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Currents To Medical Center Employees: Recently the monthly JCAHO audio conference jointly sponsored by the South Carolina and Georgia Hospital Associations focused upon lessons learned from recent surveys.This gave us the opportunity to hear from several hospitals in South Carolina that have been surveyed since January 2003. The information shared was helpful. A central theme of the audio conference was that continuous survey readiness is the right course of action. Standards are periodically amended and new survey methods are adopted so we must stay on top of all changes.  The surveyed hospitals reported that the key to a successful survey is every staff member throughout the hospital knowing and understanding how JCAHO standards apply to his or her individual job. It’s important to involve employee teams in a variety of settings in sharing with the surveyors how they fulfill the standards through their work.  Organizationwide patient safety was reported to be a top priority of the JCAHO survey teams as well. The surveyed hospitals urged the governing board, medical staff and all employees to understand the patient safety goals and program. The patient safety program needs to be evident in all areas of the hospital.  While the “tracer methodology” does not formally go into effect until calendar year 2004, the surveyed hospitals report that survey teams are beginning to use the tracer methodology now. The tracer method involves randomly selecting patients’ charts and following the patients from point of entry into the system through post-discharge. The tracer process focuses on a range of “hot buttons” such as patient safety, staff competencies, pain management, sedation, restraints, patient education, infection control and other standards.  Through maintaining a heavy emphasis on our continuous survey readiness we should be well prepared and avoid the “eleventh hour rush.” We are scheduled for the JCAHO survey in November and perhaps will be the last South Carolina hospital surveyed under the current standards. As we look to the future, JCAHO’s surveys are expected to be totally unannounced by 2006, so continuous survey readiness will serve us well. Thank you very much. W. Stuart Smith Vice President for Clinical Operations and Executive Director, MUSC Medical Center   STAR Productions presents ‘The Doctor’ With a scene from “The Doctor” to illustrate normal operating procedures, Karen Weaver, Surgery, Women and Infants Services director, presented the JCAHO standards on operative and invasive procedures at the April 15 communi-cations meeting. According to Weaver, the standards apply anywhere within the medical center campus where procedures are performed. The standards focus on operations and procedures for diagnosis, cure, decreasing or preventing impairment or disability, restoring or improving function, and relief from symptoms. Medical staff define the scope of assessment concerning invasive and non-invasive procedures and must decide on the appropriate treatment for a given patient based on patient history, physical status, diagnostic data, risks and benefits of a procedure, and the possibility of the need for blood products. Another issue addressed by Weaver involved informed consent. Before a consent form is signed, the patient and patient’s family must be educated on the risks, benefits, and potential complications of the procedure. Specifically, MUSC policy C-2 requires that patients make informed decisions regarding procedures within the medical center. The policy also addresses implied consent, patients unable to give consent, emergency situations and non-emergency situations, conference calls, treatment refusal, extension of consent and other elements of informed consent. Announcements Celeste Phillips, Clinical and Patient Education, reminded managers of the need to fill out and return Educational Needs Assessment forms for their departments. The forms were sent out electronically and one exists for management and another for staff. She urged managers to forward the correct form on to staff members. For more information, go to http://www.musc.edu/medcenter/needs_assessment.html. Dave Neff, Ambulatory Care administrator, roused managers with a direct challenge to beat his team in the fourth and final quarter of the Nectar of Life Blood Donor Competition. Neff’s team, Ambulatory CARES, is once again in first place. Katy Kuder, Human Resources coordinator, announced a training seminar on the human resources standpoint of maintaining mental wellness through organization. She also mentioned a Military Appreciation Day at 2 p.m. on May 8 in the Basic Science Building Auditorium, room 100, to honor  MUSC employees with veteran status and to support reservists currently on active duty.    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.