Edward A. Chow, M.D. President James Loyce, Jr., M.S. Vice President Dan Bernal Commissioner Cecilia Chung Commissioner Laurie Green, M.D. Commissioner Tessie M. Guillermo Commissioner David.J. Sanchez, Jr., Ph.D. Commissioner HEALTH COMMISSION CITY AND COUNTY OF SAN FRANCISCO Mayor Breed Department of Public Health Barbara A. Garcia, M.P.A. Director of Health Mark Morewitz, M.S.W. Executive Secretary TEL (415) 554-2666 FAX (415) 554-2665 Web Site: http://www.sfdph.org MINUTES JOINT CONFERENCE COMMITTEE FOR ZUCKERBERG SAN FRANCISCO GENERAL HOSPITAL AND TRAUMA CENTER Tuesday, July 24, 2018 3:00 p.m. 1001 Potrero Avenue, Building 25, 7 th Floor Conference Room H7124, H7125 and H7126 San Francisco, CA 94110 1) CALL TO ORDER Present: Excused: Staff: Commissioner Edward A. Chow, M.D., Chair Commissioner Laurie Green, M.D. Commissioner David J. Sanchez, Jr., Ph.D. Susan Ehrlich MD, Sue Carlisle MD, Alice Chen MD, Terry Dentoni, Troy Williams, Todd May, Jim Marks MD, Terry Johnson, Jeff Critchfield, Leslie Safier, William Huen MD, Basil Price, Claire Horton MD, Jennifer Boffi, Tosan Boyo, Virginia Dario Elizondo, Dan Schwager, Kim Nguyen 2) APPROVAL OF THE MINUTES OF THE JUNE 26, 2018 ZUCKERBERG FRANCISCO GENERAL JOINT CONFERENCE COMMITTEE MEETING Commissioner Comments: Commissioner Chow asked for clarification of the following statement mentioned on page 2, item 4: Commissioner Green asked how a potential decrease in diversion rates would impact ambulance flow and acute bed days. Dr. Marks stated that there is not a linear relationship between the diversion rate and the number of ambulances that arrive at ZSFG, especially since we do not divert trauma, STEMI, or stroke, but that generally it would be expected that reducing diversion would increase the number of ambulance arrivals and the number of patients admitted to acute beds. 1 P a g e
Dr. Marks submitted via email a corrected statement, which has been added to the final minutes: Commissioner Green asked how a potential decrease in diversion rates would impact ambulance flow and acute bed days. Dr. Marks stated that there is not a linear relationship between the diversion rate and the number of ambulances that arrive at ZSFG, especially since we do not divert trauma, STEMI, or stroke. He added that decreases in diversion could lead to making up to 45 acute beds available. Action Taken: The Committee unanimously approved the minutes. 3) REGULATORY AFFAIRS REPORT Troy Williams, Chief Quality Officer, presented the item. Commissioner Comments: Commissioner Chow asked for the location of the ZSFG urgent care services. Mr. Williams stated that the ZSFG urgent care services will be located in building 5 where the former emergency services were located. 4) QUALITY MEASURE UPDATE Leslie Safier, Director, Performance Improvement, presented the item. Commissioner Comments: Commissioner Chow noted that the report shows that several items are in red, indicating that these goals have not been met. He asked how these scores compare to the prior year. Ms. Safier stated that there is variability in these measures. She noted that for some measures, the number of cases is very small so one case can skew the data. Commissioner Green asked how the ZSFG handles a request from a new mother to both breast and bottle feed. She noted that it is important to educate mothers to make choices based on the understanding that either bottle or breastfeeding is not exclusionary of the other option. Dr. Chen, San Francisco Health Network Medical Officer, stated that the scores do not reflect the amount of discussion and reflection from ZSFG staff on this issue. Dr. Ehrlich stated that the ZSFG paradigm is that it is a woman s choice. She added that under the PRIME pay for performance program ZSFG must make certain metrics on this issue in order to receive revenue. Commissioner Chow asked for more information regarding the Emergency Department measures. Dr. Ehrlich stated that the Emergency Department census is usually higher in winter. The volume for this unit is increasing 7% per year. Commissioner Chow requested that the graph should show the previous year s data. 5) TRUE NORTH SCORECARD Brent Costa, Strategic Planning Manager, presented the item. Commissioner Comments: Commissioner Chow asked for more information regarding the EHR measure. Dr. Ehrlich stated that the next milestones are adoption-setting sessions in August and September. 2 P a g e
