To Medical Center Employees:
We 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.

Inpatient      Rank/Percentile*            Outpatient Clinics & Services          Rank/Percentile*
MUH 5W              98th                                        RT Maxillofacial                                99th

MUH 9E               96th                                        ART CT Surgery                               98th

ART 4E                 95th                                        Peds Sickle Cell                                98th

ART 3W               93rd                                        HCC 2 Thoracic Surgery                   98th

NNICU                 91st                                        ART Radiology                                  88th

Peds ER                 93rd                                       Mental Health Outpatient                    83rd

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 herbertj@musc.edu 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

Wins
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 month.

H1N1 vaccine
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 month. 
 
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.

HR update
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, duncanki@musc.edu

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 procedure.

•  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

Announcements
•   Janice Seymour, has joined the staff of Therapeutic Services as a business analyst. Seymour came to MUSC from Duke Medical Center.
•   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, 792-8793.
•   The next meeting is Feb. 2.

Friday, Jan. 22, 2010