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Edward A. Chow, M.D. President
David B. Singer Vice President
Cecilia Chung Commissioner
Judith Karshmer, Ph.D., PMHCNS-BC. Commissioner
James Loyce, Jr., M.S. Commissioner
David Pating, M.D. Commissioner
David.J. Sanchez, Jr., Ph.D. Commissioner
HEALTH COMMISSION CITY AND COUNTY OF SAN
FRANCISCO
Edwin M. Lee, Mayor 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, December 13, 2016 3:00 p.m. 1001 Potrero Avenue, Conference Room 7M30
San Francisco, CA 94110
1) CALL TO ORDER
Present: Commissioner David B. Singer
Commissioner David J. Sanchez, Jr.
Excused: Commissioner Edward A. Chow, MD
Staff: Barbara Garcia, Roland Pickens, Terry Dentoni, Jeff Crithfield MD, Troy Williams,
Jeff Schmidt, Todd May, Basil Price, Susan Ehrlich MD, Sue Carlisle MD, Dave Wood,
Daniel Giddings, Karen Hill, Ron Weigelt, Greg Wagner, Mary Gray, Brent Andrew,
Leslie Safier, Valerie Inouye, Chris Calwell MD
The meeting was called to order at 3:10pm.
2) APPROVAL OF THE MINUTES OF THE OCTOBER 24, 2016 ZUCKERBERG FRANCISCO GENERAL JOINT CONFERENCE COMMITTEE MEETING
Action Taken: The minutes were unanimously approved.
3) QUALITY MANAGEMENT AND REGULATORY AFFAIRS REPORTS Troy Williams, Chief Quality Officer, reviewed the reports. Commissioner Comments: Commissioner Singer asked for more information regarding the staffing rations in Psychiatry. Mr. Williams stated that CDPH had received complaints about ZSFG Psychiatry staffing ratios and in response, ZSFG is not tracking this data on a daily basis.
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Action Taken: The Committee unanimously approved the report of the 10/18/16 Quality Council Meeting minutes.
4) ZSFG DIVERSION IMPROVEMENT A3
James Marks, MD, Chief Medical Staff, gave the presentation.
Public Comment: Bob Ivory, RN, stated that he is in full agreement on the plan and look forward to working with ZSGF management to eliminate and reduce diversion. He added that diversion protocols have been developed. When the hospital is overcrowded, it is unsafe. He also stated that the new hospital has the same capacity. One third of Emergency Department resources are devoted to non-urgent patients. It will be difficult to decrease diversion rates if there is not adequate staffing throughout the hospital. Commissioner Comments: Commissioner Singer stated that by not fixing the issues with the ZSFG Emergency Department, the hospital is constraining its ability to provide services in other areas of the hospital and service system. Commissioner Singer asked for more information regarding how the Emergency Medical Service (EMS) staff make decisions about where to take patients. Director Garcia stated Urgent Care and the Sobering Center are included in the decision-making process. She added that an expansion of Medical Respite will include 10 beds and the remaining beds are in shelters; she noted that a total of 105 beds will be added which may help alleviate some flow issues in the Emergency Department. Dr. Ehrlich stated that the ZSFG Urgent Care Clinic will be moved to the old Emergency Room in an effort to improve flow issues. Commissioner Sanchez stated that the presentation gives an excellent overview of the issues and shows that that the situation has changed over time but some issues remain constant. Dr. Ehrlich stated that the Hospital Council is also dedicated to working on city-wide diversion issues. Mr. Pickens stated that he is hopeful that utilizing the existing SFDPH initiatives and Hospital Council resources will help improve the diversion rates. Commissioner Singer asked if it is possible to achieve diversion goals without solving lower-level of care patient issues. Dr. Ehrlich sated that there is not a direct correlation between lower level of care patients and rates of diversion. She noted that these issues are a factor to consider along with adding available beds, improving care coordination, and making all attempts to reroute lower level patients from utilizing the Emergency Department. Commissioner Singer asked for the probability that ZSFG will achieve its goal of 31% diversion rate in one year. Chris Calwell MD, ZSFG Emergency Department Service Chief, stated that he estimates that there is a 50% chance of achieving the goal; he predicts a 75% chance of achieving a 40% diversion rate. He noted that it is important to understand a true baseline level first. Commissioner Singer stated that the previous CEO of ZSFG stated in many ZSFG JCC meetings that the diversion rate would be zero once the new hospital opened. He noted that ZSFG staff are
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incredibly dedicated and can also get stuck in current ineffective ways of doing work. He added that unless there is a sense of crisis, stakeholders do not change behavior.
