TOPIC DISCUSSION ACTION Sue Currin and Sue Schwartz chaired the meeting. Agenda for today s meeting was presented for review.

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1 Attendance: Excused: Guest(s): Quality Council Minutes January 15, 2013 Sue Currin, Tom Holton, Valerie Inouye, Tina Lee, Anson Moon, Roland Pickens, Sue Schwartz, Lann Wilder, Troy Williams Sue Carlisle, Alice Chen, Morgen Elizabethchild, Doug Eckman, William Huen, Shermineh Jafarieh, Kathy Jung, Rachel Kagan, Jay Kloo, Elaine Lee, Todd May, Iman Nazeeri-Simmons, Cathryn Thurow, Shannon Thyne, Sharon Wicher, David Woods Kelly Brandon, Jenny Chacon, Terry Dentoni, Louise Dimattio, Brandi Frazier, Ditus Hernandez, Jon Hicks, Kathryn Horner, Fe Hortinela, Claire Horton, Kathleen Flanagan, Aiyana Johnson, Jasmeen Karan, Cheryl Kalson, David Kutys, Laure Marshall, Jessica Morton, Dana Nelson, Neil Ponferrada, Shilu Ramchand, Maggie Rykowski, Baljeet Sangha TOPIC DISCUSSION ACTION ADMINISTRATIVE Sue Currin and Sue Schwartz chaired the meeting. Agenda for today s meeting was presented for review. Agenda reviewed. POLICIES AND PROCEDURES The Minutes of the December 2012 meeting were presented for approval. The following policy and procedures were sent out by for approval Policy Investigational Drug Policy Added language re: investigational drugs may now be dispensed/administered upon written rx or order from Co-PI, or designee (in addition to PI) Added language re: education and training of nursing and pharmacy staff on protocols and administering investigational drugs. Policy HIPAA Compliance: Privacy Policy Adapted existing DPH policy language to SFGH Policy Bloodborne Pathogen Exposure: Patient as the Source Minor clarifications, including replacing duties and responsibilities of "the counselor", such as coordinating source patient evaluation, counseling, testing, and care referral. Policy 8.10 Video Capture HIPAA Compliance: Administrative Requirements Adapted existing DPH policy language to SFGH. Policy HIPAA Compliance: Authorization for Use and Disclosure of Protected Health Information Adapted existing DPH policy language to SFGH Minutes approved. Policies and procedures approved 1

2 Policy Digital Recording of Trauma Resuscitations in the Emergency Department Change to title from "videotaping" to "digital recording." Otherwise, no changes. PERFORMANCE MEASURES: PERINATAL NURSING Shilu Ramchand and Kelly Brandon presented on performance measures in Perinatal nursing: Cue based feeding for premature neonates Cue based feeding is based on infant readiness and recognizing signs of newborn behavior. AIM: Implement a standardized cue-based feeding pathway for premature infants to increase practice consistency thereby increasing positive nurse satisfaction survey results to 50% by December 2012 Background: Individual provider practice in transitioning premature infants from tube feeding to breast/oral feeding created variations in nursing practice in feeding care for premature neonates. An initial nurse satisfaction survey was conducted In May 2012 to assess this practice: 70% of nurses were not satisfied with current feeding practice 80% felt there was a need to change the current feeding practice. Results: A cue-based feeding pathway was implemented in June Nurses were resurveyed in December 2012 after the new practice was implemented and 75% of nurses were satisfied with new practice. Additional data collection is ongoing to assess the impact of cue-based feeding protocol on decreasing the length of stay to 36 weeks or less for premature infants. Patient Engagement Education Program (PEEP) in the NICU AIM: 50% of the NICU parents will have better understanding of their baby s care management by December This initiative was modeled on the education program implemented in unit 6C, and rolled out to the Neonatal ICU in June 2012 to provide mothers with information and group support. Staff nurses are trained to become facilitators of PEEP program sessions. Success was measured through a survey of patient satisfaction with PEEP. Survey results show 100% of parents surveyed agreed or strongly agreed that the program was beneficial. Challenges to address: Availability of simulation space, ensuring a variety of nurses attend the simulation training, identifying and training an increased number of facilitators, from all disciplines within the perinatal team. Strengthen the knowledge/education of nurses and MDs Support nurses and MDs with use of the feeding pathway Measure achievement of full oral feeds Summarize staff feedback about the simulation program and incorporate improvement suggestions. 2

