HEALTH COMMISSION. CITY AND COUNTY OF SAN FRANCISCO Gavin C. Newsom, Mayor Department of Public Health

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1 James M. Illig President Sonia E. Melara, MSW Vice President Edward A. Chow, M.D. HEALTH COMMISSION CITY AND COUNTY OF SAN FRANCISCO Gavin C. Newsom, Mayor Department of Public Health Margine A. Sako David J. Sanchez, Jr., Ph.D. Mitchell H. Katz, M.D. Director of Health Michele M. Seaton Executive Secretary Steven Tierney, Ed.D. TEL (415) FAX (415) Catherine M. Waters, R.N., Ph.D. Web Site: 1) CALL TO ORDER MINUTES JOINT CONFERENCE COMMITTEE FOR SAN FRANCISCO GENERAL HOSPITAL Tuesday, 3:00 p.m Potrero Avenue, Conference Room 2A6 San Francisco, CA Chow called the meeting to order at 3:05 p.m. Present: Absent: Staff: Edward Chow, MD, Chair James Illig Catherine Waters, RN, PhD (excused) Kosal Bo, Sue Carlisle, M.D., Jeff Critchfield, M.D., Sue Currin, Kathy Eng, Valerie Inouye, Sharon Kotabe, Pharm. D., John Luce, M.D., Anson Moon, Iman Nazeeri-Simmons, Gene O Connell, Marti Paschal, Dan Schwager, Barbara Walter and Troy Williams. 2) APPROVAL OF THE MINUTES OF THE JULY 8, 2008 SAN FRANCISCO GENERAL HOSPITAL JOINT CONFERENCE COMMITTEE MEETING Action Taken: The Committee approved the minutes of the July 8, 2008 San Francisco General Hospital Joint Conference Committee. 101 Grove Street San Francisco, CA

2 3) HOSPITAL ADMINISTRATOR S REPORT Gene O Connell, Hospital Administrator, presented her report. SFGH Rebuild Update An informational presentation was held before the Civic Design Review Committee of the San Francisco Arts Commission on July 21. On July 22, the Board of Supervisors approved an ordinance to place the $887.4 million hospital rebuild general obligation bond measure on the November 2008 ballot. An information presentation will be held before the Arts Commission on August 18. Design development user group meetings are in progress to review the space data sheets prepared by the various hospital departments. CMS Validation Survey The Center for Medicare & Medicaid Services (CMS) conducted a focused validation survey from July 7-10, 2008 at SFGH. The focus of the survey was to review a plan of correction submitted to the California Department of Public Health. The survey team consisted of two registered nurse surveyors and one physician surveyor. At the end of the survey, the CMS team indicated that they had minor findings related to hand hygiene, policy and procedures in the operating room, and proper documentation in the medical record. Overall the surveyors were very complimentary of the care delivered at SFGH and were highly impressed with the staff they interviewed. New Hires Frank Kuziel joined SFGH as Director of the Health Information Services effective July 14, Frank held a similar position at St. Vincent Regional Medical Center in Santa Fe, New Mexico, and is a Registered Health Information Administrator and Certified Coding Specialist. The San Francisco General Hospital Foundation recently announced the hiring of Mary Louise Casey as Director of Major Gifts. As a former Director of Development, Mary brings over 25 years of fundraising experience and has an extensive knowledge of annual funds, capital campaigns, planned giving and special events. Awards & Grants APA Family Support Services honored San Francisco General Hospital at its 21 st Anniversary Celebration Dinner on July 18. SFGH was recognized for its many years of support serving children and families. The San Francisco General Hospital Foundation has won a $1.15 million grant from the Avon Foundation to fund SFGH s breast cancer detection and treatment programs. The grant will fund upgrades to mammography equipment, augment funding for clinical trials and peer support programs for patients, and provide continued support to the Avon Comprehensive Breast Care Center. Since it opened four years ago, the center has performed 28,000 mammograms and 3,800 mobile breast screenings for women in poor communities, using a portable testing unit. Patient Flow Report for July 2008 Medical/Surgical Average Daily Census was 227.5, which is 8% over budgeted beds and 93% of physical capacity of the hospital. 16% of the Medical/Surgical days were lower level of care and 3% were decertified/non-reimbursed days. Page 2