5) HOSPITAL ADMINISTRATOR’S REPORT Susan Ehrlich, MD, Chief Executive Officer, gave the report. San Francisco Mayor, Ed Lee, Celebrate ZSFG City Workers During one of the Fleet Week day celebrations, a 34 foot cabin cruiser capsized in the San Francisco Bay, near Pier 45. Twenty-seven adults and three children were on board and went into the icy waters. Within 32 minutes, the U.S. Coast Guard, the San Francisco Police Department’s Marine Unit and a private boat captain responded and had rescued everyone out of the water. The responders included the San Francisco Fire Department, and the South San Francisco Fire Department. ZSFG became part of that team when some of the survivors were taken to the Emergency Department. ZSFG’s ED team that night – doctors, nurses, medical assistants, patient care assistants and a social worker – took expert care of the victims. One child was admitted to the Intensive Care Unit (ICU), where 8 people cared for him with skill and compassion until he was well. As a result of this big team effort, no one died during that frightening event. On October 19th, the Mayor held a press conference to celebrate all the City’s workers who were involved in this extraordinary event, including our ZSFG team. ZSFG Achieved Stage 6 of the Healthcare Information and Management Systems Society (HIMSS) Analytics Electronic Medical Record (EMR) Priscilla Chan & Mark Zuckerberg San Francisco General Hospital & Trauma Center achieved Stage 6 (Level 6 out of 7) of the Healthcare Information and Management Systems Society (HIMSS) Analytics Electronic Medical Record (EMR) Adoption Model. This distinction honors our organization’s accomplishments to implement technology solutions that have the ability to improve patient safety and quality of care.
The stage rating refers to the HIMSS Electronic Medical Record Adoption Model (EMRAM). It was created, by HIMSS, as a tool to track a healthcare organization's progress to achieving a paperless electronic record environment. The rating is based on participant surveys and it is not tied to regulatory or pay-for-performance penalties. The work over the past few years, including the roll-out of CPOE and the implementation of MAK in Med-surg, allowed the organization to reach Stage 5. The implementation of Salar, the further development of the discharge pathway in LCR, and the expansion of PACS to all radiological modalities have allowed ZSFG to qualify for Stage 6. Currently, (31%) 1,677 hospitals in the United States, including ZSFG, carry a Stage 6 designation. ZSFG is a great example of how a vision can become reality in the world of healthcare information technology.
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Congratulations to our key clinical contributors, Jenson Wong and Seth Goldman for CPOE and the discharge pathway, RJ Merck for R-PACS, Cesli Galan for MAK and Eric Shaffer and Gabe Ortiz for Salar. ZSFG 2015 Maternity Data CalQualityCare has rated ZSFG with superior performance on NTSV C-section and episiotomy rates, and above average performance on episiotomy and VBAC rates. See page 3 for specifics of ZSFG’s performance. The 2015 maternity data is reported by the California Hospital Assessment and Reporting Taskforce (CHART) through their partnership with the California HealthCare Foundation (CHCF). They provided Hospital Quality Institute (HQI) with this dataset to give hospitals the opportunity to preview their performance data in advance of public transparency on CalQualityCare.org on October 26, 2016. Secretary Diana Dooley of the California Health and Human Services Agency presented awards to hospitals that met or surpassed the Healthy People 2020 NTSV C-Section goal of 23.9% at a press call on October 26th... Congratulations to Gillian Otway and Rebecca Jackson for their outstanding leadership in Maternal Child & Health.
