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Currents Jan. 13

To Medical Center Employees:
We 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
Service                                      Percentile                      Mean
Adult Inpatient                            68 (N 956)                  85.0
Pediatric Inpatient                       82 (N 207)                  86.3
Pediatric Emergency Room         84 (N 223)                  84.5
Ambulatory Care                        87 (N 4417)                92.2
Outpatient Behavioral Health       88 (590)                  88.9

Our 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 everyone involved.
Thank you very much.

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

People—Fostering employee pride and loyalty
Pat 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.

HR update
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
Reminders: Employees who participate in PEER interviewing must complete training; Management orientation is offered to new employees and as a refresher course.
New hires: 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 Safety Goals.
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 samples.

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 field.

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

Other: Universal Protocol—Time Out: conduct a pre-procedure verification process; applicable to both OR and non-OR areas; current hospital policy revised.

Growth—Growing to meet the needs of those we serve

Dennis 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

The Catalyst Online is published weekly by the MUSC Office of Public Relations for the faculty, employees and students of the Medical University of South Carolina. The Catalyst Online editor, Kim Draughn, can be reached at 792-4107 or by email, Editorial copy can be submitted to The Catalyst Online and to The Catalyst in print by fax, 792-6723, or by email to To place an ad in The Catalyst hardcopy, call Island Publications at 849-1778, ext. 201.