3 Perinatal Emergency Simulation Training AIM: SFGH will maintain a 4% or lower Postpartum Hemorrhage (PPH) rate as a result of simulated practice of active management, indication for PPH management, and effective communication improvements amongst perinatal team members. In 2009, a simulation program was implemented on 6C that involves every team member of the perinatal and pediatric units. Currently twice monthly simulation scenarios are conducted, where obstetrical and neonatal emergencies are rehearsed. 48 RN s, 72 practitioners, 2 clerks, 24 anesthesiologists, and 28 pediatric team members participated in simulation in 2012 Conduct survey to look at nurses comfort level in dealing with PPH On-going data collection of PPH needs to be maintained Peri-Operative National benchmark for PPH rates range from 4-11% depending on the type of hospital and patient population served. SFGH has kept rate at 3 or 4% since 2009 when simulation training was implemented (rate was formerly 6 to 7%) Patty Coggan (?) and Terry Dentoni reported on Peri-op performance measures: Operating Room (OR) Start Times AIM: By November 2012, 60% of 1st OR cases of the day will be in room along with the whole OR team by 0730 and 80% of 1st cases will be in by Data collected over the last 2 years shows consistent increase in percentage of cases starting by o From 12/11 to 11/12, 1st case starts by 0730 increased from approximately 45% to 65%. Elements contributing to steady improvement have been: 1) Night shift setting up rooms for 1st cases of the day; 2) Regional blocks done in PACU holding area prior to 0700 to expedite patients entering OR on time; 3) RN Service Leads participation in reviewing cases in days prior to surgery; 4) Active participation by Anesthesia lead attending of day & OR charge nurse to deal with issues in real time; and 5) Collection, reporting & presentation of data in the Main OR area. Barriers to improvement have been: Attending MDs punctuality, equipment issues, patient lateness, and patients who present differently on day of surgery. Attending punctuality has improved significantly. Perioperative Huddle Peri-op Huddle is a PI project that monitors the effects of multidisciplinary perioperative leadership coming together daily to discuss the flow throughout the division. Collect data for specific risk groups Increase participation of nurses less accustomed to simulation trainings 3

4 AIM: By December 2012 a multidisciplinary group consisting of PACU/OR/Surgicenter/SPD and Anesthesia will convene or huddle at the OR front board daily at 2 PM. As of December 2012 there has been 100% compliance with all disciplines present at perioperative huddle. As part of the strategic plan on patient experience and staff satisfaction, this huddle will improve communication between disciplines, staff and patients with regard to patient concerns and schedule changes. This huddle has been regarded by the staff as a team builder in that breaking down silos of care helps put all of us on the same page with regard to patient care and safety. Start measuring the effect of Peri-op Huddle by: - Individualizing templates with the specific needs of the patients in an effort decreasing the lead time by structuring the templates so that they align with the patient s appointment - Tracking how many appointments start on time across all medical-surgical clinics Surgical Specialty Clinics Ditas Hernandez and Dana Nelson reported on surgical clinic performance measures. Pre-Chemotherapy Checklist on unit 4C AIM: 100% of Pre-Chemotherapy checklist completed before scheduling for chemo administration by December 2012 this goal has been reached: 1. Chemotherapy teaching is now more productive to staff and patient 2. Nursing and ancillary staff are working together to constantly improve the process Surgical Specialty Division: Proper identification of specimens on unit 3D AIM: By December 2012, all specimens sent to Pathology are 100% compliant with proper identification 2011 Unusual Occurrence cases showed an increase in number of specimens returned to 3D for incorrect container / requisition incorrect labeling. Changes implemented in 2012 include: 1. Facilitated discussion / small test of change regarding nursing ownership of specimen collection 2. Increased staff awareness and education re: National Patient Safety Goals and proper identification of specimens 3. Collaboration with Providers and bringing issues 3D unit based divisional meeting 4. Huddle with Charge Nurse every morning 2012 results have stayed near 100% compliance. Scheduling of Procedural Sedation within 2 weeks on unit 1N AIM: 100% of Procedural Sedation cases will be scheduled within two weeks of initial consultation in Oral Surgery Clinic. Success with this measure has decreased in late Since at or near 100% compliance on pre-chemo checklist and specimen identification for the last two years, start monitoring patient satisfaction, wait times, access and other more difficult issues. Continue with implemented improvement and monitoring of access measure. 4

