People—Fostering employee pride and loyalty
To Medical Center Employees:
we approach the holiday season and calendar year end, I want to thank
everyone for your dedicated efforts. We kicked off our MUSC Excellence
initiative four years ago, and we have made good progress toward most
of our goals aligned with service, people, quality, finance and
Our patient satisfaction goal for the fiscal year is the 80th
percentile, and within the adult inpatient area we are currently at the
79th percentile. In the outpatient area, we are at the 89th percentile.
Clearly there are some areas in which we need to renew our efforts to
reach our patient satisfaction goal, including AIDET, nurse leader
rounding, hourly patient rounding, discharge phone calls and other Must
Haves to improve satisfaction and quality of care.
Currently we are on track toward achieving our 75th percentile
mortality goal, with a ranking of the 79th percentile within the
University HealthSystem Consortium (UHC) benchmarking group. We have
improved our financial situation substantially compared to this time
last year. Our inpatient census and outpatient activity have been very
strong. We are exceeding our 2 percent adult medical/surgical growth
goal with a current rate of 4.8 percent; and we are exceeding our 7
percent outpatient encounters growth goal with a current rate of 7.3
As we enter into the new calendar year, we need to revitalize our
efforts around physician and employee satisfaction. In connection with
our employee satisfaction goal, we will be announcing methods in the
weeks ahead to enhance communication and increase involvement in
Finally, we have devoted a great deal of effort toward fulfilling Joint
Commission standards. Our leadership team will strive to do a better
job with more clearly integrating the Joint Commission standards and
elements of performance into our MUSC Excellence goals and actions
I wish everyone a safe and happy holiday season.
Thank you very much.
W. Stuart Smith
Vice President for Clinical Operations
and Executive Director, MUSC Medical Center
Phillips, Trans-plant Center admini-strator, praised the efforts of the
MUSC family for supporting the 2009 MUSC Angel Tree Campaign in
conjunction with the Salvation Army and Debi’s Kids. Employees picked
up a total of 1,900 angels, which almost doubled the amount of toys and
gifts collected for needy Tri-county children in last year’s campaign.
Phillips recognized university and hospital members of the Angel Tree
Board, supporting departments and individuals for their dedication to
this year’s success.
June Darby, Neurosciences Institute Administrator, related a letter
written by the parent of a North Carolina patient and written to Kelly
Cavins, R.N., Epilepsy nurse coordinator.
The patient’s mother related a letter of thanks for his extraordinary
care, attentiveness to her and her son and positive experiences while
accessing care at MUSC. She also praised multiple individuals (Kikki
Thayer, Tony Hamilton, R.Ph., Mark Wagner, M.D.) and departments
(Parking Management, Neurosciences, Therapeutic Services/Speech
Pathology) for their help during their recent visit. “My son’s
treatment, the respect, hospitality and professional-ism we experienced
at MUSC has been amazing,” she wrote.
Employee of the Month—December
Peggy Wingard, a Referral Call Center customer service representative
with Business Development & Marketing Services, was recognized for
going out of her way to assist an employee obtain and verify a phone
number to follow up with a referring physician. Wingard was cited by
Ryan Curry, Pediatric Burn Unit, for her excellent customer service
skills, helpfulness and teamwork in locating a phone number in
connection with the care of a patient. (by Hope Colyer)
Cathy Vaughn, R.N., Ashley River Tower Digestive Disease Center and
DDPCU unit educator, was recognized for going above and beyond her
duties in preparing 20 new hire nurses in the opening of the DDPCU.
Vaughn organized candidate interviews, scheduled classes, attended
meetings, provided bedside instruction, managed communication and
handled other patient care issues throughout this period. Her positive
attitude, dedication and commitment are appreciated, wrote nominator
and colleague Ashley Allen, R.N. (by Chris Zensen)
Helena Bastian, MUHA HR director, reviewed the following information:
--Selecting Talent (Must Have)—Peer interviews is required for new applicants, rehires, transfers and temporary employees.
