SAN FRANCISCO GENERAL HOSPITAL and TRAUMA CENTER. ANNUAL REPORT Fiscal Year

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1 SAN FRANCISCO GENERAL HOSPITAL and TRAUMA CENTER ANNUAL REPORT Fiscal Year

2 Presentation Summary Community Wellness Program Nursing Progress Performance Improvement and Patient Safety UCSF-SFGH Partnership Health Information Technology Environment of Care SFGH Rebuild

3 MISSION: To Provide Quality Healthcare and Trauma Services with Compassion and Respect Align care, discovery & education to advance community wellness. TECHNOLOGY SYSTEMS PEOPLE Operational Health Clinical Information Efficiency & Service & Excellence Technology Coordination

4 PEOPLE Service Excellence A Fair and Just Culture Clinical Quality Enhancing Wellness Professional and Academic Excellence SYSTEMS Efficient Management System Integration and Coordination Across Services TECHNOLOGY Meaningful Use of Information Technology Moving beyond implementation towards adoption of Health Information Technology

5 Our New Leaders Todd May, M.D. Chief Medical Officer Shannon Thyne Chief of Staff Thomas Holton Patient Safety Officer Winona Mindolovich and John Applegarth Information System Leadership

6 Listening to our patients

7 COMMUNITY WELLNESS PROGRAM Project of the San Francisco Department of Public Health at San Francisco General Hospital and Trauma Center

8 About the Community Wellness Program Values: Community Engagement and Partnerships Holistic approach Education through Empowerment Culturally, linguistically, and financially accessible Creative and innovative approaches Engaged leadership

9 BUILDING COMMUNITY TOGETHER Healthy Food Environment Initiative Healing Moves-Active Living Initiative Tobacco Free Community Initiative Community Engagement Initiative

10 Magnet Journey Shared Governance Positive Communication Training Professional Development Speakers Professional RN Certification Education Nursing Progress

11 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

12 Performance Improvement & Patient Safety Program (PIPS) Joint Commission Accreditation Quality Data Improvement Increasing alignment between hospital and clinical services through PIPS Committee 12

13 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

14 CDPH Tissue Bank Licensing In ARF/Fire , & Commission SFGH was Safety Accreditation Laboratory & Point of Care Title 15 licensed Community and Accreditation regulated Services by 33 Care Program Joint Licensing PHS/ FDA Commission agencies ARF Licensing who conducted Long Term Alcohol & a total Drug Care Certification Accreditation Joint of 41 Title X surveys/site inspections. Licensing Family of Opiate Center CDPH/ CMS EMTALA Complaint Validation CDPH Joint mission PPR LTC/Fire & lidation Life Safety Licensing survey CDPH CMS Life Safety Code of ESRD DSS Licensing DSS/ US DHHS/ Dept of Mental Licensing Health Services Administration Center for Substance US DHHS/ Abuse Treatment American College of Surgeons MERP ommission on ancer f SFGH Cancer Program Planning Federal Audit CMS ESRD Treatment Outpatient Vaccines Program for Children Program Quality DMH Assurance Review/ MHRC Licensing DEA of Pharmacy DEA Registration CDPH/ as a NTP CARF Program Blue Cross FSR & MMR of SFHP Clinics CDPH RHB of Avon Breast Center & Mammovan Joint Testing Program ACSCOT Level I Trauma Center Joint Verification PPR Hospital, LTC, Lab Commission Joint Commission Traumatic Brain Injury Certificate of DMH Distinction MHRC/Fire & Life Safety Licensing Dept. of Correction/ Jail Health US DHHS/ MQSA Commission Primary Stroke Program Joint Commission Hospital Accreditation SF Mental Health Clients Rights Advocates CDPH DEA Consolidated Accreditation Level 1 Trauma Center Designation Verification CDPH CDPH/CMS of Opiate Nurses Treatment Improving Outpatient Care for Program HealthSystem Elders Site ACSCOT/ CCSF-DPH EMS CDPH Certified Nurse Assistant PSLS Program Baby Record Friendly Review Hospital Site Visit Certification 14 Complaint Validation Licensing Pharmacy Management of Controlled substances Centering CDPH Health Care Institute LTC Site Licensing Approval/ Certification

15 Quality Data Required by The Joint Commission and CMS Heart Attack Heart Failure Pneumonia Surgical Care HCAHPS Patient Experience (CMS) 15

16 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 Blood culture taken before antibiotics administered 78% 86% Antibiotic Given within 6 Hours Recommended antibiotic selection 84% 90% 82% 100% 16

17 HCAHPS Patient Experience (CMS) Publicly reported patient survey scores identify an area for focused improvement: Hospital Rating (Top Scores): SFGH 57% State Avg 67% 17

18 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

19 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.

20 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

21 IS Accomplishments 2011 PulseCheck (Emergency Dept Information System) implementation MAK (Electronic Medication Administration Record) rollout to 5A IS steering committee reorganization Barcoded Medication Administration

22

23 Preparing for Meaningful Use Infrastructure upgrades WiFi Device replacements Mobile device management (MDM)

24 HIT objectives Complete comprehensive five-year development plan for electronic health records at SFGH by the end of Attest to Stage 1 of Meaningful Use for Medicare fiscal year Complete roll-out of Computerized Physician Order Entry to all Medical-Surgical units by end of Complete roll-out of MAK to all Medical- Surgical Units and Psychiatry by end of 2012.

25

26 Environment of Care (EOC) The seven elements of the EOC Safety Program: Safety Security Hazardous Materials/Waste Medical Equipment Utilities Fire Safety Emergency Management

27 Rebuild Highlights Excavation Generators and water tank Concrete pour Community mural Local hiring Community outreach

28 Approval Required Environment of Care Plan Report Provision of Care Policy Performance Improvement Policy

29 To provide quality health care

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