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Currents To Medical Center Employees: JCAHO standards emphasize documentation of staff competencies. One of the key competency measures is the performance evaluation document. The JCAHO survey records review process is “unforgiving” when overdue evaluations are found. We know that some JCAHO surveyors will not consider an evaluation as properly conducted if the record indicates an evaluation was overdue when completed.  Last year we revised the performance evaluation policy (Employee Performance Management System) language to indicate that evaluations should be conducted within 45 days before or after the annual review date. Our intent was to build some leeway in the policy language enabling us to avoid a survey violation if an evaluation is  “slightly overdue.” However, for internal tracking, we continue to consider the “due date” as the end of the one-year evaluation period. We do not want managers to make a practice of waiting 45 days after the one-year evaluation period to complete the evaluation. Records indicate that some improvement has been made in the rate of overdue evaluations in recent months. Approximately four percent of the Medical Center’s performance evaluations for employees in “permanent positions” were past due as of January 2003. While most are past the one-year evaluation anniversary date by less than 30 days, some are excessively overdue. (Any evaluations excessively overdue need particular attention to resolve any system issues or communication breakdown problems).  Our 4 percent overdue rate might be acceptable for some public agencies, but this overdue rate could fall short of meeting the JCAHO standards. All supervisors with responsibility for conducting performance evaluations are asked to be diligent with timely completion of evaluations. The report on evaluations due is periodically issued to managers and soon will be available through a new web-based system (IWR). Anyone with questions about the report or the new system should contact Jane Smith (792-2805/e-mail smithjan@musc.edu). Thank you very much. W. Stuart Smith Vice President for Clinical Operations and Executive Director, MUSC Medical Center STAR Productions presents ‘Sleeping with the Enemy’  Sheldon Weinstein, Social Work manager (medical center), and Nancy Draffin, Ambulatory Care Social Work Services (UMA), presented the JCAHO standards concerning abuse and neglect during the Feb. 4 communications meeting.  “The reason that abuse and neglect is so prevalent in our society is because it goes on in secrecy,” Weinstein said. “That secrecy can be broken down here at the medical center because we have opportunities to look into patients’ lives and situations.” After showing a clip from the Julia Roberts movie “Sleeping with the Enemy,” which detailed the main character’s tale of domestic violence, Draffin and Weinstein outlined JCAHO standards regarding the identification and reporting of abuse and neglect. The C-7 Policy states all licensed healthcare professionals (including physicians, nurses, social workers, mental health professionals, teachers, and law enforcement) are responsible by South Carolina law to report concerns, suspicions, or actual events relating to abuse and neglect to a social worker. If the event takes place outside an individual’s work area, such as a parking garage, Public Safety should be contacted. Sanctions exist for mandated reporters who suspect abuse or neglect and do not report it, including a $500 fine, six months in jail, or both. Weinstein and Draffin highlighted the difference between abuse and assault; assault consists of a violent interaction with someone other than a parent or caregiver and abuse consists of an interaction with a parent or caregiver. South Carolina law does not mandate reporting of assaults such as domestic violence without the consent of the victim. MUSC Medical Center must distribute cards in all common areas, like waiting rooms, detailing methods for patients to access all kinds of protective services and medical center staff must assist patients should an individual need help. Currently, the medical center educates employees concerning abuse and neglect via orientation, CATTS, and departmental orientations. The policy for abuse and neglect may be accessed on-line in the policy manual and includes hyperlinks to SC laws, SCAN manual, reporting forms, and resource links. Announcements Rosemary Ellis, Quality director, named Dawn Huggins as the new Risk coordinator for the medical center. Duggins replaces Margie Petko who recently accepted the 4 Eye Observation nurse manager position.  According to Vince Dibble, Infrastructure Services director, the telephone directory infused with outdated data is in the process of being updated. He told managers to look for update requests soon and asked them to return the requests as soon as possible.   “We are revamping the entire system. A new database has been developed and a completely new front end or web page is being built. The old system will be thrown away,” he said. The telephone update project will augment other initiatives to improve telephone billing and employee information.  Susan Carullo, Compensation and Employment manager, announced the “Fishing for Stars” incentive to recruit experienced nurses in understaffed areas like 8 East, 8 West, 6 East, 6 West, and 10 East. If a current medical center employee recruits a nurse, he or she will be eligible to receive a $2,000 bonus. The new employee must take a permanent position working 24 hours a week. The program begins Valentine’s Day and ends April 5. For information, contact Carullo at 792-1684.  Michael Irving, Patient Care Systems manager, told managers about a naming contest for the computerized clinical documentation process.  Name suggestions can be made at http://www.musc.edu/medcenter/clindocname.html before the closing date of Feb. 21.