To Medical Center Employees:
the recent medical center town hall meetings we discussed highlights of
the Employee Partnership Survey. Everyone was encouraged to attend
departmental meetings to focus upon their department’s survey results
and to develop action plans for improving employee satisfaction and
Work is also under way to prepare an organizationwide action plan. The
action plan will focus on several “opportunities” as identified by the
survey. Opportunities include the survey questions with relatively low
scores (compared to results for other questions) which offer the
greatest potential for improving overall satisfaction and engagement.
Listed below are the top organizationwide opportunities. This week I
issued a very brief e-mail survey to all medical center employees
requesting that you select the top three opportunities for
organizationwide focus. Please respond by Oct. 28. The results will be
used to help craft our organizationwide action plan. We will routinely
communicate our action plan progress as we move forward.
- My direct manager provides coaching to help me achieve my goals.
- Leaders can be trusted to be straightforward and honest.
- Leaders really listen to employees.
- Promotions are handled fairly here.
- My work group is asked for opinions before decisions are made.
- Excellent performance is recognized here.
- Leaders’ actions reflect our mission and values.
- I have opportunities to influence policies and decisions that affect my work.
- My direct manager recognizes my ideas or suggestions for improvement.
- My direct manager communicates effectively.
another matter, at the Oct. 20 management communication meeting Steve
Hargett, medical center controller, gave an update on our financial
status to date this fiscal year. We have made substantial progress as a
result of focusing on cost reduction initiatives and our high inpatient
census and outpatient volume. Additional details are included in this
Chris Rees, director of quality and patient safety, shared with the
management team highlights of the Year End Quality and Patient Safety
report given at the recent Board of Trustees meeting. This report
indicates sustained progress over the past few years with a number of
key clinical measures. We are emerging as a leader among our university
healthsystem consortium peers. Additional details are included in this
While we have made much progress as indicated above, we need to refocus
our attention upon a number of MUSC Excellence best practices which
impact patient satisfaction. Examples of these best practices include
discharge phone calls, leader and hourly rounding, AIDET and other
“Must Haves.” Everyone needs to be reminded of the 10/5 rule and
remember to escort lost visitors to their destinations. We are
ratcheting up our efforts in these areas at this time and will be
routinely communicating our progress.
Thank you very much.
W. Stuart Smith
Vice President for Clinical Operations
and Executive Director, MUSC Medical Center
People—Fostering employee pride and loyalty
Corish, R.N., Clinical Services director for Oncology and Medical
Surgical Services, read a Wins letter written by a Hollings
Cancer Center patient and brain cancer survivor who was referred to
MUSC back in August. The patient remarked about the incredible level of
professionalism and care he encountered while at MUSC. He specifically
cited excellence with the nurses, physicians, radiology oncology staff,
support staff and administrators for creating a genuine environment
that exceeded his expectations for hospital care.
Heather Koko, PharmD, interim director, Department of Pharmacy
Services, recognized the pharmacy team of Joseph Mazur, David Taber,
Tanna Cooper, Carol White and Walt Uber for having won the American
Society of Health-System Pharmacists Best Practices Award for their
program “Safety and Efficacy Analysis of an Inpatient Collaborative
Drug Therapy Management Service for Direct Thrombin Inhibitors.” The
group was among six of 46 total programs who competed for this award.
The team will receive the award at the ASHP’s Midyear Clinical Meeting
Employee of the Month – September and October
• Mark Wallace, a phlebotomist in Laboratory
Services, assisted an elderly couple who were trying to find their son
after he was admitted to ART following a heart attack. Wallace helped
the couple locate their son. (by Donna McClellan)
• Clara Wilson, Sleep Lab patient and registration
rep, who assisted a patient from Smoaks, S.C. who missed her ride home.
