas only. Smoke may not contact patients as they enter and exit buildings. The only exception is if an inpatient cannot leave his or her room. Then, the following criteria must be met: special ventilation installed order on chart from physician meets medical criteria which states the patient must satisfy one or more of the following:  patient is terminally ill patient is mentally ill (Exception: Patients cannot smoke inside the IOP facility) patient’s outcome/treatment would be adversely affected by cessation of smoking Policy A-38: Interim Life Safety Measures—These measures go into place when the fire alarm system is impaired due to system repair or when performing construction. All areas must maintain two (2) exits of escape and staff must be trained on location of exits and rerouting procedures for patients.  Training must be documented. For more detailed information or training sessions, please contact Occupational Safety at 792-3604. Policy A-40: Evacuation Policy—In an emergency, it may be necessary to relocate patients and staff. Staff must know the following procedures: Move horizontally to the next safe zone on the same floor Move vertically only if necessary. Take patients down to the next level. Use stairs. Elevators should only be used as directed by the Fire Chief/Fire Marshall or designee. Should evacuation from the building be necessary, must take patients' charts and medications  Policy A-48: Medical Device Tracking: Use the new form, Medical Device Failure/Occurrence Report, to report medical device malfunction or failure. Any medical device failure resulting in death or severe injury must be reported to Risk Management within two (2) hours. For other occurrences resulting in minor or no patient injury, notify Biomedical Engineering and Risk Management the next working day. The following steps should be taken for failed equipment:  1. Take the equipment out of service and label it as being out of service;  2. Notify Biomedical Engineering at 792-3984 (or the Hospital Service Coordinator);  3. Send the equipment with all attached pieces or parts to Biomedical Engineering.   Policy A-51:  Radio Frequency Emitting Devices —This is the old Cellular Phone policy. It now includes not only cellular phones but also digital phones, walkie-talkies, radios, or any other communication devices. Any work-related device must be approved by Biomedical Engineering. Patients must be monitored for potential radio frequency interference with medical equipment. No personal or non-work related devices should be used in patient care areas. Listed below are eight questions and answers which are considered “hot topics.” Medical Center employees need to know this information. 1.  Who has the authority to shut off medical gases? In an emergency, Respiratory Therapy or Facilities/Maintenance staff may shut off the oxygen valves to the unit as ordered by the area manager. 2.  Who checks fire extinguishers? Occupational Safety checks fire extinguishers monthly using a Bar Code system and maintains this documentation. Occupational Safety also handles the annual inspection for these extinguishers.  3.  What does the sticker on biomedical equipment mean? The sticker means the equipment is in the Biomed inventory and the date reflects when it was last checked. Most equipment is checked annually. Life support equipment (like defibrillators or ventilators) is checked every six months. 4.  What is MSDS? Material Safety Data Sheets. Service areas need to have copies of MSDS on chemicals normally located in the areas. MSDS information is also available through the Internet via the MUSC home page and by calling Occupational Safety at 792-3604 or the Physical Plant Help Desk 24 hours/7 days a week at 792-4119. 5.  What equipment can be in hallways? Only Mayday and isolation carts.  All other items must be in immediate use with a staff member present or it must be relocated out of the corridor. 6.  What needs to be on the refrigerator/freezer log? All refrigerators/freezers with patient foods, specimens or medications must be checked daily. The log must show the month/day/year and temperature reading. A statement explaining corrective action taken must be noted if the temperature falls out of the normal range. 7.  What is our fire plan? Remove the patient; Close the door; Pull the fire alarm; Call operator (792-3333)/(CMH or McClennan-Banks (953-8333)/off-campus clinics (911); Fight the fire; Remove all items from hallways and know where to move patients if needed. 8.  How do I report a work-related injury or exposure? Complete the Workers' Compensation First Report of Injury form. Contact your Employee Health Services provider. Medication Usage Paul Bush, director, Pharmacy Services, presented a number of questions and answers pertaining to medication use. The questions and answers were distributed to management and  nursing staff to assist with JCAHO preparation. Copies are available through Vivian Gettys at 792-7688. Bush emphasized that medication safety is a top priority at MUSC. Interdisciplinary Plan of Care and Information Concerning Other Policies Vivian Gettys, coordinator, Hospital Clinical Accreditation and Standards, highlighted the Interdisciplinary Plan of Care. Its purpose is to promote a collaborative, interdisciplinary approach to coordinate care and planning to meet patient care goals and achieve optimal outcomes. She reviewed the Patient Data Base-Interdisciplinary Plan of Care (PDB/IPC) documentation process used to identify patient care needs and intervention. All members of the health care team are accountable for documentation of problems, interventions, and resolutions in the interdisciplinary plan of care.  Gettys also distributed a packet of information which outlines each of the policies and information mentioned in this issue of Currents as well as information on patient/family education, patient confidentiality, customer satisfaction and grievance policy, and medical center wide security. For more detailed information, you may contact Gettys at 792-7688. Forensic (Correctional) Staff Education Paul Moss, manager, Medical Center Security, reviewed the key elements of the Prisoner Security policy which address the JCAHO standard concerning education of forensic (correctional) staff. Policy A-53: Prisoner Security Prisoners brought into Medical Center for treatment must have security coverage by responsible escort agencies. Escort agencies retain responsibility for prisoners during treatment. Prisoner patients enter via Emergency Department. A wheelchair is provided and prisoner restraining devices are covered with a sheet. Escort guard provides the following information at the Emergency Department entrance. type health services requested physician or clinical services area providing care prisoner’s risk status Escorts receive annual briefings on Medical Center policy including: when escorting a prisoner who is suspected or known to have tuberculosis (TB), personal protective equipment (PPE) is required. Remain within the prisoner's room. To ensure safety of staff, leave prisoner's room only when relieved or on request by physician or other appropriate health care provider. When requested to leave the room, always maintain visual contact with the prisoner to preclude escape attempts. Exclusion from Patient Care Betts Ellis, administrator, Institutional Relations, highlighted the Exclusion from Patient Care policy which addresses a staff member's request not to participate in an aspect of patient care which conflicts with the employee’s cultural or religious beliefs. Policy C-46: Exclusion from Patient Care—An employee may be excused from participating in care which conflicts with cultural or religious beliefs such as: handling of blood products, abortion and withdrawing of life support. Patient care will not be compromised. The employee must inform the manager in writing of specific aspects of care which conflict with beliefs or convictions. Refusal to provide care when the written request is unjustified will result in disciplinary action. Requests are to be resolved through administrative channels when necessary. MUSC Network Account Password Dave Northrup, director, Healthcare Computing Services, CCIT, announced that there has been a possible compromise of MUSC Network Account (MNA) passwords.  Although the passwords were encrypted, a file containing the passwords was inadvertently transferred over the public internet. MNA passwords control access to many university network resources including PPP, IMAP E-mail, MUSC Library resources, and many web-based applications. It does NOT control access to Groupwise E-mail, SmartStream, ClinLan, Keane, or Oacis. As a precautionary measure, it is advised that you consider changing your MNA password. Instructions for changing your password can be found at http://www.musc.edu/mna/password. If you have any questions or need further information, you can contact the CCIT Help Desk at 792-9700. Announcements Ethics cards were handed out to the management team for dissemination to employees. Additional cards are available by contacting Janet Browning at 792-1208. TB Testing: Every Tuesday and Thursday from 2 - 3 p.m. through October the TB satellite desk will be open in the lobby of the Children's Hospital. Any nursing staff willing to volunteer to place intradermal TB skin tests are asked to call Jodell Johnson at 792-4308.