HEALTH COMMISSION. CITY AND COUNTY OF SAN FRANCISCO Gavin C. Newsom, Mayor Department of Public Health. David J. Sanchez, Jr., Ph.D.

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1 James M. Illig President Sonia E. Melara, MSW Vice President Edward A. Chow, M.D. HEALTH COMMISSION CITY AND COUNTY OF SAN FRANCISCO Gavin C. Newsom, Mayor Department of Public Health Margine A. Sako David J. Sanchez, Jr., Ph.D. Mitchell H. Katz, M.D. Director of Health Jim Soos Acting Executive Secretary Steven Tierney, Ed.D. TEL (415) FAX (415) Catherine M. Waters, R.N., Ph.D. Web Site: 1) CALL TO ORDER MINUTES JOINT CONFERENCE COMMITTEE FOR SAN FRANCISCO GENERAL HOSPITAL Tuesday, 3:00 p.m Potrero Avenue, Conference Room 2A6 San Francisco, CA Sanchez called the meeting to order at 3:10 p.m. Present: Excused: Staff: Catherine Waters, RN, PhD, Member David J. Sanchez, Jr., PhD, Member Edward Chow, MD, Chair Sue Carlisle, M.D., Jeff Critchfield, M.D., Sue Currin, Delvecchio Finley, Myra Garcia, Valerie Inouye, Kathy Jung, Sharon Kotabe, Pharm. D., John Luce, M.D., Kathy Murphy, Marti Paschal, Roland Pickens, Dan Schwager, Sue Schwartz, Sharon McCole Wicher, Troy Williams. 2) APPROVAL OF THE MINUTES OF THE FEBRUARY 10, 2009 SAN FRANCISCO GENERAL HOSPITAL JOINT CONFERENCE COMMITTEE MEETING Action Taken: The Committee approved the minutes of the February 10, 2009 San Francisco General Hospital Joint Conference Committee. 101 Grove Street San Francisco, CA

2 3) HOSPITAL ADMINISTRATOR S REPORT Sue Currin, Chief Operating Officer, presented the report. SFGH Organizational Announcements After 25 years at SFGH, the past 11 as CEO, Gene O Connell announced her retirement effective March 20. Dr. Mitch Katz, Director of the San Francisco Department of Public Health, has named Sue Currin, RN, MSN, SFGH s long-time Chief Nursing Officer and current Chief Operating Officer, as the new CEO. Sue has been the Chief Nursing Officer for the last 8 years, providing leadership and management of all aspects of patient care services at SFGH. She began her career at SFGH as a nurse and has since served in a variety of capacities, including Director of Quality Management at SFGH and Director of Quality Management for the entire Community Health Network. She left DPH for two years to work as the Quality and Service Leader for the East Bay Service Area of Kaiser Permanente Hospital and Health Plan, overseeing quality, risk and medical staff affairs programs across four medical centers, multiple ambulatory sites, home health, hospice, and contracted services. Sharon McCole Wicher, Director of Behavioral Health Services, has been appointed to the position of interim Chief Nursing Officer effective March 2. Sharon has been the Nursing Director for Acute Psychiatry, Psychiatric Emergency Services and the Behavioral Health Center for the past eleven years. Throughout her career, Sharon has held numerous clinical and administrative leadership positions. Clinically, Sharon has served as a Nurse Educator, Clinical Faculty and Director of Staff Development. Sharon's leadership positions have been progressive from Nurse Manager to Director of Nursing. Sharon was also the Executive Director of the California Nurses Association (CNA) Region XI where she was responsible for professional standards of practice and government relations issues. Patti O Connor RN, MS, has been appointed to the position of interim Nursing Director for the Emergency Department, effective March 2. Patti has been the Trauma Program Manager at SFGH for the past five years and will continue in that role. Patti s professional career has spanned 30+ years and includes both clinical and administrative leadership positions in Emergency, Flight and Trauma Nursing. Patti has been instrumental in the development and implementation of new programs including: REACH Air Medical Program; Ross General Hospital Emergency Department; Marin County Paramedic System, and Kaiser San Rafael Trauma Program. In addition, she has managed the Emergency Department and Trauma Program at Santa Rosa Memorial Hospital, as well as the Alameda County Medical Center Trauma Program. SFGH Rebuild Update User groups will reconvene to sign off on design development plans and to discuss equipment and procurement activities; mock-ups of the OR, ED exam room, ICU, and med-surg rooms will be constructed in the service building starting next month. Site utility work to relocate the major power utilities into the hospital will also begin in April. This work requires the temporary relocation of the sleep rooms, occupational therapy, respiratory therapy and cardiology services. The Rebuild Steering Committee met on February 24 to review the current status of the hospital drawings; the Civic Design Review Board will meet on March 16 for a final review of the drawings. An oversight committee has begun biweekly meetings to coordinate activities and discuss construction impacts. Page 2

