laguna honda hospital and rehabilitation center 14... · 25.11.2014 · the second phase of the...

Laguna Honda Joint Conference Committee Report November 25, 2014

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Joint Conference Committee

Laguna Honda Hospital and Rehabilitation Center

Administrator’s Report

November 14, 2017


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Contents

State of the Hospital

Wait List Admissions, Discharges and Expirations Average Daily Census Paid Beds and Occupancy Discharge Disposition Staffing Report

Budget and Finance

Financial Report Gift Fund Report

Initiatives and Milestones

Regulatory Care Experience Campus Community Activities and Events Learning and Development Recognition Performance Improvement

Attachments

Quarterly Gift Fund Report FY17-18 Q1 Quality Council Meeting Minutes for August and September 2017 True North Goal – Safety: Falls with Major Injury PI Storyboard and A3 True North Metrics FY 17-18 Q1 Update General Acute Care Hospital 2017 Recertification Survey Plan of Correction Draft FY16-17 Laguna Honda Annual Report Value Stream Mapping Workshop 2 – Discharges Back to Prior Living Situation Laguna Honda Lean Transformation Presentation Hospital-Wide Policies and Procedures for Approval


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State of the Hospital

Wait List

Average wait time in days from referral date to decision approved date (09/01/2016 to 09/30/2017): 5.57

Average wait time in days from decision date to admission date (09/01/2016 to 09/30/2017): 9.87

Number of people on waiting list as of 10/31/2017: 39

Admissions, Discharges, and Expirations by Month (09/01/2016 to 09/30/2017)

Average Daily Census (09/01/2016 to 09/31/2017)

Period SNF

Occupied Beds Held

Total SNF

Census

Acute Medical Census

Acute Rehab Census

Total Daily

Census

Total Paid Beds

Percent Occupancy

09/01/16 – 09/30/17

750.95 5.88 756.83 0.43 2.03 753.41 759.29 99%

Sept-

16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

Apr-17

May-

17

Jun-17

Jul-17

Aug-17

Sept-

17

New Admissions 33 36 33 38 41 33 31 40 35 32 27 41 40

Planned Discharges 7 17 15 15 13 13 14 12 11 12 16 14 16

Unplanned Discharges 4 0 2 2 8 3 2 7 7 4 2 5 4

Expirations 16 19 18 16 17 16 13 17 23 13 10 18 14

0

10

20

30

40

50

60

No

. of

Res

iden

ts

TotalsNew Admissions: 460| Planned Discharges: 175 | Unplanned Discharges: 50 |

Expirations: 210


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Paid Beds and Occupancy by Month (09/01/2016 to 09/30/2017)

760.8 760.3 761.2 760.4 759.8 759.4 759.9758.7

755.6757.5 758.4 759.9 759.3

99.1 99.0 99.1 99.0 98.9 98.9 98.9 98.8 98.4 98.6 98.7 99.0 98.9

80

85

90

95

100

700

710

720

730

740

750

760

Perc

ent

Occ

up

ancy

AV

G T

ota

l Pai

d B

eds

Total Paid Beds & Percent Occupancy (Combined SNF & Acute)Total paid beds = total daily census + beds held.

Percent occupancy = total paid beds ÷ total operational capacity (768).

AVG Total Paid Beds Percent Occupancy


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Community Discharge Dispositions (09/01/2016 to 09/30/2017)

For the 13-month period above:

1. Analysis of out-of-county are as follows: 8.4% (n=19) individuals were discharged to out-of-county placements. Of those, 11 residents went to live with family, 3 residents returned to their previous residence and 5 residents went to Board and Care Homes that could best accommodate the residents’ needs.

2. Analysis of absent without leave (AWOL) are as follows: 46% (n=17) of the 37 AWOL incidents returned to Laguna Honda for receiving continued skilled nursing services. Of those who did not return (n=20), the Social Services Team were not able to contact 20 (54%) individuals and were able to contact zero (0%) of the former residents who chose not to return to Laguna Honda.

