SAN FRANCISCO GENERAL HOSPITAL and TRAUMA CENTER ANNUAL REPORT Fiscal Year 2011 - 2012 1 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 1
Our New Leaders Alice Chen, M.D. Baljeet Sangha SFGH Chief Integration Officer Chief Patient Experience Officer And Deputy Chief Operating Officer 2
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Preparing for Tomorrow 4
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 5
SFDPH Service Excellence Committee Service Excellence Partners Core Group Workforce Patient Experience Experience Work Group Work Group Projects and Takeaways Way-finding for Patient Ambassador Patients Project Patient Experience Noise Reduction at Rounds Night Guest Welcome Signage Package Workforce Forum Medication Teaching Staff Recognition Program Goal: To attain 80% positive scores in inpatient (HCAHPS) and outpatient (CG-CAHPS) experience surveys by 2015. 6
CLINICAL QUALITY PERFORMANCE HIGHLIGHTS- SEPSIS Measure Benchmark Q3 2011 Q4 2011 Q1 2012 Q2 2012 FY 11/12 Trendline Sepsis Bundle Compliance (Out of avg 30 cases/quarter. Higher = better) 13% 30% 30% 45% TBD Source: chart review of confirmed cases of severe sepsis (exluding comfort care patients) Sepsis Mortality Rate (Out of avg 160 cases/quarter, Lower = better) 19% 10% 18% 15% TBD Source: discharge diagnoses- includes suspected and confirmed cases of sepsis and septic shock Goal: To reduce sepsis mortality by 15% annually. 7
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Magnet Designation American Nurses Credentialing Center Certification which exemplifies: Quality Patient Care Nursing Excellence Innovations in Professional Nursing Practice 9
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 10
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 11
What people are saying about Just Culture. I am so grateful the Just culture builds hospital is doing Just trust. It feels good Culture. Its good for to be starting at a the staff, which hospital that has means it will make made such a the hospital safer for commitment. patients. New RN hire at SFGH Senior Med-Surg nurse A Fair and Just Culture supports a learning culture that focuses on proactive management of system design and management of behavioral choices. The Three Behaviors At-Risk Behavior Human Error Reckless Behavior A choice: Conscious disregard of Product of our current risk believed insignificant or system design and substantial and unjustified justified risk behavioral choices Console Coach Discipline TRUST – HUMANISTIC CARE Staff Leadership Behavioral choices informed by Systems design/maintenance SFGH policies Cultivate honest, fair feedback Engage in honest, fair feedback Consistent execution of just culture 12
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) 13
COMMUNITY WELLNESS PROGRAM Project of the San Francisco Department of Public Health at San Francisco General Hospital and Trauma Center 14
Year 1: Wellness Achievements Core Initiatives: Healing Moves/Active Living Healthy Food Environment Tobacco-Free Community Community Engagement Seasonal Festivals & Cultural Awareness . 15
BUILDING COMMUNITY TOGETHER “It Gets Better” 16
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 Lean Pillars of Transformation Two Pillars Respect Continuous For Improve- People ment 17
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 18
Lean Video http://youtu.be/oHzso3SonMM 19
… to Adoption of Health IT SFGH has met Meaningful Use Stage 1 on INVISION 20
Electronic Charting Taking Hold 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% 21
What is Integration? SFDPH IDS Initiative Financial and clinical accountability for the health of a defined population of 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 HOSPITAL CARE ED CARE URGENT SERVICE LEAN EMR CARE EMR EXCELLENCE SPECIALTY CARE MENTAL HEALTH PRIMARY CARE-PCMH FOUNDATION 22
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 23
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 24
Provision of Care Policy Updated demographics data General edits Update links to Appendices and Cross Reference documents. 25
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: 26
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