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MUSCMedical LinksCharleston LinksArchivesCatalyst AdvertisersSeminars and EventsResearch StudiesPublic RelationsResearch GrantsMUSC home pageCommunity HappeningsCampus NewsApplause


Currents  Jan. 5

To Medical Center Employees:
As 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 meetings. 
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 Services requirements. 
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

People—Fostering employee pride and loyalty

•    Kim 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 practices.

HR update
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,

•   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,

•  SuccessFactors 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 CATTS.

•   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,

•   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.

ESL 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 40 hours.

January – Benefit of the Month
Lunchtime Losers 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
Reece Smith, 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.

Employees 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.

According to 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 action plan.

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.

Managers were 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 mode).

Leaders are 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.

Terri Ellis, 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

Finance–Providing the highest value to patients while ensuring financial stability

Steve Hargett, medical center controller, gave the financial report for the five month period ending Nov. 30 FY 2010 and FY 2009.

Hargett reported 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

Heather 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 reconciliation forms.

The National Patient Safety Goal (2.02.01)–was created to ensure that mistakes do not occur from using confusion abbreviations, acronyms, symbols or dose descriptions.

Medical Center 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.

Inpatient and 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.

Other -- 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.

In conclusion, 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

The Catalyst Online is published weekly by the MUSC Office of Public Relations for the faculty, employees and students of the Medical University of South Carolina. The Catalyst Online editor, Kim Draughn, can be reached at 792-4107 or by email, Editorial copy can be submitted to The Catalyst Online and to The Catalyst in print by fax, 792-6723, or by email to To place an ad in The Catalyst hardcopy, call Island Publications at 849-1778, ext. 201.