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Healthcare Food Service Week October 3 – 7th, 2016 During the first week of October, ZSFG recognized the integral role food service staff have in helping patients and employees of healthcare facilities stay well-nourished and healthy. FNS staff are important in providing patient food service. They complete temperature, sanitation and product checklists, audits, schedule employees, coordinate service to over 25 inpatient nursing units. They have been working very hard to improve patient experience with food through menu enhancements and by implementing iCare, our patient experience paradigm. Eun Sun Park, from 4A Skilled Nursing Facility, shared, “They [Foodservice Workers] go above and beyond to provide better quality of services and satisfaction for our residents. They always kindly responded to my requests, assessed the situations, and provided reasonable resources and solutions, which saved the day. ” Congratulations to the Food and Nutrition team for their friendly approach to serving our patients and community. National Pharmacy Week October 16-22nd, 2016 During the week of October 16th, ZSFG celebrated National Pharmacy Week. Over 3.5 billion prescriptions are written in the U.S. each year, and four out of five patients who visit a physician leave with a prescription. It is predicted that by the year 2030, half of all Americans will have at least one chronic condition, most of which require medication as part of the treatment plan. The World Health organization (WHO) estimates that only 50% of people with chronic conditions in developed countries are adherent to prescribed treatments. Here are a few noteworthy accomplishments from ZSFG Pharmacy staff: Last year, over 2.4 million doses of medication were dispensed from Omnicells and over
150,000 IV medications were dispensed from the inpatient pharmacy
ZSFG’s Outpatient Pharmacy filled almost 110,000 prescriptions while dramatically improving turnaround times for waiting prescriptions (to under 30 minutes)
Our hospital-based clinical pharmacists managed anticoagulation treatment for over 1500 patients
Pharmacy staff completed medication history collection and reconciliation for more than 10,000 patients, 85% of all those admitted to the hospital through the Emergency Department from August, 2014 through July, 2015
Our Outpatient Pharmacy is a dispensing site for Office-Based Opiate Treatment (OBOT) and provides methadone dosing for over 100 patients
Sara Conrad, one of ourpharmacists working in the inpatient pharmacy, will be recognized this month by the California State Board of Pharmacy for 50 years of dedicated service to the pharmacy profession
Thank you to the ZSFG pharmacy team for their stellar service to our patients. Compliance Week October 24th - October 27th, 2016 This year, the Compliance Week theme is Building a Culture of Compliance. Festivities included a panel discussion, compliance fair, virtual quiz bowl and an essay contest.
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Compliance officers keep patient data safe while allowing clinical professionals the access they need for treatment. They introduce new training programs, policies, procedures and codes of conduct to raise awareness about what is required. Thank you to our compliance team for continuing to support our staff with regulatory changes. Respiratory Care Week October 23-29th, 2016 The American Association for Respiratory Care officially designated the last week in October as Respiratory Care Week to draw national attention to the importance of lung health. The announcement came from the Oval Office when then-president Ronald Reagan supported the efforts of the organization. The event is in October because the fall is typically a time when patients suffering lung disease have difficulty breathing and may need help. We thank our Respiratory Care Practitioners who provide professional, compassionate care here at ZSFG. Patient Flow Report for October 2016
Attached please find a series of charts depicting changes in the average daily census.
Medical/Surgical Average Daily Census was 203.13, which is 100% of budgeted staffed beds level and 81% of physical capacity of the hospital. 12.10 % of the Medical/Surgical days were lower level of care days: 1.46% administrative and 10.64% decertified/non-reimbursed days. Acute Psychiatry Average Daily Census for Psychiatry beds, excluding 7L, was 43.16, which is 98.1% of budgeted staffed beds and 64.4% of physical capacity (7A, 7B, 7C). Average Daily Census for 7L was 5.26, which is 75% of budgeted staffed beds (n=7) and 43.8% of physical capacity (n=12). Latest Utilization Review data from the INVISION System shows 73.24% non-acute days (72.72% lower level of care and 0.52% non-reimbursed). 4A Skilled Nursing Unit ADC for our skilled nursing unit was 25.6, which is 91% of our budgeted staffed beds and 85% of physical capacity. Salary Variance to Budget by Pay Period Report for Fiscal Year 2016-2017 For Pay Period ending October 7, 2016, Zuckerberg San Francisco General recorded a 1.34 % variance between Actual and Budgeted salary cost – actuals were $179,901 over budget. For variance to budget year-to-date, San Francisco General Hospital has a negative variance of $1,730,209/1.8%.