3. A resident is discharged Against Medical Advice (AMA) when he/she chooses to leave Laguna Honda Hospital against the advice of their physician. For patients/residents discharged AMA (n=13), the physician discussed with the patient/resident the risk of leaving AMA.

47.1%, House/Apt.

9.8%, Hotel

5.8%, AMA16.4%, AWOL

8.4%, Out of County

7.6%, Other

2.7%, B & C

2.2%, Specialized Housing - HIV

LHH Discharge DispositionsSept. 2016 - Sept. 2017

N=233


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Staffing Report

Laguna’s current vacancy rate stands at 5.2% and the hospital is actively recruiting for 68 vacant positions. The vacancy rate is in-line with the health care industry.

In October and November, DPH Human Resources is offering supervisory trainings in leaves management that includes strategies to return employees back to work and employee accountability in time and attendance. Related to training, the City’s Department of Human notified DPH and Laguna that managers and supervisor once again will be required to take a mandatory 2 hour in-service on harassment prevention as required by California Government Code. The in-service is required every two years and newly hired or promoted supervisors as well as employees appointed to acting assignments as supervisors must take the training within 6 months of assuming the new position or acting role.

As of October 27th, 2017, Laguna Honda has achieved a 98% completion rate for performance appraisals.

Budget and Finance Gift Fund Report The fiscal year 2017-18 1st quarter Gift Fund Balance Report is attached.

Financial Report We are currently projecting an overall salary expenses shortfall of $1.4 million by year end. The variance is mainly due to the increased need for coaches in an effort to facilitate patient flow within the network. There were also unbudgeted event and various mandatory trainings that required overtime to backfill (e.g. F$P GO LIVE, SOGI and CPI trainings). SOGI – Sexual Orientation and Gender Identification CPI – Crisis Prevention Intervention


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Initiatives and Milestones

Regulatory Clinical Laboratory Improvement Amendments (CLIA) Survey – September 1st A Los Angeles-based field examiner from CLIA visited the Respiratory Services Department on September 1st. During the 2 hour visit, which takes place every two years, an inspection of the Arterial Blood Gas Lab was performed and no deficiencies were found. Two recommendations were made in regards to staff education. Health at Home Survey – September 6th-13th Health at Home received its tri-annual survey by the California Department of Public Health (CDPH). The weeklong survey took place between September 6th-13th and no major care deficiencies were found. David Snyder, Administrator for Health At Home, indicates that any other findings are correctable and will be addressed once the final report is available from surveyors.


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Relicensing and Recertification Survey – October 16th-24th Surveyors from CDPH completed a six-day survey period during October 16th-24th. There were a total of 14 surveyors on campus visiting individual departments and interviewing residents and staff. The survey was two-fold: 1) a recertification survey to evaluate compliance with the federal long-term care Medicare/Medicaid program requirements and 2) a licensing and certification (L&C) survey to evaluate compliance with California’s Code of Regulations, Title 22, as it pertains to operating a skilled nursing facility. Overall, the survey was successful in large part to the contributions made by staff to ensure Laguna Honda meets both state and federal regulations for skilled nursing facilities. The effort was spearheaded by Regina Gomez, Director of Quality Management as well as other Laguna Honda leaders who led the Survey Support Center. Their work resulted in no substandard care findings and a zero medication error rate. Once the official findings from the survey is made available, any necessary and appropriate plans of corrections will be submitted.

Care Experience

New Biometric Reader for the Employee Wellness Hub – September 22nd

The Employee Wellness Hub was given a biometric reader by Health Service System. The machine measures height, weight, BMI (body mass index), percentage of body fat and is capable of giving a print out of your results. While the machine is easy to use, 1:1 instruction is available from the current Wellness Hub monitor. Staff are encouraged to take their measurements before exercising for best results.

