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Currents March 6
To Medical Center Employees:
On Feb. 27 and 28, the management team, including nearly all Medical
Center supervisors with responsibility for hiring and performance
evaluations, took part in our fifth Leadership Development Institute
(LDI). The LDIs involve off-campus exercises designed to train managers
to be better leaders and to focus upon our organizational goals. The
LDI Team has done a super job of planning, organizing and conducting
the LDIs since March 2006.
 At
the February LDI five leaders were given Pillar Awards for their
exceptional accomplishments in exceeding our pillar-based goals. The
following individuals received Pillar Awards:
Sonja Muckenfuss, director, Children’s Services—substantially
increasing patient satisfaction scores for the Children’s Hospital and
exceeding the Service Goal; Angela Raney, manager, Women’s Health
Services—substantially increasing patient satisfaction scores for the
Prenatal Wellness and OB/GYN clinics and exceeding the Service Goal;
Michael Hartley, nurse manager, IOP, 1North & BICU—substantially
reducing seclusion and restraints and exceeding the Quality Goal;
Bambi Miller, IDX registration application coordinator—significantly
improving collection and denial rates and exceeding the Finance Goal;
Debbie Browning, nurse manager, Peds ED & PICU, interim nurse
manager, 8D—significantly increasing the Pediatric Emergency Department
visits and exceeding the Growth Goal.
Also, clinical and support departments were given quarterly department
awards for exceptional patient satisfaction results or for supporting
the award winning clinical departments in an exemplary fashion. These
departments received banners to recognize their exceptional
performance.
Departments and respective managers included: Children’s Services &
Perinatal Services – 8D – Debbie Browning, interim nurse manager;
Support Department – Children’s Hospital Volunteer Services, Christine
Messick, coordinator; Adult Hospital – 10E – Kristen Wachsmuth, nurse
manager; Support Department – Clinical Effectiveness & Patient
Safety, Glenn Richmond, manager; IOP – Behavioral Intensive Care Unit
(BICU) – Michael Hartley, nurse manager; Support Department – Dietary –
Brad Mastellar, general manager; IOP Outpatient Services – Geriatric
(GERO) – Cynthia Dominick, manager; Outpatient Services &
Clinics (On Campus – Pediatrics) – Pediatric Transfusion Clinic,
Kathy Sellers, manager; Support Department – Rutledge Tower Ambulatory
Pharmacy, Heather Kokko, manager; Outpatient Services & Clinics (On
Campus – Adult ) – Hollings Cancer Center Thoracic Surgery Clinic,
Rhonda Breland, manager; Support Department – Laboratory Services –
Hollings Cancer Center Blood Draw, Pat Wanstreet, manager; Outpatient
Services & Clinics (On Campus – Adult) – Gazes Rehab Clinic, Judi
Buckman, manager; Support Department – Biomedical Engineering, Stan
Trojanowski, manager; Outpatient Services & Clinics (Off Campus) –
West Ashley ENT, Dr. David White; Most Improved Service Area
(Overall) – 8D – Children’s Hospital, Debbie Browning, interim nurse
manager.
Congratulations to all staff and managers of departments that received
the awards. See the MUSC Excellence Web site (http://mcintranet.musc.edu/muscexcellence/serviceteams/focus/rewardfocus.htm)
for additional information concerning the awards. Next week’s The
Catalyst will include additional details.
At the LDI we also heard presentations from our Press Ganey
representative, Marty Lebbin, and our Studer Group account leader, Don
Dean, concerning our Employee Perspectives Survey. Plans were made for
managers to roll out the survey results to all departments and to
involve everyone in preparation of action plans focusing on areas for
improvement.
The administrative team expressed appreciation for the excellent
participation rate in the survey. While there are some high performing
areas in regards to employee satisfaction, overall we were disappointed
in the scores for the administrative team and we are committed to
improving employee satisfaction. Improved employee satisfaction will
help improve our patient satisfaction and reduce turnover. Plans are to
conduct a follow up survey in the future to measure progress after
action plans have been implemented.