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0102030405060708090
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Acute PsychiatryAverage Daily Census
Includes Units 7A, 7B, 7C Excludes 7L
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Includes Units 7A, 7B, 7CExcludes 7L
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Commissioner Comments: Commissioner Singer encouraged the SF Health Network to use the ZSFG maternity data listed in the report to advertise the high quality of services to potential consumers. Mr. Pickens stated that there was a specific marketing component of the ZSFG Obstetrics unit in the SF Health Network branding.
6) PATIENT CARE SERVICE REPORT Terry Dentoni, Chief Nursing Officer, gave the report. Professional Nursing for the Month of October 2016 Nursing Professional Development Nursing department staff from Inpatient Psychiatry, Utilization Management, Women’s Health Center, Skilled Nursing Facility unit, Richard Fine Peoples Clinic, Family Health Center, Falls Prevention Taskforce, and the Acute Care for the Elders unit are precepting 12 of the 24 FACES for the Future Program local high school students here at ZSFG for their internship this November and December. Our ZSFG staff preceptors share their work history and job duties with these John O’Connell High School FACES scholar students opening the window to the idea of a healthcare professional career. ZSFG nursing staff will partake in the annual San Francisco International School’s career day expo Friday, November 18th representing the nursing profession to the senior students who are all recent immigrants in the unique SFUSD high school, a close neighbor to ZSFG. Nursing Recruitment and Retention Nursing orientation and training programs are in full swing this November. The Emergency department had 10 nurses begin the ED training program. Labor and Delivery new staff are being oriented with one to one preceptors. NICU has 2 staff currently in the training program and they are doing well. Pediatrics has 3 staff in the midst of their training program. Psychiatry has 6 RN beginning their training program this November and December. In Critical Care 6 nurses have started their training program this month. Medical/Surgical nursing have 47 nurses in the didactic portion of their training program that began November 10th. PeriOperative nursing has a request to hire six RN staff will be starting their training program in January.
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Lower Level of Care Discharge Data for the month of November 2016 MedSurg
Discharge Destination % LLOC Patients
11 Acute Hospital 0.6%
13 AMA (includes AWOL) 2.9%
14 Board & Care 1.7%
18 Expired 4.0%
19 Home 47.1%
20 Hospice - Facility 3.4%
23 Hotel Temporary 0.6%
25 Medical Respite 6.3%
27 Psych Board & Care 1.1%
28 Psych Inpatient 1.1%
33 Shelter 6.3%
34 Skilled Nursing Facility 12.1%
35 SNF Rehab 8.0%
99 Other 4.6%
Grand Total 100.0%
PSY ( Excludes 7L)
Discharge Destination % LLOC Patients
10 Acute Diversion Unit 24.3%
13 AMA (includes AWOL) 5.4%
15 Board & Care - Elderly 2.7%
19 Home 16.2%
22 Hotel 10.8%
30 Psych Locked Facility 16.2%
31 Psych SNF 2.7%
32 Residential Treatment
Facility 8.1%
33 Shelter 10.8%
36 Sub-Acute Facility 2.7%
Grand Total 100.0%
SNF
Discharge Destination % LLOC Patients
11 Acute Hospital 14.3%
19 Home 78.6%
32 Residential Treatment
Facility 7.1%
Grand Total 100.0%
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Emergency Department (ED) Data for the Month of October 2016
October 2016 Diversion Rate: 59% Total Diversion: 302 Hours, 31 Minutes (40.6%) + Trauma Override: 136 Hours, 27 Minutes (18.3%) ED Encounters: 6243 ED Admissions: 962 Admission Rate: 15%
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Psychiatric Emergency Service (PES) Data for the Month of October 2016
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Psychiatric Emergency Service (PES) Data for the Month of October 2016…continued
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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).
Analysis:
Large increase in patients accepted and arrived, from 6% in September to 28% in October.
The percentage of referrals which were screened appropriate and cancelled decreased to 56% this month, down from 64%.
Commissioner Comments: Commissioner Singer stated that data shows variances in the Med-Surg rate and asked what is within “normal” range. Ms. Dentoni stated that the rates fluctuate.