3 CHN Retail Pharmacy Change Sharon Kotabe, Pharm. D., provided an update on the CHN retail pharmacy change. Copies of the letters for providers and patients regarding the change from Rite Aid pharmacies to Walgreens pharmacies for CHN prescription benefit recipients were provided. Patient letters are being translated into Chinese and Spanish. As soon as they are ready, they will be forwarded to current Rite Aid pharmacy locations and all CHN clinics for distribution to patients. Patient Flow Report for February 2009 A series of charts depicting changes in the average daily census for Medical/Surgical, Acute Psychiatry, 4A Skilled Nursing Unit, and the San Francisco Behavioral Health Center were attached to the report. Quality Council Minutes The Quality Council minutes for January 2009 were attached to the report. s Comments/Follow-Up Action Todd May, M.D., incoming Chief of Staff, will present the Code of Conduct to the SFGH JCC at a future meeting. 4) PATIENT CARE SERVICES REPORT Sharon McCole Wicher, Interim Chief Nursing Officer/Director of Nursing, Psychiatry, presented the Patient Care Services Report. February RN Vacancy Report Overall 2320 RN vacancy rate for areas reported is 4.62 %. SFGH Ratio Staffing Data, By Number of Shifts 2/01/09 to 2/28/09 SFGH was able to meet staffing ratios in all areas except in Medical Surgical where there was one shift in each area when the area was unable to cover breaks. Recruitment/Retention/Training/Professional Development RN Internship Program/New Graduate Training: The next new graduate transition class will be held on March 27. Recruitment: The skill mix change in the hospital-based clinics took effect on February 21, As a result, twelve (12) FTEs of RNs (total of fifteen staff) took reassignment to various clinical areas of the hospital and clinics. Orientation and training of the involved RNs to their new workplace is underway. Under a new clinical model, Medical Evaluator Assistants (MEA) will provide patient care in the clinic setting. The other classifications impacted by reassignments were the Licensed Vocational Nurses (LVN) and Unit Clerks. The total of number of LVNs was reduced by thirty-one. The plan concluded with Two (2) LVNs to 4A, one (1) LVN to 4C, one (1) LVN to BHC, nineteen (19) to staff pharmacy, discharge lounge, smoking cessation and phlebotomy service and eight (8) to LH. Under the guidelines of the new clinical model, classifications for clerks in the outpatient clinic changed from Unit Clerks (1428) to Senior Clerks (1406). Page 3

4 The bidding process was based on employment seniority with process facilitation by SEIU, HR and nursing representatives. Reassignments were completed on February 21, Retention/Professional Development: SFGH submitted a grant proposal to PacifiCare/United Healthcare for the implementation of Computerized Physician Order Entry (CPOE). The proposal is for $1.8 million and will cover one time development and implementation costs over a three year period. These awards will be made in April Preceptor training will be held on March 30 & 31, Nursing Excellence The second meeting of the hospital-wide Nursing Practice Council was held February 20. Patty Coggan RN, CNS, Nurse Manager of the Surgicenter and PACU, and Franco Herrera RN, medicalsurgical nursing, are the co-chairs of the council. Consultant Kathleen Stolzenberger PhD, RN with the American Nurses Credentialing Center visited SFGH the last week of February to assess SFGH s current readiness for Magnet designation. Kathleen spent three days meeting with staff and leadership to conduct the gap analysis and educate staff about the Magnet concept, expectations and application process. Kathleen assisted in strategic planning discussions and will be sending a report with her recommendations in the near future. The report will provide a foundation for an action plan to move SFGH toward nursing excellence. Twenty members of the SFGH nursing staff including directors, managers and RN staff supportive of Magnet and active with SEIU 1021 attended the Journey to Nursing Excellence Conference sponsored by Stanford and El Camino hospitals. The conference provided an overview of the 2009 Magnet Model, the components of the model, and the sources of evidence required for Magnet certification. The conference provided an opportunity for in-depth learning and planning in a collaborative manner for nurses at all levels of the SFGH organization Association California Nurse Leaders Annual Conference The Association of California Nurse Leaders (ACNL) held their annual conference February 11, 12 and 13 in Monterey, California. SFGH was represented with 24 nursing participants lead by Sue Currin CNO/COO. The group consisted of bedside nurses, managers and directors from various units throughout the hospital. SFGH nurses hold positions on the ACNL health policy, research and leadership committees. ED Diversion Report February 2009 The Emergency Department had a Diversion rate total of 19% (126 hours) for the month of February The ED encounters for the month of February were 3360 and 650 patient admissions. During Diversion the ED held 185 admitted patients waiting for inpatient bed assignment (ICU-11, 4B/5D-106 Med/Surgical-68). PES December 2008 PES had 495 patient encounters during January 2009 and 429 in February PES admitted a total of 141 patients to SFGH inpatient psychiatric units in February 2009, which was down from 147 in January In February, a total of 288 patients were discharged from PES, with 26 to ADUs, 19 to other psychiatric hospitals and 243 to community/home. Page 4

