10 june 1999 Volume 1
JCAHO storyboards document improvements, reflect culture
When surveyors from the Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) arrive at KU Hospital this month,
one key question theyll be asking employees is What has your department done
to improve organizational performance?
Fortunately, employees will have the answers, thanks to storyboards now on display
throughout the hospital.
Many hospital departments and units have been working for as long as
a year identifying and solving key problems. Departments then document these solutions in
the form of storyboards, which are posted for others to see.
Michelle Duncan from the Neonatal ICU and LDRP units and Dawn Walters from Pediatric
ICU show the storyboard they created with their departments on security. Many ideas they
developed were applied to other areas of the medical center.
Storyboards do three things, said Ann Babb, vice president of patient and
nursing services. They give departments a chance to document improvements, they
celebrate these improvements, and they communicate these improvements to others.
For the hospital at large, 10 storyboards on key issues have been prepared, many of which
appeared at the June 7 JCAHO Fair. The storyboards will also rotate in displays in Delp
Cafeteria, the Main Cafeteria and the second floor hallway near the Sudler Link.
One storyboard focuses on an area of vital concern: security.
The security storyboard is based on new policies and procedures that have been
developed over the past year to keep our patients safe, said Michelle Duncan, RN,
BSN, nurse manager of the NICU
and LDRP units. As examples, Duncan noted such improvements as metal detectors in the
Emergency Department, and security cameras and limited access to infant and pediatric
Babb added that at least 50 storyboards from other departments and units are complete or
There are a lot of improvements happening here all the time, Babb said.
But because it has become our culture to continually improve, people dont
always realize what weve accomplished.
Lois Clendening, director of psychiatric services and patient relations.
Marcia Gilliland, RN, BSN, provided information to fair attendees on infection
prevention and control.
Richard Gatan and Wanda Jackson, Information Services.
Melissa Jensen, Department of Nursing, served as receptionist
during the fair.
Kristen Knightley, RN, and Ann Hoak, RN
The June 7 JCAHO Fair featured information and
giveaway items from departments throughout KU Hospital. Approximately 570 people attended
the fair, which was designed to help employees, physicians and students prepare for the
upcoming JCAHO survey.
Prepare now for key survey points
JCAHO surveyors will focus on several key points during their June 21-25 visit.
Grace Legaspi, Organizational Improvement, was among the exhibitors at the JCAHO Fair.
Discuss patient information only with staff who have a need to know. Do not
discuss patient information in public areas. Do not share computer passwords, and sign-out
when leaving your computer.
Standards of Care
Be prepared to talk about policy, protocol and your responsibilities if you are involved
in: adverse drug reactions; conscious sedation; food/drug interactions; emergency
medications; medication security, or use of restraints.
Find a problem to fix
Organize to solve the problem
Clarify current situation
Understand problem sources
Select the best solution and try it
Plan the improvement
Do planned activities
Check to validate improvement
Act to hold the gains
Tips can help answer the four most commonly asked JCAHO questions
There are only 11 days left until the Joint Commission survey begins, said
Ann Babb, vice president of patient and nursing services. The JCAHO Fair was a
success, policies and procedures are current, notebooks are being distributed . . . we are
However, there are several simple tips that are helpful if the survey team stops you
to ask questions, informally, in the hallway. These tips are based on the four most
commonly asked questions.
First, be prepared to tell JCAHO surveyors what your role or job is, and why it is
important to carrying out our mission. If you are unclear about our mission, there are
framed posters throughout the hospital and it is included in JCAHO materials,
Second, know how patient confidentiality is kept. There are patient confidentiality
policies. However, you could answer informal questions and tell about the steps we have
taken. We have a secured computer system and computers are turned off when not in use. We
do not have hallway conversations about patients and we observe patient privacy by closing
bed curtains, making sure patients are covered and other measures, Babb said.
Third, there will likely be questions about how we provide continuity of
care. The answer is straight-forward. Continuity of care for our patients is
provided through interdisciplinary teams utilizing our standards of care, Babb
Fourth, questions regarding performance improvement will be asked. There are several
subjects that clearly show performance improvement. These subjects include security,
competencies and training, OR pharmacy and establishing a teamwork approach with
physicians. Storyboards and storybooks have been developed on these subjects. And remember
. . . PDCA . . . thats the performance improvement model . . . plan, do, check,
act! concluded Babb.
