MUHA's Isabel Detzler, coordinator for Interpreter Services & Cultural Competency, gave an update on the medical center’s language access/interpreter services program.
 
Detzler reminded managers that these services provide language access assistance for patients/families that require it as mandated by the Joint Commission (JC). It can be provided in person, by use of assistive devices, telephone or video.
 
She emphasized that “communication breakdowns, whether between care providers or care providers and their patients, are the primary root cause of nearly 3,000 sentinel events reported to the JC.”
 
Interpreter services has 16 staff interpreters who provide round-the-clock coverage of inpatient and outpatient areas at the Children’s Hospital, Medical University Hospital, ART and IOP as well as Rutledge Tower (60-plus clinics), Hollings Cancer Center (18 clinics), IOP, SEI (adult and peds) and Women’s Center at Cannon Place. Policy updates were made to foreign language interpreters (A-30). Policy A-28 and A-29 merged into a single policy (A-29) stating that interpreter services now coordinates American Sign Language (ASL) interpretations. Staff must call Pacific Interpreters directly for any language other than Spanish. If Interpreter Services cannot assist in a timely manner, managers also may use Pacific Interpreters for Spanish.
 
Clinical staff should use language identification cards and wear interpreter information badges which have contact and pager information. Detzler reminded managers that using the cards and badges meets JC compliance. The list of ASL contracted interpreters is available at http://wwwmusc.edu/interpreter.   For emergencies, MUSC recently contracted with LifeLinks for video interpretation of deaf and hard of hearing patients. The ASL video interpretation equipment is located in 5E, the adult ED and Chest Pain Center at ART. For information, call 792-5078 or e-mail detzler@musc.edu.

SuccessFactors update
Maggie Thompson, service excellence manager, Ambulatory Cares and Kim Duncan, MUHA HR, both members of the SuccessFactors implementation team, reviewed details of the upcoming implementation of SuccessFactors, a new online performance management system. The system will be launched in July.
 
SuccessFactors, which includes MUHA and UMA employees, supports the organization’s shift to a common review date and pay for performance model. It will incorporate Performance Management policy (#16) and newly redesigned evaluation forms. The effort involved MUHA HR, the Performance Evaluation design team and SuccessFactors implementation team to help meet JC requirements.
 
Managers/supervisors will be able to access SuccessFactors through the MUHA HR Web site using your NetID. A new supervisor tree will track supervisor and the direct reporting structure of employees within the organization (must be updated by June 15).
 
Leaders should complete evaluations using the 2008-09 planning stage document (old Position Description/Performance Evaluation) form for employees hired prior to April 2009. Employees hired after April 2009 should have their planning stages completed using the old form until the migration to the new system is complete. Managers should update employee job responsibilities, identify support staff for training, update the supervisor tree to define reporting relationships and complete their 2010 staff pillar goals in LEM and eventually, SuccessFactors, to track monthly/quarterly results (June 15 to Aug. 31).
 
From June 15 to July 10, SuccessFactors training is scheduled in the computer labs including super user training. Managers, supervisors and key support staff must attend. Registration is via CATTS. A SuccessFactors intranet site is available on the MUHA HR Web page. The site features a timeline, quick reference guides, training schedule, etc. Once SuccessFactors is launched, all employees will be able to access the system via the MUHA HR site, as well as remotely (at home or away) using a separate link.

Stand down Wednesdays
Lois Kerr, accreditation manager, unveiled details of a new top down-bottom up approach to Joint Commission (JC) readiness with the start of Stand Down Wednesdays beginning June 3. The effort provides an action plan and focuses on putting patients first. It will be led by two clinical SWAT teams (MUHA administrators and managers), a tactical SWAT team (service line directors), a tracer team and JC steering committee.
 
Stand Down Wednesdays—conducted Wednesday mornings

Clinical SWAT Team documentation tool—department managers (inpatient, procedure, OR or outpatient areas, including EDs) should complete a six-question weekday audit form for their area. Procedure areas managers will continue to conduct time outs, site markings, informed consent, etc.
 
Administrators also will be rounding weekly in units. They’ll be specifically looking at non-compliant issues: obstructed corridors, Wallaroos, locked med carts, privacy and confidentiality, competency folder review (using the HR grid) and armbands.
 
The Tactical SWAT team meets weekly to review data submitted by administrators and tracer teams to determine priorities, focus, etc. A Tracer team will visit four units (including outpatient areas and IOP) on Mondays and Wednesdays and share their findings with the unit charge nurse as well as managers, directors and administrators. The JC steering committee will work on education efforts with functional chapters, serve as ambassadors and help coordinate a periodic performance review by September.

Quality – Providing quality patient care in a safe environment
Karen Weaver, R.N., director of Surgical Services, spoke about MUHA’s updated Time Out policy (C-25) and universal protocol used throughout the medical center.
 
Updates were made based on JCAHO, manager/leadership recommendations. The policy sets guidelines for the prevention of wrong site of surgeries or procedures, wrong person surgeries or procedures or performance of wrong procedure. Verification of the site will be documented using the Pre-Operative Checklist, the Operative Nursing Record, the Moderate Sedation Documentation form, the Universal Protocol Procedure Safety Checklist (new) and the Universal Protocol Surgical Safety Checklist (new—OR use only).
 
The Time Out process and forms should be used any time a surgery or invasive procedure is performed hospitalwide including ambulatory areas/clinics (with the exception of arterial and intravenous lines, naso-gastric tubes and Foley catheters). Clinical staff must follow the verification protocol and Time Out policy in the pre-op, procedure prep and operating/procedure room.
 
The Time Out forms replace the old Non Operative Room Anesthesia (NORA) forms. The purpose of the Time Out process is for all clinical staff to take the time to verify what’s being done—correct patient, site, procedure, patient’s positioning, correct equipment/devices required. If a team changes out during the procedure, another Time Out is performed and marked on the sheet as an additional time out.

Announcements

Patent/visitor parking will be redirected to both the Jonathan Lucas Street and Ashley-Rutledge garages. During this transition, Parking Management will work with hospital administrators to accommodate and communicate these changes. Throughout June, notices will be placed around G lot and handouts will be distributed to customers as they exit. A student after-hours program that currently utilizes G lot will be transferred to the President Street Parking garage. More details will be presented via Broadcast Messages and The Catalyst.