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Currents Fiscal Year 2001-2002 has been challenging. As the year comes to an end, now is a good time to reflect upon our accomplishments. Among other distinctions, we received the National Consumer Choice Award for the fourth year in a row for our reputation and image in our community. Throughout the year, the Medical Center maintained a consistently high patient census. The strategic planning process for determining alternatives for future new clinical facilities, to include funding mechanisms, remained on track. A final decision for a new hospital location should be made during the upcoming fiscal year. Progress continued with numerous capital improvement projects to improve our current facilities, including the opening of eight new operating rooms. “Patient Safety” was introduced as a third organizationwide priority in addition to “customer service” and “cost control.” Numerous patient safety initiatives were put into motion. A Health Information Security Office was created and committees were appointed to address compliance with the Health Information Portability and Accountability Act (HIPAA). The JCAHO committee structure was reconfigured with the objective of achieving organization-wide continuous readiness. We enhanced our recruitment and retention plan, improved our Affirmative Action Plan and laid the foundation for strengthening our employee training program.  The planning and communication process was completed for the smooth transfer of UMA Ambulatory Care employees to the Hospital Authority payroll this July to ensure compliance with new Medicare reimbursement regulations. Through the support of the S.C. General Assembly and others, Medicaid funding (state match dollars) was not reduced. This provides funding next fiscal year at the current level. We received a favorable audit report indicating a $9 million net income after completion of the first year (Fiscal year 2000-2001) of the Hospital Authority. The Medical Center appears to be on track to achieve a positive bottom line for this fiscal year. The above lists a limited number of accomplishments. Our most significant overall accomplishment has been the day-to-day fulfillment of our mission by providing excellent and compassionate patient care. Thanks to all for a job well done. W. Stuart Smith Vice President for Clinical Operations and Executive Director, MUSC Medical Center Chair, 1999 Trident United Way Campaign Human Resources standards review As part of ongoing efforts to maintain continuous readiness for Joint Commission on Accreditation of Healthcare Organizations (JCAHO), June’s focus is on human resources standards to include variance reports, human resources staffing indictors and vendor competency. Members of the Medical Center Human Resources staff reviewed key standards with the management team at the June 4 communications meeting. In particular: HR.1—The hospital leaders define qualifications and performance expectations for all staff positions. The intent of this standard: A hospital’s ability to fulfill its mission and provide for its patients’ needs is directly related to its ability to provide qualify, competent staff. HR.2—The hospital provides an adequate number of staff members whose qualifications are consistent with job responsibilities. The intent of this standard: Departments provide an adequate number of staff members with the experience and training needed to serve and fulfill the department’s part of the hospital mission. HR.3—The leaders ensure that the competence of all staff is assessed, maintained, demonstrated and improved continually. The intent of HR.3: The hospital assesses staff development needs on a hospital-wide, departmental, and individual level, and uses these assessments toplan continuing staff education. HR.4—An orientation process provides initial job training and information and assesses the staff’s ability to fulfill specified responsibilities. Intent of HR.4: The orientation process assesses each staff member’s ability to fulfill specific responsibilities. The process familiarizes staff members with their jobs and with the work environment before the staff begins patient care or other activities. Human Resources director Helena Bastian challenged the management team to answer several questions, all of which were answered correctly. Who is responsible for (JCAHO) Human Resources Management? All of leadership. What factors do we consider when defining qualifications and performance expectations for staff positions? The Hospital’s mission and values; the case mix of patients served by the hospital or department; the degree of complexity of care required by patients; the care provided by the hospital, including treatment and the technology used in patient care; and the expectation of the hospital, its patients and customers. How do we determine that staff members are qualified to fulfill the job responsibility? Verify education and training are consistent with applicable legal and regulatory requirements and hospital policy; verify individual is licensed, certified or registered; and verify that an individual’s knowledge and experience are appropriate for his/her job responsibilities. How do we determine staffing needs in our departments? Variance reports; services provided in department; staffing indicators; changes in technology or equipment; acuity level; and competency level of staff. How do we assess competency on an ongoing basis? Position description, performance evaluation, identification of specific training needs (new equipment/ increase in errors or deficiencies), identification of departmental or unit-specific annual competencies, review of aggregate data. Does HR.4 apply to contract employees?  Yes, the organization must manage contracted services (human resources) in a manner similar to how we manage employees on our payroll. This includes the need to ensure for documentation of contracted employees’ competencies. Are all departments expected to provide a departmental orientation? Yes, each department is expected to provide an departmental (unit-specific) orientation which will serve to verify that employees are informed of their responsibilities and demonstrate appropriate competencies to fulfill their duties. In July, the activities for continuous readiness will focus on the initial assessment of the documentation system and screening process. Paid Time Off Policy revised Several minor revisions and some clarifications to the Human Resources Policy Manual regarding paid time off (PTO) will be made effective July 1. The changes were presented to the management team at the June 4 communications meeting. Helena Bastian, director of Human Resources for the Medical Center, noted the following changes: Leave Accrual—A sentence was added to section II stating that in order for employees to accrue leave for the month, they must work or be in paid status for a least half of the budgeted full time equivalent hours. This is a clarification of existing policy. Transfer of Leave—Section V was modified to indicate that after July 1, leave cannot be transferred from another MUSC entity to the Authority except in cases of mandated organizational change.  This change has been planned since the Hospital Authority implementation and the planned change was explained in the “old” policy. PTO Cash-in - Section X was modified to eliminate the option to roll PTO funds into a 401(k) or 403(b) due to tax issues and tax calculation problems that occurred last year. Extended Sick Leave (ESL) Credits for Retirement - Section XI was revised since the newly defined contribution retirement plan(s) will not be designed to give service credit for sick leave. According to Katy Kuder, Benefits and Records coordinator, as of July 1, all new hires in “permanent positions” will have a choice of selecting the state’s option retirement plan (ORP) or the state retirement system (SCRS). The ORP plan vendors will be Aetna-ING, Valic, TIAA-CREF and CitiStreet. “This ORP plan is a cash-based system, therefore retirement benefits are determined by the balance in the account and years of service do not apply,” Kuder said. “However, the state retirement plan is a defined benefit plan that is based on a formula that uses sick leave and applies it toward service credit to extend the length of service at retirement.” PTO upon Termination - Section XII has been modified to add the word “retirement.” This is not a change in policy; the word was added for clarification. The revised PTO policy, Authority Human Resources Policy #18, will be available through the Medical Center Intranet.  If you have questions or comments about the policy, e-mail Bastian at bastianh@musc.edu. Meducare using new forms  MUSC has instituted a new form for ambulance transport of non-emergent patients that is designed to be more user friendly, according to Peggy McLawhorn, billing coordinator for Meducare. “This form is only needed for non-emergent transports,” McLawhorn said. “They are not necessary for MUSC inter-facility transports, that is, from any MUSC facility to another MUSC facility.” The form asks for yes and no responses to three key questions, then asks for specific condition(s) that prevent the patient from being transported by means other than an ambulance. The forms, which were revised in April, will comply with requirements set forth by insurance carriers such as Medicare and Tricare. “The form should be filled out by someone who is familiar with the patient,” said McLawhorn. New employees named Kim Gadsden was introduced as the new nurse manager for 10 East. She served as interim manager since Jan. 1, and began officially in May. Gadsden was formerly senior charge nurse for 10 East. Erni Moore was named to the new position of hemaphersis coordinator, starting May 6. She came from the Greenville Memorial Hospital System with more than 25 years of hemapheresis experience. Originally, Moore was at MUHA, and started the program in the late 1970s. Colleen Corish, Clinical Services director for Hollings Cancer Center, made the announcements.