3 Acute Psychiatry ADC for Psychiatry beds was 60.2, which is 72% of budget and 62% of physical capacity. Latest Utilization Review data from the Mental Health billing system, month of June, shows 79% nonacute days (20% lower level of care and 58% non-reimbursed). This data is based on discharges and does not include our 7L Forensic patients or days where the patients have not been discharged. 4A Skilled Nursing Unit ADC for our skilled nursing unit was 29.0, which is 4% over our budgeted beds and very close to 97% of physical capacity. San Francisco Behavior Health Center ADC for the San Francisco Behavior Health Center was 100.3, which is 5% below both our budgeted beds and our physical capacity. Quality Council Minutes The Quality Council minutes for June 2008 were attached to the report. Committee Comments/Follow Up Illig asked staff to bring clarifying information at the next meeting about why the percentage of administrative and denied days continues to increase. Ms. O Connell said that Liz Gray is preparing a placement report for the next meeting. The Committee agreed to reschedule the September San Francisco General Hospital Joint Conference Committee meeting to Wednesday, September 10, 3:30 p.m. 4) PATIENT CARE SERVICES REPORT Sue Currin, R.N., Chief Nursing Officer, presented the Patient Care Services Report. July RN Vacancy Rate Overall 2320 RN vacancy rate for areas reported is 8.55% SFGH Ratio Staffing Data: 07/01/08 to 07/30/08 SFGH was able to meet staffing ratios in all areas except in Psychiatry where there was one shift when the area was unable to cover breaks. Recruitment/Retention/Training/Professional Development RN Internship Program: New graduate RNs have been hired in the medical-surgical and critical care areas. The new graduate RNs will start in August and will participate in each of the training program scheduled to begin in late September to early October Recruitment: Candidates have been hired for training programs and additional open positions. At present, applications far exceed available positions. Retention/Professional Development: The first cohort of SFGH nurses in the USF Clinical Nurse Leader program will be completing the program in August The ten SFGH nurses in the program completed classes on August 6, and will be honored at pinning ceremony on August 12, 2008 at USF and awarded a Master s degree in Nursing. In addition, the group will participate in a Page 3

4 conference at USF titled, The Clinical Nurse Leader Program in California: Improving the Healthcare System. Betty and Gordon Moore Foundation - Bay Area Journey to Nursing Excellence Grant Program San Francisco General Hospital and Trauma Center has applied and received a $40,000 grant from the Betty and Gordon Moore Foundation - Bay Area Journey to Nursing Excellence Grant Program. This grant will allow the hospital to contract with an external consultant from the American Nurses Credentialing Center (ANCC). The ANCC consultant will provide assessment, guidance and educational services in support of our journey to nursing excellence and Magnet designation. Emergency Department (ED) Diversion Report - July 2008 The Emergency Department had a Diversion rate of 31% (197 hours) for the month of July Trauma Override comprised 4% (30 hours) of the diversion hours recorded. There was no significant change in the rate compared with the previous month s data. During Diversion, the ED held 329 admitted patients waiting for inpatient bed assignment (ICU-17, 4B/5R-128 Med/Surgical-184). During July 2008, the hospital was on Condition Yellow for 21% (131 hours). This is a 16% increase in Condition Yellow hours compared to the previous month. EMSA suspension hours were not available at the time this report was released. Psychiatric Emergency Services (PES) Diversion Report June 2008 PES had 484 patient encounters during June and 504 in July. PES admitted a total of 138 patients to SFGH inpatient psychiatric units in July 2008, which was up from 116 in June In July, a total of 366 patients were discharged from PES, with 36 to ADUs, 15 to other psychiatric hospitals and 315 to community/home. In July, PES was on Condition Yellow for a total of 1.7 hours, which was down from 2.65 hours in June. The average length of Condition Yellow decreased in the month of July to 1.70 hours from 2.65 hours in June. There was a decrease in Condition Red from June to July. PES was on Condition Red for hours during 18 episodes in July. The average length of Condition Red was 9.86 hours. In June, PES was on condition Red for hours during 16 episodes, averaging hours. The average length of stay in PES for the month of June was hours, which was a decrease from hours in June. 5) MEDICAL STAFF REPORT Jeff Critchfield, M.D., Chief of Staff, presented the Medical Staff Report. New Chief for the SFGH Neurosurgery: MEC approved the appointment of Dr. Geoffrey Manley as the Chief of the SFGH Neurosurgery Service. Dr. Manley is an Associate Professor in Residence of Neurological Surgery, co-director and Principal Investigator, Brain and Spinal Injury Center and Chief of Neurotrauma, SFGH. His specialty interests lie in the repair of injury to the central nervous system. Among Dr. Manley's research interests are investigations of brain oxygenation during hemorrhagic shock, the role of aquaporin water channels in cerebral water transport, direct measurement of oxygenation and metabolic, cellular, and Page 4