Clothing Delivery for Residents – September 25th

The Volunteer Services Department have begun to pilot a Clothing Delivery service to residents on three neighborhoods, including South 2, South 3 and Pavilion Mezzanine. This effort is intended to provide residents a more hands-on experience in regards to developing their personal style. It also adds a therapeutic element by allowing residents to engage a retail shopping activity once a month. The program rotates through the neighborhoods at least once a month and is operationalized with volunteers and supporting departments including Nursing, Activity Therapy and Social Services.

Influenza Vaccine Available – October 2nd

Influenza (“Flu”) season is upon us and Laguna Honda made vaccinations available to all hospital residents, staff and volunteers. There is also a dedicated Influenza Prevention and Management program, which includes testing and education protocols, in place to ensure that the hospital is a safe environment for all. Staff who receive the vaccination are eligible to win prizes through a special raffle! Those who choose to opt out of receiving the vaccination are required sign a declination and will need to wear a mask at the beginning of the Mandatory Masking period on November 1. The hospital is tracking compliance rate through the efforts of


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Christina Lee, MD, Bi Huang, RN, and Melanie Ferrer, RN. To date, approximately 80% of Laguna Honda campus staff have received the influenza vaccine. Of those who have not received the influenza vaccine, mandatory masking in the Hospital building will be enforced starting November 1st.

Black African American Health Initiative (BAAHI) Learning Series Event – October 19th Dr. Denise Boston was the featured speaker and presented at Laguna Honda to over 50 participants in Moran Hall. The Dr. Boston spoke on working with African American Families and provided experiential training on infusing culture into practice. Developing and implementing a strength-based approach that recognizes African American patterns of mutual support and coping strategies that were effective in the past was the focus of the learning series. We would like to thank Dr. Ayanna Bennett, DPH Director of Interdivisional Activities, for initiating and organizing the BAAHI Learning Series Events.

Campus Community Activities and Events Virginia Leishman Memorial Service– September 21st Laguna Honda celebrated the life of Virginia Leishman, former Chief Nursing Officer and Director of Nursing, during a memorial that was attended by more than 200 current and former staff members. The service was led by Spiritual Care Coordinator Bob Deel and included personal tributes from many of Ms. Leishman’s closest colleagues who spoke about their favorite memories of her. Combined Charities – October 2nd to November 10th Dr. Michael McShane (Medical Services), Nikki Santana (Rehabilitation Services) and Daisy Quitoriano (Nursing Services) were Laguna Honda representatives in this year’s Combined Charities Campaign. The trio informed staff across the hospital of campaigned and stressed the importance of giving to those immediately in need such as victims of recent natural disasters. They set out to beat raised total from last year and are optimistic the final tally will indicate their success. Laguna Honda Hospital Community Mural Paint-in Day – October 14th

The second phase of the Laguna Honda Mural Project officially kicked off with a Mural Paint-In Day for the community. On Sunday, October 14th, Precita Eyes Muralists artists Yuka Ezoe and Elaine Chu led a group of volunteers that included hospital staff to put the first coat of paint. The mural is a seamless extension of the first phase and features wild animals and plants that are native to the city. The two artists and volunteers will continue working through the next few weeks. The mural is anticipated to be completed by the end of the calendar year.


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National Pharmacy Week - October 15-21

The Pharmacy Department dispenses over 100,000 doses of medication each month for Laguna Honda residents. They are a set of professionals who are committed to improving pharmacy services and working with our nursing and physician partners to achieve a medication error free standard across the hospital.

