To Medical Center Employees:
As we approach the holiday season and calendar year end, I want to thank everyone for your dedicated efforts. We kicked off our MUSC Excellence initiative four years ago, and we have made good progress toward most of our goals aligned with service, people, quality, finance and growth. 

Our patient satisfaction goal for the fiscal year is the 80th percentile, and within the adult inpatient area we are currently at the 79th percentile. In the outpatient area, we are at the 89th percentile. Clearly there are some areas in which we need to renew our efforts to reach our patient satisfaction goal, including AIDET, nurse leader rounding, hourly patient rounding, discharge phone calls and other Must Haves to improve satisfaction and quality of care. 

Currently we are on track toward achieving our 75th percentile mortality goal, with a ranking of the 79th percentile within the University HealthSystem Consortium (UHC) benchmarking group. We have improved our financial situation substantially compared to this time last year. Our inpatient census and outpatient activity have been very strong. We are exceeding our 2 percent adult medical/surgical growth goal with a current rate of 4.8 percent; and we are exceeding our 7 percent outpatient encounters growth goal with a current rate of 7.3 percent.

As we enter into the new calendar year, we need to revitalize our efforts around physician and employee satisfaction. In connection with our employee satisfaction goal, we will be announcing methods in the weeks ahead to enhance communication and increase involvement in decision making.

Finally, we have devoted a great deal of effort toward fulfilling Joint Commission standards. Our leadership team will strive to do a better job with more clearly integrating the Joint Commission standards and elements of performance into our MUSC Excellence goals and actions plans.

I wish everyone a safe and happy holiday season.

Thank you very much. 

W. Stuart Smith
Vice President for Clinical Operations
and Executive Director, MUSC Medical Center

Wins
Kim Phillips, Trans-plant Center admini-strator, praised the efforts of the MUSC family  for supporting the 2009 MUSC Angel Tree Campaign in conjunction with the Salvation Army and Debi’s Kids. Employees picked up a total of 1,900 angels, which almost doubled the amount of toys and gifts collected for needy Tri-county children in last year’s campaign. Phillips recognized university and hospital members of the Angel Tree Board, supporting departments and individuals for their dedication to this year’s success.

June Darby, Neurosciences Institute Administrator, related a letter written by the parent of a North Carolina patient and written to Kelly Cavins, R.N., Epilepsy nurse coordinator.
 
The patient’s mother related a letter of thanks for his extraordinary care, attentiveness to her and her son and positive experiences while accessing care at MUSC. She also praised multiple individuals (Kikki Thayer, Tony Hamilton, R.Ph., Mark Wagner, M.D.) and departments (Parking Management, Neurosciences, Therapeutic Services/Speech Pathology) for their help during their recent visit. “My son’s treatment, the respect, hospitality and professional-ism we experienced at MUSC has been amazing,” she wrote.

Employee of the Month—December
Peggy Wingard, a Referral Call Center customer service representative with Business Development & Marketing Services, was recognized for going out of her way to assist an employee obtain and verify a phone number to follow up with a referring physician. Wingard was cited by Ryan Curry, Pediatric Burn Unit, for her excellent customer service skills, helpfulness and teamwork in locating a phone number in connection with the care of a patient. (by Hope Colyer)

Cathy Vaughn, R.N., Ashley River Tower Digestive Disease Center and DDPCU unit educator, was recognized for going above and beyond her duties in preparing 20 new hire nurses in the opening of the DDPCU. Vaughn organized candidate interviews, scheduled classes, attended meetings, provided bedside instruction, managed communication and handled other patient care issues throughout this period. Her positive attitude, dedication and commitment are appreciated, wrote nominator and colleague Ashley Allen, R.N. (by Chris Zensen)

HR update
Helena Bastian, MUHA HR director, reviewed the following information:
--Selecting Talent (Must Have)—Peer interviews is required for new applicants, rehires, transfers and temporary employees.

--Peer Team training is scheduled for Jan. 20—8:30 a.m. to 12:30 p.m., Room 2408, Ashley River Tower. Employees can self-enroll via CATTS, http://www.musc.edu/catts.