--Peer Team training is scheduled for Jan. 20—8:30 a.m. to 12:30 p.m.,
Room 2408, Ashley River Tower. Employees can self-enroll via CATTS,
--Standardized Orientation Summary Sheet (new hires or
transfers)—Clinical and non-clinical forms can be used for
unit/departmental orientation (effective Nov. 9).
--Leader Orientation (formerly Management Orientation)—for leaders
participation in LDI—Jan. 15 (session 1); Jan. 22 (session 2); Jan. 29
(session 3); participants can enroll via CATTS, http://www.musc.edu/catts.
--Success Factors—Staff training— Employee Profile—training scheduled in ART in January
--360 model (Internal Customer Survey Pilot)—open to HR, Business
Development & Marketing, Staffing Office, Decision Support and
Ambulatory Care/Performance Improvement & Staff Development
Qualification Tracking (Joint Commission Action Plan)—located in LDI
Tracking Data Base—Information must be entered for all employees.
Questions may be directed to Helena Bastian, firstname.lastname@example.org or Karen
Pre-employment/Post Offer Screening-Respiratory Fit Testing— Effective
Jan. 4, Respiratory Fit Testing will be included as part of the
pre-health screening. Fit testing training sessions will continue
through Feb. 2.
Quality—Providing quality patient care in a safe environment
Caraviello, R.N., interim nurse quality program coord-inator and nurse
alliance chair, reviewed changes to the hospital’s high alert
medications policy (Policy C-61).
definition of a high alert medication—Those drugs involved in a high
percentage of medication errors and/or sentinel events and medications
that carry a higher risk for abuse, errors or other adverse outcomes.
alert medications include: controlled substances, PCA meds, epidural
meds, chemotherapy, insulin, electrolyte supplemental doses,
thrombolytics, anticoagulants, digoxin, neuromuscular blockers, renal
replacement fluids, parental nutrition, titrated infusions,
investigational chemotherapy meds, antisepsis meds, oxytocin, pulmonary
antihypertensive meds and transplant meds.
Caraviello reminded employees there are five rights of medication
administration—The right way—every day, every time (right patient,
drug, dosage, time and route).
MUSC’s independent double check for any high alert medication is
required but co-signature documentation is not required. A double-check
involves two LP/LIPs and must occur at initiation, dosage change (not
titrations), replacement, when a bolus is given, during transfer of
care, to include end of shift change. It was presented at the meeting
per Policy C-61, that the IV site, tubing and connections are
patient-labeled and functional.
Post meeting, it was approved to remove the IV site and tubing check as
part of the High Alert Medication double check. IV sites and tubing
should be checked per Policy C-61 before any medication is administered
by the primary RN, however this aspect does not need to be checked by
the second RN during the high alert independent double check
Hospital staff will perform interview audits and unit rounding to monitor double checks.
For information, contact Caraviello, 792-0258 or email@example.com.
90-day Action Plan Update
Chris Rees, director of quality and patient safety, shared a report
resulting from November’s Joint Commission accreditation visit focusing
on staff knowledge of performance improvement (PI) activity and its
A survey conducted with 1,100 hospital employees in early December
confirmed that only 46 percent of staff were aware of and were able to
articulate their area/department’s PI activity. Rees and leadership
hopes to improve this by February to 84 percent.
The survey did show that 95 percent of people were aware that MUSC uses the IMPROVE model for process improvement.
The respondents of the survey clearly stated that the most effective
way to communicate was through succinct emails and face to face
meetings with their supervisor. All managers and supervisors should be
sharing their LEM goals and 90-day action plans with their staff in
January and this would be an excellent time to talk to staff about how
those plans are their performance improvement activities.
There will be additional long term actions to create a standard
platform for improved communication throughout the organization as well
as the development of reminder cards for staff to use highlighting
their unit’s specific improvement activities.
- Perette J.
Sabatino, R.N., is the new interim Stroke Program manager in the
Department of Neurosciences Stroke Center. Sabatino has been with MUSC
for 10 years and worked previously in many nursing roles including
MSICU nurse educator. She joined the Stroke Program in September.
- Current MUSC Medical Center census as of Dec. 15 is 683 beds, which is considered full capacity.
- The next meeting is Jan. 5.
Friday, Dec. 18, 2009