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Currents To Medical Center Employees: Recently we held three town hall sessions and I would like to thank everyone  for attending. Overall we had good participation, but the 6:30 p.m. session had very sparse attendance so we won’t select that time again.   The town hall topics included a summary of the pilot incentive plan experience, as previously communicated in this newsletter, a recap of our efforts to address smoking, improvements in wheelchair management, visitor identification matters and other topics.  The “evaluation summary” returned by participants indicated strong agreement that the town hall sessions were valuable for sharing information, with three percent of the participants feeling the sessions were of no value.   The open discussion and comments provided on the evaluation forms were helpful and I will follow up on the suggestions to the extent practical. Among other comments was that we solicit employee suggestions. Years ago we had an employee suggestion program and I will be reestablishing it in the future.    On another matter, I want to thank everyone for your cooperation during the recent hurricane alert. We do our best to get the word out on how we will respond including work schedule expectations. We must work cooperatively with the local Emergency Operations Center, hospitals in our area and others. We do our best not to overreact, but we must ensure for the safety of our patients and well being of all employees.  Inevitably hazardous weather situations cause anxiety. Be assured we will use our experiences to continually improve our emergency preparedness plan and procedures.    Thank you very much. W. Stuart Smith Vice President for Clinical Operations and Executive Director, MUSC Medical Center Procedures for service recovery discussed Carol Younker, Medical Center Risk Management, presented procedures for service recovery in the event of patient complaints. She said that encouraging patients to express complaints creates the opportunity for MUSC Medical Center to recover dissatisfied patients by resolving problems to each patient’s satisfaction.   A complaint, as defined by the Centers for Medicare and Medicaid Services (CMS), is any expression of dissatisfaction by a patient or patient’s representative regarding care or services (inpatient or outpatient) that can be addressed on the spot. These include such examples as food tray has wrong diet, an unclean room, the thermostat in room is malfunctioning, there is a delay in receiving prescribed medication, or there is inadequate communication from the physician.   Younker explained the difference between a complaint and a grievance. As defined by CMS, a grievance is any formal or informal written or verbal expression of dissatisfaction with care or service that is made by the patient or patient's representative that is not resolved at the time of the complaint by staff present. She added that a written complaint is always considered a grievance; all complaints alleging abuse, neglect, patient harm or hospital non-compliance with CMS requirements are considered grievances; and if a patient requests that complaint be handled as a “formal” complaint or requests a written response then it must be processed as a grievance.   CMS requires the hospital must establish a process for prompt resolution of patient grievances and must tell patients how to file a grievance. Here at MUSC Medical Center we notify patients through our document “Patient Rights and Responsibilities.” Patients or their legal representatives have a right to register a grievance and are encouraged to notify their provider or the supervisor of the area. If that is not possible or successful then they are encouraged to contact the Patient and Family Liaison Program at 792-5555. Patients are also informed they have the right to contact outside regulatory agencies in an effort to resolve their concerns.   CMS also requires the grievance process must specify time frames for review of the grievance and the provision of a response: Neglect of abuse allegations must be reviewed immediately; Most grievances should be resolved and written response sent to the patient within seven days. Documentation maintained by the Medical Center must include details of the complaint. Within the Patient and Family Liaison Program, a database is used to categories grievances.   Database categories include: access concerns, billing and financial issues, care and treatment, communication, environment, humaneness, lost articles, medical records and violation of patient rights. Findings of the grievance process are integrated into QA/PI efforts by direct feedback to managers regarding each grievance and its resolution,  monthly reports to administrators/directors regarding prior month grievances, and involvement of HIPAA compliance officer, Human Resources, and department chairs as appropriate.   Younkers said service recovery efforts will continue to be important as we strive toward service excellence. Tactical Plan—Reduce costs Vicki Marsi announced the continued successful achievement of cost reduction goals and introduced Hannah Waites of the Utilization Review Division of the Department of Finance who summarized review procedures. Commercial review: Pre-certification of admission   Clinical information is faxed or phoned to the payer. prior to admission by physician’s office/clinic or hospital registration staff for elective admissions (approx. 35 percent) within 24-hour workday by UR for urgent/emergent admissions (approx. 