5 In 2012, access improvement initiatives included: 1. Confirmation / reminder call initiated 2. Designated phone number to call for cancellations 3. Financial clearance on the day of first visit prior to scheduling 4. Cancelled procedure appointments are filled with next available patient 5. Collaboration and communication between financial staff, eligibility, MD leadership, patient advocate, Nurse Manager, and 1N staff, including pamphlets and signage re: clinic services. Decrease wait times in 3M Surgical Clinic AIM : In line with the LEAN process the 3M clinic will standardize staff work flow to decrease both the wait time in the clinic (lead time) and the wait time for next available clinic appointment by 50%. Results: Average Lead time decreased from 131 minutes (Oct 2012) to 50 minutes (Dec 2012) for a sample of patient visits. Improvements included: Daily morning huddles to plan the day and address issues. Creation of standard work for 3M staff Individualizing appointment templates Implementation of guidelines for Service Attending s to follow regarding clinic cancellation. Additional improvement workshops (Kaizens) are scheduled for 3M to continue reducing wait time and waste. Additional requested data will be collected. It was requested that the surgical clinic team collect additional data on all 3M and 4M clinic sessions, including the incidence of clinics starting and ending late. Improve patient and staff satisfaction in 3M Surgical Clinic AIM : To improve patient, visitor and staff experience in the 3M clinic in alignment with hospitalwide service excellence initiative and the SFGH strategic plan. -A poker chip pilot is being conducted to measure patient satisfaction. When a patient is roomed, they are given a poker chip and told to answer whether they would recommend the clinic to family and friends and to enter their poker chip in a yes or no bin. Positive responses have been between 80 to 100% in December the 3M Staff Satisfaction Gallup Poll is being re-administered to focus on the following statements: I know exactly what is expected of me at work, I have the training I need to accomplish my role My opinions really seem to count at work My department/ unit works well together. The poll results are currently at 89% staff satisfaction. 5

6 SMOKING CESSATION Sheryl Calson presented on Inpatient Tobacco Treatment (ITT): Nicotine Replacement Therapy AIM: To improve the rate of Nicotine Replacement Therapy (NRT) for high risk inpatients (Core Measures+) identified as smokers on admission, the following initiatives are being undertaken: A new database developed and piloted since January: More indicators are being tracked: general, social, + high risk patients (CVA, HIV), assessments, NRT during & at discharge, outpatient referral, etc. ITT Information and staff cards were distributed on February 1st New Years Resolution & on May 31st World No Tobacco Day. These educated 96 RN staff Improvement was noted in total patients visited & Nicotine Patch Initial Visit: fewer patients with a core measure diagnosis (AMI, HF, Pneumonia). 78% of all patients received NRT during hospitalization. Challenges on implementing the smoking cessation initiative include: Improving total and priority ITT visits, inpatient NRT during hospitalization and at discharge, limited use of e-referrals for smoking cessation, lack of physician champion, unclear management of outpatient smoking cessation services. Follow up requested: Create a new aim and metrics for smoking cessation improvement, such as increasing the number of patients that are seen. Goals will be presented to Administrative Operations Committee for approval. Contact Kristen Bibbins- Domingo, MD for assistance with identifying a physician champion. Follow up with Roland Pickens re: Outpatient Smoking cessation resources in DPH. APPOINTMENT SHOW RATE TASK FORCE Claire Horton presented on the Appointment Show Rate Task Force: No Show Appointment Rates AIM: To measure and decrease appointment no-show rates. Variable factors that affect show rates include: Quality of appointment reminders Workflow for confirming demographic information Ability of patients to easily cancel/reschedule appointments Sense of accountability among patients for coming to visits Provider / clinic practices toward no-show patients Clinic bump rates (cancelled clinics) Ability of clinics to schedule in advance There were several show-rate bright spots in , in Radiology, General Medicine Clinic, Children Health Center, Unit 6M, and Rehabilitation. All the clinics who are improving in appointment no shows are those who have a robust confirmation call system, which are dependent on having adequate staffing. Follow up activities include: Create a pool for clerks to decrease unanswered calls Ask patients through community engagement group how they like to receive appointment reminders Bump rates and unanswered calls are going to start to be tracked on the Primary Care 6

