Presentation Summary SFGH Strategic Plan Update Environment of Care - - PDF document

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SAN FRANCISCO GENERAL HOSPITAL and TRAUMA CENTER

ANNUAL REPORT Fiscal Year 2011 - 2012

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Presentation Summary

 SFGH Strategic Plan Update  Environment of Care Report

– Approval Requested

 Provision of Care Policy

– Approval Requested

 Performance Improvement and

Patient Safety Policy

– Approval Requested

 SFGH Rebuild

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Our New Leaders

Baljeet Sangha Chief Patient Experience Officer And Deputy Chief Operating Officer Alice Chen, M.D. SFGH Chief Integration Officer

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Preparing for Tomorrow

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Making Positive First Impressions

http://youtu.be/lE-xLmKH3ns

Reinforcing Service Excellence Standards

• Make Positive First Impressions
• Treat Others as Guests
• Develop Service Recovery
• Communicate Effectively
• Create a Team Spirit
• Project a Positive Attitude
• Be Passionate about Excellence

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SFDPH Service Excellence Committee

Service Excellence Partners

Workforce Experience Work Group Core Group Patient Experience Work Group

Projects and Takeaways

Way-finding for

Patients

Patient Experience

Rounds

Guest Welcome

Package

Medication Teaching Patient Ambassador

Project

Noise Reduction at

Night

Signage Workforce Forum Staff Recognition

Program Goal: To attain 80% positive scores in inpatient (HCAHPS) and outpatient (CG-CAHPS) experience surveys by 2015.

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CLINICAL QUALITY PERFORMANCE HIGHLIGHTS- SEPSIS

Measure Benchmark Q3 2011 Q4 2011 Q1 2012 Q2 2012

TBD

13% 30% 30% 45%

TBD

19% 10% 18% 15%

FY 11/12 Trendline

Sepsis Mortality Rate

(Out of avg 160 cases/quarter, Lower = better)

Source: discharge diagnoses- includes suspected and confirmed cases of sepsis and septic shock

Sepsis Bundle Compliance

(Out of avg 30 cases/quarter. Higher = better)

Source: chart review of confirmed cases of severe sepsis (exluding comfort care patients)

Goal: To reduce sepsis mortality by 15% annually.

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Magnet Designation

American Nurses Credentialing Center

Certification which exemplifies:

 Quality Patient Care  Nursing Excellence  Innovations in Professional Nursing

Practice

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Magnet Accomplishments 2011-2012

 Nursing Shared Governance at system

level

 National Database of Nursing Quality

Indicators

 Charge RN Leadership Training  Development of Nursing Professional

Practice Model

Next Steps

 Roll-out Professional Practice Model  Conduct gap analysis  Respond to 2012 NDNQI national results  Improve Falls with Injury and Hospital

Acquired Pressure Ulcer rates

 Develop peer review system  Create structure for nursing evidence-

based practices Goal: To Attain Magnet Designation by 2015

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Magnet Actions 2013

 Integrate Service Councils into Shared

Governance structure

 Roll-out Professional Practice Model  Conduct gap analysis  Respond to 2012 NDNQI national results  Evaluate and develop nurse-sensitive

indicators

 Develop peer review system  Create structure for nursing research

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What people are saying about Just Culture.

I am so grateful the hospital is doing Just

• Culture. Its good for

the staff, which means it will make the hospital safer for patients.

Senior Med-Surg nurse

Just culture builds

• trust. It feels good

to be starting at a hospital that has made such a commitment.

New RN hire at SFGH

The Three Behaviors

Reckless Behavior

Conscious disregard of substantial and unjustified risk

Discipline A Fair and Just Culture supports a learning culture that focuses on proactive management of system design and management of behavioral choices.