Wilson assisted her by calling various agencies but no one could help
her. Finally, Wilson called her aunt who picked her up and escorted the
patient safely home. (by Barrie Tyler)
• Dorann McCutcheon, R.N., 7A, praised McCutcheon for
providing an excellent level of continuous patient care. Pascoe read
comments submitted in a recent Patient Satisfaction Survey that
mentioned McCutcheon in the care of a three-year old patient. The
comments included: “She [McCutcheon] provides the extra touch that
makes patients and families feel comfortable.” (by Carla Pascoe)
Karen Rankine, MUHA HR Organization Education & Development manager, reviewed the following information:
Joint Commission HR Standards Plans of Action:
• HR.01.02.05 – The organization verifies staff qualifications
Organization findings: Documentation is not consistent in unit files.
Tracking of expiration dates is currently a very manual and cumbersome
Plan of action: Develop standardized process to track necessary
qualifications, requirements (background checks, certifications, etc.).
Develop standardized form and review by MUHA Education & Steering
group. Roll out to managers, directors, etc.
Process will be implemented, completed and monitored by Oct. 22.
Initiate implementation of online system to enhance tracking capabilities.
• Tracking information – Ultimately, SuccessFactors
will be able to track licensure/certification and competency
• For the present time, the LDI tracking database will be used.
Rankine recognized Mary Fischer, Clinical Services Administration, for
developing this added feature of staff qualifications in the LDI
• HR.01.06.01 – Staff are competent to perform their responsibilities.
Organizational findings: Documentation of required orientation is not
consistent in unit/department files. Forms are not standardized
Plan of action: HR Education & Training staff have revised
orientation tools to include hospitalwide and unit/department specific
orientation to be used for assessments. Tools to be presented to MUHA
Education & Steering group and implemented by Oct. 22.
• Open enrollment ends Oct. 31. For information, visit https://www.musc.edu/medcenter/news/insurance_enrollment.htm
• Smoker certification is due by Nov. 15. Visit https://www.musc.edu/medcenter/news/smoker_certification.html
• Questions, call Mark Stimpson, 792-9320.
• FY 2008-09 was financially a challenging year.
Concentrated efforts by everyone in the organization led us to a
positive bottom line. It is because of employee commitment that the
medical center is able to implement performance pay increases.
• Performance Pay Increase – effective Oct. 11 pay period, reflective in Nov. 4 pay check.
• Probationary employees employed prior to April 2009
will be eligible for a meets pay adjustment. Those employees employed
prior to Sept. 1 will be eligible to receive a one percent pay
• The PTO Cash in-Conversion to ESL will be available to eligible employees for the
• Dec. 9 payout; employees may request up to 40 hours
of PTO for cash in /conversion to ESL. Request forms can be accessed on
the HR Web site under “forms.” Completed forms must be submitted to
Payroll by Nov. 20; PTO cash in will be paid via direct deposit.
Benefit of the Month – November: PTO cash in /PTO conversion
Finance – Providing the highest value to patients while ensuring financial stability
Hargett, medical center controller, presented the final report for
FY2009. MUHA’s audit was completed Oct. 15 finishing the year on a
positive note with $3, 498,897 in net assets – reflecting a good
turnaround with the enterprise. Hargett remarked that several positive
audit adjustments were responsible for the final audit numbers
differing from the numbers reported earlier.
The hospital overcame some payback to Medicaid program’s overpayment of
disproportionate share funds for FY2005 to 2007 of $24 million. For
first quarter FY2010, the hospital sits on a profit $12 million in net
assets thanks to tremendous patient volume, charges, controlling costs,
etc. Hargett also explained the loss on swap termination is $5.25
million. The hospital is accruing funds for the eventual payment to
Bank of America. MUHA plans to accrue the entire amount of this payment
over the next six months. As of Sept. 30, cash on hand is $33 million
and 13 days cash on hand.
