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 successful.
 
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
Peggy 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 accreditation.

People—Fostering employee pride and loyalty
Fred 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 906-8410.

Patient Compass
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 reader usability.
 
Visit http://www.muschealth.com.

Privacy update
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.

Announcements

• Hannah Waites, Utilization Management manager, will retire from MUSC after  17 years. Cheryl Ericson, Clinical Documentation Improvement manager, Patient Access Services, also will manage utilization review.

• The next meeting is Nov. 17.

Friday, Nov. 6, 2009