--Standardized Orientation Summary Sheet (new hires or transfers)—Clinical and non-clinical forms can be used for unit/departmental orientation (effective Nov. 9).

--Leader Orientation (formerly Management Orientation)—for leaders participation in LDI—Jan. 15 (session 1); Jan. 22 (session 2); Jan. 29 (session 3); participants can enroll via CATTS, http://www.musc.edu/catts.

--Success Factors—Staff training— Employee Profile—training scheduled in ART in January

--360 model (Internal Customer Survey Pilot)—open to HR, Business Development & Marketing, Staffing Office, Decision Support and Ambulatory Care/Performance Improvement & Staff Development

Staff Qualification Tracking (Joint Commission Action Plan)—located in LDI Tracking Data Base—Information must be entered for all employees. Questions may be directed to Helena Bastian, bastianh@musc.edu or Karen Rankine, rankinkh@musc.edu.

EHS Pre-employment/Post Offer Screening-Respiratory Fit Testing— Effective Jan. 4, Respiratory Fit Testing will be included as part of the pre-health screening. Fit testing training sessions will continue through Feb. 2.
 
Quality—Providing quality patient care in a safe environment
Kellyanne Caraviello, R.N., interim nurse quality program coord-inator and nurse alliance chair, reviewed changes to the hospital’s high alert medications policy (Policy C-61).

MUSC’s definition of a high alert medication—Those drugs involved in a high percentage of medication errors and/or sentinel events and medications that carry a higher risk for abuse, errors or other adverse outcomes.

High alert medications include: controlled substances, PCA meds, epidural meds, chemotherapy, insulin, electrolyte supplemental doses, thrombolytics, anticoagulants, digoxin, neuromuscular blockers, renal replacement fluids, parental nutrition, titrated infusions, investigational chemotherapy meds, antisepsis meds, oxytocin, pulmonary antihypertensive meds and transplant meds.
 
Caraviello reminded employees there are five rights of medication administration—The right way—every day, every time (right patient, drug, dosage, time and route).
 
MUSC’s independent double check for any high alert medication is required but co-signature documentation is not required. A double-check involves two LP/LIPs and must occur at initiation, dosage change (not titrations), replacement, when a bolus is given, during transfer of care, to include end of shift change. It was presented at the meeting per Policy C-61, that the IV site, tubing and connections are patient-labeled and functional.
 
Post meeting, it was approved to remove the IV site and tubing check as part of the High Alert Medication double check. IV sites and tubing should be checked per Policy C-61 before any medication is administered by the primary RN, however this aspect does not need to be checked by the second RN during the high alert independent double check
 
Hospital staff will perform interview audits and unit rounding to monitor double checks.
 
For information, contact Caraviello, 792-0258 or caraviek@musc.edu.

90-day Action Plan Update
Chris Rees, director of quality and patient safety, shared a report resulting from November’s Joint Commission accreditation visit focusing on staff knowledge of performance improvement (PI) activity and its comprehension.
 
A survey conducted with 1,100 hospital employees in early December confirmed that only 46 percent of staff were aware of and were able to articulate their area/department’s PI activity. Rees and leadership hopes to improve this by February to 84 percent.
 
The survey did show that 95 percent of people were aware that MUSC uses the IMPROVE model for process improvement.
 
The respondents of the survey clearly stated that the most effective way to communicate was through succinct emails and face to face meetings with their supervisor. All managers and supervisors should be sharing their LEM goals and 90-day action plans with their staff in January and this would be an excellent time to talk to staff about how those plans are their performance improvement activities.
 
There will be additional long term actions to create a standard platform for improved communication throughout the organization as well as the development of reminder cards for staff to use highlighting their unit’s specific improvement activities.

Announcements

• Perette J. Sabatino, R.N., is the new interim Stroke Program manager in the Department of Neurosciences Stroke Center. Sabatino has been with MUSC for 10 years and worked previously in many nursing roles including MSICU nurse educator. She joined the Stroke Program in September.

• Current MUSC Medical Center census as of Dec. 15 is 683 beds, which is considered full capacity.

• The next meeting is Jan. 5.

Friday, Dec. 18, 2009