People—Fostering employee pride and loyalty
To Medical Center Employees:
we enter the winter season and the possibility of icy road conditions,
everyone needs to be familiar with department-based plans and relevant
medical center policies including the Medical Center Weather Emergency
Plan (policy A-64) and the Human Resources Hazardous Weather and
Emergencies (policy 13).
Our policies refer to the Intermediate Weather Alert Plan which applies
in the less severe weather situations, such as icy roads. Under the
intermediate plan, staff may need to report early or remain one or more
hours after their normal shift.
Also, the management team should ensure everyone is familiar with the
Medical Center Employees General/Emergency Information line (aka Green
Card) and how it is used to facilitate good communication during
hazardous weather conditions. Departmental representatives should be
prepared to update department-specific instructions if necessary.
On another matter, Joan Herbert, director of organizational
performance, updated the management team on the organizationwide
employee partnership survey action plan at this week’s management
communication meeting. Additional details are included in this
newsletter. Joan will be scheduling a series of open forum meetings
during Jan. 25 to 29 to solicit suggestions from staff. The times and
locations for the forums will be announced. We also will discuss the
organizationwide action plans at future medical center town hall
Much work is under way to take our rounding and audits of clinical and
support activities to another level as indicated in this newsletter.
The intent is to ensure that we provide high quality care and maintain
a safe work environment while we appropriately document our fulfillment
of Joint Commission standards and Center for Medicare and Medicaid
I am optimistic about the new year. While there are opportunities for
improvement, we are making good progress with our pillar-based goals
around service, people, quality, finance and growth. Thanks to all for
a job well done.
W. Stuart Smith
Vice President for Clinical Operations
and Executive Director, MUSC Medical Center
Phillips, Transplant Center administrator, announced that Timothy
Whelan M.D., a pulmonary transplant physician from University of
Minnesota, has signed on with MUSC and will join William Yarbrough,
M.D., lung transplant surgeon, to restart the medical center’s lung
transplant program beginning this summer.
• Peggy Thompson,
director of Patient Accounting and Revenue Systems, reported that the
medical center’s revenue for charges from December collections
accounted for a record $80.6 million in collections/cash.
• Reece Smith,
medical compliance director, shared the positive outcome of a 2009
Medicaid audit evaluating the medical center’s billing and coding
Helena Bastian, MUHA HR director, reviewed the following information:
• Mango update – Mango
replaced the former management directory and has been upgraded to allow
users to update the system, manage information, etc. All leaders who
attend the LDI sessions must be entered into the Mango system with the
correct role (manager, supervisor/coordinator, etc.). SuccessFactor’s
Leader evaluation forms will be determined by what’s entered in Mango.
Questions should be directed to Kim Duncan, 792-1962, firstname.lastname@example.org.
• HR education and
training updates: Protecting Yourself in the Digital Age Identity,
Party 2, 1-2:30 p.m., Jan. 13, Room 628, Clinical Sciences Building;
New leader orientation, Jan. 14, 21 and 28 and Selecting Talent for
Peer Team Members, 8:30 a.m. to 12:30 p.m., ART Rm. 2408. Employees may
self-enroll via CATTS, http://www.musc.edu/catts.
update–Employee Profile Training, 1-2 p.m., Jan.7, 2West Amphitheater.
Training for the new Internal Customer Survey process will begin the
week of Jan. 11. Dates and times are listed in CATTS. Register via
• Staff Qualification
Tracking (HR Joint Commission Action Plan) – located in LDI Tracking
Data Base -- Information must be entered and maintained for all
employees. Request access by contacting Mary Fischer, email@example.com.
• PTO & ESL accrual
maximum carry over into 2010 – PTO maximum (Policy 18—Paid Time Off
Policy), the 2009 yearly cut-off date is the pay period ending date,
which includes Dec. 31, 2009 work day.
For Calendar Year
2008, Dec. 31, 2009 workday is in the pay period that ends Jan. 2.
