To Medical Center Employees:
have continued to focus on controlling costs and improving operational
efficiency while providing high quality and compassionate care. We know
that many hospitals have observed decreasing patient satisfaction
results when staff morale has been affected by cost containment
initiatives or other organizational change. In most areas our patient
satisfaction scores have remained strong, but we have some work to do
with adult inpatient areas.
Following is a summary of our patient satisfaction results for the
quarter ending Dec. 31, 2008. Our goal is to achieve the 80th
percentile or higher.
Patient Satisfaction Results
Oct. 1 – Dec. 31, 2008
68 (N 956)
82 (N 207)
Room 84 (N
87 (N 4417)
Outpatient Behavioral Health 88 (590)
patient satisfaction data clearly indicates that consistent use of our
MUSC Excellence best practices such as AIDET, nurse manager patient
rounding, discharge phone calls and other “Must Haves” will improve
patient satisfaction results and clinical outcomes. I ask that all
directors, service line administrators and others work closely with
your patient satisfaction (Press Ganey) super users to carefully assess
patient satisfaction data for your specific areas, communicate results
to staff and focus on opportunities for improvement.
Recently we received the results of the “Immediate Bedding” process
improvement initiative led by Dr. Chris Carr, medical director, Adult
Emergency Services, and Sandra Gould, nurse manager, Adult Emergency
Services. This process improvement initiative focused on decreasing
time from patient arrivals to bed assignment, shortening the
door-to-doctor time and improving collections. A project team including
emergency services physicians and nurses, patient registration and
admissions staff, security, parking management and other areas began
their work in November 2008. The patient satisfaction results indicate
Adult Emergency Services achieved a 95th percentile ranking since this
project was initiated. This Immediate Bedding project is an outstanding
example of how working together to implement and consistently carry out
best practices allows us to continue to excel. We tip our hats to
Thank you very much.
W. Stuart Smith
Vice President for Clinical Operations
and Executive Director, MUSC Medical Center
People—Fostering employee pride and loyalty
Votava, Medical Fragile Children’s Pro-gram (MFCP) manager, shared a
win about the program and news about 18-year-old Nikki, an MFCP patient
who won praise for singing at Gov. Mark Sanford’s Inaugural Prayer
Service in January 2007.
Nikki was invited to attend the Presidential Inaugural
festivities in Washington, D.C. Nikki was chosen by the Stafford
Foundation, which helps sponsor disadvantaged adults to attend the Jan.
20 inauguration of president-elect Barak Obama. She will attend the
event with her foster mom.
Helena Bastian, MUHA HR director, presented the following information:
January/February Training: Management
Orientation—Jan. 22 and Jan. 29; Personnel File Review—Jan. 26; CATTS
Admin Access Training— Feb. 4; How to Complete a PEAR—Feb. 10;
Selecting Talent—Feb. 11; FMLA—Feb. 19; and AIDET Refresher—Feb. 23
Employees who participate in PEER interviewing must complete training;
Management orientation is offered to new employees and as a refresher
PEAR deadline (due Wednesday prior to orientation); new employees are
entered into Identity Manager upon receipt of PEAR; HR conducts a
download to CATTS several times a week, therefore, new hires are now in
CATTS (provided HR has the PEAR) prior to orientation; 2008 CATTS will
be archived Jan. 30; 2009 CATTS lessons will be available Feb. 1; and
continue with calendar year to complete mandatory CATTS lessons
N95 respirator annual fit testing (N95 is a minimal respiratory
protection device): OSHA requirement; need to identify staff who need
N95 fit testing ; (an e-mail will be forwarded with information to
assist managers in the assessment process); MUSC Occupation and Health
will coordinate fit testing sessions.
Joint Commission Survey Readiness Rounds
Carl Kennedy, outcomes manager in the Center for Clinical Effectiveness
& Patient Safety and a member of the Joint Commission Survey
Readiness team, reviewed specific changes to the 2009 National Patient
This year’s posters were revised to reflect the Joint Commissions
numbering sequence and are bright yellow. Managers should remove any
old posters from their areas. They may obtain posters from Room 204,
RTA, or call 792-2719.
Goal #1—Patient identification
Eliminate transfusion errors by implementing a two-person bedside/chair
side verification process when giving blood products or taking blood
Goal #2—Improve effectiveness of communications among caregivers
When delivering meal trays, dietary services will use the patient’s full name and date of birth to identify patient.
Document critical lab results, tests and radiological results in the
medical record and notify the physician/provider with results within 30
minutes of receipt of critical information.
Goal#3— Improve the safety of using medications
Reduce the likelihood of patient harm associated with use of
anticoagulant therapy. Ensure these patients are identified, educated
regarding medications, receive dietary consults and are assessed for
potential food/drug interactions.
Must label medications, medication containers (syringes, basins,
bottles) or other solutions in procedural areas, on and off the sterile
Goal #7 Reduce the risk of health care-associated infections
By January 2010, implement best or evidence-based practices to prevent:
multi-drug resistant organism infections; central line-associated blood
stream infections; surgical site infections
Goal#8—Accurately and completely reconcile patient medications across the continuum of care
In settings where medications are minimally used or prescribed for a
short duration (ED, outpatient radiology surgery and clinics), modified
medication reconciliation processes are performed
Universal Protocol—Time Out: conduct a pre-procedure verification
process; applicable to both OR and non-OR areas; current hospital
Growth—Growing to meet the needs of those we serve
Frazier, administrator for facilities and capitol planning and June
Darby, Neurosciences Service Line admini-strator, reviewed the 9E
project and planning update.
Frazier heads a 9E Planning Coordinating Committee to discuss and
coordinate the move-in. Plans are to open the first 15 beds by April 5
and remaining eight beds by May 5.
Patients will be admitted on April 6. By May 5, remaining staff will
complete orientation. Current staff hired for 9E are floating to other
units for orientation or to fill staffing needs. 9E beds provide an
additional 20 beds, combining for a total of 46 beds, for 9E and 9W.
Other activity includes relocation of neuroscience clinics in Rutledge
Tower Jan. 23 with patient care beginning Jan. 26: Neurosurgery
and Spine Clinic from RT 9 to RT6; Neuromuscular Clinic from RT2
to RT9; and EMG from CSB to RT9 (mid-February).
The next meeting is Jan. 27.
Friday, Jan. 16, 2009