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Town hall praises employees, progress

To Medical center employees:

I want to thank everyone who attended our town hall meetings. Meetings began Feb. 18 and one final department-based meeting for this series of town hall meetings is scheduled for March 9. To date, 880 have attended the meetings. This newsletter includes highlights of the town hall meetings. We will post the town hall meeting video on the Medical Center Intranet soon.
On another matter, on March 2 the medical center held its 16th MUSC Excellence Leadership Development Institute (LDI). Nearly all leaders with responsibility for hiring and conducting performance evaluations attended. The LDIs are designed to make our management team better leaders. 
We kicked off the LDIs four years ago. The LDIs are a component of our MUSC Excellence structure and strategy. The other structural components include Service Excellence Teams and the Leadership Evaluation Team which is responsible for establishment of goals and associated metrics.
At the March 2 LDI, among other things, we revisited our progress over the past four years and discussed next steps. The MUSC Excellence plan for the remainder of this calendar year will include continued focus upon the work of the Service Excellence Teams; accomplishment of our pillar-based goals; sustaining high quality LDIs while conducting additional in-house training; and addressing priorities identified by an organizational assessment and our patient satisfaction results. These priorities include:

Global Priorities
•    Development of new and existing leaders

Reintroduce Evidenced-Based Leadership tactics and strategies to leaders
Enhance training including  quality-related training

•    Accountability

Leaders’ Monthly Meeting Model
Interdepartmental Survey Process
Renewed focus upon everyone’s goals
Hardwire High/Middle/Low Conversations and Follow Up

•    Front-line Staff Education
•    Discharge Calls
•    Rounding on Employees/Link Rounding to Recognition and Education on Burning Issues
•    Enhance Education and focus upon HCAHPS
•    Focus upon Reducing Readmissions
•    Improve Inpatient Discharge Process

Targeted Priorities
•    Unit / Department Specific

Focus on areas with low patient satisfaction results
Develop action plans

•    IV Issues and Patient Satisfaction Results
•    Others as needed

Thanks to all for a job well done. 

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

Using the MUSC Excellence pillar format, Stuart Smith, vice president for operations and executive director of MUSC medical center, reviewed  the fiscal year (FY) 2009-2010 organizational goals and results with employees.

Smith noted the significance of this quarter’s 2009-10 results with no highlighted red sections in each of the five pillar areas–service, people, quality, finance and growth. Smith recognized seven inpatient units for achieving high percentile rankings for patient satisfaction (October to December): inpatient–MUH 5West (98th); MUH 9East (98th); ART 4East (95th); ART 3West (93rd); NNICU (91st); Pediatric ER (93rd) and IOP 1North (90th); outpatient–RT Maxillofacial (99th); ART CT Surgery (98th); Pediatric Sickle Cell (98th); HCC 2 Thoracic Surgery (98th); ART Radiology (88th); and Mental Health-Outpatient (83rd).

Smith reminded employees about the upcoming Employee Partnership Survey (goal: 72.5, 2009 actual 71.5), and Physician Satisfaction Survey (goal: 71.2, 2009 actual 76.2) and encouraged good employee participation in both surveys.

This goal measures ultimate outcomes based upon the hospital’s patient concerns and expectations compared to what’s provided and patient mortality and conditions. MUSC is a member of the University Health System Consortium and compares its outcomes with the consortium’s database of 100 hospitals. MUSC’s goal is to achieve the 75th percentile. Smith reported that the hospital’s second quarter report already ranks the hospital in the 85th percentile, which translates to a life-saving facility.

Days cash on hand goal is 21 days. By December, MUSC’s was at 14.2 days. Smith reminded employees that meeting this goal is important, especially as the hospital readies for emergencies like the 2010 hurricane season. It’s important to have finances available in the event of a natural disaster so that the hospital can financially operate and adequately care for patients throughout that period.

In measuring Medical-Surgical discharges, the medical center is already surpassing its goal of two percent. As of January, the medical center reported a total of 6.4 percent in this category. Outpatient encounters remain steady at 4.7 percent since January (goal is 7 percent).