5 molecular responses in clinically relevant animal models of brain injury, and metabolic monitoring of severely injured patients during resuscitation and critical care. Cancer Awareness, Resources and Education (CARE), Theater Project This past week the CARE program sponsored a theater performance, The Attitude of Gratitude: Touched by Cancer. The project is an extension of the cancer support group based at SFGH. Many of the players in the show are SFGH patients. The Araceli Theater Project culminates in a multilingual performance (English/Spanish/Cantonese) and short documentary film that addresses specific themes related to a cancer diagnosis including: emotional responses to the disease, political views, interpersonal dynamics and interactions with the health care system. Hospital Rebuild User group meetings have resumed with participation by SFGH staff in the planning of details in each of the rooms Action Taken: The Committee approved the selection of Dr. Geoffrey Manley as the Chief of the SFGH Neurosurgery Service. 6) FINANCE REPORT Valerie Inouye, Chief Financial Officer, presented a finance report that outlined some of the challenges SFGH faces with respect to meeting its salary budget. If the hospital is to continue providing its current level of service, it will never be able to meet its salary budget. If we are mandated to meet it then services will need to be reduced. The Lewin report took away the myth that SFGH is overstaffed. Ms. O Connell said there would be a finance report every month. Committee Comments/Follow Up Chow asked staff to clearly delineate as the months go by the details of the budget challenges and the implications of all the different levels of services that are required. Illig is going to request a meeting with the Mayor s Office about SFGH s budget. 7) PUBLIC COMMENT 8) CLOSED SESSION: A) Public comments on all matters pertaining to the closed session None. B) Vote on whether to hold a closed session (San Francisco Administrative Code Section 67.11) Action Taken: The Committee voted to hold a closed session. The Committee went into closed session at 4:10 p.m. Present in the closed session were Chow, Illig, Kosal Bo, Medical Staff Services, Page 5

6 Sue Carlisle, M.D., Associate Dean, Jeff Critchfield, M.D., Chief of Medical Staff, Sue Currin, Chief Nursing Officer, Kathy Eng, Director, Health at Home, Sharon Kotabe, Pharm. D., Pharmacy Director, John Luce, M.D., Chief Medical Officer, Anson Moon, Senior Health Program Planner, Iman Nazeeri-Simmons, Associate Hospital Administrator, Gene O Connell, Executive Administrator, Marti Paschal, Director of Administrative Operations, Dan Schwager, Director of Medical Staff Services, Barbara Walter, Nursing Administration and Troy Williams, Director, Risk Management. C) Closed session pursuant to Evidence Code Sections 1157(a) and (b); ; Health and Safety Code Section 1461; and California Constitution, Article I, Section 1 APPROVAL OF CLOSED SESSION MINUTES OF JULY 8, 2008 Action Taken: The Committee approved the July 8, 2008 closed session minutes. CONSIDERATION OF CREDENTIALING MATTERS Action Taken: The Committee approved the Credentials Report. CONSIDERATION OF PEER REVIEW, QUALITY OF CARE, PERFORMANCE IMPROVEMENT D) Reconvene in Open Session The committee reconvened in open session at 4:35 p.m. 9) ADJOURNMENT 1. Possible report on action taken in closed session (Government Code Section (a)2 and San Francisco Administrative Code Section 67.12(b)(2).) 2. Vote to elect whether to disclose any or all discussions held in closed session (San Francisco Administrative Code Section 67.12(a).) Action Taken: The Committee voted not to disclose discussions held in closed session. The Committee adjourned the meeting in memory of Dr. Ellen Wolfe. The meeting was adjourned at 4:35 p.m. Michele M. Seaton Health Commission Executive Secretary Page 6