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To Medical Center Employees:

At the March 7 communications meeting, Lois Kerr, accreditation manager, gave an update on the “Ten Top Things to Make or Break You” in an unannounced JCAHO survey. Everyone should be attuned to these “hot buttons” and make sure we are properly prepared. Highlights from Ms. Kerr’s presentation are outlined below.
 
A few weeks ago Rosemary Ellis, Quality and Patient Safety Director, discussed the National Patient Safety Goals during the communications meeting. She issued “MUSC is Safe” cards that should be attached to all employees’ identification badges. These cards provide an easy reference summary of actions needed for patient safety and recaps our Performance Improvement Model (IMPROVE). I am asking managers and educators to be sure all staff receive these cards and to ensure everyone is familiar with our methods to fulfill the National Patient Safety Goals. Additional details regarding the goals and the actions we take to comply with the goals are outlined in this newsletter.
 
Finally, please remember the next Medical Center Town Hall meetings will be held March 14 at 11:30 a.m. and March 15 at 7:30 a.m. and 2:30 p.m. in the 2 West Amphitheater. Our discussion will focus upon our employee satisfaction survey action plans and a general overview of our “hardwiring excellence” plan.
 
Thank you very much.

W. Stuart Smith
Vice President for Clinical Operations
and Executive Director, MUSC Medical Center

JCAHO preparation continues, ACC begins

In the Feb. 14 communications meeting, Quality director Rosemary Ellis reviewed information about the National Patient Safety Goals and shared staff education tools and communications strategies with managers to use and teach their staff. Ellis reminded the audience of the Medical Center’s priority to provide good, quality health care within a safe environment. She concluded her presentation by distributing the “MUSC is Safe” cards to all hospital employees asking that they wear and attach the cards to their identification badges. To obtain a copy of Ellis’ “MUSC is Safe” PowerPoint presentation, refer to the Communications Web site.

http://www.musc.edu/medcenter/JCAHO/
               
Top 10 Make-or-Break Issues
JCAHO manager Lois Kerr reviewed a list of top 10 make-or-break issues to help managers and staff prepare for the upcoming JCAHO survey.
 
They are:
  • Staff’s inability to articulate section/unit’s Performance Improvement (PI) process. Hospital staff should know about PI processes within their area and how it contributes to the medical center’s service mission.
  • Inability to validate a physician or work staff competency. Staff must be proficient in following protocol regarding competency information.
  • Improper storage and cluttered egress areas. A new performance team was formed to improve storage areas within the hospital. Staff should clearly understand and be able to relate their unit’s plan or hospital policies regarding egress areas during an emergency.
  • Expired medications and supplies. Improvements in this area can be attributed to staff alertness and quality assurance.
  • By-passing the informed consent process. This includes the universal protocol of informed consent including time out.
  • Staff’s inability to articulate and demonstrate knowledge of 2006 National Patient Safety Goals. Quick reference information in the form of  “MUSC IS SAFE” cards were distributed to staff Feb. 14.
  • Unfamiliarity with emergency management procedures. Staff should be comfortable and proficient of their knowledge of their unit’s emergency management plan.
  • Use of non-calibrated and non-verified equipment. Equipment standards will be judged by frequency-of-use basis with consideration to the vendor’s and hospital’s own risk verification policies.
  • Violation of patient confidentiality. Staff need to be more vigilant and less complacent in protecting patient information.
  • Insufficient and non-existent documentation. Tighter guidelines between patients and documenting information are needed.

Phase 1 Action Coordinating Committee
Clinical Services administrator Marilyn Schaffner gave an update on the Phase 1 Action Coordinating Committee formed to establish a comprehensive  implementation plan for the new hospital. The committee, co-chaired by Schaffner and Heart & Vascular Center administrator Bill Spring, is composed of a dozen work teams.
 
The 12 chairpersons of these implementation work teams are: Natalie Ankney, diagnostics and interventions; John Franklin, support; Karen Weaver, OR; June Darby, ancillary; Sue Pletcher, Patient Access; John Heffner, physician; Sharon DeGrace, nursing; Betts Ellis, Human Relations; Sherry Gillespie Miller, ambulatory; Lisa Montgomery, university; Dave Northrup, information technology; and Dennis Frazier, facilities.
 