Commissioner Chow asked if the salary variance is expected to change since it is a new fiscal year. Dr. Ehrlich stated that the new ZSFG budget should better reflect adequate staffing for the hospital s higher volume of patients. Commissioner Green asked if there is a correlation between ZSFG readmission and diversion rates. Dr. Ehrlich stated that there is little variation in readmission rates but the diversion rates vary considerably so she does not think there is a significant relationship. 6) HOSPITAL ADMINISTRATOR S REPORT Susan Ehrlich M.D., Chief Executive Officer, presented the item. LIKELIHOOD TO RECOMMEND PATIENT SATISFACTION SCORES ZSFG s Likelihood to Recommend Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Scores Likelihood to recommend (LTR) is one of the best measures for comparing one hospital to another and is a leading indicator of patient satisfaction. ZSFG s May 2018 LTR HCAHPS score was 81%, above our target of 80%. Since January 2018, we have seen our LTR score trend upward. We attribute this to the realignment of departmental CEX improvement activities to ZSFG s operational priorities, e.g. Patient Flow (inpatient) and Access (specialty care) and leveraging the daily management system (DMS) rollout to engage departments and sustain improvements. In addition to seeing an upward trend of LTR scores, we are equally excited for the transition of our HCAHPS patient satisfaction survey vendor from NRC Health to Press Ganey. Press Ganey is one of the nation s leading provider of patient satisfaction surveys, and will provide ZSFG with tools to diversify our survey methodology (by adding electronic internet surveying capabilities), enable real-time patient feedback, and increase patient response rates. Go live for Press Ganey is scheduled for October 2018. We look forward to our partnering with Press Ganey to compare our performance, look for opportunities to do better and deliver a positive, consistent experience for our patients across the continuum of care. NEW DIRECTOR AT CENTER FOR VULNERABLE POPULATIONS, MARGOT KUSHEL, MD Margot Kushel, MD has been announced as the new Director of the UCSF Center for Vulnerable Populations (CVP) at Zuckerberg San Francisco General and Trauma Center (ZSFG). Dr. Kushel is a Professor of Medicine at the University of California San Francisco in the Division of General Internal Medicine at Zuckerberg San Francisco General Hospital. She is a core faculty member of UCSF s Center for Vulnerable Populations and a faculty affiliate of the Philip R. Lee Institute for Health Policy Studies. Dr. Kushel's research focuses on the causes and consequences of homelessness and housing instability, with the goal of preventing and ending homelessness and ameliorating the effects of homelessness on health. Dr. Kushel s research seeks to inform clinical practice, programs, and policies. She is currently principal investigator on multiple large research grants. Dr. Kushel is evaluating several county-wide initiatives to alleviate chronic homelessness. She maintains an active clinical practice at the Richard H. Fine People s Clinic at Zuckerberg San Francisco General Hospital and attends on the inpatient medicine service. She is a frequent speaker at the local, 3 P a g e
state, and national level about issues of homelessness and its relationship to health and healthcare. Dr. Kushel obtained her AB from Harvard University and her MD from Yale School of Medicine. She completed her residency at the UCSF/SFGH Primary Care Internal Medicine program, chief residency at SFGH, and her fellowship in General Internal Medicine at UCSF/SFGH. MEDICAL STAFF DINNER On Wednesday, June 27, approximately 150 ZSFG staff attended the Annual Medical Staff Dinner. Highlights of the event included distribution of the Krevans awards to each Department's outstanding Resident leaders, as well as the Rapaport Award to Chief of Pediatrics Elena Fuentes- Afflick, MD for her outstanding career contributions and leadership to ZSFG. There was also a 'changing of the guard', as outgoing Chief of Staff Jim Marks, MD handed the gavel to incoming Chief of Staff Claire Horton, MD. Chef Michael Jenkins and his team prepared and served a delicious meal for the participants. Director Barbara Garcia presented an award to.and President of the Health Commission Edward Chow, MD provided a status update of the Department of Public Health and expressed their gratitude for the great accomplishments of the ZSFG Medical Staff. KAIZEN PROMOTION OFFICE FELLOWS FOR 2018 Bridgette Hargarten, Nurse Manager, is participating as a Kaizen Promotion Office (KPO) Fellow this year. Immersed in Lean Management principles as a KPO Fellow, Bridgette has been providing coaching in A3 Thinking for the ZSFG Emergency Department (ED), Psychiatry and Medical Surgical units, primarily focusing on Staffing A3s to optimize nursing staff participation on interdisciplinary teams. Currently, she is assisting with the roll out of the Daily Management System in the Emergency Department, and is collaborating with the ED nurse leaders and providers to implement CARE START, an initiative to determine appropriate placement of patients between the ED and Urgent Care Clinic. Dr. Hemal Kanzaria, Assistant Professor of Clinical Emergency Medicine, is also participating as a KPO Fellow this year. Dr. Kanzaria is a certified lean leader, and his work has focused on the social determinants of health in the ED. He has co-led the creation of a new interdisciplinary social consult service that has been incredibly successful in preventing short and non-acute stays to the hospital, instead providing patients with services that allow them to stay in the community. Dr. Kanzaria also works with the SFDPH Whole Person Care project, and serves as the Director of Complex Care Analytics for the SFHN. 4 P a g e
PATIENT FLOW REPORT FOR JUNE 2018 Attached please find a series of charts depicting changes in the average daily census. Medical/Surgical Average Daily Census was 228.43 which is 113% of budgeted staffed beds level and 91% of physical capacity of the hospital. 18.34% of the Medical/Surgical days were lower level of care days: 7.03% administrative and 11.31% decertified/non-reimbursed days. Acute Psychiatry Average Daily Census for Psychiatry beds, excluding 7L, was 42.53, which is 96.7% of budgeted staffed beds and 63.5% of physical capacity (7A, 7B, 7C). Average Daily Census for 7L was 4.9, which is 70% of budgeted staffed beds (n=7) and 40.8% of physical capacity (n=12). Latest Utilization Review data from the INVISION System shows 77.19% non-acute days (62.07% lower level of care and 15.13% non-reimbursed). 4A Skilled Nursing Unit ADC for our skilled nursing unit was 29.07, which is 103.8% of our budgeted staffed beds and 96.89% of physical capacity. Salary Variance to Budget by Pay Period Report for Fiscal Year 2017-2018 For Pay Period ending June 15, 2018, Zuckerberg San Francisco General recorded 4.49% variance between Actual and Budgeted salary cost actuals were $659,897 over budget. For variance to budget year-to-date, ZSFG has a negative variance of $12,921,215 / 3.6% 5 P a g e
Average Daily Census Average Daily Census Medical/Surgical 260 250 240 230 220 210 200 190 180 170 160 150 140 130 120 110 100 90 80 70 60 50 40 30 20 10 0 FY 2011-2014 FY 2017-2018 Decert Days Admin Days Acute Days Medical/Surgical 260 250 FY 2011-2014 240 230 220 210 200 190 FY 2017-2018 180 170 160 150 FY 2013-2014 FY 2014-2015 FY 2015-2016 FY 2016-2017 FY 2017-2018 6 P a g e
Average Daily Census Average Daily Census 65 60 55 FY 2011-2014 Acute Psychiatry Average Daily Census Includes Units 7B, 7C Excludes 7L 50 45 40 FY 2016-2017 35 30 25 20 15 10 5 0 Admin ADC Decert ADC Acu te ADC 80 70 FY 2011-2014 Acute Psychiatry Average Daily Census Includes Units 7B, 7C Excludes 7L 60 50 40 30 20 10 FY 2017-2018 0 FY 2013-2014 FY 2014-2015 FY 2015-2016 FY 2016-2017 FY 2017-2018 7 P a g e
Average Daily Census Average Daily Census 30 4A Skilled Nursing 25 20 15 10 5 0 Ave rage Bed Holds Skilled Nursing Days 4A Skilled Nursing 40 35 30 25 20 15 10 5 0 FY 2013-2014 FY 2014-2015 FY 2015-2016 FY 2016-2017 FY 2017-2018 8 P a g e
Commissioner Comments: Commissioner Chow thanked Dr. Ehrlich for the report and noted that the Rappaport Award recipient was left out of the report. Ms. Nguyen stated that the awardee was Elena Fuentes-Afflick MD, Chief of Pediatrics. 7) PATIENT CARE SERVICE REPORT Terry Dentoni, Chief Nursing Officer, presented the item. Professional Nursing for the Month of June 2018 Bridgette Hargarten, Nurse Manager, is participating as a Kaizen Promotion Office (KPO) Fellow this year. Immersed in Lean Management principles as a KPO Fellow, Bridgette has been providing coaching in A3 Thinking for the ZSFG Emergency Department (ED), Psychiatry and Medical Surgical units, primarily focusing on Staffing A3s to optimize nursing staff participation on interdisciplinary teams. Currently, she is assisting with the roll out of the Daily Management System in the Emergency Department, and is collaborating with the ED nurse leaders and providers to implement CARE START, an initiative to determine appropriate placement of patients between the ED and Urgent Care Clinic. 9
Emergency Department (ED) Data for the Month of June 2018 June 2018 Diversion Rate: 53% ED Diversion 298 hours (41%) + Trauma Override 84 hours (12%) Total ED Encounters: 6707 ED Admissions: 1067 ED Admission Rate: 15.91% 10
Psychiatric Emergency Service (PES) Data for the Month of June 2018 Overview: On February 1, PES in collaboration with the Progress Foundation initiated a Pilot for Diversion of ADU Candidates from PES to DUCC. Our data suggests that the test has been successful. In June, PES completed 662 patient encounters. The Condition Red/Diversion rate decreased this month, from 12.2% in May to 10.2% in June. The median length of stay increased this month, going from 12 hours in May to 14.5 hours in June. The Leadership Team opted to disclose the median values because they may be less sensitive to the effects of outliers with protracted stays. As a result, PES was more accessible and accepted 93% of all appropriate transfer requests from other hospitals for emergency psychiatric assessments in the month of June. 11
Psychiatric Emergency Service (PES) Data for the Month of June 2018 continued 12
Psychiatric Emergency Service (PES) Data for the Month of June 2018 continued 13
Request for Inter-Facility Transfer to PES from other Hospitals A priority of PES is to improve the timeliness and appropriateness of inter-facility transfers from referring hospitals. The following three types of PES referrals have been observed: Accepted and Arrived, Accepted and Cancelled, and Inappropriate Referral. Accepted and Arrived Referrals refer to patients that have been approved by PES for admission and are transferred and admitted to PES. The transfer of these patients has been authorized by PES based on EMTALA regulations as well as the communication of clinical condition between the sending and the receiving physicians. Screened Appropriate but Cancelled Prior to Acceptance refers to patients that have been screened by a triage nurse and have preliminary approval, but the paperwork has not been reviewed by a physician. Their transfer was then cancelled by the referring facility. This cancellation could be because the referring hospital has decided to place the patient on their own psychiatric unit or because the patient has cleared psychiatrically and the 5150 hold has been dropped. Inappropriate Referrals refer to patients identified through the PES screening process to be inappropriate for transfer and admission to PES for evaluation and disposition. Common reasons for PES to decline transfer of a patient from a referring hospital are medical status (not medically stable for transfer) and insurance status (e.g., private insurance or out of county Medi-Cal). Commissioner Comments: Commissioner Chow asked for more information on the KPO Fellowship. Ms. Dentoni stated that the fellowship is for middle-management level staff and lasts for 18 months. 8) ZSFG RN HIRING AND VACANCY REPORT Terry Johnson, ZSFG Human Resources, presented the item. Commissioner Comments: Commissioner Green noted that when the CPMC campuses close, there will be opportunity to hire experienced nurses. Commissioner Chow requested a graph to show Human Resource trends. 9) MEDICAL STAFF REPORT Claire Horton, M.D., Chief of Medical Staff, presented the item. Commissioner Comments: Commissioner Chow noted that the lower level of care data shows a decrease from 18% to 11%. Dr. Ehrlich stated that ZSFG has worked hard towards reducing the number of lower level of care patients so they can be placed in the most appropriate level of care. Mr. Pickens noted that efforts are being made throughout the San Francisco Health Network to help patient flow. 14
Action Taken: The following items were unanimously approved: Interim Service Chief of ZSFG Psychiatry Clinical Service Clinical Service Rules and Regulations for MRI Screening 10) OTHER BUSINESS This item was not discussed. 11) PUBLIC COMMENT There was no public comment. 12) CLOSED SESSION A) Public comments on All Matters Pertaining to the Closed Session B) Vote on whether to hold a Closed Session (San Francisco Administrative Code Section 67.11) C) Closed Session Pursuant to Evidence Code Sections 1156, 1156.1, 1157, 1157.5 and 1157.6: Health and Safety Code Section 1461; and California Constitution, Article I, Section 1. CONSIDERATION OF CREDENTIALING MATTERS CONSIDERATION OF PERFORMANCE IMPROVEMENT AND PATIENT SAFETY REPORT AND PEER REVIEWS RECONVENE IN OPEN SESSION Action Taken: 1. Possible report on action taken in closed session (Government Code Section 54957.1(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).) 13) ADJOURNMENT The meeting was adjourned at 4:41pm. The Committee approved July 2018 Credentialing Report and Performance Improvement and Patient Safety Report. The Committee voted not to disclose other discussions held in closed session. 15