7 Improvement actions needed include: Commitment to continued workflow improvement (through LEAN) Expansion of robust confirmation call systems could have significant impact Adequate staffing critical for robust confirmation call system Continued improvement work needed on reminder letters Commitment to consistent demographic updates, on all units In line with Service Excellence, all units need to work on improved phone access Need to incorporate review of bump rates (% of appointments cancelled by a physician in a clinic) into NSTF evaluation IT fixes on making primary and secondary patient phone numbers for appointment scheduling Dashboard being developed through the Quality and Leadership Academy UPDATE: LEARNING CENTER UPDATE: QUALITY MANAGEMENT DATA CENTER Aiyana Johnson shared highlights on the Currin-Carlisle Learning Center s first year of operation: Opened the learning center space to support SFGH s education and training needs (5 training rooms available) Launched new e-learning modules and trained over 600 existing and new staff on the ECW rollout Supported Service Excellence trainings: 3,000 staff and leaders were trained over 5 weeks Updated new employee orientation content to include a clinical orientation component and to align content to regulatory requirements and the SFGH strategic plan Laure Marshall shared highlights on the Quality Management Data Center s first year of operation. Since it began operating in March 2012, the Data Center now supports SFGH with: the development of clinical and operational quality dashboards, at all levels of the organization (hospital-wide, clinic/service-specific, unit/project specific) management of reporting to external bodies focused on quality (e.g. CMS, NAPH) providing data to clinicians across the hospital for quality improvement work supporting analysts by hosting workshops on how to use internal databases effectively and forums to discuss challenges related to reporting -Develop strategic plan trainings around Fair and Just Culture and Staff and leadership development stories -Develop an online room scheduling system and tap and go registration -Develop simulation training programs around clinical quality 2013 goals include: -adding 2 analysts and a Meaningful Use project manager -centralizing data requests -managing increased quality reporting requirements from external agencies -launching the Data Center website 7

8 UPDATE: SERVICE EXCELLENCE Troy Williams, Jeff Critchfield, Kathryn Horner and Baljeet Sangha gave an update on Service Excellence Service Excellence is an SFDPH wide commitment and journey that is making a commitment to achieve service excellence through a partnership among front-line staff, providers, leadership and patients. Service Excellence has a basic infrastructure in place to provide support (Partners) coaching, guidance, and has tailored its themes to units with staff involvement Current projects include: A guest welcome package, patient experience rounds, medication side effects teaching, a patient ambassador project, patient way finding, improved elevator signage, a grievance review process to identify areas of patient dissatisfaction (rude, unprofessional conduct, dissatisfaction with care, appointment scheduling, and inappropriate billing), and a noise reduction at night initiative Also in process is the creation of a staff recognition program and a financial services project team. Challenges include: - Competing priorities within DPH - Lack of robust communication network that reaches front-line staff - Multiplicity of efforts within service excellence - UCSF/ SFGH Unique organization - Measuring our progress - Supporting managers in a meaningful way with the critical role they play in the service excellence initiative - Developing our current infrastructure to support the sustainability of our work Projects include: Behavioral Credo Implementation Service Excellence Physician Training LHH / COPC / SFGH Service Excellence Integration Dissemination and Education of HCAHPS & CG-CAHPS and other Service Excellence metrics (e.g. Concern Statements, Patient Experience Rounds etc.) Engage workforce Build upon patient, family, and community engagement ANNOUCEMENTS NEXT MEETING No announcements February 19, 2013, 10am to Noon, 2A6 8