SAN FRANCISCO GENERAL HOSPITAL and TRAUMA CENTER

SAN FRANCISCO GENERAL HOSPITAL and TRAUMA CENTER 1 WHY IS SAN FRANCISCO GENERAL HOSPITAL IMPORTANT? and Trauma Center (SFGH) is a licensed general acute care hospital which is owned and operated by the City & County of San Francisco, Department of Public Health. SFGH provides a full complement of inpatient, outpatient, emergency, skilled nursing, diagnostic, mental health, and rehabilitation services for adults and children. SFGH is the only trauma center in the City and County of San Francisco, serving 1.5 million residents of San Francisco and northern San Mateo County. SFGH BY THE NUMBERS *415 budgeted beds *100,000 Patients Treated * of all inpatient care in San Francisco *1,340+ Babies Born (#1 reason for hospital stay) *53,000+ Emergency Visits *23,000+ Urgent Care visits *3,500+ Trauma Cases *30% of all ambulances come here *527,178 Outpatient Visits *Approximately 2,700 City and 1,300 UCSF employees is the Heart of the City. We save lives. We serve the City's community health needs. We fight diseases. We teach new doctors and nurses. We lead new health care innovation. We serve you in times of emergency. is where miracles happen. If you're severely injured, you'll be cared for at our world-class trauma center (Level 1) where staff is ready 24/7 to deliver the comprehensive treatment you need to stay alive. is a key provider for Healthy San Francisco, the City's innovative program to provide uninsured residents with access to affordable, quality health care. San Francisco General is a teaching hospital. We partner with UCSF to train doctors and other health professionals. Our hospital is home to 20 research centers and labs that benefit patients worldwide. US News & World Report ranks UCSF 4th best in research training and 5th best in primary care-the only medical school to rank in the top five in both categories. San Francisco General is on the frontline in the battle against rapidly spreading disease, and it's where you and your family will be treated if you are injured in a major disaster. San Francisco General is building a great facility to provide even better care for generations to come. SFGH Unique Services & Innovative Programs Only Trauma Center in San Francisco: Lowers the risk of death by 20-25% compared to nontrauma centers Only Psychiatric Emergency Services in San Francisco: Shortened average PES length of stay from 24 to 23 hours and decreased the PES to inpatient admission rate from 30% to 26% Largest acute & rehabilitation hospital for psychiatric patients: Provides 60 of the 81 adult inpatient psychiatric beds in San Francisco Only Baby Friendly hospital in SF certified by the World Health Organization: An 85.3% in-hospital exclusive breastfeeding rate, one of the highest in California Stroke certification by The Joint Commission: success in delivering t-pa to patients presenting within the eligible time frame First ACE (Acute Care for Elders) geriatric inpatient unit in California: Reduced re-admissions for ACE patients from 10% to 6% e-referral system for specialty care that reduces waits and improves quality: Median wait times in medical specialty clinics were reduced 13% - 81%; surgical clinic wait times decreased by 10% - 41%. Orthopaedic Trauma Institute Surgical Training Facility: State-of-the-art teaching facility dedicated to innovative medical, health, and science workshops; trained 1,500 physicians & medical personnel in 2009 Video Medical Interpretation services in over 20 languages: Improved timely interpreter access from an average wait of 30 minutes to 3 minutes Award-winning outpatient diabetes care management program: 90% adherence to positive exercise & diet lifestyle changes after attending group classes

2 SAN FRANCISCO GENERAL HOSPITAL and TRAUMA CENTER FY 05-06 FY 06-07 FY 07-08 FY 08-09 Proj. 09-10 FYTD 09-10 Physical Beds 478 478 478 456 456 456 Budgeted Beds 409 409 429 415 415 415 Actual Days 154,487 160,225 160,804 151,234 149,034 99,220 ADC 422 439 439 414 408 408 Average Daily Census vs. Budgeted Beds 450 i i 440 VI 430 ::s ~ 420 ~ 410 ~ 8 400 s 390 e ~ 380 < 370 360 350 I I I FY 05-06 FY 06-07 FY 07-08 FY 08-09 Proj. 0~10 I_ADC-+-Budgeted Beds I

