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SAN FRANCISCO GENERAL HOSPITAL and TRAUMA CENTER
ANNUAL REPORT Fiscal Year 2010 - 2011
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SAN FRANCISCO GENERAL HOSPITAL and TRAUMA CENTER ANNUAL REPORT - - PowerPoint PPT Presentation
SAN FRANCISCO GENERAL HOSPITAL and TRAUMA CENTER ANNUAL REPORT - - PowerPoint PPT Presentation
SAN FRANCISCO GENERAL HOSPITAL and TRAUMA CENTER ANNUAL REPORT Fiscal Year 2010 - 2011 1 Presentation Summary Community Wellness Program Nursing Progress Performance Improvement and Patient Safety UCSF-SFGH Partnership
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MISSION: To Provide Quality Healthcare and Trauma
Services with Compassion and Respect
PEOPLE
Clinical & Service Excellence
SYSTEMS
Operational Efficiency & Coordination
TECHNOLOGY
Health Information Technology
Align care, discovery & education to advance community wellness.
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PEOPLE SYSTEMS TECHNOLOGY
- Service Excellence
- A Fair and Just Culture
- Clinical Quality
- Enhancing Wellness
- Professional and Academic Excellence
- Efficient Management System
- Integration and Coordination Across Services
- Meaningful Use of Information Technology
- Moving beyond implementation towards adoption of Health
Information Technology
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Our New Leaders
Shannon Thyne Chief of Staff Winona Mindolovich and John Applegarth Information System Leadership Thomas Holton Patient Safety Officer Todd May, M.D. Chief Medical Officer
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Listening to our patients…
http: / / vimeo.com/ 22641730
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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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About the Com m unity W ellness Program
Values:
Com m unity Engagem ent and Partnerships
Holistic approach
Education through Em pow erm ent
Culturally, linguistically, and financially accessible
Creative and innovative approaches
Engaged leadership
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BUILDING COMMUNITY TOGETHER
Healthy Food Environment Initiative Healing Moves-Active Living Initiative Tobacco Free Community Initiative Community Engagement Initiative
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Nursing Progress
Magnet Journey Shared
Governance
Positive
Communication Training
Professional
Development Speakers
Professional RN
Certification
Education
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Nursing Progress
Low Vacancy Rate Joint Commission
TBI and Stroke Certification
Nursing Initiatives Community
Partnerships
Dorothy Washington Fundraiser for RN
Scholarships
RN and New Graduate Training Program
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Performance Improvement & Patient Safety Program (PIPS)
Joint Commission
Accreditation
Quality Data
Improvement
Increasing alignment
between hospital and clinical services through PIPS Committee
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Performance Improvement & Patient Safety Program (PIPS)
– Sepsis & Central-line Associated Blood Stream Infection prevention – Patient Experience Initiative – Leadership & QI Academy Learning Center – Quality Data Center
– CMS Incentive Plan – Primary Care Coordination between COPC and
Hospital-based clinics
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Joint Com m ission
Traum atic Brain I njury Certificate of Distinction
In 2010-2011, SFGH was licensed and regulated by 33 agencies who conducted a total
- f 41 surveys/site inspections.