Each team is further divided into specific sub-groups. For example, the nursing implementation team, led by Sharon DeGrace, works with eight sub-groups in the areas of acute care beds, critical care beds, chest pain/Obs, dialysis, HSC, transport, infection control and nursing education.
 
Last September, committee leaders gathered at a kick-off retreat to develop a framework for the new hospital’s implementation plan. Together, they identified issues and assigned them to appropriate teams. Next, they prioritized each activity and reviewed and discussed a methodology using a patient scenario activity.
 
Schaffner identified ACC’s goal to develop comprehensive implementation strategies for a successful operation of the new facility. The committee is also focused on providing a customer-sensitive environment by ensuring an efficient coordination of care between services in the existing and new facilities.
 
To aid in tracking committee work teams and sub-groups, an intranet database called Quickbase was established. Users can access work projects and other information using the database. Schaffner assured managers that progress with this committee’s efforts will be made available in future communications reports and physician group meetings.

Magnet Designation/McNair Training
Stuart Smith addressed managers about the hospital’s current status with the Magnet designation process and McNair leadership training program.

With 2006 slated to be a busy year, efforts with the Phase 1 Action Coordinating Committee, information technology, JCAHO accreditation, hardwiring excellence project and other hospital projects, were growing to a level of activity that Smith and the administration team were concerned with. To address this, administration began evaluating hospital projects, especially the Magnet designation process and McNair Leadership Training. The administration decided to suspend the McNair project for the management team. However, the front line program will continue. In considering the Magnet process, the team turned to the experts who shared their experiences conducting the Magnet process at other hospitals. They recommended that MUSC first complete the Studer Group’s hardwiring excellence program before proceeding with Magnet. Smith praised the hardworking efforts of the Magnet Steering Committee and its progress.

Announcements
  • The Medical Center Town Hall Meeting is scheduled for 11:30 a.m., March 14 and 7:30 a.m. and 2:30 p.m., March 15, 2 West Amphitheater. There will be no Communications meeting scheduled for March 14.
  • Oncology and Medical Surgery Services clinical director Colleen Corish announced that the Bariatric Program Center recently received a Center for Excellence status. Corish praised the work of program manager Amanda Budak and her team for reaching this achievement. MUSC is one of two certified bariatric centers in South Carolina.
  • Managers are reminded to participate in the Clean Sweep Project in preparation for the JCAHO survey. A surplus/storage pickup service has been established throughout March. Managers are encouraged to complete a Property and Equipment Activity form (available on the MUSC intranet under “forms”) to move items to surplus or storage. For information, e-mail FennellM@musc.edu.

Testimonies/Letters of Appreciation
  • A letter was submitted to Pathology and Lab Medicine’s Vanessa Brown by patient, John DeBerry Jr., praising the work conducted by lab technician Nancy Jenkins in a recent visit to the outpatient blood lab. Jenkins recently assisted him in completing a three-hour test. Debarry praised her patience, plus kind and professional manner. “Nancy is certainly an asset to MUSC; the hospital and patients are very lucky to have her as a member of the staff,” wrote DeBerry.
  • Lois Kerr related her story of a friend’s 18-year-old son who was hospitalized and treated for bilateral pneumonia in 8 East. Kerr’s friend, who is a career nurse with 25 years experience, could not have been more pleased with the care and treatment he received while at MUSC.
  • MUHA Human Resources director Helena Bastian also shared a personal experience about her 19-year-old son who was involved in an automobile accident. He was transported by ambulance to MUSC and received great care from the physicians, nurses and staff. Consequently, she was asked by her son to contact his College of Charleston  professors about his situation. Bastian talked to a staff member who complimented MUSC’s outpatient services. As a new member enrolled with MUSC Options, she and her husband could not be happier with their health care choice.

Friday, March 10, 2006
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 catalyst@musc.edu. To place an ad in The Catalyst hardcopy, call Island papers at 849-1778, ext. 201.