Great Shakeout Earthquake Drill – October 19th Laguna Honda participated in the Great California ShakeOut that took place held on October 19th at 10:19 AM. This represented the hospital’s annual opportunity to practice Drop, Cover, and Hold On, which will improve earthquake preparedness. This year’s activity was a simple drill in which an overhead page and Everbridge notification alerted everyone on campus that the drill has begun. More than 9 million Californians were registered to participate this year with 1.5 million of those in the Bay Area, including over 23,000 from 91 healthcare facilities. Annual Years of Service Recognition Event – October 20th Laguna Honda held its annual Years of Service event to recognize staff at Patio Espanol. Staff who had earned years of service in five years increments, all the way to 35-years, were honored with certificates and pins. Attendees were eligible to purchase raffle tickets for prizes including passes to Disneyland, which were generously donated by the San Francisco Public Health Foundation. The event was coordinated by Elizabeth Schindler, Health Program Planner, with assistance from other committee members. National Healthcare Facilities and Engineering Week - October 22nd-28th The Facility Services Department provides Laguna Honda an operationally safe and efficient facility by ensuring that there is power, running water, and a warm, comfortable, and safe healing environment for all who walk through our doors. They are an essential member of the resident care team - the unsung heroes who keep a facility operational. Without their dedication, it would be impossible to provide services and programs to residents. National Respiratory Care Week - October 22nd-28th The Respiratory Care Services Department features four staff members that includes: Elizabeth (Liz) Bernard, Gary Sakita, Patrick Porter, and Jingyan Liu. Together, they provide services to residents year round. Grand Circus Rounds – November 5th

Laguna Honda collaborated with the Medical Clown Project on Grand Circus Rounds, an annual fundraising gala. Residents were treated to an afternoon show of magic, acrobatic performances and music from some of the best clowns across the country. The event was also featured in an article on Hoodline, a local neighborhood newspaper, as well as KCBS radio. All proceeds from the event will go towards supporting activities that benefit residents at


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Laguna Honda as well as other Bay Area healthcare facilities working with the Medical Clown Project.

Learning and Development DPH Lean Certification Education Series – October 10th–11th

More than eight Laguna Honda leaders are participating in a Lean Certification series organized by the newly formed DPH Kaizen Promotion Office and Rona Consulting Group. The education series is spaced out over the course of three months and the attendees will be required to pass a module marathon, as well as fulfill specific workshop requirements before officially earning Lean certification status. The class features other participants from across SFHN and the education portion will be completed in January 2018.

Recognition

Employees of the Month

The Employee of the Month program is a staple of Laguna Honda’s staff recognition and the Hospital’s service excellence programs. Employees of the Month are nominated by residents, visitors, volunteers, and staff and are approved by the Hospital’s Executive Committee.

October 2017 Employees of the Month

Carolina Ong, Heather Rudolph and Elise Lusk from the Rehabilitation Department are October Employees of the Month.

Each has had a long and distinguished career at Laguna Honda and individually, each has done amazing things through the years helping Laguna Honda residents achieve maximal functional independence and improved quality of life. The magic that has occurred recently is in their collaborative effort to lead the Rehabilitation Department and engage their staff in creating positive change. Their respectful and collaborative “can do” attitude has translated into two amazing results over the past several months for the Laguna Honda community. The first has been their efforts to work together with the triple check team and improved communication and workflows to deliver a much higher percentage of completed rehab charts/charges leading to a significant reduction in Laguna Honda accounts receivable days. The other big accomplishment is working together with RTZ to come up with a new and improved Rehab Database.

Two years ago, replacing the database was desired by all and feared by many. Carolina, Heather and Elise worked tirelessly together, meeting for countless hours with RTZ and their teams on designing and building a replacement that not only replicates much of what the database currently does, but it also eliminates many redundancies, improves communication and should allow for more efficient and reliable flow of clinical information related to the rehabilitation departments work with Laguna Honda residents.


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Thank you Carolina, Heather and Elise for helping to create such a positive work environment for all, where change that was once thought to be impossible is now possible.

November 2017 Employee of the Month

Lucy Guzman was selected as November 2017 for her continued stellar efforts in Social Services Department.

Lucy is in her 11th year at Laguna Honda as a Senior Clerk and the first welcoming face you see in the Social Services Department. From the inception, Lucy has displayed excellent customer service skills, diligence and devotion to her job. She maintains the workflow in a busy front office yet finds the time to help any staff in need with computer or technical issues that need resolution. She has perfected her computer skills over the years and manages many aspects of the SF GetCare discharge database. Lucy works effectively with all other hospital departments and is a resourceful problem solver who sees the job done to the end.