SAN FRANCISCO GENERAL HOSPITAL and TRAUMA CENTER 3 Average Length of Stay (excl. PSY, NUR, MHR, MRC and SNF) FY 05-06 FY 06-07 FY 07-08 FY 08-09 Proj.09-10 FYTD 09-10 Admissions 13,050 12,481 12,578 12,124 12,773 8,504 Actual Days 71,491 77,067 83,181 74,564 70,314 46,812 Discharges 13,032 12,419 12,379 11,991 12,846 8,552 Discharge Days 71,350 75,969 77,937 78,020 75,834 50,487 Average Length of Stays 5.47 6.12 6.30 6.51 5.90 5.90 Non-Acute Days 1,816 11,182 13,677 12,566 11,818 7,868 Percent Non-Acute 3% 15% 16% 17% 17% 17% Medical/Surgical (excl. Psych, SFBHC, Nursery and 4A SNF) Discharges vs. Average Length of Stay 14,000, i 7.0 ~ ~ co ~ (,) 1/1 is 13,000 12,000 11,000 6.5 ~ 6.0 8 5.5 10,000 I I 5.0 FY 05-06 FY 06-07 Proj.09-10 FY 07-08 FY 08-09 1_ Discharges -+-A-..erage Length of Stays 1

4 SFGH ACTUAL & PROJECTED DATA FY 05-06 FY 06-07 FY 07-08 FY 08-09 Proj.09-10 Total Operating Expenses $459,446,000 $518,807,000 $565,051,000 $584,158,000 $639,042,000 +13% +9% +3% +9% General Fund $ 91,485,000 $129,890,000 $135,137,000 $115,789,000 $122,079,000 Pct of Total Budget 25% 24% 19% Salaries & Fringe Benefits $262,820,000 $302,399,000 $327,662,000 $343,516,000 $362,426,000 Pct of Total Budget 57% 58% 58% 59% 57% Total Operating Expenses, General Fund and Salaries $700,000,000 $600,000,000 $500,000,000 $400,000,000 $300,000,000 $200,000,000 $100,000,000 $-... T,.. - - - - - FY05-06 FY06-07 FY07-08 FY08-09 Proj.09-10..A I ~ Total Operating Expenses ~ General Fund --.- Salaries I Admissions by Admitting Financial Class Groupings (excl. PSY, NUR, MHR, MRC and SNF) FY 05-06 FY 06-07 FY 07-08 FY 08-09 Medicare Medi-Cal Commercial Others Uninsured 2,298 2,337 2,402 2,328 3,914 3,779 3,877 3,729 455 464 483 535 1,488 1,438 1,654 1,635 4,895 4,463 4,162 3,897 Proj. 09-10 2,499 3,919 563 1,801 3,991 FYTD 09-10 1,664 2,609 375 1,199 2,657 Percent Admissions by Admitting Financial Class Groupings (excl. PSY, NUR, MHR, MRC and SNF) FY 05-06 FY 06-07 FY 07-08 FY 08-09 Proj. 09-10 FYTD 09-10 Medicare 18% 19% 19% 19% Medi-Cal 30% 30% 31% 31% 31% Commercial 3% 4% 4% 4% 4% Others 11% 12% 13% 13% 14% Uninsured 38% 36% 33% 32% 31% 31% 4% 14% 31%

