CurrentsTo Medical Center Employees:The JCAHO began unannounced surveys in January. This underscores the need for “survey readiness” and serves in the best interest of patient care and safety. In the most recent Currents newsletter I mentioned that our MUSC Excellence initiative includes various “Must Haves” that are being implemented. One of the Must Haves is rounding on employees by leaders (mangers, directors, administrators and other supervisors). Rounding enables leaders to find out what is working well, identify high performers who need to be recognized, focus on systems or procedures that need improvement and to identify the need for supplies or equipment. Many managers have rounded in the past, but it is now an expectation of all leaders, and we are taking it to a new level. Rounding can be viewed as a “tool belt” and leaders should add things to the tool belt as needed. I am asking all leaders to add JCAHO discussions and coaching to their “rounding tool belt.” On another matter, Rosemary Ellis, director of Quality, is spearheading the conversion of our patient satisfaction system. We will no longer be using National Research Corporation as our patient satisfaction vendor for inpatient and emergency services. We have recently begun using Press Ganey as our patient satisfaction survey vendor for inpatient and emergency services, and this will enable consistency by using the same vendor for inpatient and outpatient services. We will also fill the previous gap that existed with ancillary and outpatient surgery patient satisfaction reports. In order to accelerate the transition to Press Ganey, we have opted to go with the Quick Start Program. Although these survey tools are not uniquely tailored to fit our needs, using the Quick Start Program will allow us to quickly put the survey tools in place. In the future, we will be reviewing each of the Press Ganey tools and we will select questions that give us a comprehensive picture of our patients’ experience. It is important to note that our MUSC Excellence initiative places heavy emphasis on patient satisfaction scores. We will be doing a much better job of communicating patient satisfaction scores within service areas and setting specific goals as we move forward. Finally, please remember that the Medical Center Town Hall meetings will be held during the week of June 26. We will discuss MUSC Excellence and employee satisfaction matters. The meeting schedule is on page 2 of The Catalyst and can also be found at http://www.musc.edu/medcenter/news/townhall.htm. Thank you very much. W. Stuart Smith Vice President for Clinical Operations and Executive Director, MUSC Medical Center Town Hall meetings, JCAHO discussedRisk Management director Wayne Brannan shared positive news recognizing MUSC. The Medical Center has consecutively won the South Carolina Chamber of Commerce’s Commendation of Excellence Award for Safety Program Recognition. Brannan presented the 2006 award to Betts Ellis on behalf of the Medical Center.Brannan praised the hospital’s Environment of Care Committee and Injuries Subcommittee led by MUHA Human Resources Employee Relations’ Eric Frisch for initiating workplace strategies and practices to maintain a safe environment. Brannan noted that aside from the hospital’s praise with awards, MUSC also gained from positive statistics for workplace safety. In 2005, the Medical Center worked around 8 million hours with 4,527 employees and reported 18 accidents to OSHA. Brannan explained that when a company maintains a safe work place and cares about its employees, a chance for rates moves downward. Despite rising employment and insurance costs, the Medical Center costs have decreased by $134,000. Total costs decreases for both the Medical Center and university is estimated to be more than $350,000. Town Hall Meetings Betts Ellis reminded employees about the Town Hall meetings for selected session dates and times, June 26 to 30 (see schedule on page 2). Hospital Administration expects managers and directors to use the Town Hall meeting overview as a tool to review and reinforce information that is presented to staff within their work units and environments. Each session will begin with opening comments by Stuart Smith and a review of the post meeting evaluation form. Agenda items include a review of the following: MUHA Action Plan, Supplemental Medical Leave, Medical Center Pay Plan (PTO Cash-in/Conversion), Employee Satisfaction Survey and MUSC Excellence program. JCAHO Update JCAHO manager Lois Kerr reviewed a JCAHO Unannounced Visit Response Plan and protocol with hospital managers in anticipation with the upcoming JCAHO survey. The plan, which is available on the MUHA intranet, http://www.musc.edu/medcenter/JCAHO/, reviews step-by-step activity and information upon the arrival of the JCAHO survey team. Once the team arrives and identifies themselves with hospital administrative staff, they participate in an opening conference and private session to review the organization. On the first day, the JCAHO team will help establish patient and system tracers in preparation for visits to patient-care areas. They will also conduct competency assessments, a credentials conference, environment of care review; and emergency management tracer, and life safety review. Kerr emphasized the need for clinical staff to focus on priority focus areas and areas for organization. Specific focus priorities examines standards based on pre-survey information: past surveys, complaints/sentinel events, MedPar Data and Oryx Data. Priority focus areas for the organization include commu-nication, credentialed practitioners, information management, quality improvement expertise/activities and staffing. Kerr also reviewed the plan’s priority focus in multiple areas: the hospital; behavioral health; information management; credentials; commu-nication; quality improvement expertise/activities; staffing; organizational structure; medication management; patient safety; assessment and care; clinical service groups (hospital and behavioral health); and system tracers. She also reviewed the JCAHO survey scoring system which recognizes scoring standards to be compliant or not compliant after evaluating all the Elements of Performance. Once the survey team arrives, the Medical Center staff will be alerted via overhead page. Kerr encouraged managers to review their own roles and responsibilities regarding process information and to utilize this plan and other JCAHO tools, tips and resources found in the Web site to prepare staff. She closed reciting the Medical Center’s JCAHO plan motto: “Getting ready for the next patient and not for the next survey.” APOC Update Patient Support Systems manager/APOC program manager Mark Daniels gave an update about the APOC Clinical Systems project. Daniels reviewed the latest APOC program blueprint/time line. Clinical projects like the Materials Management and Pharmacy Replacement System are on schedule to be completed in September. Although the Emergency Department Tracking board implementation remains on schedule, the project’s completion is being delayed until early September due to construction, procurement and training challenges. The physician portal is slated to begin in 2007. The team is currently working to develop a data repository, which will store ongoing as well as historical clinical results from Oacis (initially for the last five years and with the intention of later acquiring information for the remaining eight years). The clinical documentation project, which represents the inpatient adult and pediatric information, will be demonstrated during the week of June 26 and will be implemented over the course of the next nine months. The start of the Emergency Department Clinical Documentation project is still being determined. The Bedside Medication Administration project will use McKesson’s Admin RX product, which will allow staff to utilize a bar code reader to scan a patient’s bedside bracelet, the staff’s badge and the medication for real-time administration confirmation. The project will be rolled out in lockstep with the clinical documentation project. Both the Orders Management and Orders Entry (inpatient) projects have been pushed forward to begin planning in July and implementation in August. The APOC team is working to have the system operational in time for the new hospital opening. Finally, Daniels reported that the two Perioperative modules, OR Manager (scheduling, preference cards, etc.) and Clinical (preop, anesthesia and PACU), are currently on schedule and will be rolled-out in early 2007. The APOC team is now based in their operational center at Charleston Memorial Hospital (CMH). Education Roll-Out Update Clinical Services Administration’s Laurie Zone-Smith announced that the next Education Roll-Out Committee meeting will take place June 29. She reported on the group’s progress and announced that the Sitter Policy (C-113) is ready to roll out. SBAR training, a mechanism for staff clinicians to alert and communicate with each other about patient situations, will be presented for dissemination to all clinical units. The committee’s goal is to implement this communication program with clinical staff by mid-July. Announcements
Friday, June 23, 2006 |
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