Lucy extends herself beyond the Social Services Department. For the past several years, she has helped Infection Control send out flu letters out to family members and conservators and tracks receipt of signed consents. As part of the hospital’s True North metrics, she surveys all discharged residents to learn their satisfaction with care at Laguna Honda and their recommendation of our facility to others. During the annual State survey, she helps back up the Command Center and has assisted in communicating information to families over the years on changes that may impact their loved ones.

Performance Improvement

Kaizen 1 Workshop – Care Planning (September 25-29)

Laguna Honda continued its Lean Transformation efforts with another Kaizen workshop during the week of September 25-29. This particular workshop, the first of three workshops resulting from Value Stream Mapping (VSM) 2, focused in on Care Planning for residents with an identified prior living situation. The workshop was co-sponsored by Jennifer Carton Wade and Wilmie Hathaway, DO. Process owners included Elizabeth Dayrit, Lisa Hoo, MD, and Grace Chen.

During the week, participants took a deeper dive into how care planning is completed for individual residents upon admission into Laguna Honda. This included Gemba observations and interviews with key stakeholders on the resident care teams (RCT) to better understand how the plan is created, documented and ultimately communicated out to residents. The team was able to accomplish the following process changes:

Visual cues and management tools into the resident care conference

Educational program for resident care teams around short stay status awareness and implications


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A mechanism to ensure referrals to clinics are expedited and flag e-referral with discharge date and short stay status

In addition, they were able to develop the following standard work:

Physician referrals for short stay residents

Discipline-specific, comprehensive hand-out to use in teaching staff on new processes and tools

Interdisciplinary data collection tool/form for use in resident care conference

The results of this first workshop will help aid the next Kaizen, which is focused on Discharge Preparation. That workshop will take place after the Thanksgiving holiday, beginning November 28th. The co-sponsors for that workshop will be Michelle Fouts and Janet Gillen. They will be joined by another interdisciplinary team of participants, with Vincent Lee serving as workshop leader.

Quality Council Meetings

Attached are the Quality Council meeting minutes for September and October 2017. Work in process include, but are not limited to the following:

True North – Employee Injuries A3

Strategic Goal – Dementia Center of Excellence A3

Payroll Based Journal A3

Activities of Daily Living Decline A3

Pressure Ulcers A3

Completed Performance Improvement Storyboard of Falls with Major Injuries and A3

True North – Care Experience and Likelihood to Recommend

Health and Safety Program Annual Report and a description report of the Product Evaluation Committee.

True North Metrics FY 17-18, 1st Quarter Update

The True North metrics first quarter update are attached. There were two new metrics that were introduced for this fiscal year: 1) Increase average monthly patient referrals to Acute Rehabilitation and 2) Develop standard work for capturing homeless data. These replaced two former metrics that reached goal the prior year.

Metrics that need particularly focus based on the first quarter include: 1) incidence of pressure ulcers, and 2) overall job satisfaction rating amongst staff. We will update the JCC of next steps for each True North goal at the November 14 JCC meeting.


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FY 16-17 Annual Report Draft

As we prepare for Laguna Honda’s annual report for FY 16-17 to the Health Commission, scheduled for December 5, 2017 on campus, we are pleased to share with the Joint Conference Committee the annual report draft. It is a summary of the highlights achieved for the past fiscal year. We welcome your input, recommendations and/or suggestions. Thank you.

Attachments

Quarterly Gift Fund Report FY17-18 Q1 Quality Council Meeting Minutes for August and September 2017 True North Goal – Safety: Falls with Major Injury PI Storyboard and A3 True North Metrics FY 17-18 Q1 Update General Acute Care Hospital 2017 Recertification Survey Plan of Correction Draft FY16-17 Laguna Honda Annual Report Value Stream Mapping Workshop 2 – Discharges Back to Prior Living Situation Laguna Honda Lean Transformation Presentation Hospital-Wide Policies and Procedures for Approval

laguna honda hospital and rehabilitation center 14... · 25.11.2014 · the second phase of the...

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