Hargett reminded managers that $50 million and 21 days cash on hand is
important to the institution since HUD, the insurer of MUSC’s bonds, is
currently holding $20 million of MUSC’s cash on escrow. If MUSC shows
three years of positive operating income and 21 days cash on hand, MUSC
will receive those funds including accrued interest. Currently, the
hospital has more than $40 million cash on hand.
Quality – Providing quality patient care in a safe environment
Joint Commission Jeopardy
Karen Rankine, Nina Epps, Point of Care testing manager, and Carl
Kennedy, Outcomes & Quality Management/Patient Safety, reviewed
human resources, waive testing (glucose meters, dip urines, hematocrit,
gastric test, etc.) and 2009 National Patient Safety Goal (NPSG)
questions in the bi-monthly interactive Jeopardy quiz.
This week’s game challenged the audience with questions about waived
testing, competency assessment, QC, primary source verification, SBAR
and medication reconciliation. To review the 2009 NPSGs visit http://www.jointcommission.org/
Quality Annual Review
Chris Rees, director of Quality & Patient Safety, reviewed the year
end quality and patient safety review presented to MUSC’s Board of
Trustees Aug. 13. This information is compiled each year in August
allowing staff to review yearly goals and accomplishments. Rees
stressed the importance of reviewing these results with MUHA employees
and recognize the positive results gained by a purposeful, committed
Quality and Patient Safety areas of focus for FY 2009 were:
Safe – CVL-related blood stream infections and culture of safety and
increased occurrence report; Effective – mortality ratios and CMS/Joint
Commission measures; Efficient – 30-day readmissions; Patient-Centered
– HCAHPS and improved outpatient scores; Timely – clinic wait times and
emergency department wait times and Equitable –check any variances
between socioeconomic class vs. mortality, length of stay, etc.
Safe -- Marked improvements were made in CVL associated blood stream
infections which was reduced by 46 percent during the first six months
of CY2009 compared to CY2008. Rees praised Infection Control and
nursing unit staff for achieving these improvements.
• Hospital saw a 28 percent increase in Good Catches
during first six months of 2009 as compared to CY 2008. There were 874
during first quarter after July’s Patient Safety LDI, which MUSC
partnered with NASA to teach leaders about driving a culture of safety
Effective -- Mortality ratio showed an 18 percent improvement during
the first seven months of 2009 as compared to CY2008. With the
pneumonia vaccination compliance increased by 58 percent – well above
state and national averages.
Hospital saw a 68 percent improvement of CMS measures during first quarter CY2009 compared to 2008.
Efficient – The hospital saw a 5 percent decrease in our 30-day readmission rate and moved up in ranking.
Patient Centered – Medical practices in the ambulatory care setting
continues to shine and be model for the organization. Medical practices
have seen their rank surpass the 90th percentile in FY 2009. Currently
at the 92nd percentile in FYTD 2010.
Timely – The emergency department has significantly reduced wait times,
which led to a 36 percent decrease in number of patients that leave
without treatment. This is a quality and safety issue.
Equity – Organization looks at numerous key measures across different ethnic groups to ensure there is no variation in quality.
Areas of Focus for FY 2010 – Safe—surgical site infections and falls;
Effective – mortality ratio and CMS/JIC core measures; Efficient –
30-day readmissions (specifically congestive heart failure and sickle
cell); Patient centered – HCAIHPS and inpatient (adult and pediatric);
Timely – try to reduce bump rates (cancellations); and Equitable.
In conclusion, Rees reminded managers that MUSC’s goal to become a
great hospital and be in the top quartile (75 percentile) is
progressing. Rees feels these goals are achievable thanks to a
committed staff and the MUSC Excellence program, which is responsible
for driving outcomes and improving our perception among national
academic medical centers. In 2006, MUSC achieved the 56th percentile in
the UHC rankings. By 2008, MUSC ranked 16th among 96 other hospitals
and moving closer to the top 10 academic medical centers in the
The next meeting is Nov. 3.
Friday, Oct. 23, 2009