5 SFGH ACTUAL & PROJECTED DATA Actual Actual Actual Actual Projection FY 05-06 FY 06-07 FY 07-08 FY 08-09 FY 09-10 Major Sources of Revenues Net Patient Revenues excl PY settlements 201,247,000 217,740,000 228,271,000 233,988,000 274,657,000 Prior Year Settlements 1,805,000 5,097,000 16,343,000 12,008,000 5,205,000 DSH &SNCP 71,277,000 72,969,000 68,51~,000 83,240,000 79,053,000 Health Care Coverage Initiative 0 0 8,237,000 19,254,000 21,000,000 HSF Enrollment Fees 0 0 0 20,908,000 21,536,000 Capitation/Mgd Care 17,413,000 20,721,000 25,640,000 26,722,000 30,817,000 Realignment 58,679,000 58,218,000 59,101,000 52,799,000 53,409,000 TOTAL 447,319,000 468,435,000 500,266,000 558,881,000 595,547,000 Source of Revenue Pending Approval AB 1383 Hospital Fee 8,000,000 32,000,000 566,881,000 627,547,000 Definitions AB 1383 Hospital Fee: Legislation authorizes the Department of Health Care Services to seek federal approval from the Centers for Medicare & Medicaid Services for the hospital fee proposal. The proceeds of a Hospital Quality Fee would be used to increase Medi-Cal payments, thereby drawing down federal matching payments. DSH: The Disproportionate Share Hospital Program is a special reimbursement program to supplement general Medi-Cal payments to hospitals that treat the greatest numbers of Medi-Cal and uninsured low-income patients. SNCP: The Safety Net Care Pool is a capped source of federal dollars created to assist in treating the large number of uninsured who use public hospital systems. HCCI: The Health Care Coverage Initiative is a three-year state program to expand health care coverage for eligible lowincome, uninsured individuals not otherwise covered by Medi-Cal. Realignment: Dedicated tax revenues from the sales tax and vehicle license fee to pay for the transfer of mental health, social services, and health programs from the state to county control.

6 SFGH DIVERSION DATA FY 05-06 FY 06-07 FY 07-08 FY08-09 PROJ.09-10 FYTD 09-10 ED Diversion Hours 1,841 1,662 2,463 2,008 2,315 1,541 Total Hours 8,760 8,760 8,784 8,760 8,760 5,832 Pet of Time on Diversion 21% 19% 28% 23% 26% 26% FY 05-06 FY 06-07 FY 07-08 FY08-09 PROJ.09-10 FYTD 09-10 Percent ED Admissions by Hours 12:01 a-6:0 16% 18% 18% 17% 18% 18% 6:01-noon 23% 21% 22% 22% 23% 23% 12:01-6p 33% 32% 33% 33% 31% 31% 6:01 p-mid 28% 28% 27% 27% 28% 28% Condition Red - SFGH Psych Emergency Services (PES) 90% ~ c: :8 70% :c c: o o 50% e o CIl E 30% i= '0 ~o 10% 0% ~ -:,'tj>~ ~ c< <01 l>«44.8%...:33.4o~.5.,~ )", \ "C <01. 3{)O% 28.4~.2% '."c/o.. ~?1 p'06/'?1,,",oz.. 23.9%..?.d..d.o/_ ~26.7% \,,< ~~ 19.0"/0 -m.0% '16.2% \J ~~o "'17 ~ ~6~4.8%17k ~11,,",~1.7% 20.3%.... TV!r.0% ~ ~ ~ ~ ~ ~'O ~'O ~'O ~'O ~'O ~'O ~~ r; > ~~ ~r; > ~~ ~~ ~o -:,-S- ~~ ~~ C:J'~ ~o~ -:,'tj>~ ~~ ~~ -:,-S- C:J'~ ~o~ -:,'tj>~ ~~ ~~ -:,.;j C:J'~ o~ l~ ~ ~0'tJ> 7/29/080~ 121151080J 3118I09tre 7/4109Duel opensm- opensm-f CrisisResidenti IBedsopenopens24- Day/Evening 24 hours