Employees with more than 360 PTO hours at the pay period ending Jan 2,
plus the accrual for that pay period ending Jan. 2 will need to
consider their excess of 360 PTO hours that will be deducted. The leave
cut off will be reflected Jan. 13 pay date.
Maximum–Employees hired prior to July 1, 2000 (Maximum carryover into
2010 is 1,440 hours); Employees hired on /after July 1, 2000 (Maximum
carryover into 2010 is 720 hours)
PTO & ESL
Accrual Maximum Carry over into 2010 – Supplemental medical leave
eligibility and accrual method: An employee must have 55 hours of
accrued ESL by the last pay period of the calendar year. Eligible
employees will automatically have 24 ESL hours transferred to SML,
which will be reflected on Jan. 13 pay date; SML balance may not exceed
January – Benefit of the Month
is a 10-week worksite weight loss program for MUSC employees and
offered via Health 1st. The program features a team of dietitians,
psychologists, exercise physiologists and other specialists to assist
employees to adopting healthy eating and exercise habits. Cost is $98
for entire program (payroll deduction available); Classes take place at
IOP-Weight Management Center; 12-1 p.m., Jan. 21. For information and
registration, e-mail name, e-mail address and phone number to
Social networking & patient privacy
medical center compliance director, reminded managers to review with
their employees the importance of HIPAA privacy rules and regulations
concerning patients. Employees should refrain from discussing
information at all times, especially in public places or venues
including social networking sites and other media.
Employee Survey Organizationwide Action Plan
Joan Herbert, MUHA
director of Organizational Performance, spoke about the medical
center’s organizationwide employee partnership plan. The effort is part
of the follow-up of the employee partnership survey. Herbert reviewed
the organization’s top 10 opportunities and the top two priorities
identified by employees in a recent online poll.
communicated that: My work group is asked for opinions before decisions
are made (46.6 percent); Leaders really listen to employees (41.3
percent) were the most important opportunities to them.
Herbert, employees of healthcare organizations utilizing the Press
Ganey survey across the country also cite having opportunities to share
their opinions as part of the decision-making process as an important
issue to them. At the same time, many organizations are identifying how
important tapping into the experience and knowledge of employees is and
will be to their success.
The draft of the
action plan will be distributed to employees by e-mail for review and
input during the month of January. Everyone is encouraged to provide
their comments about the plan. Opinions will be welcomed in writing or
during open discussion meetings that will be held during the week of
Jan. 25. A listing of the meeting times a nd locations will be included
when the action plan is sent to everyone. In addition, Herbert is
available to attend individual work group staff meetings to discuss the
Joint Commission/CMS review, audit tools
Kim Phillips also
reviewed the ongoing status of activity resulting from November’s Joint
Commission accreditation visit focusing on staff knowledge of
performance improvement (PI) activity and its comprehension.
Since then, about
60-plus hospitalwide teams were established to develop specific action
plans targeting survey results. During the review, surveyors identified
core issues that need to be addressed and corrected. Accountability by
all members of the work team is a priority. The teams have been
actively working on action plans to make these corrections and changes.
Throughout this process hospital leaders have done their best in
conserving the work by revising work and not add efforts.
provided with several audit tools and links to help them pinpoint
problems, collect information and target solutions that need to be
made. Most specific issues and areas that Joint Commission has
identified have been built into the audit. Managers should review the
most current information and use the newest audit tool links
(PowerPoint presentation with a grid and links, using presentation
encouraged to complete rounding/review/audits according to the matrix.
Access to VSurvey is not required to complete audits. Managers may use
VSurvey links from the attached matrix to enter data. Medical Record
numbers are required on all applicable audits. All required information
must be entered weekly into VSurvey by 5 p.m., Sundays. Information
will be reported to the Administrative group at the beginning of each
week for review and action.
accreditation coordinator, provided managers with details related to
changes throughout this effort, plus matrix information now located in
the communications meeting Web page and manager’s toolbox via the MUHA
intranet. Contact Ellis at 792-5106 or firstname.lastname@example.org.