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Joint Com m ission
Hospital Accreditation Survey
CDPH
PSLS Survey
CDPH
LTC/ Fire & Life Safety Licensing survey
DMH
MHRC Licensing Survey
DEA
Survey of Pharm acy DEA Registration as a NTP
CMS
ESRD Survey
DSS/ Com m unity Care Licensing
ARF Licensing Survey
CDPH
MERP Survey
ACSCOT
Level I Traum a Center Verification Survey
CDPH
Consolidated Accreditation Survey
CDPH/ CMS
EMTALA Com plaint Validation Survey
CDPH
LTC Licensing Survey
CDPH RHB
Survey of Avon Breast Center & Mam m ovan
Alcohol & Drug Program
Licensing Survey
- f Opiate
Treatm ent Outpatient Program
Joint Com m ission
Long Term Care Accreditation Program Survey
US DHHS/ PHS/ FDA
MQSA Certification Survey Joint Com m ission Prim ary Stroke Center Program Survey
SF Mental Health Clients’ Rights Advocates Survey
Nurses I m proving Care for HealthSystem Elders Site Survey
DSS
ARF/ Fire & Safety Licensing Survey
CARF
Accreditation Survey
CMS
Life Safety Code of ESRD Survey
CDPH
Tissue Bank Licensing Survey
CDPH
Certified Nurse Assistant Program Record Review Survey
Vaccines for Children Program Quality Assurance Review / Survey
Joint Com m ission
Laboratory & Point of Care Testing Accreditation Program Survey
US DHHS/ Title X
Fam ily Planning Federal Audit
Joint m m ission
PPR alidation Survey
US DHHS/ Dept
- f Mental
Health Services Adm inistration Center for Substance Abuse Treatm ent
DMH
MHRC/ Fire & Life Safety Licensing Survey
- Dept. of
Correction/ Title 1 5
Jail Health Services Licensing Survey
CDPH/ CMS
Com plaint Validation Licensing Survey – Pharm acy Managem ent of Controlled substances
ACSCOT/ CCSF-DPH EMS
Level 1 Traum a Center Designation Verification Survey
CDPH/ Blue Cross
FSR & MMR of SFHP Clinics
Baby Friendly Hospital Site Visit Certification Survey
Am erican College of Surgeons Com m ission on Cancer Survey f SFGH Cancer Program
Joint Com m ission
PPR – Hospital, LTC, Lab
Centering Health Care I nstitute Site Approval/ Certification Survey
DEA
Survey of Opiate Treatm ent Outpatient Program
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Quality Data Required by The Joint Commission and CMS
Heart Attack Heart Failure Pneumonia Surgical Care HCAHPS Patient Experience Survey
(CMS)
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Joint Commission/CMS Core Measures – SFGH PERFORMANCE
On 24 of 31 Core Measures, SFGH performs at or above national and state averages. improvement from the previous year: Example: Pneumonia
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Measure 2009 2010 Blood culture taken before antibiotics administered 78% 86% Antibiotic Given within 6 Hours 84% 90% Recommended antibiotic selection 82% 100%
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HCAHPS Patient Experience Survey (CMS)
Publicly reported patient survey
scores identify an area for focused improvement:
Hospital Rating (Top Scores): SFGH 57% State Avg 67%
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Patient Experience Improvement
Service Excellence Goals:
– Create a service excellence framework & train staff – Redesign ED & Hospital Flow – Implement ambulatory care patient experience survey in outpatient clinic areas. – Work in partnership with patients and families
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UCSF/SFGH Partnership
Provides all of the physician services
at SFGH.
Provides 1/ 3 of the resident and
medical school training for UCSF. –ACGME Resident Duty Hours Standards
Manage clinical laboratories,
respiratory therapy, biomedical engineering, and library.
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UCSF/SFGH Partnership
Manages large research effort at
SFGH
– Approximately 250 million dollars in grants – 270,000 ASF of research space, mostly in seismically challenged space by UC standards
Plans underway by UCSF for new
research building at SFGH
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IS Accomplishments 2011
PulseCheck (Emergency Dept
Information System) implementation
MAK (Electronic Medication
Administration Record) rollout to 5A
IS steering committee
reorganization
Barcoded Medication Administration
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Preparing for Meaningful Use
Infrastructure upgrades
– WiFi – Device replacements – Mobile device management (MDM)
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HIT objectives 2011-12
Complete comprehensive five-year
development plan for electronic health records at SFGH by the end of 2011.
Attest to Stage 1 of Meaningful Use for
Medicare fiscal year 2012.
Complete roll-out of Computerized Physician
Order Entry to all Medical-Surgical units by end of 2012.
Complete roll-out of MAK to all Medical-
Surgical Units and Psychiatry by end of 2012.
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Environment of Care (EOC)
The seven elements of the EOC Safety Program:
Safety Security Hazardous Materials/ Waste Medical Equipment Utilities Fire Safety Emergency Management
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Rebuild Highlights
Excavation Generators and
water tank
Concrete pour Community mural Local hiring Community
- utreach
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Approval Required
Environment of Care Plan Report Provision of Care Policy Performance Improvement Policy
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