If you have questions or you are unsure about how to handle an informal (hallway)
question, be sure to let your supervisor know . . . theres support for you,
Focus on research, academic affairs marks next phase
Over the past several years, the University has analyzed major organizational
studies and reports regarding our future direction. We have been in a developmental phase.
Now we are embarking on the next phase, said Executive Vice Chancellor Donald Hagen,
During the developmental period, KUPI and the Hospital Authority were created, and
the University established a focus on research and development of a research strategic
plan. Now it seems an opportune time to assess our organization, simplify our structure
and make it easier to achieve our goals, stressed Dr. Hagen.
To strengthen the research structure, a vice chancellor for research will be named.
The vice chancellor will develop and coordinate the research strategy to move KU to the
top third of U.S. research universities. Additionally, the new vice chancellor would work
with key research personal in all schools, act as president of the Research Institute and
as senior coordinator with the Lawrence campus in all areas of research.This individual
would also serve as an external spokesperson for research with the communities we serve.
I have developed a search committee to select a vice chancellor for academic
affairs, which will work with the deans of all schools and be the principal liaison with
the provost in Lawrence regarding academic affairs issues for the Board of Regents. This
vice chancellor will be the liaison with other Regents institutions, oversee graduate
programs for KUMC and have responsibilities to the dean of graduate school in Lawrence.
This position will be the chief academic advisor to the EVC, Dr. Hagen said.
Those reporting directly to the EVC will be the vice chancellors for academic
affairs, administration, clinical affairs, research, the executive dean for the School of
Medicine, dean for the School of Medicine in Wichita, and dean for the Schools of Nursing
and Allied Health, concluded Dr. Hagen.
Andreas J. Deymann, MD, assistant professor of pediatrics, practices at
KUMC. Dr. Deymann completed medical school at Ruhr University. He completed an internship
and residency in internal medicine and pediatrics at William Beaumont Hospital where he
became chief resident of pediatrics. Dr. Deymann is certified by the American Board of
Pediatrics and the American Board of Internal Medicine. He specializes in pediatric
Nirav J. Shastri, MD, assistant professor, practices at KUMC. He attended
Maharaja Sayajirao University of Baroda medical school, where he completed an internship
in medicine and a residency in pediatrics. He also completed a residency in pediatrics at
Jackson Childrens Hospital. Dr. Shastri is certified by the American Board of
Pediatrics and specializes in pediatric acute care, infectious disease and pulmonology
Paul A. Stoltje, MD, assistant professor, practices at KUMC. He attended
medical school at the University of Texas, then completed a pediatrics residency at the
University of Louisville and a pediatric endocrinology fellowship at Washington
University. He is certified by the American Board of Pediatrics and specializes in
pediatric diabetes and endocrinology.
Pam K. Shastri, DO, instructor, practices at KUMC. She completed medical
school at the University of Health Sciences and an internship and residency, both in
pediatrics, at KU. Dr. Shastri specializes in pediatric ambulatory care.
Marilyn E. Duke-Woodside, MD, assistant professor, practices at KUMC. She
completed medical school at the University of New Mexico where she also completed her
internship and residency in pediatrics. Dr. Duke-Woodside completed a fellowship at the
University of Texas. She is certified by the American Board of Pediatrics and specializes
in pediatric neurology.
Front & Center
Prateek Sharma, MD, assistant professor, gastroenterology, met the press this week with
Eric Davis, St. Louis Cardinals right fielder and colon cancer survivor. Davis is visiting
hospitals in cities where the Cardinals play to promote the benefits of early cancer
screening and detection.
Seventy-four junior volunteers, whose interests include medicine, nursing and
something meaningful to do with my summer, arrived at KU Hospital this week
for summer duty. Aged 13 to 18, they come from every county in the region. From left are:
Ryan Leggio; Theresa Steffens; Kavitha Balachandran; Kristin Tweedly; Quinishia Tatum;
Derrick Lindsay; Kim Schaefer; Julianne Rader; Eric Mitchell; Carolyn Timberlake; Maghan
Threadgill, and A.J. Prasad.
From left, infants Taylor Gagnon, Colton Heinen and Brendan Wilson and their parents
visited the Neonatal ICU last week for a check-up. The three were born within six weeks of
each other with gastroschisis, a condition in which internal organs are exposed. Roberta
Sonnino, MD, performed corrective surgery on each.