7 HSF HEALTH CARE UTILIZATION 52,034 participants enrolled-87% of the estimated 60,000 uninsured adults in San Francisco As of April 9, 2010, SFGH's General Medicine Clinic is the medical home for 5% (2,601) of HSF participants and the Family Health Center is the medical home for 9% (4,683) of HSF participants. HSF clinical encounters: 82% for illness; 18% for preventive care eatthy San Francisco, ou,. H~JJtlJAe:rm ~m From April 2008-March 2009, 78% of HSF participants used primary care services, nearly 10% had at least one specialty care visit, 3% had an inpatient admission, and nearly 59% utilized prescription services During FY 2008-09, there were approximately 2,484 specialty care visits by HSF participants at SFGH First year data showed a 27% decrease in emergency department visits at SFGH among HSF participants Only 7.9% of emergency department visits by HSF participants were avoidable compared to 15% for Medi-Cal recipients Service utilization - SFGH FY 2007-08 FY 2008-09 Percent Change Hospital admissions per 1,000 43.09 25.88 - participants No. of hospital days per 1,000 157.89 104.33-34% participants Average length of stay - 3.66 4.03 10% hospitalization ED visits per 1,000 participants 216 157-27% Source: Healthy San Francisco Annual Report to the San Francisco Health Commission Year 2008-09), September 1,2009 (For Fiscal

8 PERFORMANCE IMPROVEMENTS Expanded ereferral, the electronic referral system for specialty care, into General Surgery and Health at Home Implemented escheduling for Ophthalmology patients to increase screening for diabetes and hypertensive patients Designated a psychiatric unit cohort for non-acute Psych patients to free beds for acute patients waiting in Psychiatric Emergency Services Initiated ED flow project utilizing industrial engineering principles for improving operational efficiencies with the ~oal of reducing ED diversion by 50% by November 2010 Expanding the redesign of the chronic care program by integrating mental health services into the General Medical Clinic and the Family Health Center Implementing processes to improve patient flow, including the Institute for Healthcare Improvement training of administrative staff. Utilizing IHI's Real-Time Demand Capacity methodology to improve patient flow between the OR, PACU and Med-Surg Wards Hospital Compare Core Measures (See attached performance graphs): - Pneumonia: vaccination, blood cultures, smoking cessation, antibiotics within 6 hours, antibiotic selection, flu vaccination - Acute Myocardial Infarction: aspirin at arrival, aspirin at discharge, ACEI or ARB, smoking cessation, beta blocker at discharge, PCI within 90 minutes of arrival, inpatient mortality - Heart Failure: discharge instructions, LVS evaluation, ACEI for LVSD, smoking cessation - Surgical Care Improvement Project.: antibiotic within 1 hour, appropriate antibiotic, antibiotic discontinued, CARD 2 Beta Blocker therapy Current Core Measure Improvement Focus: Improve performance on all pneumonia measures to 95% by July 30,2010. The action plans are attached.

Pneumonia 9 Performance Measures Pneumonia: 2 - Pneumococcal Vaccination (>age 65) Pneumonia: 3b - Blood Cultures - ED 10/06 1107 4/07 7/07 10/07 1108 4/08 7/08 10108 1109 4/09 7/09 10109 1110 4/10 7/10 - Pneumonia: Pneumococcal screen (>age 65) - 2 - Pneumococcal screen (>age 65): Targets Pneumonia: 4 - Smoking Cessation 10/06 1107 4/07 7/07 10/07 1108 4/08 7/08 10/08 1109 4/09 7/09 10/09 1110 4/10 7/10 - Pneumonia: Blood Cultures (before Abx) - 3b - Blood Cultures - ED: Targets Pneumonia: 5b - Antibiotics within 6 Hours 10/06 1107 4/07 7/07 10/07 1108 4/08 7/08 10/08 1109 4109 7109 10/09 1110 4/10 7/10 - Pneumonia: 4 - Smoking Cessation - 4 - Smoking Cessation: Targets 4/07 7/07 10/07 1/08 4/08 7/08 10/08 1109 4/09 7/09 10/09 1110 4/10 7/10 - Pneumonia: Antibiotics within 8 Hours - 5b - Antibiotics within 6 Hours: Targets

