AGENDA. Introduction and Executive Leadership Year in Review Environment of Care Report and Policy Approvals

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2 AGENDA Introduction and Executive Leadership Year in Review Environment of Care Report and Policy Approvals

3 San Francisco General Hospital and Trauma Center Executive Leadership Roland Pickens, Interim Chief Executive Officer Brent Andrew, Chief Communications Officer Jenna Bilinski, Kaizen Promotion Office Director Max Bunuan, Associate Hospital Administrator for Facilities & Support Services Margaret Damiano, Associate Dean of Administration, UCSF Terry Dentoni, Chief Nursing Officer Karen Hill, Departmental Personnel Officer HR/SFGH Valerie Inouye, Chief Financial Officer Shermineh Jafarieh, Associate Hospital Administrator Aiyana Johnson, Associate Hospital Administrator / Chief Care Experience Officer Winona Mindolovich, Acting Associate Chief Information Officer Iman Nazeeri-Simmons, Chief Operating Officer Kimvan Nguyen, Director, Administrative Operations & Government Affairs Basil Price, Director of Security Terry Saltz, Rebuild Director Baljeet Sangha, Associate Hospital Administrator Troy Williams, Chief Quality Officer David Woods, Chief Pharmacy Officer Executive Medical Staff Leaders Sue Carlisle, M.D., UCSF Vice Dean Todd May, M.D., Chief Medical Officer James Marks, M.D., Chief of Medical Staff Jeff Critchfield, M.D., Medical Director, Care Experience and Risk Management Lukejohn Day, M.D., Chief Integration Officer William Huen, M.D., Associate Chief Medical Officer 3

4 A Year in Review Achieving excellence is an ongoing journey.

5 Mission The mission of the San Francisco General Hospital & Trauma Center is to provide quality health care and trauma services with compassion and respect. Vision Our vision is to be the best hospital by exceeding patient expectations and advancing community wellness in a patient-centered, healing environment. Values Learn by going to see Improve using Plan, Do, See, Act (PDSA) problem-solving Engage through teamwork and collaboration Care by showing respect and developing staff as leaders

6 True North

7 True North Category True North Metric Owner Goal Target FY1415 Safety Patient Harm Will Huen & Troy Williams By July 2016, reduce the annual number of harm events to 169 events Quality Care Experience Observed to expected Will Huen & Troy Williams mortality ratio 30-day readmission rate Measure of Patient Satisfaction By July 2016, reduce observed to expected mortality ratio to 0.80 Michelle Schneiderman By July 2016, reduce SFGH 30 day readmission by 10%. By July 2019, reduce SFGH 30 day readmission by 15% Jeff Critchfield & Aiyana Johnson By Q1 2017, improve HCAHPS Likely to recommend SFGH to friends from 60 to 80th percentile Access and Flow Terry Dentoni & Jim Marks By July 2016, reduce ED Patient Left without being seen (LWBS) rate from 8% to 6% Access and Flow Terry Dentoni & Jim Marks By July 2016, reduce ED Arrival to Departure Time or Patient Discharge Access and Flow Terry Dentoni & Jim Marks By July 2016, reduce ED Arrival to Departure Time or Patient Admission Develop People Staff Satisfaction Iman Nazeeri-Simmons By July 2016, train additional 200 staff and physicians in A3 problem-solving Financial Stewardship Developing Problem- Solvers Iman Nazeeri-Simmons By July 2016, 100% of executives have authored at least two A3's FY1415 Salary Budget Valerie Inouye By July 2016, meet labor & vs Actuals salary budget goals Length of Stay Will Huen Decrease inpatient length of stay to 6.2 days % 12% 80% 62% 6% 8% 210 mins 249 mins 360 mins 492 mins % 35% $320,780,334 $317,942,

8 Daily Management System It really strengthens our ability to improve. - Director of Surgical Services

9 Model Cells Operating Room Medical/Surgical Post-Anesthesia

10 Model Cell Improvement Work Model Cell OR PACU 5D Improvement Work Reduce average room turnover time by 25% by November, Reduce Pathology Specimen Slip Defects Reduce percent of peripheral IVs that have a defect to less than 15%. Baseline Current Goal 45 mins 38 mins 30 mins 20% 1.4% 0% 80% 10% 15%

11 Value Stream Improvement Work Outpatient Pharmacy Outpatient pharmacy has reduced the time to refill a prescription from over 2 hours to less than 30 minutes.

12 Cases/block Value Stream Improvement Work Surgical And Procedural Services Cataract Surgery Cases Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Month In May 2014, patients needing cataract surgery had a 300 day wait. Through improvement work, the number of patients receiving cataract surgery increased from 4 to 11 cases per block time.

13 FOR APPROVAL Environment of Care Report Performance Improvement and Patient Safety Program Provision of Patient Care

14 QUESTIONS?