Above: Celebrating record-breaking pledges of $915,000 during the Childrens
Miracle Network Telethon last weekend were (L-R) Russell Kinsaul, KCTV 5, Anne Peterson,
KCTV 5, Karen Carlin, executive director of CMN and William Jackson, KCTV 5.
Above: Maureen Muehlebach, former KUMC orthopedic patient, shared her story with Mix
93.3 deejay Kelly Urich during the June 4-6 CMN radiothon.
Aid station voted best
Participants in the Annual Hospital Hill Run June 6 at Crown Center voted the Finish Line
Aid Station sponsored by KUMC as the Best Aid Station of the event. The station was
coordinated by Jan Schmidt, associate director of Kirmayer Fitness Center, and supported
by 15 KUMC employees. Each year, area hospitals staff a designated aid station with water,
ice and other refreshments to nourish participants in the 5K, 12K and 1/2 marathon events.
Scholarship deadline approaching
Friday, June 18, is the deadline for applications for the Reathea Mae Resco Scholarship,
which supports a students efforts while working in basic science cancer research,
and two Dr. W.S. Sutton Scholarships, which support a students efforts while working
in genetic research. Applicants should provide a letter of interest that includes a
description of the research, appropriate transcripts and a letter from his or her faculty
advisor to the Office of Academic Affairs, 5015 Wescoe.
KUMC officials to present at Technology Showcase
Helen Conners, RN, PhD, associate dean of academic affairs at the School of Nursing, and
Linda Davies, PhD, director of academic support, will present a seminar on distance
learning at the Kansas Technology Showcase, which is scheduled for June 16 and 17 at the
Kansas Expocentre in Topeka. David Cook, PhD, associate director of telemedicine, will
also make a presentation. The event is sponsored by the cities of Topeka, Wichita, and
Kansas City and the University of Kansas, Kansas State University and Kansas Technology
Last call for early birds
The last day for early bird registration for aerobics and yoga classes at the Kirmayer
Fitness Center is Friday, June 11. The five-week sessions start June 14. The early bird
cost for aerobics is $14 for two times a week, or $18 for three times a week. The early
bird cost for once-a-week yoga classes is $24. Sign up at the Fitness Center.
Nurses secrets revealed
Last months Nurses Week observation celebrated the professional skills, the
dedication and the teamwork that make the 750 RNs and PRNs who work at KU Hospital among
the best in the business. But did you ever wonder what keeps them going? Consider these
facts: During Nurses Week, the Department of Nursing distributed 1,536 bags of
M&Ms candy, 1,200 donuts, 1,080 cookies and dessert bars and 1,077 lunches.
Professional tennis discounts offered
KUMC employees qualify for discounted tickets to Kansas City Explorers professional tennis
matches. Tickets for the July 16 match featuring Monica Seles are $35 each, a savings of
$5. Two-for-one pricing starting at $10 is available for matches scheduled for July 6, 9,
12, 19 and 24. Season ticket prices start at $50. To receive your discount, call
913-362-9944 and identify yourself as a KUMC employee.
Full-size gas stove, 4 years old, $80. Call 422-7830 after 6 p.m.
Moving sale: White camel back loveseat, $100; full-size mattress set w/frame, $250; GE
digital answering machine, $15; halogen lamp, $8; Samsung 13 television w/remote,
$75, others. OBO for all items. Call 236-4178.
Mother Earth News magazine collection, issues
#1-125, except 120 & 121, spans January 1970-October 1990, $500 OBO. Call Steve,
Dark wood dining room set, 37 x 53 x 30 table with two 9 leaves, 5
chairs (incl. captains chair),
well-used but solid, $250 OBO. Call 722-6175.
Double bed mattress, box springs and frame, $40; posture chair, S-shape, good for working
at computer, $10. Call 753-0300 or 381-7949 and ask for Peggy.
Lawn Boy push mower, Silver Series, 4.5 HP, like new, runs great, $150. Call 741-3777.
Portable dishwasher, white w/butcher block top, works, $60 as is. Call 432-7475.
