Presentation Summary

Transcription

1 SAN FRANCISCO GENERAL HOSPITAL and TRAUMA CENTER ANNUAL REPORT Fiscal Year Presentation Summary SFGH Strategic Plan Update Environment of Care Report Approval Requested Provision of Care Policy Approval Requested Performance Improvement and Patient Safety Policy Approval Requested SFGH Rebuild 1

2 Our New Leaders Alice Chen, M.D. SFGH Chief Integration Officer Baljeet Sangha Chief Patient Experience Officer And Deputy Chief Operating Officer 2

3 3

4 Preparing for Tomorrow 4

5 Making Positive First Impressions Reinforcing Service Excellence Standards Make Positive First Impressions Treat Others as Guests Develop Service Recovery Communicate Effectively Create a Team Spirit Project a Positive Attitude Be Passionate about Excellence 5

6 SFDPH Service Excellence Committee Core Group Service Excellence Partners Patient Experience Work Group Workforce Experience Work Group Projects and Takeaways Way-finding for Patients Patient Experience Rounds Guest Welcome Package Medication Teaching Patient Ambassador Project Noise Reduction at Night Signage Workforce Forum Staff Recognition Program Goal: To attain 80% positive scores in inpatient (HCAHPS) and outpatient (CG-CAHPS) experience surveys by

7 CLINICAL QUALITY PERFORMANCE HIGHLIGHTS- SEPSIS Measure Benchmark Q Q Q Q Sepsis Bundle Compliance (Out of avg 30 cases/quarter. Higher = better) Source: chart review of confirmed cases of severe sepsis (exluding comfort care patients) TBD 13% 30% 30% 45% FY 11/12 Trendline Sepsis Mortality Rate (Out of avg 160 cases/quarter, Lower = better) Source: discharge diagnoses- includes suspected and confirmed cases of sepsis and septic shock TBD 19% 10% 18% 15% Goal: To reduce sepsis mortality by 15% annually. 7

8 8

9 Magnet Designation American Nurses Credentialing Center Certification which exemplifies: Quality Patient Care Nursing Excellence Innovations in Professional Nursing Practice 9

10 Magnet Accomplishments Nursing Shared Governance at system level National Database of Nursing Quality Indicators Charge RN Leadership Training Development of Nursing Professional Practice Model Next Steps Roll-out Professional Practice Model Conduct gap analysis Respond to 2012 NDNQI national results Improve Falls with Injury and Hospital Acquired Pressure Ulcer rates Develop peer review system Create structure for nursing evidencebased practices Goal: To Attain Magnet Designation by

11 Magnet Actions 2013 Integrate Service Councils into Shared Governance structure Roll-out Professional Practice Model Conduct gap analysis Respond to 2012 NDNQI national results Evaluate and develop nurse-sensitive indicators Develop peer review system Create structure for nursing research 11

12 What people are saying about Just Culture. I am so grateful the hospital is doing Just Culture. Its good for the staff, which means it will make the hospital safer for patients. Senior Med-Surg nurse Just culture builds trust. It feels good to be starting at a hospital that has made such a commitment. New RN hire at SFGH A Fair and Just Culture supports a learning culture that focuses on proactive management of system design and management of behavioral choices. The Three Behaviors Human Error Product of our current system design and behavioral choices Console At-Risk Behavior A choice: risk believed insignificant or justified Coach Reckless Behavior Conscious disregard of substantial and unjustified risk Discipline Leadership Systems design/maintenance Cultivate honest, fair feedback Consistent execution of just culture TRUST HUMANISTIC CARE Staff Behavioral choices informed by SFGH policies Engage in honest, fair feedback 12

13 AHRQ Culture of Safety Survey Goal: Implement a Fair and Just Culture program and attain a 15% overall improvement score in our Culture of Safety Survey scores by 2016 Going Forward Work with Human Resources to align policies with Fair and Just Culture Principles Establish a deeper dive curriculum for leaders to apply these principles. ( Spring 2013) 13

14 COMMUNITY WELLNESS PROGRAM Project of the San Francisco Department of Public Health at San Francisco General Hospital and Trauma Center 14

15 Year 1: Wellness Achievements Core Initiatives: Healing Moves/Active Living Healthy Food Environment Tobacco-Free Community Community Engagement Seasonal Festivals & Cultural Awareness. 15

16 BUILDING COMMUNITY TOGETHER It Gets Better 16

17 What is LEAN? A systematic approach of continuous improvement used for the identification and elimination of waste to provide the greatest value to the customer and staff Lean Pillars of Transformation Two Pillars Respect For People Continuous Improve- ment 17

18 The LEAN Approach Customer perspective defines value Leadership and staff improving care together Identify which process steps create value and which are waste (muda) Rapid Improvement Events (kaizen) Eliminate root causes of waste and promote continuous flow Optimize the use of available resources 18

19 Lean Video 19

20 to Adoption of Health IT SFGH has met Meaningful Use Stage 1 on INVISION 20

21 Electronic Charting Taking Hold Meaningful Use of INVISION/LCR at SFGH (Inpatients) Reporting date range 10/28/12 to 11/3/12 # Measure Target Current 1 Advance Directives Status Charted 50% 97.73% 2 CPOE Charted Med Order 30% 78.45% 3 Demographics Charted 50% % 5 Med Allergy List Charted 80% 93.67% 6 Med List Charted 80% 97.89% 7 Problem List Charted 80% 85.65% 8 Smoking Status Charted 50% 87.17% 9 Structured Lab Results 40% 72.97% 10 Vital Signs Charted 50% 62.17% 21

22 EMR What is Integration? SFDPH IDS Initiative Financial and clinical accountability for the health of a defined population of patients. Deliberate organization of patient care activities to facilitate appropriate delivery of services across the continuum of care. Whole > Σ parts Building Blocks of Integration LEAN HOSPITAL CARE ED CARE URGENT CARE SPECIALTY CARE MENTAL HEALTH SERVICE EXCELLENCE EMR PRIMARY CARE-PCMH FOUNDATION 22

23 Accomplishments Primary care initiatives included standardizing care for all DPH primary care behavioral health integration model primary care-based care management programs focused on high risk patients development of a strategic plan for DPH primary care (both SFGH based and COPC) Accomplishments Specialty care initiatives included expansion of ereferral, now includes 46 services: pediatric, adult, SFGH, LHH new Telehealth initiatives in dermatology and ophthalmology primary care-specialty care workgroups focused on communication and comanagement 23

24 Going Forward Data dashboards Timely, relevant, actionable Clinical, operational, financial Ensuring adequate PC capacity Hospital and ED transitions EMR integration LEAN/Coleman and Service Excellence Environment of Care Report Code Silver Policy and Training Implementation Building 5 Elevators Emergency Generator Replacement Project 24

25 Provision of Care Policy Updated demographics data General edits Update links to Appendices and Cross Reference documents. 25

26 Performance Improvement and Patient Safety Policy The Patient Concern Subcommittee is now part of our Service Excellence Committee, where patient concerns and grievances will be analyzed. Added Patient Safety Officer role and responsibilities, and the Patient Safety Plan. Delineated responsibilities of the Medical and Administrative Directors of Risk Management: 26