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Currents To Medical Center Employees: Recently Lois Kerr, accreditation manager, and Kathy Wade, accreditation consultant, conducted an unannounced mock survey using the JCHAO’s tracer methodology. The unannounced mock survey was in keeping with JCAHO’s new unannounced survey plan which underscores the need for continuous readiness.  Also, the mock survey served as a preliminary exercise for preparation of our self assessment. The “new” JCAHO standards require a self-assessment at the 18 months period following the most recent survey. The self-assessment requires that we carefully review our compliance with all standards and the “elements of performance” and that we score ourselves.  The tracer process involves a “systems approach” in which a patient (or patient chart) is randomly selected and followed by a surveyor through the organization according to the sequence of care given. The tracer process examines all components of care including the “hand off” of patients moving through the various patient care units and service areas. The tracer survey process involves interaction with staff to verify their competencies and understanding of policies and procedures. In general, the mock survey revealed that we need to renew our focus upon clearly and consistently communicating policy and procedure changes to the front-line caregiver. While we have developed good policies, all employees need to be familiar with policies and procedures and be able to verbally articulate how we fulfill our standards of care.  I am calling upon the JCAHO Steering Committee, Lead Team, Quality Council, Clinical Education, Human Resources, and others to revisit our communication and training methods to close the gaps noted in the mock survey.  Thank you very much.   W. Stuart Smith Vice President for Clinical Operations and Executive Director, MUSC Medical Center   Patient Safety Week March 6 through 12 Becky Davidson is the new coordinator of the Red Cross Donor Room, replacing Annie Lovering. At the introduction Tuesday, Davidson acknowledged that she had “some big shoes” to fill following Lovering’s tenure as coordinator. “I’d like to announce a March Madness in the donor room,” she quipped to laughter of the audience. Patient Safety Week Mary Allen, quality coordinator in the Department of Quality Management, announced an upcoming “Recipe for Success National Patient Safety Goals,” to be held during Patient Safety Awareness Week, March 6-12. The goals are: Establish shift assignments and assemble supplies; Evaluate for anticipatory needs and perform brief rehearsal; Employ effective handwash-ing before and after care; Check patient identification for each process—read ID bands and labels; Use effective communication—document, especially on MAR and vital sign sheets; Add an extra dose of “read back” for verbal orders; Ensure prompt attention to critical lab values—handle with care; Be alert for look-alike or sound-alike products—generic and brand names; Fold in the independent double check when initiating and reprogramming IVs and PCA; Take care to prevent falls—slippery when wet “Roll together and bake. Utilization of this recipe is expected to increase staff effectiveness, expected outcomes and dish up a platter of Provider of Choice.” Maureen Sheakley, medication safety coordinator in Pharmacy Services, announced new MUSC Policy C112 concerning call-in prescription to non-MUSC community pharmacies.  Purpose:   To ensure that prescriptions are safely communicated from MUSC to non-MUSC community practices Who:   Licensed professionals or their designees may call in prescriptions How to call in a prescription: Follow the Medication Order Writing Guidelines Speak slowly and clearly Spell the medication name Specify numbers clearly. Example: A dose of fifty should be stated as 5-0 to distinguish it from fifteen. Give patient’s date of birth to ensure correct patient identification and to allow pediatric dose checking Avoid slang terms such as Magic Mouthwash and GI Cocktail that can contain different ingredients at different locations List all active ingredients in a compounded prescription (e.g., mouthwashes, ointments, creams). In addition, it is strongly recommended to include the concentration that is needed, although each pharmacy may prepare these differently.  Give contact information (name, phone number, pager number) for call backs (if necessary). Type of Communication If there is direct contact, it must be with a pharmacist or pharmacy technician only. The caller must request a “read back” of the prescription. If you have to leave a recorded message, the MUSC caller must verbalize the prescription twice. When feasible, a hardcopy should be faxed to the pharmacy. Tactical Plan Quality Management director Rosemary Ellis presented her portion of the Tactical Plan to improve care, quality, safety and effectiveness, covered by four major initiatives assigned to work-groups: Clinical Pathways Objectives: Review Comparative benchmark for opportunities Create teams to investigate identified areas, develop pathways, incorporate safety practices into pathways Develop methodology to track variance, aggregate data and report back to applicable teams for improvement opportunities Status: Review has been initiated. Improvement Processes Objectives: Identify and implementation processes to reduce time from problem identification to implementation of a fix Dashboard of key quality and safety performance measures Continue to develop a culture that supports safety-mindedness Indentify and act on oppportunities to increase coordination of various safety and quality improvement initiatives Evaluate effectiveness of current orientation and trainingprocesses to build basic organizational competency in RCA and FME among management team and ultimately front line staff. Status: Development of tool has begun. Will be a searchable tool. Key Clinical Performance Indicators Objectives: Identify valid and reliable internal and external data sources Create and disseminate comparative report to clinical and administrative leaders for opportunity identification and action Provide resources to support data drill down and analysis Create forum to share success stories and lessons learned. Status: Quarterly report developed and disseminated to department chairs and administrators. Future plans for this effort will be to coordinate effort with HBI initiative Patient Safety Oversite Group Objectives: Implement processes and procedures that integrate evidence-based practices that prevent the occurrence of hospital-acquired complications Identify performance indicators to determine utilization of evidence-based practices Develop monitoring and feedback mechanism. In her “Tips for Staff,” Ellis advised that changes need to be monitored, for example, by asking what processes were put in place to assure the change is working. Always pair education with a process change. By example, she advised that mayday carts carry a card that tell people what to do with cart contents after a mayday. Basket Raffle Oncology and Medical/Surgical Services nurse manager Yvonne Martin announced that Maureen McDaniel is the raffle winner to receive the 2005 Nurses Week “Pamper Yourself” basket full of items valued at $350.  The raffle, which extended through February, had its drawing Feb. 28 and raised “a phenomenal $1,303,” Martin said. She said that the chili sale lasted only an hour and a half before it was sold out and had raised $506. Combined with a December chili sale, $1,046 was raised. The committee also collected donations from honorariums amounting to $190.