People—Fostering employee pride and loyalty
To Medical Center Employees:
are making good progress toward most of our fiscal year 2009-10
pillar-based goals aligned with service, people, quality, finance and
growth. As we begin the second half of the fiscal year, I want to
revisit where we currently stand with our service goal which is
measured by our patient satisfaction survey results.
The goal is to achieve or exceed the 80th percentile of some 1,700
health care facilities in the Press Ganey database. Currently our adult
inpatient ranking is at the 78th percentile and outpatient clinics are
now ranked at the 88th percentile. Listed below are some areas that are
achieving exceptional results.
Outpatient Clinics & Services
ART CT Surgery
HCC 2 Thoracic Surgery
Mental Health Outpatient
IOP 1N 90th
*Quarter ending 12/31/09
Our overall scores are very encouraging; however, a number of areas
need to renew their efforts. Our Press Ganey survey super users
should ensure everyone within their areas of responsibility is fully
informed. Leaders and service area-specific patient satisfaction
teams should verify that best practices (aka “Must Haves”) are
purposefully implemented and sustained.
Leaders, patient satisfaction teams and others who would like
assistance with training or developing patient satisfaction action
plans may contact Joan Herbert, director, Organizational Performance at
email@example.com or 792-0820.
Thanks to everyone for your dedication in providing quality and compassionate care and service.
W. Stuart Smith
Vice President for Clinical Operations
and Executive Director, MUSC Medical Center
Kim Phillips, Transplant Center Service Line administrator,
announced that MUSC will receive a medal of honor from the Department of Health
and Human Services for organ donor conversion from DHHS. DHHS awards hospitals
that can maintain organ donor conversion rates greater than 75 percent.
Typically, hospitals averaged at 50 percent conversion rate. Transplant centers
can’t succeed without very good organ recovery agencies.
Phillips also recognized the first-year anniversary of the South
Carolina Organ Donor Registry in January. Visit their Web site, http://www.every11minutes.org to update
or apply to the donor registry.
As of Jan. 16, the renovated University Hospital cafeteria
opened for business.
Helena Walo, 8E nurse manager, announced that as of December
2009, 8E achieved zero rates for MRSA, VRE and Central Line Blood
Stream Infections in their unit. This is the first time this unit, a medical
acute care floor, has attained zero rates for all three infections in the same
Cheryl Brian, interim manager for Employee Health Services, reminded
managers and employees that DHEC will be administrating free H1N1
vaccines (nasal, injections, preservative-free) to employees and their
families from 9 a.m. to 4 p.m., Friday, Jan. 22 at Harborview Tower
lobby, 19 Hagood Avenue and also from 9 a.m. to 4 p.m., Saturday, Jan.
23 at the Charleston County Health Department, 334 Calhoun Street. No
appointment is necessary.
Employee of the Month – January
Meredith Strehle, chair of MUHA Excellence’s Rewards & Recognition
team and Kathy Stockholm, assistant director of Environmental Services
at University Hospital, recognized January’s employee of the
Carrie Ladson, Environmental Services supervisor, was recognized in a
letter originating from ART nurse Tricia Budde for her help and
initiative in cleaning out a patient’s truck after he arrived very sick
at the medical center. The patient had vomited in the inside of his
vehicle and had no friends or family to take care of it during his
hospitalization. Keys were secured from the patient by Hospital
Security and passed on to Ladson where she and other staff cleaned it.
Once discharged, the patient expressed his gratitude to Ladson and
hospital employees for their extra efforts. “What a wonderful display
of team effort and generosity,” wrote Budde. (by John Franklin).
Quarterly Injury Prevention newsletter
Kristin Greeson, Trident Area Safe Kids coordinator with the Children’s
Hospital (CH) and Stephanie Power, Surgical Acute and Critical Care
(SACC) service line injury prevention coordinator, spoke about a new
internal advocacy group established through collaboration with SACC
service line and CH staff and physicians. They unveiled a new Injury
Prevention newsletter that shares important data, research and general
news to raise awareness about injury prevention to help MUSC employees
become safety experts throughout the Tri-county community. The
newsletter is available via the MUHA intranet.
