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Currents To Medical Center Employees: I wish to thank Krispy Kreme Donuts for donating more than 4,000 donuts for employee recognition during National Hospital Week. Also, I want to thank the Department of Marketing and Business Development for their creative work in designing the “Charleston’s Most Preferred Health Care Provider” T-shirts issued to recognize National Hospital Week.  Recently our Joint Commission on Accreditation of Healthcare Organizations (JCAHO) consultants conducted a three-day mock survey. Their findings indicate that in general we have made good progress with our continuous survey readiness campaign, but some improvements are needed. For instance, we need to ensure everyone is well attuned to the practical application of JCAHO standards dealing with patient privacy, medications, medical records, patient safety, performance management and other standards. We also need to be diligent to ensure no snags with the basic “house-keeping” related standards.  Patient records must be maintained in a fashion ensuring patient confidentiality. Patient information should not be visible to the public or other staff.  Medication areas need to be clean. Medications should be secured and properly inventoried. Prescription pads must be secured. Needles and syringes need to be secured and monitored. Medication refrigerators and freezers should be locked. Temperatures need to be checked to ensure for acceptable ranges and thermometers must be working.  Patient safety, as indicated below, is a JCAHO priority. We all need to be familiar with the National Patient Safety Goals and how we have implemented the goals.  Medical records need to be properly maintained to include completion of all necessary data elements. The interdisciplinary care plan must be completed and include problems identified. Assessment and reassessment of pain needs to be documented. Unacceptable abbreviations must not be used.  All alarms must be in working order, audible and able to be heard over background noise. The Medical Center must maintain an equipment inventory of alarms.  We are expecting a November 2003 JCAHO survey of the Medical Center. We will continue to use this newsletter and other forms of communication to underscore JCAHO standards that need particular attention. Anyone who has questions about the standards should contact their manager, director or Terri Ellis, JCAHO coordinator (e-mail: ellist@musc.edu or call 792-5106). Thank you very much. W. Stuart Smith Vice President for Clinical Operations and Executive Director, MUSC Medical Center   JCAHO messages, policies need to be conveyed to staff Lois Kerr and Kathy Wade, JCAHO consultants, told managers about JCAHO readiness.  During a question and answer session, Kerr reminded managers to take JCAHO standards, messages, and policies back to staff.  “Joint Commission surveyors are known to ask managers to leave the unit while the staff is surveyed,” Kerr said. “It is imperative that your staff is aware of the six national patient safety goals, our policies in relation to these goals and what we’re doing to make sure that these initiatives are implemented.” The six goals are: Improve accuracy of patient identification, improve communication effectiveness among caregivers, improve safety of high alert medications, prevent wrong-site, patient or procedure events, improve the safety of infusion pumps and prevent free flow, and improve the effectiveness of clinical alarms.  Specific information concerning the safety initiatives can be located on the MUSC Medical Center Intranet. Click on “Performance Improvement” go to “Quality Network” and click on “Patient Safety.” Announcements Becky Dornisch, Annual Fund director, and Jenny Clifton, YES Campaign coordinator, spoke to managers about the importance of supporting university and medical center programs via the YES program.  The chairperson for this year’s program is Gail Stuart, dean of the College of Nursing, and the goal is $220,000. Since 1998, employees contributed $2 million in funding to more than 350 funds within the Health Sciences Foundation. “Participation is the key,” Dornisch said. “When we go to corporations and businesses to ask for donations or funding, we are consistently asked what our employee participation rate is. If we can show them that we have a 15 percent rate or better, it shows possible donors that our employees care about the place that they work in and in turn, businesses may be more likely to donate.” Donations may be made to the YES Campaign via payroll deduction, check, or cash and must include a YES Pledge Form.   Sharon Knowles, Information Security officer, introduced managers to the “Know the Code” decision tree located on the intranet to help medical center staff and personnel handle requests for patient information on the phone. To access the decision tree, go to http://www.musc.edu/hipaa/KnowTheCode.pdf. Michael Irving, Patient Care Systems manager, announced the winning names for two system naming contests. In the competition to come up with a name for the new Clinical Documentation system, Dora Johnson, PACU, received $100. The system will be known as C3, which stands for Computerized Clinical Charting.  Mary Allen, Environment of Care coordinator also received $100 in the “Name that Thang” contest. The name LYNX will be used to refer to the successor to the ClinLAN system.     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.