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Currents To Medical Center Employees: Final preparations are underway for the JCAHO survey of the Medical Center scheduled for Nov. 17 through 21. A substantial amount of educational material concerning the standards and the Medical Center’s policies and practices to fulfill those standards has been issued. The Medical Center Intranet (see http://www.musc.edu/medcenter/JCAHO) provides easy access to a wide range of helpful material. Also, since July, I have issued a weekly, electronic JCAHO educational packet to all directors for sharing with staff.  Finally, several weeks ago a “hard copy” MUSC Medical Center Information Handbook was disseminated to all employees to enhance understanding of policies, procedures and resources that help us with fulfilling the standards. The JCAHO survey team will devote a considerable portion of their survey time in patient care units to interact with staff and examine open records. Their presence in the service areas will provide opportunities to demonstrate our customer service attitudes, enthusiasm and competencies.  Among other things, it will be important that we demonstrate knowledge of the six National Patient Safety Goals including: improve accuracy of patient identification, improve communication effectiveness among caregivers, improve safety of high alert medications, prevent wrong-site, wrong patient, wrong procedure events, improve the safety of infusion pumps and prevent free-flow, and improve the effectiveness of clinical alarms. We also need to be knowledgeable of specific practices adopted by the Medical Center to fulfill these goals.  Details concerning our initiatives to meet the patient safety goals can be located in the MUSC Medical Center Information Handbook and the Medical Center Intranet. Also, a laminated card for attaching to the identification badge that highlights the patient safety goals and the IMPROVE PI model was issued several months ago. Anyone who needs this card can call 792-8533 or e-mail DeVeauxA@musc.edu. Thank you very much. W. Stuart Smith Vice President for Clinical Operations and Executive Director, MUSC Medical Center How to use IMPROVE model in compliance with JCAHO Judi Bucknam, Otolaryngology clinical coordinator, presented an example of how the IMPROVE model was used in her unit to managers and directors.  The IMPROVE model was implemented in conjunction with JCAHO compliance and stands for the following: Identify the problem or opportunity, Measure it, Problem Analysis, Remedy the cause, Operationalize the plan, Validate the effectiveness of the intervention and Evaluate for sustained improvement in the process. First, Bucknam and her colleagues identified a problem within their unit, namely, lack of documentation when nurses conducted patient education. An opportunity arose to improve involve-ment of patient in their care, communication among the disciplines, and to improve patient outcomes through standardized forms. Next, to measure the problem, Bucknam created goals of 100 percent documentation compliance, improved re-sponse to medical record audit question nine, positively impact responsed to Patient Satisfaction Survey questions nine and 10, and improved patient outcomes through standardized teaching. During problem analysis, Bucknam noted that charts were not accessible to nurses for documentation, quarterly medical record audits were only 75 percent completed, and monthly Patient Satisfaction Surveys yielded lower scores then Ambulatory Care benchmarks. In remedying the cause of the problem, Bucknam suggested designing standard-ized, population specific pre-printed forms, educating and training nurses and physicians regarding those forms, revising forms to reflect current practices and grant nurses initial access to the forms. During operationalization of the plan, Bucknam’s scope of change included promotion like colorful posters to inform the staff of the changes, incorporating the opinions of leaders, obtaining approval through the MUSC forms committee, inservicing staff including nurses, physicians and other disciplines, piloting the forms for two weeks and auditing the pilot, making revisions as needed, distributing the forms to all staff, and a final implementation of the new forms with all specialties in September 2003. Validating the effectiveness of the intervention entails monitoring any changes by graphing chart audits monthly and comparing those findings with last year’s audits, as well as graphing and monitoring Patient Satisfaction results. In terms of sustained improvement, Bucknam plans to monitor the process in 30, 60, and 90-day intervals, then quarterly, then 6-month and yearly intervals. She will also conduct random audits annually with assistance from Patient Education Committee members, monitor nurse teaching competencies through OCCE # II questions B&C, and poll nurses regarding chart accessibility and improved process. Bucknam said the IMPROVE model taught her several things, including increased understanding of the