Helena Bastian, MUHA HR director, briefly spoke about the upcoming distribution of
Internal Customer Service Surveys via Success Factors. A pilot for this
survey was successfully completed in December. The survey will be sent
out by departments who have interdepartmental customer service score as
a pillar goal. Bastian encouraged participation. Questions regarding
the survey may be directed to Kim Duncan, HRIS manager,
Happy New You TV spots
Chris Murray, director of Business Development and Marketing, unveiled
details about the new “Happy New You” television advertising campaign,
which focuses on promoting good health and prevention in the community.
The Web site offers free online screening tools (weight chart, health
assessment quizzes, etc.) to support MUSC employees, their families and
the Tri-county public in keeping their health resolutions for 2010 via
MUSCHealth.com. Another feature includes the capability of sharing
information in the Web site with others, perpetuating the good health
of others. Visit http://www.muschealth.com/happynewyou
Quality – Providing quality patient care in a safe environment
2010 NPSG update
Carl Kennedy, Outcomes & Quality Management/Patient Safety,
reviewed details about the Joint Commission’s National Patient Safety
Goals (NPSG) for 2010. Kennedy distributed 2010 NPSG posters (white
& blue) to hospital managers and reminded staff to remove all
previous NPSG posters.
2010 updates featured 11 goals compared to 20 goals in 2009. Of these,
seven goals have been integrated to standards; 1 goal has been deleted
and the medication reconciliation goal is being clarified.
2010 goals retained include — Two identifiers (01.01.01); transfusion
ID (01.03.01); critical results (02.03.01); medication labeling
(03.04.01); anticoagulation (03.05.01); hand hygiene (07.01.01);
multidrug-resistant organisms (07.03.01); central line infections
(07.04.01); surgical sige infections (07.05.01); suicide prevention
(15.01.01) and universal protocol.
Goals moved to standards are — prohibited abbreviations (02.02.01);
look-alike/sound-alike (03.03.01); falls (09.02.01); patient education
(13.01.01) and MET Response Team (16.01.01).
Deleted from the manual – Manage as sentinel events all indentified
cases of unanticipated death/major permanent loss of function related
to a healthcare-associated infection. (07.02.01)
Updates include: patient identifiers (01.01.01) — Emphasis placed on
the use of two appropriate identifiers for the patient and not relying
on family members as one of these identifiers.
Critical values (02.03.01) – removed requirement to define critcal
tests; focus is now on critical results and developing a sustained
program; handoffs (02.05.01) – (moved to standards) emphasis on
hospital’s process for hand-off communication provides for opportunity
for discussion between giver and receiver; medication labeling
(03.04.01) – change: All original containers from meds or solutions do
not need to remain available for reference in the
perioperative/procedural area until the conclusion of the procedure.
Reminder-completely label all medications; anticoagulation therapy
(03.05.01) – focus on providing specific education for staff, parents
and families; hand hygiene (07.01.01) – focus on developing and
defining a reliable program implemented by the hospital and patient
involvement (13.01.01) –(moved to standards) emphasis on how hospital
implements its methods to communicate responsibilities for preventing
and controlling infection to licensed independent practitioners, staff,
visitors and patients; provide information for visitors, patients and
families, including hand and respiratory hygiene practices
• Universal protocol – pre-procedure verification; focus on a
standardized process, added items must be available for procedure
includes relevant documentation; labeled diagnostic and radiology test
results, any required blood products and/or special equipment for
• Definition of an LIP (medical resident, physician assistant or
advance practice nurse), one who is ultimately accountable for the
procedure and is present when a procedure is performed.
• Time out Team is specifically identified and agrees to correct
patient identity; correct site and procedure to be done, documentation
requirements are defined by hospital.
• Outcomes & Quality Management/Patient Safety and a member of the Joint Commission Survey Readiness Rounds team
• Janice Seymour, has joined the staff of Therapeutic
Services as a business analyst. Seymour came to MUSC from Duke Medical
• Action O-I reports are due for the quarter ending Dec.
31. Data is due in the system by Feb. 15. A review or training is being
offered on the hour and half hour from 8 to 9:30 a.m., Jan. 27 and from
8 a.m. to noon, Feb. 3, Room 271, main hospital. Call Pam Marek,
• The next meeting is Feb. 2.
Friday, Jan. 22, 2010