Pneumonia 10 Pneumonia: 6b - Antibiotic Selection - Non ICU Pneumonia: 7 - Influenza Vaccination Vaccine policy implemented 1/08 4/08 7108 10/08 1/09 4/09 7109 10109 1110 4/10 10/06 1107 4107 7107 10/07 1108 4/08 7108 10/08 1109 4/09 7109 10/09 1110 4/10 7/10 - Pneumonia: 6 - Antibiotic Selection -Targets - Pneumonia: Influenza Vaccination - 7 - Influenza Vaccination: Targets

AMI 11 Performance Measures AMI: I - Aspirin at Arrival AMI: 2 - Aspirin at Discharge..< ---------- /7 ---------- 10106 1/07 4/07 7/07 10107 1108 4/08 7/08 10108 1109 4/09 7109 10109 1110 4/10 7/10 10106 1107 4/07 7/07 10107 1108 4108 7/08 10108 1109 4/09 7/09 10109 1110 4/10 7/10 - AMI: Aspirin at Arrival -Targets AMI: 3 - ACEI or ARB for LVSD - AMI: Aspirin at DIC - 2 - Aspirin at Discharge: Targets AMI: 4 - Adult Smoking Cessation 10106 1107 4/07 7/07 10107 1108 4/08 7/08 10108 1109 4/09 7/09 10109 1110 4/10 7/10 - AMI: ACEI for LVSD - 3 - ACEI or ARB for LVSD: Targets 10106 1107 4/07 7/07 10107 1108 4/08 7/08 10108 1109 4/09 7/09 10109 1110 4/10 7/10 - AMI: Adult Smoking Cessation - 4 - Adult Smoking Cessation: Targets

AMI 12 AMI: 5 - Beta Blocker at D/C AMI: 8 - PCI Within 90 Minutes of Arrival ~ -~/ 10/06 1/07 4/07 7/07 10/07 1/08 4/08 7/08 10/08 1/09 4/09 7/09 10109 1110 4/10 7/10 - AMI: Beta Blocker at DIG - 5 - Beta Blocker at DIG: Targets AMI: 9 - Inpatient Mortality 10/06 1/07 4/07 7/07 10/07 1/08 4/08 7108 10/08 1/09 4/09 7/09 10/09 1/10 4/10 7/10 - AMI: PGI Within 90 Minutes of Arrival - 8 - PGI Within 90 Minutes of Arrival: Targets 10/06 1107 4/07 7/07 10/07 1108 4/08 7/08 10/08 1/09 4/09 7/09 10/09 1110 4/10 7/10 - AMI: Inpatient Mortality - 9 - Inpatient Mortality: Targets

Heart Failure 13 Performance Measures Heart Failure: 1 - Discharge Instructions include all required elements New Hospital DIC Instructions New Cardiac DIC Instructi ns ~---+----'::-"'" Heart Failure: 2 - Evaluation of LVS Function ------------------------------------------------ 10/06 1107 4/07 7/07 10/07 1108 4/08 7/08 10/08 1109 4/09 7/09 10/09 1110 4/10 7/10 10/06 1107 4/07 7/07 10/07 1108 4/08 7/08 10/08 1109 4/09 7/09 10/09 1110 4/10 7/10 - Heart Failure: Discharge Instructions - 1 - Target: National Average --- ~~----------- Heart Failure: 3 - ACEI for LVSD - Heart Failure: Evaluation of LVS Function - National Average Heart Failure: 4 - Adult Smoking Cessation Advice/Counceling 10/06 1107 4/07 7/07 10/07 1/08 4/08 7/08 10/08 1109 4/09 7/09 10/09 1110 4/10 7/10 - Heart Failure: ACEI for LVSD - National Average 10/06 1107 4/07 7/07 10/07 1108 4/08 7/08 10/08 1109 4/09 7/09 10/09 1110 4/10 7/10 - Heart Failure: 4 - Adult Smoking Cessation - 4 - Adult Smoking Cessation: Targets

