TOPIC DISCUSSION ACTION Iman Nazeeri-Simmons and Todd May co-chaired the meeting. Agenda for today s meeting was presented for review.

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1 Attendance: Excused: Guest(s): Quality Council Minutes May 15, 2012 Sue Carlisle, Idy Chan for Morgen Elizabethchild, Tom Holton, Will Huen, Valerie Inouye, Shermineh Jafarieh, Kathy Jung, Tristan Cook for Rachael Kagan, Jay Kloo, Elaine Lee, Tina Lee, Todd May, Sharon McCole-Wicher, Anson Moon, Iman Nazeeri-Simmons, Shannon Thyne, Lann Wilder, Troy Williams, David Woods Sue Currin, Doug Eckman, Roland Pickens, Sue Schwartz, Cathryn Thurow Irin Blanco, Akilah Cadet, Leslie Dubbin, Brandi Frazier, Aiyana Johnson, Jasmeen Karan, David Kutys, Sharon Kwong, Laure Marshall, Megan Moore, Michael Pfeffer, La Phengrasamy, Dennise Rosas, Julie Russell, Fred Ryan, Ana Sampera TOPIC DISCUSSION ACTION ADMINISTRATIVE Iman Nazeeri-Simmons and Todd May co-chaired the meeting. Agenda for today s meeting was presented for review. Agenda reviewed. The Minutes of the April 17, 2012 meeting were presented for approval. Minutes approved. POLICIES AND PROCEDURES The following P&Ps were presented by Fred Ryan for approval: 8.13 HIPAA Compliance: Patient/Client/Resident Rights Regarding Protected Health Information: Unchanged Computer Based Training: New policy introduced governing mandated, hospital wide computer based training: Unchanged Overhead Paging System: Unchanged Subpoenas and Legal Process: Unchanged Violence in the Work Place: Zero Tolerance Policy updated to reflect the replacement of the Management Response Team by the newly created Critical Incident Response Team Critical Incident Response Team (CIRT): New policy reflecting the replacement of the Management Response Team by the newly created Critical Response Team. EOC Safety Policy Statement: Unchanged All policies approved. 1

2 EOC Environment, Health and Safety Officer Authority and Responsibility: Unchanged EOC Annual Review of the Safety Management Program: Unchanged EOC Structure, Attendance and Reporting Relationships: Unchanged EOC Environmental Health and Safety: Unchanged EOC Use of Extension Cords and Adapters: The policy details appropriate use of certain UL listed power strips.the revised policy further restricts the use of extension cords and adapters. EOC Code Silver: New policy introduced by the EOC committee duck and cover and barricade when there is a shooter in the hospital. EOC Radiation Safety Subcommittee: Radiological Equipment Exposures: Section 2.3.2x - Explicit assignment of "As Low As Reasonably Achievable" (ALARA) exposure limits for (a) skin and (b) eye exposures. Numbers were added to provide reference values against which to compare any measured skin and eye doses. Levels selected are 1/10th of the US NRC occupational exposure limits in order to catch exposures well before mandatory reporting. Section 8 & 9 Added clarifications to the equipment testing procedures, representing significant negotiation between Radiology and Biomedical Engineering to ensure that appropriate people are notified of substantial equipment repairs, timetable for post repair testing, and how repairs are to be documented. Section and Appendix B - Explicitly spelled out policy & procedure for pregnant employees. EOC Laser Safety Program: Laser safety online training is now an initial competency as opposed to an annual. EOC Requests for Environmental Services: Unchanged 2

3 PERFORMANCE MEASURES: MEDICAL SOCIAL SERVICES Sharon Kwong and Megan Moore reviewed highlights from the Medical Social Services report: Mild Traumatic Brain Injury In collaboration with the Neurosurgery Service (NSU), the Emergency Department (ED) social workers developed educational materials to be disseminated to Mild Traumatic Brain Injury (mtbi) patients prior to discharge from the ED. The process includes: ED medical staff confirms mtbi diagnosis and provides usual medical care and discharge instructions ED medical staff refers patient to ED social workers Social worker provides intervention (i.e., education) Results: Approximately 20-25% of the total number of mtbi patients were referred to the ED social workers from July 2011 April Referrals decreased from Jan-March The educational packet consists of introducing coping strategies, providing a list of resources, recommendations to cease alcohol use and reassurance. Preliminary findings for those that received the packet show a significant decrease in alcohol use from preinjury to post injury. 95% of the patients surveyed found the intervention helpful. There were also positive outcomes in: Concussive symptoms, Anxiety, Depression, PTSD, and Maintaining community functioning. NSU provided an in-service to ED medical staff in April to encourage referrals. An upward trend is shown for the month of April. Efforts to increase the number of referrals are ongoing. Social Admissions A second performance measure is to decrease the number of hospital social admits (to inpatient from the Emergency Department) to 0% by May Data is collected from the daily Administrator On Duty (AOD) reports: From July 2011 April 2012, there were 23 patients counted as social admits on the AOD reports. Of these, 48% (11) were admitted. Actions/Plans Being Implemented: AOD & SFGH ED Social Worker implemented timely identification and notification of potential social admits to the Director of Social Services and/or Social Services Supervisor and Utilization Management. In October 2011, a Utilization Management Nurse was assigned to the ED to determine the level of care of potential Social Admit patients in the ED. The issue of social admits will be discussed in future Executive Staff Committee meetings. 3

