To Medical Center Employees:
During 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 engagement.
 
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.
  

On 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 newsletter.
 
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 newsletter. 
 
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

Colleen 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 in December.

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)

HR update
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 process.

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 verification.
•    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 tracking database.
 
•    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 throughout organization.

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.

HR reminders
•    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.

Wins
•    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 adjustment.

•    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

Steve 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 organization.

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 country.

Announcements
The next meeting is Nov. 3.

Friday, Oct. 23, 2009