san francisco general hospital and trauma center
TRANSCRIPT
SAN FRANCISCO GENERAL HOSPITAL and TRAUMA CENTER
ANNUAL REPORT Fiscal Year 2010 - 2011
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Presentation Summary
Community Wellness Program Nursing Progress Performance Improvement and
Patient Safety UCSF-SFGH Partnership Health Information Technology Environment of Care SFGH Rebuild
MISSION: To Provide Quality Healthcare and Trauma Services with Compassion and Respect
PEOPLE Clinical & Service Excellence
SYSTEMS Operational Efficiency & Coordination
TECHNOLOGY Health Information Technology
Align care, discovery & education to
advance community wellness.
PEOPLE
SYSTEMS
TECHNOLOGY
• Service Excellence • A Fair and Just Culture • Clinical Quality • Enhancing Wellness • Professional and Academic Excellence
• Efficient Management System • Integration and Coordination Across Services
• Meaningful Use of Information Technology • Moving beyond implementation towards adoption of Health
Information Technology
Our New Leaders
Shannon Thyne Chief of Staff
Winona Mindolovich and John Applegarth Information System Leadership
Thomas Holton Patient Safety Officer
Todd May, M.D. Chief Medical Officer
COMMUNITY WELLNESS PROGRAM
Project of the San Francisco Department of Public Health at San Francisco General Hospital and Trauma Center
About the Community Wellness Program
Values: Community Engagement and Partnerships Holistic approach Education through Empowerment Culturally, linguistically, and financially accessible Creative and innovative approaches Engaged leadership
BUILDING COMMUNITY TOGETHER Healthy Food Environment Initiative Healing Moves-Active Living Initiative Tobacco Free Community Initiative Community Engagement Initiative
Nursing Progress Magnet Journey Shared
Governance Positive
Communication Training
Professional Development Speakers
Professional RN Certification
Education
Nursing Progress
Low Vacancy Rate Joint Commission
TBI and Stroke Certification
Nursing Initiatives Community
Partnerships
Dorothy Washington Fundraiser for RN Scholarships
RN and New Graduate Training Program
Performance Improvement & Patient Safety Program (PIPS)
Joint Commission Accreditation
Quality Data
Improvement Increasing alignment
between hospital and clinical services through PIPS Committee
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Performance Improvement & Patient Safety Program (PIPS)
– Sepsis & Central-line Associated Blood Stream Infection prevention
– Patient Experience Initiative
– Leadership & QI Academy Learning Center
– Quality Data Center
– CMS Incentive Plan – Primary Care Coordination between COPC and
Hospital-based clinics
Joint Commission
Traumatic Brain Injury Certificate of Distinction
In 2010-2011, SFGH was licensed and regulated by 33
agencies who conducted a total of 41 surveys/site inspections.