65 percent) Commercial review: Continued stay clinical info submitted by phone or fax on 100 percent covered by insurance at intervals set by their payer authorizations received and results are communicated via computer to appropriate key areas denial of days are appealed by UR UR by other agencies UR monitors all outside agencies who perform “on site” review at MUHA: Cigna, Companion Health Care, Workman’s Compensation, Occassion-al insurance company representatives to access for discharge planning needs.   Medicare/Medicaid Review: InterQual Criteria, the screening criteria set used by CMS and SC QIO, is used exclusively by MUHA/CMH during the review process. 100 percent are reviewed for admission justification Monitored at appropriate intervals throughout the hospitalization Hospital Issued Notice of non-coverage (HINN) may be issued to patients not meeting Interqual criteria Lifetime Reserve Day Letters issued when regular Medicare days are ending Medicare guidelines for review also used for most Medicaid patients Carolina Medical Review (QIO) Reviews Medicare and Medicaid cases on a monthly basis Reviews cases for other government initiatives, i.e. Hospice, payment errors Reports findings to individual hospitals, CMS and SC Medicaid Communicates with UR manager, the QIO contact for MUHA/CMH/IOP, concerning quality and utilization issues related to Medicare/Medicaid patients Denial of Days/Services: Medicare and Medicaid Appeals are processed by UR and the physician for those cases in which there is disagreement with the Carolina Medical Review (QIO) denial. Action Data The Action O-I Reports can be run/viewed the second quarter (April-June). The Web site is http://actionoi.solucient.com.   The administration has chosen to lower the percentile goal from the 50th to the 45th. Pamela Marek demonstrated the instructions for the change which are also posted on the communication section online. The typical reports each department runs are the KPI (Key Performance Indicator) and the Trend and Compare. Everyone who attended the report training class has access to the reporting module. Others will need to call or e-mail Pamela Marek to obtain access.   There will be two report training classes offered this quarter: Sept. 20 from 2 to 4 p.m. and Sept. 29 from 8 a.m. to noon in the computer training room, 220 Clinical Science Building. The classes are about 30 minutes and begin on the hour and the half hour. Call Pamela Marek, at 792-8793, for answers to questions. Specimen Labeling Project Donna McClellan and Carol Dobos presented information on specimen labeling, the objective of which is to ensure patient safety by minimizing the number of specimen labeling errors. They advocate labeling the specimen at the patient’s bedside.   Actions taken include: Clinical policies revised to clarify specimen labeling/patient identification policies Educational modules developed for all clinical staff New employee training module developed Educational blitz developed Signage created McClellan and Dobos reported a sharp decrease in specimen labeling errors to 0.06 percent and approaching a benchmark of 0.02 percent. They displayed a Mislabeled Specimen Investigation form to be filled out in the event of a specimen labeling error. Heart Walk Hustle Meredith Sanders gave an update of the Heart Walk Hustle totals, the grand total being $4,309.58. The top fundraiser at the Hustle was Little Hearts at $811. The top raffle was Clinical Services Administration at $585.75 and the top vendor was Sticky Fingers hosted by the Pharmacy Family at $433 or 25 percent of Stick Fingers proceeds.   Sanders reminded that the Heart Walk Hustle Auction is still on and open to anyone, on or off campus. “If they are in California,” she said, “they can still bid in our auction. The auction Web site is http://www.muschealth.com/auction/.   She said that the auction will close at noon on Sept. 23.   Totals of the competing Lowcountry hospitals are: MUSC $36,565 of a goal of $100,000; Trident $22,393 of a goal of $45,000; and Roper $13,325 of a goal of $30,000.   The 2005 Lowcountry Heart Walk will be held at 9 a.m. Sept. 24 at Liberty Square. Update: Lewis Blackman Hospital Patient Safety Act Clinical Services administrator Marilyn Schaffner gave a policy update and progress report on brochures, badges and white boards.   The hardcopy brochure’s final draft is at the printer and is to be distributed by the Admissions Department upon patient admission to the hospital.   The process for documentation of patient/family receipt of brochure will be to add it to the Informed Consent form the patient will sign upon patient admission to the hospital.   New resident badges for current residents will be completed soon and badges for attending physicians have been changed to designate attending and have been distributed.   Titles for employee badges are currently under review by directors. Also they are waiting for a final list from DHEC indicating a consensus of titles to finalize the MUSC list.   White boards in the main hospital are complete, in TCU 24 are complete and six are outstanding and in Children’s Hospital they are complete but in some areas laminated sheets are used to conserve space. The MUHA policy management update: C-109 Chain of Command and Physician Notification Revised to provide guidelines to implement the chain of command to address administrative/clinical/safety issues and/or breakdowns in communication or behaviors that affect patient care, patient safety, or delays in treatment. Contact individual is Rosemary Ellis. C-124 Paging Availability and Response Time New policy to standardize urgent patient care paging requests and the response time for all patient care related pages. Contact individual is Rosemary Ellis.   Any questions should be addressed to the contact individual.     Friday, Sept. 15, 2005 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.