Connect to purpose
Reading a patient letter, Smith recognized the caring efforts of 7th floor Rutledge Tower’s Infectious Disease Clinic featuring Lynn Dorris, R.N., Marie Ladson and Camelia Marculescu, M.D.
He also applauded this quarter’s monthly employee winners: Fredrika Wright, Lamona Wilder, Stacie Buckley, Carrie Ladson, Andrea Coulter, Jill Sadlier, Cathy Vaughn, R.N., Peggy Wingard, Brian Libby, Mark Daniell, Heidi Grund, R.N., and Robert Kippes. Also recognized were Physician of the Month winners: David White, M.D., Ernest Quinn, M.D., and Mark W. Wagner, M.D.

Culture of Safety

June Darby, R.N., Neurosciences service line administrator, reviewed the organization’s 2009 Culture of Safety survey results. The survey was conducted last March and reported that 72 percent employees graded their work area with an “A/B” rating. In response, management developed 54 action plans relating to safety throughout the organization. A second survey was conducted in January resulting in 87 percent of employees providing an “A/B” rating. The national average for this survey at 73 percent and employees recognized MUSC as a national leader for culture of safety.
MUSC also focused on improving occurrence reporting. Recently, the hospital changed the use of terms redefining “near misses” as “good catches” and entering that information in Patient Safety Net reporting. The hospital has reported a 29 percent increase in occurrence reporting in FY 2009 which allowed leaders to evaluate trends across the organization and communicate where improvements were needed.
October’s Joint Commission (JC) review of MUSC found several issues for improvement within the medical center. JC's response was a change in how they normally report on their findings:
  • JC identified a pattern or trend that provided  inconsistent accountability across the organization
  • Continued non-compliance on some standards
  • Need for increased coordination of efforts regarding life safety and environment of care
MUSC submitted its  own report, The Annual Periodic Performance Review (a self assessment or report card of all JC standards and elements of performance and action plans), appealing to the JC regarding the survey’s findings.
MUSC’s current status with JC is pending based on these activities. In response, MUSC has formed teams to work on two standards—clinical issues (led by Pat Cawley, M.D., and Marilyn Schaffner, Ph.D., R.N.) and environment of care (EOC) (led by Betts Ellis).

Medical Center Employee Partnership Action Plan
Sharon DeGrace, R.N., Surgery and Medicine Acute & Critical Care service line administrator, reviewed the top opportunities with the 2009 Employee Partnership Plan Survey.
More than 4,300 medical center employees participated in the Employee Partnership Survey. The survey firm, Press Ganey, identified 10 opportunities from the 50 survey questions. A second internal mini survey  was conducted asking employees to select two or three key issues to focus upon from the 10 opportunities. More than 950 employees responded and they listed “My work group is asked for opinions before decisions are made” and “Leaders really listen to employees.” Leadership wants to continue receiving employee feedback as part of the action plan process. For this toll, data is collected, assessments are made, action plans are developed, evaluations are conducted and information is shared. 
Leadership will track action plans using a Stop Light report (green-completed; yellow-in process; red-not happening at this time). To submit ideas, contact Joan Herbert, R.N., organizational performance director, 792-0726 or
The Employee Partnership Survey will be conducted in April. In 2009, a total of 4,362 (62 percent) of MUHA employees participated in the survey. This year’s goal is 75 percent participation or 4,882 employees to complete the survey.

Annual employee evaluations
In 2009, MUHA transitioned from using independent review dates to a common review date for all employees. This change will occur three months after MUHA employee evaluations have been completed in 2010. As the organization is able, increases will be paid out to those employees who are eligible.
2010 Annual MUHA Employee Evaluations, using SuccessFactors online reporting program, provides a  paperless system. The  new employee evaluation rating scale: mentor (4-5), consistent (3-2) and inconsistent (1). Structure changes include job competency (meets/does not meet), job responsibilities (weighted 25 percent, scale of 1-5); pillar goals (weighted 25 percent, specific to each department) and standards of behavior (weighted 50 percent).
To be eligible for a pay increase, an employee must be rated as either “mentor” or “consistent.” Department managers will be reviewing evaluations with their employees in the near future.

Friday, March 5, 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.