To Medical Center Employees:
Last week, six Joint Commission surveyors completed a weeklong
accreditation survey of the medical center. I want to thank everyone
who participated in the survey. The survey team commented about the
high quality care we provide. All indications show, based on comments
of the surveyors, the survey as successful.
Unlike previous years, the final decision is made by the Joint
Commission Central Office rather than by the surveyors themselves. We
expect a final report from the Central Office in a few weeks and will
issue an update at that time.
On another matter, as we wrapped up leaders’ evaluations this year it
became apparent that some were not fully attuned to the details of
their metrics-based pillar goals. We believe, for some, this was a good
learning experience we can continue to build upon.
This year, all employees have at least two service area-specific pillar
goals built into performance evaluations. These goals amount to 25
percent of the overall evaluation ratings. We all need to remain
focused on our goals, routinely knowledgeable about our progress and
take action as needed. Anyone who has questions should talk to their
manager, director or administrator. Working together we will all be
Finally, we conducted a recent brief internal survey of all MUHA
employees to rank the top 10 opportunities as identified by the
Employee Partnership Survey. The plan is to develop an organizationwide
action plan around the opportunities selected as most important.
We had 1,743 responses during the course of the one-week survey. Top
opportunities identified include “my work group is asked for opinions
before decisions are made” and “leaders really listen to employees.” We
will begin developing action plans and will communicate the specifics
around these and other topics soon.
Thank you very much.
W. Stuart Smith
Vice President for Clinical Operations
and Executive Director, MUSC Medical Center
Service—Serving the public with compassion, respect and excellence
Thompson, dir-ector of hospital patient accounting and revenue systems,
announced a new business partner working with the medical center,
Chamberlain-Edmunds, an advocacy group that assists self-paid patient
find financial funding. Hospital Patient Accounting has reorganized
their process and Chamberlain-Edmunds is the result of an
interdepartmental work group involving Mary-Elise Merrell, Clinical
Effectiveness; Stephen Godbold, Children’s Hospital; Cheryl McWilliams,
Tri-county Medicaid, George Seblonka, UMA Patient Accounting and Helen
Thomas, Patient Access Services. Chamberlain-Edmunds staff will be
working on the floors and units visiting patients and reviewing patient
medical records, etc.
- As of Nov.
3, MUSC’s Chest Pain Center at ART passed DHEC inspection and is now
operating as a fully functioning emergency department. Ambulances
transporting patients with chest pain or related symptoms will be
received as early as Nov. 4 or 5.
- HCC received
accreditation with commendation from the American College of Surgeons.
Recognized was Linda Cope, HCC’s cancer registry and Nestor Esnaola,
M.D., associate professor, Department of Surgery, and chief physician
for this accreditation process and chairperson of the Cancer Program
Committee who were responsible for meeting the requirements of this
People—Fostering employee pride and loyalty
Thompson, community liaison for Institute of Psychiatry
Seasons, addressed managers about Seasons outpatient
program, located in McClennan-Banks Building.
This partial hospitalization program and outpatient service supports
adults, age 40 and above, who are struggling to deal with psychiatric
illnesses like anxiety, depression, bipolar disorder, etc. Thompson
said that these services are needed for patients who need assistance
following a hospital discharge. For information, call 792-5567 or
Peggy Thompson and Regina Dell, operations manager in hospital patient
accounting, spoke about Relay Health’s Patient Compass Web site now
used by patients to pay hospital bills. The program was activated Sept.
28. Currently, there have been 455 visitors to the site, 744 visits, 79
patient enrollees, 1,207 transactions generating $186,000 paid online.
Regarding Web site security, Relay Health provides secure servers to
decrease the vulnerability of the system. If a patient pays their bill
using a credit card, the site features a secure socket layer. Data
stored on the server is encrypted and only the last four numbers of the
credit card or SSN is displayed. A 3-digit verification code is not
stored. Credit card information is not stored on MUSC servers or
communicated through the network. Patient Compass is 508 compliant for
Reece Smith, medical center compliance director, spoke to managers
about the Health Information Technology for Economic and Clinical
Health (HITECH) portion of the new Federal Stimulus Act. Essentially,
it tightens current HIPAA privacy and security standards and provides
incentives for hospitals and physicians to use electronic medical
record technology and disincentives for failure to meet privacy and
security standards. HITECH’s breach notification standards
(enforcement date is Feb. 17, 2010) defines a breach as an
impermissible use or disclosure under the Privacy Rule that compromises
the security of privacy of protected health information (PHI) such that
use or disclosure poses a significant risk of financial, reputational,
or other harm to the affected individual.
Encrypted PHI is a safe harbor/exception. When a breach is discovered,
MUSC must: Individual—notify immediately; Media—notify immediately in
cases of 500-plus individuals; Government notice—Annual notice of all
breaches and immediate notice in cases of 500-plus individuals.
Misdirected faxes—Always verify fax numbers; use a coversheet with name
and phone number of sender; whenever possible, use automated faxing
system, notify the owner of the faxing system or the Compliance Office
immediately if you are aware of an incorrect fax number in one of these
systems so it can be corrected.
E-mail PHI only when necessary and in compliance with the hospital’s
Patient Confidentiality policy; if going outside MUSC’s firewall,
always use encryption; secure mail—http://www.musc.edu/infoservices/exchange/securemail.html.
MUSC will continue to conduct weekly audits of employees and periodic
“for cause” audits; You must use the official Authorization to Disclose
PHI at http://www.musc.edu/cce/ORDFRMS/pdf/all_all_consent_authtorelease.pdf if you access the records of an individual for reasons other than treatment, payment and operations.
Bring the completed form to HIS to be scanned into the patient’s record.
Password protect your Blackberry; Call the Compliance Office if you
suspect a breach of PHI (electronic or otherwise); a photo of a
patient’s face is considered PHI; PHI should never go into a
wastebasket; new container lids are being distributed within the next
two to three months to support both PHI and non-PHI paper. Contents
will be protected for confidentiality and recycled. Questions
should be sent to the Compliance Office, 792-4037.
Waites, Utilization Management manager, will retire from MUSC
after 17 years. Cheryl Ericson, Clinical Documentation
Improvement manager, Patient Access Services, also will manage
- The next meeting is Nov. 17.
Friday, Nov. 6, 2009