4 The appropriateness of using the AOD Report as the data source to identify social admits was discussed. The general consensus was that the AOD report is not the best source. The role of Adult Protective Services (APS), a component of the Department of Human Services, in relation to social admits was discussed. It was reported that it is not uncommon for APS to transport clients to SFGH for medical clearance and then rely on SFGH Social Workers to find appropriate placement. The Council agreed that there is a potential misuse of SFGH resources, that it is APS s responsibility to place these patients/clients. Data is needed to support interdepartmental discussion with APS. The committee requested the development of a specific action plan on reducing social admits and a data tracking system to show when and where hospital resources are being inappropriately used. PERFORMANCE MEASURES: UTILIZATION MANAGEMENT Ana Sampera reviewed highlights from the Utilization Management (UM) report: AIM: Reduce the average monthly number of lower level of care (LLOC) patients to 20 patients by June 2012 Monitoring Process: Daily identification of LLOC patient s, provided by Utilization Management Staff Challenges identified: There are insufficient board & care level of care placements in the community both locked and unlocked. Various team members determining the level of care. Slow transition of patients at LLOC from the acute hospital to SNFs, respite care, board & care, etc. Communication breakdown between interdisciplinary team. Changes made: Meeting regularly, both in person and by with both Social service and placement leadership. Rounding two times per week with leadership from Nursing, SW, UM, placement team and inviting the primary physician to the rounds on as-needed basis. Working closely with leadership from placement team and LHH to identify and resolve barriers to discharge to proper level of care. In collaboration with various departments, developed an interdisciplinary discharge planning process with clear role definitions. Outcome: Target not met. Although the number of patients on the LLOC list remains a challenge, the number of days waiting for SNF Rehabilitation placement has decreased from 8.1 days in 2011 to 6.2 days in Conversely, the average length of stay (LOS) for Long Term SNF has increased from 15.9 days to 18.9 days. Action Plan: Continue to work closely with LHH, Placement team and primary Attending. Monitor the LLOC list daily. Next Steps: Monitor the LOS by placement type to clearly identify community placement resource needs. 4

5 The committee discussed the implications of not meeting this target. SFGH has an imperative to reduce the number of non-acute patients, and to manage patients utilization of hospital resources. The financial consequences for SFGH, when our patients are admitted to other hospitals and we are not notified or we do not act to return these patients to SFGH are significant. In addition, there are out-of- network patients admitted to SFGH. SFGH must notify their health care providers within 24 hours of arrival in order to be reimbursed. Both situations are possible sources of lost revenue. The only alternative to increasing revenue is cutting cost. Improved data is necessary for implementing changes. For instance, the financial burden of providing medications to out of network patients with a fixed pharmacy budget need to be highlighted through robust data driven utilization management reports. Types of placement (e.g., SNF, Rehab, board and care) needed by our patients were discussed. UM has limited say regarding discharge placement. Physicians determine patient readiness for discharge and recommend the type of placement. The UM placement team meets regularly to discuss the level of care using objective criteria to dictate disposition options to physicians. UM is currently studying length of stay while awaiting placement. The preliminary data shows that SNF beds are not needed as much as placements at other, often lower level of care, sites. Ana Sampera presented a draft UM workflow map. The purpose of the workflow map is to find ways to streamline or make the UM process more efficient A UM analyst has been hired who will manage this study going forward. The analyst is scheduled to start in July. Quality Management offered its services to help with data analysis around this study so that results will be available by July 1 st. UPDATE: PATIENT FLOW Shannon Thyne and Leslie Dubbin presented an update on patient flow: The Patient Flow committee was created to address patient flow issues across the Emergency Department (ED) and inpatient setting. The goal is to decrease turnaround time for admitted patients and patients coming in through the ED. Successes of the committee include: Using the ED Rape Treatment room as a treatment room when it is not being used for rape treatment services. This essentially added an extra room in the ED, for a total of 25 rooms. All rape treatment exams that do not involve medical injuries or mental health concerns have been moved to a more patientcentered room in 6E. 5

6 Opening the pediatric urgent care clinic for two extra hours per day till 10:00pm. This allows the clinic to see, on average, an extra 11 patients a day; patients who would have gone to the ED. The nursing report is now a computer-generated sign out. This has increased the content of information that nurses receive at sign out. A workgroup of the committee will study timely consultation in the ED and patient discharge. It currently takes an additional 3-5 hours longer in the ED if a patient has a consultation. There are currently no consequences for consultants and residents not coming to ED in timely manner for consultations. In order to better manage the workgroups and sub-committees around patient flow, the Patient Flow committee is switching to one monthly 2 hour meeting instead of twomonthly 1 hour meetings. The committee s mission has expanded as more and more committees and workgroups report in. There is a challenge to keep things focused and to get sub-committees to understand that the flow committee is not a directive committee, but a coordinating/advisory body. The Patient Flow Committee will report at a future Executive Staff Committee meeting. It was noted that Finance needs to be involved in the development of an Observation Unit. UPDATE: LEAN Iman Nazeeri-Simmons presented an update on Lean: Mike Rona Consulting has been hired to train hospital staff on using Lean. Two areas of focus for Value Stream Mapping are the Urgent Care Clinic and the General Surgery Clinic (3M), which will take place in July Informational. NEXT MEETING June 19, :00am to Noon, 2A6 Informational 6