To Medical center employees:
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
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:
• Development of new and existing leaders
Reintroduce Evidenced-Based Leadership tactics and strategies to leaders
Enhance training including quality-related training
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
• 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
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.
- Need for increased coordination of efforts regarding life safety and environment of care
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.
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 email@example.com.
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