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Joint Commission
Hospital Accreditation
Survey
CDPH PSLS
Survey
CDPH LTC/Fire & Life Safety Licensing
survey
DMH MHRC
Licensing Survey
DEA Survey of Pharmacy
DEA Registration
as a NTP
CMS ESRD
Survey
DSS/ Community
Care Licensing
ARF Licensing Survey
CDPH MERP
Survey
ACSCOT Level I Trauma Center
Verification Survey
CDPH Consolidated Accreditation
Survey
CDPH/ CMS
EMTALA Complaint Validation
Survey
CDPH LTC
Licensing Survey
CDPH RHB
Survey of Avon Breast
Center & Mammovan
Alcohol & Drug
Program Licensing Survey
of Opiate Treatment Outpatient Program
Joint Commission
Long Term Care
Accreditation Program Survey
US DHHS/ PHS/ FDA
MQSA Certification
Survey
Joint Commission
Primary Stroke Center
Program Survey
SF Mental Health Clients’ Rights
Advocates Survey
Nurses Improving
Care for HealthSystem
Elders Site Survey
DSS ARF/Fire &
Safety Licensing
Survey
CARF Accreditation
Survey
CMS Life Safety
Code of ESRD
Survey
CDPH Tissue Bank
Licensing Survey
CDPH Certified Nurse
Assistant Program Record Review Survey
Vaccines for Children Program Quality
Assurance Review/Survey
Joint Commission Laboratory & Point of Care
Testing Accreditation
Program Survey
US DHHS/ Title X Family
Planning Federal Audit
Joint mmission
PPR alidation Survey
US DHHS/ Dept of Mental
Health Services Administration
Center for Substance
Abuse Treatment
DMH MHRC/Fire
& Life Safety
Licensing Survey
Dept. of
Correction/ Title 15 Jail Health Services
Licensing Survey
CDPH/CMS Complaint Validation
Licensing Survey – Pharmacy
Management of Controlled substances
ACSCOT/
CCSF-DPH EMS Level 1 Trauma
Center Designation Verification Survey
CDPH/ Blue Cross FSR & MMR of SFHP Clinics
Baby Friendly Hospital Site
Visit Certification
Survey
American College of Surgeons
Commission on Cancer Survey f SFGH Cancer
Program
Joint Commission
PPR – Hospital, LTC, Lab
Centering Health Care
Institute Site Approval/
Certification Survey
DEA Survey of
Opiate Treatment Outpatient Program
Quality Data Required by The Joint Commission and CMS
Heart Attack Heart Failure Pneumonia Surgical Care HCAHPS Patient Experience Survey
(CMS)
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Joint Commission/CMS Core Measures – SFGH PERFORMANCE
On 24 of 31 Core Measures, SFGH performs at or above national and state averages.
improvement from the previous year: Example: Pneumonia
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Measure 2009 2010
Blood culture taken before antibiotics administered
78% 86%
Antibiotic Given within 6 Hours
84% 90%
Recommended antibiotic selection
82% 100%
HCAHPS Patient Experience Survey (CMS)
Publicly reported patient survey scores identify an area for focused improvement: Hospital Rating (Top Scores): SFGH 57% State Avg 67%
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Patient Experience Improvement
Service Excellence Goals: –Create a service excellence framework &
train staff –Redesign ED & Hospital Flow – Implement ambulatory care patient
experience survey in outpatient clinic areas.
–Work in partnership with patients and families
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UCSF/SFGH Partnership Provides all of the physician services
at SFGH. Provides 1/3 of the resident and
medical school training for UCSF. –ACGME Resident Duty Hours
Standards Manage clinical laboratories,
respiratory therapy, biomedical engineering, and library.
UCSF/SFGH Partnership
Manages large research effort at SFGH –Approximately 250 million dollars in
grants –270,000 ASF of research space, mostly
in seismically challenged space by UC standards
Plans underway by UCSF for new research building at SFGH
IS Accomplishments 2011
PulseCheck (Emergency Dept Information System) implementation
MAK (Electronic Medication Administration Record) rollout to 5A
IS steering committee reorganization
Barcoded Medication Administration
Preparing for Meaningful Use
Infrastructure upgrades – WiFi – Device replacements – Mobile device management (MDM)
HIT objectives 2011-12 Complete comprehensive five-year
development plan for electronic health records at SFGH by the end of 2011.
Attest to Stage 1 of Meaningful Use for
Medicare fiscal year 2012. Complete roll-out of Computerized Physician
Order Entry to all Medical-Surgical units by end of 2012.
Complete roll-out of MAK to all Medical-Surgical Units and Psychiatry by end of 2012.
Environment of Care (EOC) The seven elements of the EOC Safety
Program: Safety Security Hazardous Materials/Waste Medical Equipment Utilities Fire Safety Emergency Management
Rebuild Highlights
Excavation Generators and
water tank Concrete pour Community mural Local hiring Community
outreach
Approval Required
Environment of Care Plan Report Provision of Care Policy Performance Improvement Policy