1994 Geo Metro, 5-spd., hatchback, A/C, 35 mpg, well-maintained, bargain price. Call
1993 Ford Festiva, 5-spd., A/C, CD player, 84K miles, good cond., $3,200 OBO. Call
1990 Ford F250 4X4, tilt, cruise, A/C, new wheels, 115K miles, $6,300 OBO. Call 432-1035.
1991 Grand Voyager LE, loaded, exc. cond., 116K miles, $5,500. Call 897-6431.
1981 Ford Crown Victoria, 8 cyl., power windows, door locks and front seat adjustments,
automatic trans., power steering, runs good, exterior & interior good, approx. 85K
miles, $1,500 OBO. Call 362-9010 and leave message.
1995 Plymouth Neon Highline, 4-door, great cond., 58K miles, $5,800 OBO. Call Brian,
For Sale: House 2 blocks from KUMC, 3BR, 2BA, lvg. rm., dng. rm., den, fin. bsmnt., all
appliances, 1 car detached garage w/work room on 2 lots, exc. cond., new paint and carpet,
renewed hardwood floor, $72K. Call 531-0097.
For Rent: 3BR, 1BA house in Prairie Village, 5 miles to KUMC, 1 car garage, fenced yard,
C/A, $775/mo., available July 1. Call 441-0873.
Roommate Wanted: 2 nursing students and 1 cat looking for roommate (female 21-25
preferred) for 3BR apt. in nice Mission neighborhood 5 minutes from KUMC, separate bath,
$270/mo. plus 1/3 cable, phone and electric, available Aug. 1. Call 432-2146.
Used kayak for family use. Call 718-2773 (cell phone) or 831-0942 between 8-10 p.m.
Healthy males aged 18-40 wanted for metal allergy study. Financial compensation. Call ext.
Persons with short bowel syndrome (removal of a significant portion of small intestine,
with or without removal of portions of the colon). The intent of the study is to determine
the amount and nature of foods consumed, number of food aversions and the Body Mass Index
(height and weight relationship) of the subjects. Call Peter L. Beyer MS, RD, Dietetics
and Nutrition, ext. 5355.
Monday, June 14:
Alzheimers Disease Support Group,
noon-1:30 p.m., Delp Cafeteria.
National Stuttering Project Support Group, 7-9 p.m., 1018
Tuesday, June 15:
Kansas Cancer Institute Research Round Table, Biomarkers in
and Prevention of Breast Cancer, noon, Lied Auditorium.
Breast Cancer Weight Control Support Group, noon-1 p.m.,
Radiation Oncology Conference Room.
Cognitive Therapy Addiction Group,
1-2:30 p.m., Family Medicine Clinic.
Wednesday, June 16:
Diabetes Self-Management Series,
9-11 a.m., 1107 KU Hospital.
KUMC Interfaith, noon-1 p.m.,
Eye Care: Cataracts and Glaucoma, noon-1:30 p.m.,
Anxiety Support Group, 4-5:30 p.m.,
Adult Outpatient Psychiatry Clinic. $10 fee, Call 588-1300 before attending your first
Thursday, June 17:
Fit For Life seniors exercise program, 10-11 a.m., Wyandotte
Room, Main Cafeteria.
Research Seminar, JayDoc.Net: A
survey of medical students and attitudes, noon-1 p.m. G567 KU Hospital.
Burn Patient Family Support Group,
6-7 p.m., Burn Center Waiting Room.
Prostate Cancer Support Group, 7-9 p.m., Reike Auditorium.
IN THE CENTER
Donald Hagen, MD - Executive Vice Chancellor KUMC
Irene Cumming - CEO and President KU Hospital
Ken Arnold - Editor
Leslie Champlin - Writer
Jim Burton - Graphic Designer
IN THE CENTER is the employee and student publication of the University of Kansas
Medical Center. It is published weekly by the office of Public Relations and Marketing.
The deadline for submitting news briefs is noon on the Thursday before they are to appear.
Send story ideas to Ken Arnold, editor, G114 Hospital, or e-mail: <karnold> or call
Send or bring your ad to G114 KU Hospital, or fax to ext. 1225, or e-mail: <karnold>
by noon Thursday of the week before it is to run. Ads run free of charge for employees,
students and volunteers. For-sale ads are limited to three items. All ads must include the
advertisers name and work extension (or medical student box number) for
verification. Only home phone numbersno pager numbers or KUMC extensionswill
be published. No ads for commercial services or pets for sale will be accepted. Ads will
not be taken by telephone. Only one phone number per ad. Ads may be held a week of space
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