Thank you very much.
W.
Stuart Smith
Vice
President for Clinical Operations
and
Executive Director, MUSC Medical Center
Quality—Providing
quality patient care in a safe environment
 As of
January, the Joint Commission
on Accreditation of Hospital
Organizations (JCAHO) unveiled a new title change and logo. Now known
simply as the Joint Commission (JC), the organization’s new tagline is
“Helping Health Care Organizations Help Patients.”
The new logo, featuring four triangles, represents the organization’s
commit-ment and renewed emphasis to quality performance improvement.
Following last fall’s survey, the JC expects the Medical Center to be
practicing evidence-based outcomes.
Changes to the 2007 National Patient Safety Goals (NPSG) include an
addition to medication reconciliation, two new goals and a scoring
change to help demonstrate compliance.
The 2007 NPSG changes include: Goal 8: Accurately and completely
reconcile medications across the continuum of care. (8B) A complete
list of the patient's medications is communicated to the next provider
of service when a patient is referred or transferred to another
setting, service, practitioner or level of care within or outside the
organization. The complete list of medications is also provided to the
patient on discharge from the facility; Goal 13: Encourage patients'
active involvement in their own care as a patient safety strategy.
(13A) Define and communicate the means for patients and their families
to report concerns about safety and encourage them to do so; Goal 15:
The organization identifies safety risks inherent in its patient
population. (15A) The organization identifies patients at risk for
suicide (Behavioral Health Care, Hospital [applicable to psychiatric
hospitals and patients being treated for emotional or behavioral
disorders in general hospitals]).
For more information about NPSG http://www.jointcommission.org/PatientSafety/NationalPatientSafety
Goals/.
- Patient Safety Week, March
4-10
The 2007 National Patient Safety Week theme, Patient Safety: A
road taken together, relates to medication safety. To commemorate
the recognition, a variety of educational displays will be displayed
around midday throughout the week at locations including the Main
Hospital, Children’s Hospital and Charleston Memorial Hospital.
Displays will focus on various medication safety topics related to pain
management, resuscita-tion, DVT-deep vein thrombosis prevention, NPSG
and infection prevention.
A new hospital survey on patient safety culture was conducted with
staff March 7.
Sponsored by the Quality Interagency Coordination Task Force (QuIC),
the survey was funded by the Agency for Healthcare Research and
Quality. The QuIC was established under a 1998 presidential directive
collaborating federal agencies involved in health care services to work
together to improve quality care.
Results from a previous safety culture survey showed that hospital
employees agreed that teamwork contributed to a unit’s continuous
improvement towards patient safety. They also affirmed that hospital
management was supportive to a work environment that promotes patient
safety. Employees also agreed that hospital procedures and systems were
effective in the prevention of errors.
A recent S.C. DHEC report unveiled a recent rise of statewide influenza
cases. MUSC still has available flu vaccine. Flu vaccine is a Joint
Commission require-ment for health care workers.
Beginning this spring, staff will soon have the ability to verify the
status of attending physicians and their credentials for providing
their services and medical privileges at MUSC. Quality Management and
Patient Safety have begun evaluating a15-physician pilot group and will
expand to larger groups in coming weeks.
People—Fostering
employee pride and loyalty
Follow up from the fifth Leadership Development Institute event (Feb.
27-28)
First
assignment: Man-agers are
asked to meet with staff to review
generational differences. Work groups should work together to identify
two techniques that can improve communications with staff. Areas should
submit an activity summary using the Leadership Evaluation Management
(LEM) tool by April 27.
Second assignment: Leaders should schedule staff time to review
Employee Perspective Survey results. Individual Work Group Report CDs
will be distributed to area directors who will share with managers.
