To Medical Center
Recently the South Carolina Department of Health and Environmental Control (DHEC) conducted a MUSCwide radiation safety survey. The survey findings revealed a number of deficiencies that are being addressed. At the Aug. 2 communication meeting, Wayne Brannan, director of University Risk Management, presented key elements of the action plan to address the radiation safety survey findings.
Physicians and staff throughout the medical center play a key role in fulfilling our radiation survey action plan. For instance, approximately 1,600 individuals are required to wear Film Badges to ensure for their safety and to comply with regulatory requirements. All concerned individuals will be re-educated on the radiation safety policy and all badge wearers will need to sign an attestation statement verifying their understanding of the policy. Among other things, the policy requires that badges be properly worn and turned in promptly each month to enable radiation exposure readings.
The action plan also includes new documentation, auditing and reporting requirements. Everyone's full cooperation is needed. Additional details are included in this newsletter.
On another matter, we are now in the midst of the hurricane season. As mentioned in a recent Currents newsletter, the management team needs to ensure everyone is familiar with their department-based emergency weather plan, relevant medical center policies and how to access the general/emergency information line (aka "Green Card"). Medical center leadership will closely monitor weather systems as they develop and will issue appropriate notification in a timely manner concerning approaching storms.
W. Stuart Smith
Vice President for Clinical Operations
and Executive Director, MUSC Medical Center
People–Fostering employee pride and loyalty
--Due Aug. 31
--Planning stage forms are due Sept. 30
--HRIS is offering two different training classes throughout the summer --SuccessFactors: Annual Performance
--Review Training for Supervisor and Admin Staff or SuccessFactors Reporting Class. Register via CATTS.
SuccessFactors: Updating Pillar Goals
Most of the 2011 Pillar Goal results are now available. Visit this link to find out where/when results are available for common goals, http://mcintranet.musc.edu/muscexcellence/Documents/End%20of%20Year%20Resuslts%20Reporting%20FY11.pdf.---Anyone interested in reserving some time in a training room for help with loading pillar goal information, contact Michelle Foreman, 792-6219 or Kim Duncan, 792-1962.
Updating Pillar Goal Results in SuccessFactors
- Make all pillar goal updates from the “goals” tab, not from actual performance review form. As long as the review is still in “supervisor review” step, it will accept changes you make on the “goals” tab.
- Group goals must be updated by the goal owner or his/her proxy; these results will immediately get assigned to all employees who are linked to that goal as soon as you save the update.
- Employees should have their results updated.
2012 Pay Plan – Detailed pay plan located within HR Policy #15 (Compensation), Section C -- Overall Rating: 4.5+ ( 2 percent of base salary); 3.75-4.49 (1.5 percent of base salary); 2.75-3.74 (1 percent of base salary) and 1.00-2.74 (no increase)
United Way Day of Caring – Sept. 9
- While staffing for patient care cannot be compromised, MUHA employees who are signed up for an MUSC team and who get approval from their supervisor, may be given paid administrative leave.
- Administrative leave can be granted for the number of hours an employee is out. For Kronos documentation, timekeepers should include a comment, “United Way Day of Caring,” when entering administrative leave for the employee. Contact Patty Burn, 792-7544 or Lynn Campbell, 792-1684.
First Day of School Initiative (supported by MUSC)
- This program encourages parents to take their children to school on the first day to support the connection between children and teachers.
- MUHA managers and supervisors are encouraged to allow employees to use up to two hours of PTO or adjust work schedules so employees can be with their children during this time. Patient care cannot be compromised, therefore leave may not be reasonable for some direct care providers.
- First Day of School initiative applies Aug. 16 for Charleston County Schools. However, MUHA extends this support for area public and private schools within surrounding counties.
First Day Festival – Aug. 14
Liberty Square at the SC Aquarium and Charleston Maritime Center – Free event activities, educational exhibits, snacks, face painting and more. Call 885-4190.
Project Requests update
Dan Furlong, OCIO, presented a follow-up presentation about the new project submission process for requesting any clinical projects using OCIO resources e-CareNet (CPOE, Nursing Documentation, AdminRX, Oacis) or Picis. No clinical project can be processed by OCIO without being entered and prioritized by the committee. Projects are scored by a hospital leadership committee and weighted based on criteria on their own merits. Projects involving compliance (JC, CMS), Joint Commission, 5/5 or meaningful use topics are considered top priority. Details about the OCIO project request system are found via the medical center intranet (forms toolbox).
Service – Serving the public with compassion, respect and excellence
- Wayne Brannan, University Risk Management director, reviewed results from a recent DHEC Radiation Safety Survey in June. Brannan has worked with a survey team, which includes Lois Kerr, accreditation manager and Glenn Goudy, radiation safety, to respond to reported recommendations.
- Issues were found with the hospital’s film badge program where staff members were no replacing their personnel monitoring badges in a timely manner and in some cases, badges were absent. Badge coordinators are responsible for ensuring badges are received and returned by the 10th day of every month.
- Badge owners are responsible for wearing badges, ensuring their badge is returned whenever they receive a new badge; sign out when they receive or return a badge; and signing a film badge agreement, which states they will adhere to the Radiation Safety Film Badge Policy (to be distributed during the next badge delivery).
Facility-specific operator training –
- Only trained physicians and SCRQSA certified radiology technologists will be permitted to operate equipment
- Operating procedures will be generated for particular X-ray systems (including any restrictions of operating techniques) and posted on MUSC intranet by Sept. 1
- Physicians, appropriate radiology technologists and other operators will be required to have documented evidence of training and competency
- Nursing staff, physicians and technologists in radiation areas will be required to complete an online educational module
- Posting of SCRQSA certification – Notices and signs will be posted to the public in all waiting areas where radiation safety services are provided
Personnel monitoring – angio suites
- A time-out by the technologist will be performed to verify that all staff in the area are wearing badges
Any person not wearing a badge will be directed to wear a badge or is prohibited from that area
Violation of this process will lead to disciplinary actions
- Shawn Valenta was named respiratory therapy assistant manager in the adult University Hospital. Valenta, who was previously night manager, has been with MUSC since 2003
- Sallie Campbell, was named manager of IOP’s Children’s Day Treatment Program. Campbell, a social worker, has worked with adults and management before accepting this role.
- The next meeting is Aug. 16.