10 june 1999 • Volume 1 • Number 13

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 they’ll 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 areas.
Babb added that at least 50 storyboards from other departments and units are complete or nearing completion.
“There are a lot of improvements happening here all the time,” Babb said. “But because it has become our culture to continually improve, people don’t always realize what we’ve 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.

Confidentiality
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.

Performance Improvement
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

Executive Forum

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 ‘on target.’”
“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,” related Babb.
“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 stressed.
“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 . . . that’s 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 . . . there’s support for you,” advised Babb.

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, MD.
“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.

Physicians’ Update

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 critical care.

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 Children’s Hospital. Dr. Shastri is certified by the American Board of Pediatrics and specializes in pediatric acute care, infectious disease and pulmonology including asthma.

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 Children’s 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 student’s efforts while working in basic science cancer research, and two Dr. W.S. Sutton Scholarships, which support a student’s 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 Enterprise Corporation.

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 month’s 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&M’s 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.

FOR SALE:
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, 897-5052.
Dark wood dining room set, 37” x 53” x 30” table with two 9” leaves, 5 chairs (incl. captain’s 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.
AUTOMOTIVE:
1994 Geo Metro, 5-spd., hatchback, A/C, 35 mpg, well-maintained, bargain price. Call 248-9282.
1993 Ford Festiva, 5-spd., A/C, CD player, 84K miles, good cond., $3,200 OBO. Call 383-9274.
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, 677-5687.
HOUSING:
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.
WANTED:
Used kayak for family use. Call 718-2773 (cell phone) or 831-0942 between 8-10 p.m.
STUDY SUBJECTS:
Healthy males aged 18-40 wanted for metal allergy study. Financial compensation. Call ext. 6028.
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.

coming
UP

Monday, June 14:
•    Alzheimer’s Disease Support Group,
noon-1:30 p.m., Delp Cafeteria.
•    National Stuttering Project Support Group, 7-9 p.m., 1018 Orr-Major.
Tuesday, June 15:
•    Kansas Cancer Institute Research Round Table, “Biomarkers in Risk Assessment
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.,
3041 Wescoe.
•    “Eye Care: Cataracts and Glaucoma,” noon-1:30 p.m., Community Room,
KU MedWest.
•    Anxiety Support Group, 4-5:30 p.m.,
Adult Outpatient Psychiatry Clinic. $10 fee, Call 588-1300 before attending your first meeting.
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 ext. 1298.

Ad Policy
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 advertiser’s name and work extension (or medical student box number) for verification. Only home phone numbers–no pager numbers or KUMC extensions–will 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 is limited.

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