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Currents To Medical Center Employees: This past year we kicked off our continuous JCAHO survey readiness campaign.  Continuous readiness should enable us to avoid an eleventh hour rush job in preparing for our expected November 2003 survey, and it serves to prepare our organization for an unannounced survey.  Recently unannounced focus surveys were conducted at two local hospitals, but the survey team did not visit MUSC. In anticipation of a possible unannounced survey at MUSC, Lois Kerr, JCAHO consultant, reviewed “hot button items” with the management team that likely would be addressed in an unannounced survey. Among the “hot buttons,” staffing related matters are a JCAHO priority. As alluded to below, JCAHO standards require that hospitals measure the relationships of two clinical and human resources staffing effectiveness indicators for inpatient areas.  At the beginning of this fiscal year we began data collection to measure the relationship between patient satisfaction and worked hours; and medication errors and employee turnover. The data is being compiled and evaluated by Quality Management and the Staffing Effectiveness Subcommittee. At this point, no clear patterns or relationships have been indicated. In the future, unit specific information regarding these staffing effectiveness indicators will be provided to managers for consideration and analysis.  We have made good progress with our JCAHO continuous survey readiness campaign. It is important that we understand the standards and be knowledgeable of how the standards are applied in our organization. Thanks to all for a job well done   W. Stuart Smith Vice President for Clinical Operations and Executive Director, MUSC Medical Center STAR Productions present ‘JCAHO Unannounced Survey Preparation’ Lois Kerr reminded managers at the Feb. 11 communications meeting that JCAHO unannounced surveys are always a possibility, despite the upcoming full survey in November.  “They could come, or they could not come, but either way we need to facilitate a constant state of preparation throughout the medical center,” Kerr said. Kerr presented possible unannounced JCAHO survey topics including infection control in all areas of the hospital, initial assessment of patients, leadership roles in PI, medication use, and human resource planning. In terms of infection control, Kerr mentioned easy to do activities like cleaning out staff refrigerators and handwashing. Initial assessment is considered a possible topic due to the JCAHO ideal that the bottom line of patient safety begins at this first level care. Kerr said leadership roles include all department heads, and not just the upper crust administration. “And medication will cease to be an issue when we live in a perfect world,” she said. Concerning human resources, Kerr mentioned the comparisons of medical errors to staffing turnovers and patient satisfaction and staff work hours. At this time, there seem to be no correlations between medical errors and staff turnover rates. The maintenance of JCAHO National Safety Goals, like accuracy of patient identification, communication among caregivers, and safety of high-alert medications, remain medical center priorities. The recently developed resident supervision policy is in place and the first annual report on that policy will be presented to the MUSC Board of Trustees at the next meeting. Kerr concluded the presentation with a quick reminder of the various disaster plans, fire plans, and important emergency numbers.