Human Error

Product of our current system design and behavioral choices

At-Risk Behavior

A choice: risk believed insignificant or justified

Console Coach

TRUST – HUMANISTIC CARE

Staff

Behavioral choices informed by SFGH policies Engage in honest, fair feedback

Leadership

Systems design/maintenance Cultivate honest, fair feedback Consistent execution of just culture

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AHRQ Culture of Safety Survey

Goal: Implement a Fair and Just Culture program and attain a 15% overall improvement score in our Culture of Safety Survey scores by 2016

Going Forward

 Work with Human Resources to align

policies with Fair and Just Culture Principles

 Establish a deeper dive curriculum

for leaders to apply these principles. ( Spring 2013)

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COMMUNITY WELLNESS PROGRAM

Project of the San Francisco Department of Public Health at San Francisco General Hospital and Trauma Center

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Year 1: Wellness Achievements

Core Initiatives:

 Healing Moves/Active Living  Healthy Food Environment  Tobacco-Free Community  Community Engagement

Seasonal Festivals & Cultural Awareness

.

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BUILDING COMMUNITY TOGETHER

“It Gets Better”

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What is LEAN?

A systematic approach of continuous improvement used for the identification and elimination of waste to provide the greatest value to the customer and staff

Continuous Improve- ment Respect For People

Lean Pillars of Transformation Two Pillars

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The LEAN Approach

 Customer perspective defines value  Leadership and staff improving care

together

 Identify which process steps create value

and which are waste (muda)

 Rapid Improvement Events (kaizen)–

Eliminate root causes of waste and promote continuous flow

 Optimize the use of available resources

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Lean Video

http://youtu.be/oHzso3SonMM

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… to Adoption of Health IT SFGH has met Meaningful Use Stage 1 on INVISION

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Meaningful Use of INVISION/LCR at SFGH (Inpatients) Reporting date range 10/28/12 to 11/3/12 # Measure Target Current 1 Advance Directives Status Charted 50% 97.73% 2 CPOE Charted Med Order 30% 78.45% 3 Demographics Charted 50% 100.00% 5 Med Allergy List Charted 80% 93.67% 6 Med List Charted 80% 97.89% 7 Problem List Charted 80% 85.65% 8 Smoking Status Charted 50% 87.17% 9 Structured Lab Results 40% 72.97% 10 Vital Signs Charted 50% 62.17%

Electronic Charting Taking Hold

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What is Integration?

 SFDPH IDS Initiative  Financial and clinical accountability

for the health of a defined population

• f patients.

 Deliberate organization of patient

care activities to facilitate appropriate delivery of services across the continuum of care.

 Whole > Σ parts

Building Blocks of Integration

PRIMARY CARE-PCMH FOUNDATION EMR EMR

LEAN

SERVICE EXCELLENCE HOSPITAL CARE ED CARE URGENT CARE SPECIALTY CARE MENTAL HEALTH

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Accomplishments

 Primary care initiatives included…

– standardizing care for all DPH primary care – behavioral health integration model – primary care-based care management programs focused on high risk patients – development of a strategic plan for DPH primary care (both SFGH based and COPC)

Accomplishments

 Specialty care initiatives included…

– expansion of eReferral, now includes 46 services: pediatric, adult, SFGH, LHH – new Telehealth initiatives in dermatology and ophthalmology – primary care-specialty care workgroups focused on communication and co- management

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Going Forward

 Data dashboards

– Timely, relevant, actionable – Clinical, operational, financial

 Ensuring adequate PC capacity  Hospital and ED transitions  EMR integration  LEAN/Coleman and Service Excellence

Environment of Care Report

 Code Silver Policy and Training

Implementation

 Building 5 Elevators  Emergency Generator Replacement

Project

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Provision of Care Policy

 Updated demographics data  General edits  Update links to Appendices and Cross

Reference documents.

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Performance Improvement and Patient Safety Policy

 The Patient Concern Subcommittee is now

part of our Service Excellence Committee, where patient concerns and grievances will be analyzed.

 Added Patient Safety Officer role and

responsibilities, and the Patient Safety Plan.

 Delineated responsibilities of the Medical

and Administrative Directors of Risk Management: