JCC

Report

March 27, 2012

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Contents

State of the Hospital 1CensusWait ListBudget and FinanceStaffing

Initiatives and Milestones 2Resident Success

Community IntegrationDischarge HouseholdOmbudsman In-Service

Innovative PracticesWebmedxCoumadin ProtocolDiet ChoicesMFAC AwardsMobile Compuer LabAdmin Mixer

Healing EnvironmentCustomer Service Initiative

Community PartnershipsAlzheimer’s Training FilmNAPHMass Prophylaxis DrillIntegrated Delivery SystemCity Hall FellowsArt for ResidentsSound Abatement

Events, Awards and Honors 7Cultural CelebrationsNational Nutrition MonthEmployees of the Month

AttachmentsCommunity Integraton PowerpointFact Sheet on Sound Mitigation Actions

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State of the Hospital

Census Report

Average Daily Census for 1/19/2012 to 3/19/2012: SNF Occupied

Beds Held

Total SNF Acute Census

Total Daily Census

Total Paid Beds

Percent Occupancy

738.89 9.39 748.28 5.98 747.05 756.44 98%

Wait List Report

Average wait time from12/13/11-3/13/12 was 9.28 days. Average wait time from 7/1/11-3/13/12 was 13.38 days. As of 3/13/12, there were 17 people on the waiting list.

Budget and Finance

Financial Report

The hospital will request an $18 million supplemental appropriation of general fund revenue for operations in the current fiscal year. The request is based on the financial projection for the 2nd quarter which anticipates a need for $5.7 million to cover a shortfall caused primarily by state action to reduce the Medi-Cal per diem rates for skilled nursing facilities. The rate reduction is currently the subject of litigation. The remaining $12.3 million in the supplemental request would fund an expected deficit due to unmet structural needs in the budget.

Transition Budget

There has been no major change in the transition budget since the last JCC meeting in January. The $10 million budget is 74% spent. The remaining budget balance will fund facilities maintenance contracts until the remodel work of the administrative building has completed. Our projection is that the budget is sufficient and will be fully spent.

Gift Fund Report

There is no update to the quarterly Gift Fund report since the last JCC meeting in January. The next quarterly report, for the period ending March 31, 2012, will be available for the JCC meeting in May.

Staffing Report

We invite commissioners to join us in welcoming interim Chief Nursing Officer Madonna Valen-cia to her new position. Donna replaces Debbie Tam, who served as interim CNO for three years, and guided the nursing staff through the transition to the new hospital. Donna is a former Laguna

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Honda nursing operations director, nurse manager and quality management nurse. The hospital executive and nursing staffs are pleased to have her at the nursing helm.

We also are grateful for the leadership and vision of Debbie Tam, who took on the job of CNO at a critical moment for the organization and provided stability and experience to move us forward. Debbie will now serve as bed control coordinator.

Bidding took place in two staffing categories in February and March to support the hospital’s goal of consistent staff-to-resident assignments. Vacant nursing positions were filled via a bid process and all of the hospital’s home health aides (100%) participated in their first hospital-wide bid, further integrating them into the delivery of care. Nursing staff whose assignments float from neighborhood to neighborhood now operate out of a designated neighborhood and float only to other neighbor-hoods within a specific nursing program. The system provides staff who float with a consistent point of contact for updated information about care practices and employee policies, and assignment to a program helps to build clinical competencies. The system also strengthens staff engagement and supports consistent assignments of staff to residents.

Laguna Honda staff reached a 99.6% performance appraisal completion rate, far exceeding the 95% goal. Congratulations for this high rate go to both managers and the employees they supervise for taking on the challenge of examining work performance and committing to quality improvements for the following year.

The hospital’s employee vacancy rate is 7%. As projected, the vacancy rate is higher than usual because the city is approving only clinical positions to capture vacancy savings to help narrow the budget gap.

Initiatives and Milestones

We have set four strategic goals to help establish and maintain excellence: resident success, innova-tive practices, community partnerships and a healing environment. Recent initiatives and milestones appear below as they relate to the strategic goals.

R e s i d e n t S u c c e s s

Community Reintegration Report

Social Services Director Janet Gillen will present a special status update on community reintegration efforts at the JCC meeting. A Powerpoint handout accompanying her presentation is attached to this report.

Discharge Household

The North 3 staff, supported by clinical leadership in all departments, began preparing this month to

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establish a household dedicated to residents who are preparing to be discharged.

The discharge household, which will open in July 2012, is intended to assist residents returning to community living with targeted resources and programming. The intention is for residents to gain momentum toward discharge by providing the opportunity for people making the transition to compare notes about resources, share ideas, and build a support network before their move.

Discharges will continue from all other neighborhoods as well, and residents will have the option to move to the North 3 discharge household to take advantage of intensive discharge-related programming provided by each clinical discipline.

Rehabilitation specialists will help residents develop daily routines to help make community re-entry successful. Full time rehab staff will be dedicated to the household. Pharmacists will assist residents to become experts in obtaining and administering their own medications. Physicians will begin to treat residents in the clinics rather than in the neighborhood to acustom them to the out-patient experience. Nursing staff will assist with training in self-medication and restorative aides will provide increased treatment.

Substance use treatment counselors will connect residents to community services. Social workers will continue to facilitate placement and mentoring. Activity therapists will pioneer a completely new approach. All diversional activities will take place off the neighborhood and will focus on skills building and development of attitudes, knowledge and self-esteem for life planning. Dietitians will provide education in meal planning and preparation.

Laguna Honda discharges have come predominantly from the Rehabilitation program and the Positive Care program. The discharge household is one initiative among several intended to support discharges from other skilled nursing neighborhoods. The discharge household will assist Laguna Honda to become a 5-star facility by 2014. Attaining the 5th star in the Centers for Medicare and Medicaid Services’ Nursing Home Compare report requires special attention to resident centered care, including making sure residents are at the right level of care whether here at the hospital or elsewhere in the community.

Ombudsman Provides Residents’ Rights In-Service

California Long Term Care Ombudsman Benson Nadell provided live in-service training to nurs-ing staff on residents’ rights in February. The materials for the course were designed by the Laguna Honda Quality Management Department. The course, which is required training, emphasized two pillars of resident-centered care: listen and respect.

I n n o v a t i v e P r a c t i c e s

Webmedx System

In another step toward electronic medical records, Laguna Honda implemented the Webmedx sys-

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tem in March. Physician progress notes are now dictated or typed and uploaded to the lifetime clini-cal record (LCR) enabling the record to reflect more integrated and up-to-the minute information on health status.

Pharmacy Introduces New Coumadin Protocol

As of March 1, Laguna Honda physicians have the option of ordering Coumadin via a protocol involv-ing clinical pharmacists, enabling improved management of this complicated medication. Pharma-cists consult with primary care providers as outlined in the protocol.

Recent research indicates that a pharmacist-run anticoagulation service can improve care and re-duce complications, hospitalizations, emergency room visits and overall costs. The hospital’s proto-col follows the most recent American College of Chest Providers (ACCP) guidelines recommending a systematic process to manage oral anticoagulation dosing that includes a knowledgeable provider, an organized system of follow-up, and clearly outlined procedures for dose adjustment and blood draw intervals. The protocol also frees physicians to attend to other patient-care responsibilities.

Diet Choices Expanded

Seventy-five residents are participating in a new resident-centered Nutrition Services program that allows them to select meal choices from a menu for the next day.

The menus are sent to residents after they confer with their dietitian. Residents can choose entrees, side dishes and beverages for three meals a day from a selection of options for each meal. Menus are distributed with breakfast and are submitted by 2:00 pm. When the diet office doesn’t receive a selection by the daily deadline, the next day’s menu defaults to the resident’s previously indicated preferences.

Staff Recognized at the MFAC Good Government Awards

Laguna Honda staff members were recognized in February at the 32nd Annual Municipal Fiscal Advisory Committee Good Government Awards for their innovative work in the largest hospital move in California history. We invite commissioners to join us in congratulating awardees David Woods, Debbie Tam, Regina Gomez and Willie Ramirez for their creativity and leadership in helping us make a smooth transition.

Mobile Computer Lab

The Information Systems team and Clinical Informatics staff deployed a mobile computer lab in February to bring classes about entering vital signs, heights and weights into the electronic record directly onto the resident neighborhoods so that staff members could get hands-on experience without time away.

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The mobile lab contains a projector and six laptops on a mini med cart. It allowed informatics trainers to conduct 6-8 weekly classes. When all neighborhood staff members have the training under their belt, the documentation of vital signs, heights and weights will go electronic.

Administration Quarterly Mixer

Hospital staff and residents gathered March 2 at the hospital café for the quarterly Administration Mixer. As part of our strategic goal for innovative excellence, the Administration team committed to providing a welcoming and healing environment in the administration office and to hosting a quarterly get-together to foster informal communication among administration, staff, residents, family members, visitors and others. The mixer was the second one of the fiscal year, and provided an opportunity to foster community, build relationships, and discuss issues in an informal setting.

H e a l i n g E n v i r o n m e n t

Customer Service

The hospital’s suggestion box project, initiated by a resident and managed by the administrative operation staff, has resulted in a number of important improvements to campus life.

Facilities Services staff increased the availability of disabled parking in front of the Pavilion thanks to one suggestion. The Vocational Rehabilitation program now offers classes in English as a second language thanks to another suggestion. Rehabilitation staff has made courtesy wheelchairs available for visitors in the Pavilion lobby.

Facilities Services installed wall hooks in the bathrooms on the esplanade for hanging jackets and purses. Facilities and Nutrition Services staff installed a microwave in the hospital café, and the Volunteer Services coordinators made changes in the rules of use at the library to make computers more available for residents.

C o m m u n i t y P a r t n e r s h i p s

Alzheimer’s Training Film

Alzheimer’s and dementia care specialists spent three days at Laguna Honda March 5, 6, and 7 mak-ing a training film featuring the hospital’s nursing staff for use by other long term care facilities serv-ing clients with memory loss.

The project is funded by a grant from the National Institute on Aging. It is the second time Laguna Honda has participated in the making of the regularly updated film. The hospital served as the film-ing site in 2009 at the request of the national Alzheimer’s Association.

The film demonstrates best practices in Alzheimer’s care. It is made by Health Care Interactive, a Minnesota-based company that produces training materials for clinicians.

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National Association of Public Health Systems

The 2012 Fellows of the National Association of Public Health Systems met in San Francisco last week.

The Fellows, including Laguna Honda Chief of Staff Dr. Steve Thompson, CBHS Medical Director Irene Sung, Community Programs Director Marcellina Ogbu, Community Clinics Medical Director Lisa Johnson and SFGH Assistant CMO Will Huen met with Executive Administrator Mivic Hirose, learned about the hospital’s rehabilitation program from Rehabilitation Coordinator Jennifer Carton-Wade and toured Laguna Honda.

They also spent much of a day with staff and administrators at San Francisco General Hospital.

Mass Prophylaxis Exercise

Laguna Honda will practice mass screening and dispensing of prophylaxis in conjunction with the DPH Communicable Disease Control and Prevention Unit on March 29. The drill will provide hospi-tal staff an opportunity to experience the roles they will fill in the rare event of an infectious disease emergency, such as an Anthrax attack, when antibiotics will need to be dispensed to everyone in the Bay Area.

The DPH control and prevention team will send the hospital an alert on the morning of the 29th. The hospital incident command system will be activated and teams of hospital staff will distribute mock antibiotics at the hospital clinic and select resident neighborhoods. A debrief will follow.

DPH Integrated Delivery System Recommendation

This month Laguna Honda will participate in a series of departmental informational meetings con-vened by Deputy Director of Health Tangerine Brigham to seek input from employees on integrated delivery system (IDS) recommendations. Tangerine will present the draft recommendation for an IDS at four hospital meetings—one for managers and three for employees, residents, visitors and volun-teers.

The IDS recommendations are the result of a department-wide and community stakeholder plan-ning process begun in 2009 to strengthen the integration of DPH services. The goals are to promote access to care, improve health outcomes, focus on client satisfaction and reduce costs.

City Hall Fellows

Participants in the City Hall Fellows program, which places public policy students in city agencies for hands-on experience, spent a day at Laguna Honda in February. The Fellows toured the hospital, spoke with residents, and interviewed Executive Director Mivic Hirose about her role and coming changes in health care. The hospital was delighted to host the group of talented young people as they explore careers in the public sector.

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Art for Residents

Thanks to the San Francisco Arts Commission, Laguna Honda residents are now able to select prints from the civic art collection to decorate their rooms.

Residents Pedro Reyes (l.) and Cassandra Watts (r.), both artists themselves, are pictured above with their selec-tions.

Pedro participates in an adaptive art program at Laguna Honda, painting with a brush that attaches to his head. He chose a landscape with horses. “Looking at the painting,” he said, “it is paradise.”

Cassandra selected a brightly colored bird. “You know,” she said, “because I am an artist, I like the bird.”

More details about the program are posted on the Laguna Honda Facebook page, and a press release is available at lagunahonda.org.

Sound Abatement Update

Hospital engineers reconfigured the air ducts on the roof of the Pavilion in March.

In an email to staff, Dellbrook resident Terry Thompson, who serves as a contact for his neighbors on the sound abatement matter, commended the effort as “fantastic” and reported a “substantial drop” in noise.

Sound consultants Charles Salter and Associates took measurements during the week of March 19. As of the publication date for this report, we were awaiting the findings.

The hospital continues to seek other solutions to the fire alarm complaints from neighbors. A meet-ing with neighbors and DPH staff to discuss options is set for April 5 at 3:00 p.m. in the Kanaley Cen-ter. For a complete review of mitigation actions, please see the appendix.

Events, Awards and Honors

Cultural Celebrations

A critical part of the culturally competent care at Laguna Honda is the hospital’s effort to honor the holidays and other celebrations important to its diverse resident population. Two wildly successful events in February, were the Chinese New Year and Black History Month celebrations, which were among the most vibrant and jam-packed in memory.

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Chinese New Year

A joyous crowd of residents, volunteers, visitors and staff members crowded the esplanade this month to celebrate Chinese New Year. The hospital’s stellar Activity Therapy Department organized the colorful celebration, which included the first-ever parade down our “main street,” games, music, art, and costumes. Hospital visitors who happened upon the event were swept up in the enthusiasm of the day. Our thanks to students from the College of Idaho for setting up and staffing the tables.

Black History Month

San Francisco Supervisor Malia Cohen spoke to a full house as part of the hospital’s commemoration of Black History Month in the Pavilion Cafe on February 16. Her message: Everyone can make a con-tribution that matters. Also on the day’s agenda: soul food, music, poetry. Resident Shirley Middleton read a selection of her newest poetry. Dr. Yeva Johnson performed flute music, and hospital neigh-bor and volunteer Evernese McNight brought her church choir, which regaled a crowded room with gospel tunes.

National Nutrition Month

March is National Nutrition Month, and the hospital’s registered dietitians launched an education campaign in concert with their national association, the Academy of Nutrition and Dietetics, formerly the American Dietetic Association.

The campaign focuses attention on the importance of making informed food choices and developing sound eating and physical activity habits. Under the theme of “Get Your Plate in Shape,” the hospital’s dietitians provided nutrition information to staff throughout the month and hosted a special event on eating right in the Pavilion Café.

Registered Dietitian Day, also celebrated in March, increases awareness of registered dietitians as the providers of food and nutrition services and recognizes RD’s for their commitment to helping people enjoy healthy lives.

Employees of the Month

The members of the Clinical Informatics team were February’s em-ployees of the month. These are the masterminds who were able to troubleshoot the complex Aeroscout tracking system among many other things. Aeroscout is the resident protection system the hos-pital uses to help prevent residents who are a wander risk due to dementia from becoming lost.

The team also reads and understands the equipment manuals for our new high tech hospital—and they are still smiling! From left to

right on the next page: Larry Reyes, Jotter Carinal, Mel Ferrer and Monique Decharat.

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The March Employee of the Month is Araceli Pasalo, North 4 charge nurse. She was nominated by resident Felipe Martinez, who says he submitted her name because she is such a hard worker. Felipe said that even when the neighborhood has big parties like Cinco De Mayo or Fiestas Patrias, she is the one that is holding down the fort. We thank her for everything she does.

Attachments

Community Reintegration Powerpoint Fact Sheet on Sound Reduction Actions

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Community Integration

JCC PresentationMarch 2012

Community Reintegration

The hospital has developed a concentrated focus on discharge planning that supports

• Independence

• Needs and preferences

• Appropriate level of care

• Community collaboration

• Discharge Fairs

• Peer Mentors on Campus

• Targeted Resources – Executive Discharge Support Team

• Referrals to Targeted Case Management

• Referrals to Direct Access to Housing (DAH) and West Bay Housing

• Referrals to Diversion and Community Integration Program

Discharge Activities

Discharge Fair

DCIP Team

Discharges involve community partners and are coordinated through the Diversion and Community Integration Program.

• DCIP Coordinator• In-Home Supportive Services (IHSS)• Department of Aging and Adult Services• DPH Housing & Urban Health• DPH Community Behavioral Health Services• DPH Community Primary Care Clinics• DPH Placement Office• DPH Targeted Case Management• Laguna Honda Admissions & Eligibility• Laguna Honda Social Services• Community Living Fund• Waiver Specialist• West Bay Housing Corp.

Community HousingResidents are discharged to four primary types of housing sites.

• Scattered Site Housing (SSH) units became available in July 2009. The population is more independent and has access to wrap-around services.

• Direct Access to Housing (DAH) has been included in the DCIP program since January 2008. The population is more “at risk,” with wrap-around services and on-site resources.

• Residential treatment sites are often a first step to the community prior to placement in permanent housing.

• Medical and psychiatric board and care homes provide oversight for clients who cannot live independently.

Community Housing

Most discharges are to Scattered Site Housing and DAH housing.

199 participants were housed in Scattered Site and DAH units under the Laguna Honda Rental Subsidy Program from January 2008 to February 15, 2012.

– 111 new SSH units were secured through West Bay Housing Corporation (WBHC).

– The LHH Rental Subsidy Program covers rent, unit modifications, and repairs.

Housing Requests

2009 2010 2011 Total

Request for Housing 46 75 58 179

Approved for Scattered Site 35 54 25 114

Approved for Direct Access to Housing 7 9 24 40

Total Approved 42 63 49 154

Total Denied 3 0 0 3

Deferred 1 12 9 22

*The two most common reasons for deferring housing are residents needing to access residential substance treatment first and/or additional clinical information needs to be reviewed to determine appropriate housing type.

Housing RequestsReasons for Deferred Housing Requests from 2009 to 2011 Number of Clients Percentage

Need substance use treatment prior to housing 8 36%

Need additional information regarding client 7 32%

Financial issue 2 9%

Possible B&C placement 2 9%

Pending medical stability 1 5%

Preferred housing has no vacancy 1 5%

Legal issue 1 5%

TOTAL: 22 100%

Outcomes of Deferred Housing Requests from 2009 through 2011 Number of Clients Percentage

Appropriate for B&C 5 23%

Approved for DAH 4 18%

Approved for SSH 4 18%

AWOL/AMA 3 14%

Went to other housing (non-SSH/non-DAH) 2 9%

No update 2 9%

Residential treatment 1 5%

Out of county 1 5%

TOTAL: 22 100%

SSH Housing Retention (West Bay Housing)

DAH Housing Retention

Overall Housing RetentionSSH DAH

RETENTION RATE 86% 63%Reasons for Vacating

Died 6% 13%Need Higher Level of Care 12%Moved to Other Housing 6%Moved Out of County 1%Eviction 4%Incarcerated 1%Abandoned Unit 2%Entered Treatment Program 1%Subsidy Completed 2%Voluntarily Vacated 3%

ReadmissionFactors Associated with LHH Readmissions

2009 through 2011

4 Respite2 Hospice

8

4

22

0

5

10

15

20

25

Medical Decline Only CLP Related Only Medical Decline and CLPRelated

Planned Readmission

Num

ber o

f DC

IP C

lient

s

CLP = Community Living Plan: refusal of wrap-around services/not adhering to service plan.

Quality Management Outcomes

• Targeted Case Management phone survey of non-rehab discharges (since 8/09). – 57% response rate– 86% positive response. – 14% reported problems with durable medical equipment which have all been resolved.

• Laguna Honda phone survey of rehab discharges since 8/09..– 68% response rate – 96% positive response. – 4% reported problems such as pain due to walking up stairs to their home and awaiting

arrival of their wheelchair. These issues have all resolved.

• DCIP semi-annual mail survey of residents who have been in the community for six months to a year. The surveys conducted in July 2011 indicates:

– 31% return rate– 100% satisfied with overall quality of DCIP services.– Face-to-face surveys recently started.

2011 DischargesAnnual Percentage of Community Reintegrations from Each Specialty Program

2011 (N=160)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Program

Ann

ual P

erce

ntag

e

2011 3% 19% 61% 18%

Hospice Positive Care Rehabilitation SNF

2012 New Initiative: Discharge Household

In March 2012, the hospital dedicated a 15-person household on the North 3 neighborhood to residents transitioning to the community.

The intention is that residents will gain momentum toward community living by participating together in planning for their lives outside the hospital.

2012 Goals

Activities

• The opening of N3 discharge household

• Two more discharge fairs to be held in 2012

• Increased referrals to the Peer Mentor Program

• Increased referrals to the Vocational Rehabilitation Program

Performance Measures

• Discharge Household will show a 50% increase of general SNF discharges in 1 year

• Continued monitoring of readmissions to Laguna Honda

• Continued monitoring of quality indicators

Fact Sheet on Sound Reduction Actions Updated March 2012 Covering: Pavilion Air Chiller, Boiler and Door Alarms, Fire Alarms

1. Pavilion Air Chiller Background: Prior to the rebuild, Laguna Honda housed a power plant in the Clarendon Valley that operated all day every day as well as a laundry facility that operated from 5 a.m. to 9 p.m. They were removed to make room for the new hospital. The chiller on the roof of the Pavilion began operating in 2010. To address concerns, Laguna Honda took the following actions. Date Action Status

August 2010 • Carrier Corp. retained by city to evaluate sound • Carrier submits recommendation for sound absorbent

blankets matching the frequency range of the sound

Complete Complete

September 2010 Sound blankets installed on three sides of the chiller per Carrier’s recommendations

Complete

November 2010 • Sound blankets removed on orders of Office of Statewide Hospital Planning and Development (OSHPD)

• Sound containment structures (“doghouses”) installed over chiller motors

Complete Complete

January 2011 • Salter & Assoc. retained by Turner Construction Co. to take sound measurements

• Salter reports air cooling equipment operating at 5dBA greater than manufacturer’s specifications

• Department of Public Works requests manufacturer correction

Complete Complete Pending

May 2011 • Sound attenuation package installed on internal chiller mechanisms

• Salter reports manufacturer’s package does not substantially reduce noise level

Complete Complete

June/July 2011 • OSHPD approval obtained to place temporary sound blankets on wall directly behind chiller to prevent reverberations

• Blankets installed

Complete Complete

September 2011 Sound blankets repaired and re-hung Complete January 2012 Lighting system on MUNI substation turned off Complete

Fact Sheet on Sound Abatement Efforts

Updated March 2012

January/February 2012

• Exhaust fan motor wrapped in sound absorbent material

• Variable frequency drives bypassed

Complete Complete

March 2012 • Air Ducts Reconfigured • Salter retained to take measurements • Salter issues sound report

Complete Complete Pending

2. Boiler and Door Alarms Background: From August to December 2010 the new buildings were in a process of transition from the general contractor to the city. The new boilers were ignited and the boiler alarms were activated. Testing also began on door alarms. To address concerns, Laguna Honda took the following actions. Date Action Status August 2010 Hospital establishes paging system to alert engineers to

boiler alarms for faster shut-off. Neighbors report alarms are silenced more rapidly.

Complete

August – November 2010

Staff education on door operation; key cards issued so staff will ndoors triggering alarms

Complete

December 2010 Boiler malfunction; control sequences fixed; no further complaints about boiler alarms

Complete

3. Fire Alarms Background: Alarms are required to be tested every quarter on every shift as well as during annual inspections by the California Department of Public Health. To address concerns, Laguna Honda took the following actions. Date Action Status Fall 2011 • Hospital establishes hot line for neighbors to report

alarms for quicker shut-off • Hospital engineers and neighbor representative meet

with Fire Department

Complete Complete

Ongoing Staff education on fire alarms and preventing false alarms Complete

March 2012 City assesses regulatory requirements under governing statues (1998 NFPA §72)

Complete

March 2012 Hospital researches alternative annunciating devices (chimes instead of horns) to reduce external sound and still comply with legal requirements. No alternatives found.

Complete

March 2012 Hospital to consult with OSHDP fire division to request removal or minimization of external fire alarms

Complete

March 2012 Hospital to convene follow-up meeting with Fire Dept

Pending