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 Health Information Technology Environment of Care SFGH Rebuild
M ISSION : To Provide Quality Healthcare and Trauma Services with Compassion and Respect Align care, discovery & education to advance community wellness. T ECHNOLOGY S YSTEMS P EOPLE Operational Efficiency & Coordination Health Information Technology Clinical & Service Excellence
P EOPLE • Service Excellence • A Fair and Just Culture • Clinical Quality • Enhancing Wellness • Professional and Academic Excellence S YSTEMS • Efficient Management System • Integration and Coordination Across Services T ECHNOLOGY • Meaningful Use of Information Technology • Moving beyond implementation towards adoption of Health Information Technology
Our New Leaders Todd May, M.D. Shannon Thyne Chief Medical Officer Chief of Staff Thomas Holton Winona Mindolovich and John Applegarth Patient Safety Officer Information System Leadership
Listening to our patients… http: / / vimeo.com/ 22641730
COMMUNITY WELLNESS PROGRAM Project of the San Francisco Department of Public Health at San Francisco General Hospital and Trauma Center
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
BUILDING COMMUNITY TOGETHER Healthy Food Environment Initiative Healing Moves-Active Living Initiative Tobacco Free Community Initiative Community Engagement Initiative
Nursing Progress Magnet Journey Shared Governance Positive Communication Training Professional Development Speakers Professional RN Certification Education
Nursing Progress Dorothy Washington Fundraiser for RN Scholarships RN and New Graduate Training Program Low Vacancy Rate Joint Commission TBI and Stroke Certification Nursing Initiatives Community Partnerships
Performance Improvement & Patient Safety Program (PIPS) Joint Commission Accreditation Quality Data Improvement Increasing alignment between hospital and clinical services through PIPS Committee 12
Performance Improvement & Patient Safety Program (PIPS) – CMS Incentive Plan – Primary Care Coordination between COPC and Hospital-based clinics – Sepsis & Central-line Associated Blood Stream Infection prevention – Patient Experience Initiative – Leadership & QI Academy Learning Center – Quality Data Center
DEA CDPH DSS Dept. of Joint Survey of CARF Com m ission Correction/ In 2010-2011, SFGH was Tissue Bank ARF/ Fire & Opiate Nurses Accreditation Laboratory & Licensing Title 1 5 Safety Treatm ent I m proving Survey Survey Point of Care Licensing Outpatient Jail Health DSS/ Testing Care for US DHHS/ Survey Program Services licensed and regulated by 33 Accreditation Com m unity HealthSystem US DHHS/ Dept Joint Licensing Survey PHS/ FDA Program Survey Care Elders Site Com m ission of Mental Licensing Survey MQSA Health Services ARF Licensing Long Term agencies who conducted a total Alcohol & Certification Adm inistration Survey Care Joint Drug Survey Center for Accreditation Com m ission Program Program CDPH Substance US DHHS/ Prim ary ACSCOT/ Survey of 41 surveys/site inspections. Abuse Stroke Title X Licensing Survey CCSF-DPH EMS Consolidated Treatm ent Center Fam ily of Opiate CDPH/ Accreditation ACSCOT Level 1 Traum a Program Planning Treatm ent Survey Center Designation CMS Federal Audit Outpatient Survey Verification Survey Level I CMS EMTALA Program Vaccines for Traum a Com plaint Joint Centering Children Center CDPH Joint Validation Com m ission ESRD Verification Health Care Program Survey Survey Survey PPR – Com m ission I nstitute Site Quality DMH LTC Hospital, Assurance Licensing Approval/ CDPH Joint LTC, Lab Hospital Survey Review / Survey MHRC Certification m m ission Licensing Survey Accreditation PPR LTC/ Fire & Joint Survey Life Safety alidation Com m ission Survey CDPH Survey Licensing DEA survey Traum atic Survey of Certified Nurse CDPH Brain I njury CDPH CDPH/ CMS Pharm acy Assistant SF Mental Certificate of CDPH Am erican DEA DMH Program Record RHB PSLS Health Baby Friendly Com plaint College of Distinction CMS CDPH/ Registration Survey Review Survey MHRC/ Fire Hospital Site Validation Surgeons Clients’ MERP as a NTP Survey of Blue Cross & Life Visit Licensing Survey Com m ission on Rights Survey Avon Breast Life Safety – Pharm acy Certification Cancer Survey Safety FSR & MMR of Code of Center & Advocates Managem ent of f SFGH Cancer Survey Licensing SFHP Clinics 14 ESRD Mam m ovan Controlled Program Survey Survey Survey substances
Quality Data Required by The Joint Commission and CMS Heart Attack Heart Failure Pneumonia Surgical Care HCAHPS Patient Experience Survey (CMS) 15
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 Measure 2009 2010 Blood culture taken 78% 86% before antibiotics administered Antibiotic Given within 6 84% 90% Hours Recommended antibiotic 82% 100% selection 16
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% 17
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 18
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.
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
IS Accomplishments 2011 PulseCheck (Emergency Dept Information System) implementation MAK (Electronic Medication Administration Record) rollout to 5A IS steering committee reorganization Barcoded Medication Administration
Preparing for Meaningful Use Infrastructure upgrades – WiFi – Device replacements – Mobile device management (MDM)
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.
Environment of Care (EOC) The seven elements of the EOC Safety Program: Safety Security Hazardous Materials/ Waste Medical Equipment Utilities Fire Safety Emergency Management
Rebuild Highlights Excavation Generators and water tank Concrete pour Community mural Local hiring Community outreach
Approval Required Environment of Care Plan Report Provision of Care Policy Performance Improvement Policy
To provide quality health care… http: / / vimeo.com/ 30152304
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