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Currents To Medical Center Employees: The JCAHO survey is almost upon us and is scheduled for Nov. 17 - 21. I appreciate the hard work that has gone into preparing for the survey. Now is the time for all concerned to take ownership of “eleventh hour” tasks needed to ensure everything is in order. While all details about the survey schedule have not been resolved, we are expecting a five-member survey team. The team will include an administrator (team leader), a generalist who will assist the administrator, a physician, a nurse and a behavioral health specialist. Each day of the survey will kick off with an opening conference with the Medical Center leadership group at 8 a.m. At 8:30 a.m., the survey team members will be individually escorted to patient care units and service areas. The surveyors are expected to spend one and a half to two hours in-patient care units and their visits will likely include consultative sharing of information with staff. The JCAHO survey team will regroup for a conference at 4 p.m. each day and will probably leave the facility at 4:30 p.m. The survey team will return one evening for an unannounced visit. The Medical Center management team will be given a progress report at the end of each day (times to be announced) of the survey in 2 West Amphitheater.  More specific information concerning the survey schedule will be given  to the management team soon for sharing with all employees. Again I very much appreciate everyone’s hard work in preparation for this survey.  I know the JCAHO survey team will be impressed.  Thank you very much. W. Stuart Smith Vice President for Clinical Operations and Executive Director, MUSC Medical Center   15 things to survive  JCAHO survey  Lois Kerr, JCAHO consultant, passed around a large bowl filled with numbers at the Oct. 28 communications meeting and asked those managers who received numbers one through 15 to stand at the front of the room to help her with a presentation.  Each manager was asked to read aloud one of the “15 Things to Survive the JCAHO Survey.”  They are as follows:  Know when they are coming  Know the communication process for your patient care team  Know how employees are oriented to job changes  Know what competency is required for a particular job  Know the practices for confidentiality and privacy  Keep hallways clean and wallaroos closed  Know what to do in a disaster  Know your staffing plan and measures  Know what your team or unit has improved  Know your range dose and first dose policy  Know how and when equipment is checked for safety  Know the medical record documentation requirements  Know your infection control practices  Know the National Patient Safety Goals  Wear your employee identification badge. JCAHO Environment of Care Update Al Nesmith, Safety, Security, and Volunteer Services director, reminded managers that while it is not necessary to know the name of every EOC plan, it was required by JCAHO that each staff member know that MUSC has seven plans. (safety, security, hazardous materials and waste, emergency management, fire protection, medical equipment management, and utility systems plans).  Nesmith reported on the May 14 and Oct. 24 disaster drills and was proud to announce that the disaster response rate for the Medical Center was more than 90 percent. Remote MUSC sites, including Impact, Star West, Behavioral Health, Children’s Day Treatment, and Psychiatry North have all completed the appropriate drills as well. This must also be known by all medical center staff for the upcoming JCAHO survey. Nesmith also said that each remote site received an updated remote site emergency procedure chart in case of fire, violent person(s), and utility failure. The  emergency/disaster performance standard for all medical center employees is to continue your activities, unless instructed to change activities by your supervisor, manager, or director. Nesmith’s hazard surveillance top issues were corridor and hall obstructions, blocked access to emergency and fire fighting equipment such as fire extinguishers and oxygen shut-off valves, and open wallaroos. He reminded those in attendance to review the Medical Center disaster manual available on the Intranet.  MUSC Medical Center to go for Magnet Status Laurie Zone-Smith, Clinical Services Administration, gave a presentation concerning the Medical Center’s efforts to achieve accreditation from the Magnet Recognition Program Award administered by the American Nurses Credentialing Center that recognizes excellence in nursing service. As a magnet hospital, the Medical Center would be viewed as part of the “gold standard” in health care by attracting and retaining professional nurses, interdisciplinary team members and physicians. Focusing efforts on innovations and infrastructure supporting a healthy work environment, healthy nurses, and healthy patient outcomes, MUSC’s application must meet the highest standards of excellence for nursing and should successfully demonstrate how we meet the “Scope and Standards for Nurse Administrators for Magnet Recognition.” Only 88 health care organizations are recognized by the program nationwide, with each hospital exhibiting the core attributes of influential nurse executives, nursing as a professional discipline, administrators value and support nurses, unit level decision making, good communication among administrators, nurses, physicians and other team members, and demonstration of nursing control over nursing practice. Becoming a magnet hospital seems to have an effect on many aspects of the hospital experience for staff and patients, including decreased needle sticks, nurse turnover, work-related injuries and illnesses, and burnout and fatigue, as well as decreased patient mortality, failure to rescue rates, patient shock and cardiac arrest, pulmonary compromise after major surgery, patient falls, medication administration errors, unplanned hospital readmissions, length of stay, and patient pressure ulcers. In addition, Magnet hospitals see an increase in nurse satisfaction with career and current job and nurse ratings of quality of patient care. Currently, MUSC Medical Center is in the initial stage of the accreditation process to become a magnet hospital. On Nov. 1, a letter of intent to apply for Magnet recognition was sent to the Magnet Commission.  Within two years of completing the application, appraisers will review and decide whether or not to conduct a site visit. The appraiser’s report is then sent to the commission, and magnet status will be determined based on the report and the application. All hospital staff are encouraged to participate in Magnet efforts and activities to achieve the goal of recognizing the MUSC Medical Center as a Magnet Hospital. Announcements Cheryl Brian, Occupational Safety and Health, informed managers of a change in the collection of Blood Contamination Sources. Sources will no longer need a fingerstick collection for the HIV Stat. The new procedure will require a two milliliter lavender tube and a six milliliter SST tube. All HIV Stat positive results should be considered as preliminary positive and will be sent to a reference lab for confirmation by Western Blot. If the HIV Stat result is negative, no further HIV testing will be performed.  HIVAB HIV-1/HIV-2 EIA will no longer be included in the Source’s Blood Contamination Profile. The HIVAB HIV-1/HIV-2 EIA test will continue to be used to obtain baseline antibody results for employees and staff when a blood exposure occurs.