Managers are encouraged to use roll-out tools, including a survey tool
kit, sample Power Point presentation and Press-Ganey Solution Starters
(12 question dimensions/sections), which can also be found at the LDI
Web site. Teams should prepare and complete an action plan by April 15
and submit details using the LEM by April 30.
Third assignment: MUSC Excellence’s AIDET (Acknowledge, Introduce,
Duration, Explanation and Thank You) Managers should develop a
department-specific AIDET program and establish a roll-out process by
March 17. The complete AIDET Competency Assessment Tool should be
entered via CATTS by April 15.
Hardwired Project: Staff rounding for outcomes should include rounding
on patients, staff and internal customers. Managers are encouraged to
continue writing at least two thank you notes monthly and manage up
staff and faculty.
New leader/supervisor/manager/director informa-tion: All new leaders in
the Medical Center are encouraged to attend any of the Medical Center
Human Resources’ quarterly management training sessions. David McNair
of McNair Associates, is expected to assist with MUHA new leader
training. Current leaders are asked to provide instruction to new
leader staff on accessing the MUSC Excellence Web site and LDI
reference information in preparation for the next scheduled LDI session.
The center’s LDI 6 is scheduled for June 6-7.
March 1 meeting results featured revisions to test request cards and
Medication Administration Record (MAR) changes. The request, submitted
by Marilyn Jenkins, manager of the Fast Flow Lab/Laboratory Services,
asked that the revised test (lab) request cards be used by medical
staff in conjunction with the green lithium heparin tubes with gel now
required by tests. However, Lab Services will continue to accept the
yellow SST tubes until inventory is depleted.
Holly Griffin, PharmD, submitted a request to the MAR format. Changes
relate to proper use of bolding and font size of specific words
on medications to ensure readability and support safety purposes.
HR policy 33—Hospital volunteers must be at least 14 years old to
participate in volunteer programs (i.e. Candy Stripe Program).
HR policy 12—Amendment to the MUHA Standards of Behavior (MUSC
Excellence) policy. Under the respect, employees should refrain from
criticizing MUSC in the workplace, the community and in the presence of
our customers.
Primary source verification of licensure and registration should be
conducted at the time of renewal. Departments are reminded to enter the
renewal information via CATTS.
Standards of Behavior should be discussed and signed off for all job
applicants during the interview process.
Sharon Dunning, R.N., has joined the Transitional Care Unit staff as a
nurse educator. Dunning comes to MUSC from Atlanta with lots of
experience in teaching and nursing management.
Dave Northrup, director of Clinical Systems, Office of CIO, reminded
staff of Daylight-Saving Time (begins at 2 a.m., March 11) and how it
will affect the GroupWise calendar system. The system will not
automatically adjust appointment times. Users are reminded to review
their system calendar by March 9 or prior to the change. For more
information, visit http://www.musc.edu/infoservices/gw_dst.html.
Finance—Providing
the highest value to patients while ensuring financial stability
Stephen Hargett, MUSC Medical Center controller, updated the management
team on the fiscal year financial performance of the Medical Center for
the seven month period ending Jan. 31.
Following
are selected highlights:
For the seven month period, the
Medical Center had a net income of $20.6 million or 4.7 percent
compared to the pillar goal of 5 percent; This 4.7 percent net income
is down from 5.2 percent at the end of December due to a substantial
increase in supplies during January; The Medical Center reported an
unexpected increase in supplies (volume related). Hargett asked
managers to review supply numbers for January.
Also, the Medical Center's days cash on hand increased from 35.2 days
in December to 39.4 days in January.
MUHA Excellence pillar goal
statements
Service—Serving the public with compassion, respect and excellence
People—Fostering employee pride and loyalty
Quality—Providing quality patient care in a safe environment
Finance—Providing the highest value to patients while ensuring
financial stability
Growth—Growing to meet the needs of those we serve
Friday, March 9, 2007
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
Publications at 849-1778, ext. 201.
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