Surgical Care Improvement Project 14 Performance Measures Surgical Care Improvement Project: 1 Antibiotic within 1 hour of incision - Surgical Care Improvement Project: 2 Appropriate antibiotic selection 10/06 1107 4/07 7/07 10107 1108 4/08 7/08 10/08 1109 4/09 7/09 10/09 1110 4/10 7/10 10106 1107 4/07 7/07 10/07 1108 4/08 7/08 10/08 1109 4/09 7/09 10/09 1110 4/10 7/10 - Surgical Care Improvement Project: 2 - - 2 - National rate Antibiotic within 1 hour of incision Surgical Care Improvement Project: Antibiotic discontinued within 24 hours - Surgical Care Improvement Project: - National rate Appropriate antibiotic selection Surgical Care Improvement Project: CARD 2 Beta Blocker therapy for patients on BB Clinical Lead Assigned 10/06 1107 4/07 7/07 10/07 1108 4/08 7108 10/08 1109 4/09 7/09 10/09 1110 4/10 7/10 10106 1107 4/07 7/07 10/07 1108 4/08 7/08 10/08 1109 4/09 7/09 10/09 1110 4/10 7/10 - Surgical Care Improvement Project: 1 - - National Rate - Surgical Care Improvement Project: 3 - Beta - National rate Antibiotic discontinued within 24 hours Blocker therapy

Surgical Care Improvement Project 15 Surgical Care Improvement Project: 6 Appropriate Hair removal ~-=========:::::---====-=--=-==~~- Surgical Care Improvement Project: VTE 1 VTE Prophylaxis ordered 10106 1/07 4/07 7107 10107 1108 4/08 7108 10108 1109 4/09 7109 10109 1110 4/10 7/10 - Surgical Care Improvement Project: 4 - Hair - National rate removal Surgical Care Improvement Project: VTE 2 VTE given 10106 1107 4/07 7/07 10107 1108 4/08 7108 10108 1109 4/09 7109 10109 1110 4/10 7/10 - Surgical Care Improvement Project: 7 - VTE - National rate Prophylaxis ordered 10106 1107 4/07 7107 10107 1108 4/08 7108 10108 1109 4/09 7/09 10109 1110 4/10 7/10 - Surgical Care Improvement Project: 6 - VTE - National rate given

16 See attached Core Measure Performance Graphs - Data through Quarter 4 2009. Core Measure Performance is reported publicly at: WWW.HOSPITALCOMPARE.HHS.GOV CURRENT CORE MEASURE IMPROVEMENT FOCUS: PUBLIC HOSPITAL IMPROVEMENT COLLABORATIVE (2009/2010 Grant from California Health Care Foundation to assist public hospitals improve core measure performance). SFGH AIM: Improve performance on all Pneumonia (PN) measures to 95% by July 30,2010 FOCUS: Improvement of measures related to care provided in the Emergency Department MEASURE Blood Cultures in ED prior to Initial Antibiotic Initial Antibiotic Selection for CAP - ICU and Non ICU Initial Antibiotic Received within 6 HOIJrs of Arrival AIM 95% of PN patients who have blood cultures drawn in ED have documented date and time of specimen collection prior to first antibiotic dose. Data: 032009 77% 042009 75% 95% of eligible patients with community acquired pneumonia receive recommended antibiotic regimen. Data: 032009 67% 042009 95% of PN patients receive 1SI dose of antibiotics within 6 hours of hospital arrival. Data: 032009 74% 042009 89% Actions: ACTION ED Faculty will consider adopting standard PN order set requiring collection of Blood Cultures on all PN patients Future Process: ED Information System will store collection time (-1 year away) Actions: Involvement of Infectious Disease Physician and Antibiotic Pharmacist, providing physician education re: Antibiotic Regimens. Test use of sample PN order set to guide antibiotic ordering Instituted re-review of selected cases by Antibiotic Pharmacist to validate data collection Actions: Test strategies to "find pneumonia patients quicker": o Assess Triage accuracy ore-assess all patients in waiting room at established intervals. ED Flow Committee established to assess and improve patient through-put.