5 In February, PES was on Condition Yellow for a total of 1.8 hours, which was down from 4.7 hours in January. There was an increase in Condition Red from January to February. PES was on Condition Red for hours during 17 episodes in February. The average length of Condition Red was hours. In January, PES was on condition Red for hours, during 13 episodes, averaging 8.49 hours. The average length of stay in PES for the month of February was hours, which was an increase from hours in January. 5) MEDICAL STAFF REPORT Jeff Critchfield, M.D., Chief of Staff, presented the Medical Staff Report. Revised ACC Proposal for Treatment and Referral Guidelines MEC unanimously endorsed practices outlined in the final draft of the Ambulatory Care Committee s (ACC) Proposal for Treatment and Referral Guidelines. This proposal will address the need for a uniform procedure for revision of guidelines that are already posted or for review of those that are in development. This proposal will also ensure that guidelines are reviewed periodically, remain current, useful, and accurate. Cancer Committee Report The SFGH Cancer program reported its activities for the past 6 months with highlights including receiving a SF Foundation Hearts Grant to renovate the chemotherapy treatment area. The Distinction in Mentoring Award Recipients As an Academic Senate Award, the Distinction in Mentoring Award (DIM) is an award given by faculty to faculty to celebrate and inspire excellence in faculty mentoring, an essential component to faculty success and institutional excellence. The Distinction in Mentoring Award for a faculty at the Assistant or Associate rank was given to Priscilla Hsue, MD, Assistant Adjunct Professor in the Department of Medicine, Division of Cardiology at SFGH, in recognition of her outstanding mentorship. Dr. Hsue is the site director at SFGH for the UCSF Cardiology Fellowship Program and has mentored medical students, residents, nurses, and fellows in research as well as helping to obtain independent support for these individuals. SFGH Leadership At the March 5, 2009 ADM-MEC meeting, members gave a standing ovation to Ms. O Connell, with deep appreciation of her excellent leadership and outstanding work. At the March 9, 2009 CLIN-MEC, members gave a warm welcome to Sue Currin, RN, MS, new Chief Executive Officer. 6) PUBLIC COMMENT None. 7) CLOSED SESSION: A) Public comments on all matters pertaining to the closed session None. Page 5

6 B) Vote on whether to hold a closed session (San Francisco Administrative Code Section 67.11) Action Taken: The Committee voted to hold a closed session. The Committee went into closed session at 3:40 p.m. Present in the closed session were Sanchez, Waters, Sue Carlisle, M.D., Jeff Critchfield, M.D., Sue Currin, Delvecchio Finley, Myra Garcia, Kathy Jung, Sharon Kotabe, Pharm. D., John Luce, M.D., Kathy Murphy, Marti Paschal, Roland Pickens, Dan Schwager, Sue Schwartz, Sharon McCole Wicher, Troy Williams. C) Closed session pursuant to Evidence Code Sections 1157(a) and (b); ; Health and Safety Code Section 1461; and California Constitution, Article I, Section 1 APPROVAL OF CLOSED SESSION MINUTES OF FEBRUARY 10, 2009 Action Taken: The Committee approved the February 10, 2009 closed session minutes. CONSIDERATION OF CREDENTIALING MATTERS Action Taken: The Committee approved the Credentials Report. CONSIDERATION OF PEER REVIEW, QUALITY OF CARE AND PERFORMANCE IMPROVEMENT D) Reconvene in Open Session The committee reconvened in open session at 3:55 p.m. 10) ADJOURNMENT 1. Possible report on action taken in closed session (Government Code Section (a)2 and San Francisco Administrative Code Section 67.12(b)(2).) 2. Vote to elect whether to disclose any or all discussions held in closed session (San Francisco Administrative Code Section 67.12(a).) Action Taken: The Committee voted not to disclose discussions held in closed session. The meeting was adjourned at 3:55 p.m. Jim Soos Acting Executive Secretary to the Health Commission Page 6