10 JUNE 1999 • VOLUME 1 • NUMBER 13
JCAHO storyboards document
improvements, reflect culture
W
hen 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.
“Storyboards do
three things,” said
Ann Babb, vice
Michelle Duncan from the Neonatal ICU and LDRP units and
president of patient
Dawn Walters from Pediatric ICU show the storyboard they
and nursing services. created with their departments on security. Many ideas they
developed were applied to other areas of the medical center.
“They give departments a chance to document
boards on key issues have been prepared,
improvements, they celebrate these
many of which appeared at the June 7
improvements, and they communicate
JCAHO Fair. The storyboards will also
these improvements to others.”
rotate in displays in Delp Cafeteria, the
For the hospital at large, 10 story-
Continued on page 6
Prepare now for key survey points
JCAHO surveyors will focus on several key points during their June 21-25 visit.
Confidentiality
Performance Improvement
Standards of Care
Plan the improvement
Do planned activities
Check to validate improvement
Act to hold the gains
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.
Grace Legaspi, Organizational Improvement,
was among the exhibitors at the JCAHO Fair.
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.
THE UNIVERSITY OF KANSAS MEDICAL CENTER
Find a problem to fix
Organize to solve the problem
Clarify current situation
Understand problem sources
Select the best solution and try it
Executive Forum
2
Tips can help answer
the four most commonly
asked JCAHO questions
Focus on research,
academic affairs
marks next phase
“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.
“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.
Dr. Deymann
Dr. Nirav Shastri
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
Dr. Stoltje
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.
Dr. Pam Shastri
of Texas. She is certified by the American
Board of Pediatrics and specializes in
pediatric neurology.
Pam K. Shastri, DO, instructor,
practices at KUMC. She completed
medical school at the University of Health
Sciences and an internship and residency,
Physicians’ Update
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
Dr. Duke-Woodside
3
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.
4
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.
5
JCAHO
Continued from page 1
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.”
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.
6
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
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.
visit us online at:
http//www2.kumc.edu/publications/inthecenter/
7
c o m i n g
U P
CLASSIFIEDS, ETC.
Full-size gas stove, 4 years old, $80. Call 422-7830
after 6 p.m.
1995 Plymouth Neon Highline, 4-door, great cond.,
58K miles, $5,800 OBO. Call Brian, 677-5687.
HOUSING:
Moving sale: White camel back loveseat, $100; fullsize 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.
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.
Mother Earth News magazine collection, issues
#1-125, except 120 & 121, spans January 1970October 1990, $500 OBO. Call Steve, 897-5052.
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.
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.
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:
FOR SALE:
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.
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.
•
•
•
•
•
Irene Cumming
CEO and President
KU Hospital
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:
•
•
Donald Hagen, MD
Executive Vice Chancellor
KUMC
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:
•
•
Fit For Life seniors exercise program, 1011 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.
Ken Arnold
Editor
IN THE CENTER 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 if space is limited.
Monday, June 14:
IN THE CENTER
is the employee and student
publication of the University of Kansas Medical Center.
It is published weekly by the Public Relations and
Marketing Department. 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.
3901 RAINBOW BOULEVARD • KANSAS CITY, KS 66160 • (913) 588-5000 • WWW.KUMC.EDU