IMPROVE process, the Forms Committee process and form criteria, how to obtain data, that involving staff directly in a process change yields positive results and compliance, and the literature review she conducted supports the concept of standardization in teaching staff new processes. McNair Consulting asks Medical Center to celebrate! David McNair, McNair Consulting Group, asked managers to give themselves and their staff credit for nearly reaching the goal of 95 percent in patient satisfaction. This places the Medical Center in the top 10 percent of hospitals that track patient satisfaction. Improvement of patient satisfaction has been on a steady incline for the past year, with projected numbers demonstrating that patients are leaving the Medical Center feeling better and excited about their care, and in many cases, prompting them to tell family and friends about their good experience. McNair congratulated everyone and reminded those in attendance that reaching this level is definitely worth celebrating, as much time and effort has been placed in achieving patient satisfaction goals. Human Resources Update: “Focusing on HR Processes” Susan Carullo, Medical Center Human Resources manager, said at a recent meeting and focus group consisting of Medical Center staff and consultants, managers submitted approximately 40 recommendations and currently, 27 have been implemented or are on the way.   According to the management group, Medical Center HR is viewed as doing many things well, such as Internet advertisement, posting job openings in professional periodicals, the general orientation process, and the new management orientation process. Room for improvement was cited concerning timeliness of the posting process, the application and hiring process, recruitment initiatives, and scheduling physicals. Concerning the posting and application process, the implementation of the PeopleAdmin system has reduced posting “wait time,” eliminated the paper trail and loss of paper applications, increased the applicant pool and enabled the applicant to manage his or her application and apply for more than one position at a time. For the interviewing and hiring process, management orientation helps managers with their own hiring processes, as well as providing a review of interviewing questions and techniques, and introduces the interview rating scale/grid. Also, HR will continue to present special training sessions on specific topics as they arise. Recruitment and retention processes are improved through ongoing salary surveys and market analysis, increased career fair attendance, participation in elementary and high school outreach programs, and participation in the SCHA mentoring program. Some of the Medical Center’s future improvements include enhanced HR interview training to incorporate behavioral and cultural questions, increased focus on hiring the “right person” for the job, more communication about the Medical Center’s expectations of applicants during the interview process, streamline the APPLE/PEAR process, e-postcards and digicards for applicants, a benefits section in the management orientation, continued work with recruitment and retention efforts, and continued promotion of the Medical Center within the community. Announcements Chris Kerrigan, Trident United Way president, talked to managers about the Trident United Way and its philanthropic efforts, including home-delivered meals, after-school programs, and its partnership with MUSC to work on making sure every child in the Lowcountry has a “medical home,” meaning that children in this community should have primary care physicians and should not rely on the emergency room for primary care visits. He thanked the managers and staff for MUSC’s past participation and encouraged attendees to donate and to ask staff to donate to TUW again this year. Kerrigan also mentioned the new hotline number, 211, as an excellent resource to call for help of just about any kind, excluding emergency services associated with 911. For more information, visit http://www.tuw.org. Pamela Marek reminded managers of an Action O-I Web training course offered in the Computer Training room 220 in the Clinical Sciences Building. The training takes about 20 minutes per person and the room is equipped with plenty of workstations. Sessions will be held from 8:30 a.m. to 12 p.m.  Oct. 29 and  from 1 to 4:30 p.m. Oct. 30. Third quarter data must be entered by Oct. 31. For more information, contact Marek at 792-8793 or Clay Owens at 792-1701. Catalyst Online is published weekly, updated as needed and improved from time to time by the MUSC Office of Public Relations for the faculty, employees and students of the Medical University of South Carolina. Catalyst Online editor, Kim Draughn, can be reached at 792-4107 or by email, catalyst@musc.edu. Editorial copy can be submitted to Catalyst Online and to The Catalyst in print by fax, 792-6723, or by email to petersnd@musc.edu or catalyst@musc.edu. To place an ad in The Catalyst hardcopy, call Community Press at 849-1778.