Finance–Providing the highest value to patients while ensuring financial stability
Hargett, medical center controller, gave the financial report for the
five month period ending Nov. 30 FY 2010 and FY 2009.
that cash by the end of November was $36.9 million and 15 days cash on
hand maintaining positive cash levels since April 2009. In November
2008, cash was $5.3 million and 2.2 days cash on hand and continued on
an upward trend in building up cash through increased volume and
controlling costs. Hospital Patient Accounting’s record $80.6 million
in collections/cash for December should result in a cash balance of $38
million. Hargett reminded managers that December also is a busy month
for cash outflow with the quarterly license tax (Medicaid
disproportiate share tax), three payrolls and other activity.
For the first five
months ending in November, the medical center has a $17 million profit
(budget was $11 million) compared to FY2009 which resulted in a $9
million loss. Hargett recognized the hard work and dedication of MUSC
employees for the financial turnaround and success. He also spoke about
the swap termination arrangement as part of borrowing which resulted in
an $8.7 million loss when it terminated Dec. 1. The medical center
budgeted for the loss over the entire year and reserve for the $8.75
million in the first five months of the fiscal year. The remaining
$3.645 million in the budget will provide a financial cushion
throughout the remainder of the fiscal year. Management hopes to
maintain a break-even period from December through January and
forecasts a positive budget variance for the entire year.
Quality–Providing quality patient care in a safe environment
Kokko, PharmD, director of Pharmacy Services, spoke about medication
order writing guidelines in compliance to policy. The topic also is
part of a specific action plan developed and communicated by Kokko and
Pharmacy Services staff. She reminded managers that medication order
writing is a critical component in providing the safest and highest
quality patient care.
The November Joint
Commission review revealed several key areas of improvement, which
includes the writing of medication orders and completion of medicine
Patient Safety Goal (2.02.01)–was created to ensure that mistakes do
not occur from using confusion abbreviations, acronyms, symbols or dose
Policy (C-078) Medication Orders–For patients less than 17 years old,
practitioners should follow weight-based dosing (patient’s weight
recorded on order); for patient weighing less than 40 kilos, include
dose per kilo per interval on order. Dosage should be entered in metric
units. If dose is a volume, include desired concentration.
clinic medication orders–date and time of order (military time);
medication name (include all appropriate salt forms including
calcium-chloride or calcium gluconate); route of administration,
frequency/interval (include appropriate parameters for al PRN orders;
signature, credentials and legible pager number.
unapproved abbreviations–medication names cannot be abbreviated;
correction of an order that has not been processed–strike through the
entire order with a single
line, and write “error” and initial (Not following this procedure
presents a patient safety and legal risk for MUSC); adding medication
orders to a chart that’s already signed and in possession of
prescriber–write orders in a new section of physician order form; write
an explicit order for each action that should be taken–write to
discontinue meds when clinically appropriate.
As of Jan. 4,
Pharmacy Services will not accept incorrectly written medication orders
and prescribers will be asked to correct orders in the chart before
they can be processed (including verbal or telephone medication
orders). Please contact your pharmacist with questions. Kokko thanked
all medical center personnel for their support and cooperation in
helping to maintain excellence in patient care and safety.
Kokko reminded managers about the policies regarding clinical
refrigerator logs (vaccine storage, medication, dietary, and breast
milk refrigerators). The vaccine refrigerator is for products stored
for several days (requires twice-a-day checks), while the dietary,
breast milk or medication refrigerators use one log (for freezer or
refrigerator). Staff can download a copy of the logs in the forms
toolbox found on the MUHA intranet.
• The next meeting is Jan. 19, Room 402, Basic Science Building.
Friday, Jan. 8, 2010