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MUSC Medical Links Charleston Links Archives Catalyst Advertisers Seminars and Events Research Studies Public Relations Research Grants MUSC home page Community Happenings Campus News Applause


Currents Feb. 15

To Medical Center Employees:
Our accreditation standards define the four phases of emergency management as mitigation, preparedness, response and recovery. Mitigation and preparedness occur before an emergency; response and recovery occur during and after an emergency.

The emergency management phases are helpful as a frame of reference as we address our current financial situation. We have sought to use our 5/5 cost savings initiatives and other tactics within the past six months for mitigation and preparedness. While some progress has been made with our 5/5 plans, the cost per unit of service is slightly more than the 2009 base and we are not yet meeting our goal.

State policy makers are considering Medicaid cuts that could be in the range of 15 percent by the new fiscal year. A 5 percent cut equates to $10 million. We need to go into our financial emergency preparedness phase at this time in order to try to mitigate this loss.

Our preparedness will involve continuing with and producing results from the 5/5 plans plus: freeze this year’s capital purchases unless essential for patient care and safety; delay the fiscal year 2012 capital review process; limit hiring to only urgently needed direct care positions; monitor staffing versus workload and eliminate any staffing variance; eliminate overtime unless required for patient care; and freeze any out-of-state travel unless approved by administration.

We need the attention of all leaders and the message needs to be appropriately delivered to all employees. Our goal is to address this potential emergency while providing quality care and protecting jobs.

We will discuss our financial situation and other topics at the medical center town hall meetings scheduled to take place at times and locations indicated below. There will also be several town hall meetings for large departments in place of their routine department- based meetings.

Evaluations from previous town hall meetings indicate relatively brief sessions have been well received. Our plan is to limit the meetings to 30 minutes. Attendance is strongly encouraged.

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

Town hall meetings
Feb. 18: 10 a.m., 2W Amphitheater; Feb. 18: 11 a.m., ART Auditorium; Feb.
21, 10 a.m., 2W Amphitheater; Feb. 21, 2 p.m., IOP Auditorium; Feb. 22: 11 a.m., 2W Amphitheater; Feb. 23: 7 a.m., 2 West Amphitheater; Feb. 23: 11 a.m., Storm Eye Auditorium; Feb. 24: 7:30 a.m., 2 West Amphitheater; Feb. 24, Noon, ART Auditorium; and March 1, 7 a.m., ART Auditorium

People–Fostering employee pride and loyalty

Helena Bastian, MUHA Human Resources director, presented the following topics:

  • 30/90 day rounding form update At 30-day rounding, the status of unit/ department orientation and position- specific orientation should be completed; At 90-day rounding, verification that orientation documentation was completed should be completed; 30/90-day rounding form may be accessed on the MUHA HR Web site under “forms.”
  • MUHA HR’s next new hire reception is from 1-2 p.m., Tuesday, March 3, IOP lobby. Open to new employees hired between October and December 2010 (celebrating 90 days with MUSC). Reception is sponsored by the Employer of Choice and Rewards & Recognition Service Teams.
  •  MUHA February town hall meetings are scheduled from Feb. 16 to March 1 at various campus locations. Leaders will discuss fiscal year 2010/2011 goals, employee recognition, cost savings initiatives, hand hygiene campaign as well as questions and answers.

For information on meetings, visit news/townhall.htm.

Quality—Providing quality patient care in a safe environment

Lois Kerr, accreditation manager, and Kathy Wade, Medical Director’s Office, reviewed new changes imposed by the Joint Commission (JC) for 2011.

  • New JC terminology—accredited (perfect survey), accredited with follow up (1-6 months unannounced), contingent accreditation (30 days unannounced), preliminary denial. Failure to correct the JC’s findings may result in a loss of Medicare funding.
  • The JC and the Centers for Medicare & Medicaid Services (CMS) will score Medicare Conditions of Participation. If conditions level of participation is not met, JC will return unannounced within 60 days for a follow up. The report will be shared with CMS who may also conduct an unannounced visit.
  • For-Cause surveys—JC may conduct an unannounced visit for significant patient safety or quality issue or trend of complaints, reports, etc or if the reason to believe is not truthful in information shared with them.

Standard changes for 2011

  • Utilization Review Plan/admission— continued stay and discharge review (per CMS)
  • Visitor patient rights (CMS)
  • Qualifications for language interpreters
  • Identifying communication needs including hearing, language, vision, etc.
  • Staffing effectiveness—Sentinel Event Review
  • Safe injection practices q  New medical staff standards (March)
  • Name a director for outpatient services (CMS)
  • Medical staff approves director of nuclear services (CMS)
  • Radiation and radiation exposure tracer—FDA recommendations
  • Added days for Life Safety Survey
  • 10 percent of average daily census will be reviewed
  • Ongoing Performance Evaluation and Focus Performance Evaluation tracer
  • Contracted services tracer
  • Cleaning, disinfecting and sterilizing
  • Interventional radiology and radiology tracers
  • Clinical information tracer
  • Anesthesia standards (CMS)
  • New reduced, requirements for medication reconciliation
  • Fire response plan 
  • Emergency operations plan
  • Institute of Psychiatry—director of social services
  • Suicide risk assessment tracer

How MUSC will organize 

  • Changing and evolving audits based on compliance, standards, findings, etc – administrator rounds; manager’s weekly chart audits for inpatient; manager’s weekly chart audits for outpatient; procedures/time out—universal protocol; Safety Wednesdays
  • Redesigned expert tracer team
  • New open medical record review
  • New accreditation and regulatory

2011 MUSC events
JC Diabetes survey (April); Stroke (late summer); JC Desk survey VAD program- desk audit (fall); ACS trauma program (May/June); CMS transplant program (late summer) and Chest Pain Center (September). Full organizational survey (April)

The next meeting is March 1 at 2W committee Amphitheater.

Friday, Feb. 18, 2011

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.