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7) ZSFG RN HIRING AND VACANCY REPORT Ron Weigelt, Director of Human Resources, DPH, presented the report. Mr. Weigelt introduced Daniel Giddings as a new SFDPH recruiter to assist in ZSFG-related hires. Karen Hill stated that notices were sent to 580 per-diem staff encouraging them to apply for permanent positions. Director Garcia stated that the Mayor has requested that CCSF Departments not increase FTEs in the near future; this will not impact ZSFG hiring processes but will impact the general SFDPH. Commissioner Comments: Commissioner Singer asked for an update on SFDPH Human Resources data systems to the full Commission in the future.
8) MEDICAL STAFF REPORT
James Marks, MD, Chief Medical Staff, presented the report. ADMINISTRATIVE Electronic Health Record (EHR) Strategy Announcement Ms. Barbara Garcia announced to members at the November 14, 2016 Leadership MEC meeting that after several months of due diligence, teamwork, and professionalism, the Health Department and UCSF teams exploring the possibility of a shared electronic record have concluded that the shared model could not be accomplished within the budget pre-approved by the Board of Supervisors. Members, while disappointed with the outcome of the UCSF APeX shared model, expressed their gratitude to the Department’s leadership for their work and commitment to the adoption of an enterprise-wide EHR. Following the announcement, Dr. Marks received l feedback from a number of medical staff members expressing disappointment and sadness with this decision. Dr. Marks reminded members that included in the roles of Service Chiefs is managing these responses and providing clarifications. Service Chiefs are highly encouraged to discuss this important issue at faculty meetings. Bullet points include:
“NO Go” decision despite six month of extensive work by UCSF and DPH teams
Greater than $70 M gap in the final budget
DPH is moving forward with acquisition of an enterprise EHR
DPH will issue a Request for Proposal (RPF) for a fair and competitive method of selecting a vendor.
Six month delay expected with the Go Live date SERVICE REPORT: Neurology Clinical Service– J. Claude Hemphill III, MD, Service Chief The report included the following:
Mission and Scope of Services – Clinical Mission, Clinical Scope, Research Mission and Teaching Mission.
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inpatient Services – General Ward Services, General Consultation Service, Neurocritical Care Service, Night Resident Rotation
Outpatient Services – General Neurology Clinics, Sub-Specialty Clinics (Epilepsy, Stroke Clinic, Geriatrics Neuro, and Neuroimmunology)
Neurodiagnostic Laboratory Services – EEG, EMG,)
Training and Teaching – UCSF Neurology Residents, Outside service interns/residents, Neurocritical Care Fellows, and Medical Students.
Attendings and Staff
Performance Improvement Activities – General (Neurology PI Committee, Faculty Meeting, Morning Report, and Professor Rounds), Projects (Time to next 3rd New Outpatient Appointment, Acute Stroke Activation, A3 regarding external stroke mortality benchmarks.
NIH Funded Research Projects (PI)
Income/Expenses by Fund Source Fiscal 2014-2016
Assets – Strong ties with UCSF Dept. of Neurology, Brain and Spinal Injury Center, Grant Support, Collaboration with SFGH, Quality of UCSF Neurology Residents and Fellowships, International Reputation for Neurocritical Care/Stroke & HIV Neurology Programs
Challenges – Outpatient Clinic Infrastructure, underfunded service, Impact of Parnassus Funds Flow Model, Grant Funding (esp Federal) increasingly challenging.
Goals: (1) Re-engineer outpatient neurology services (create Neurology service links to SFHN primary care providers and improve subspecialty services) (2) Capitalize on existing expertise, relationships with other Clinical Services, and new hospital to implement visionary programs that highlight ZSFG, (3) Fund service pro-actively so that improvements can be realized as opposed to continual “catch-up”, (4) Mentor and support junior faculty towards extramurally funded clinical and translational research (5) Enhance philanthropy to realize mission goals..
While the Service continues to deal with outpatient issues like lack of space, challenges faced by providers who are expected to deliver inpatient and outpatient services concurrently and high no-show rate are making it difficult for providers to have individual panel of patients, Dr. Hemphill reported that the Service has achieved major improvements in TNAA, and improved flow during clinics since the 2014 MEC report. Dr. Hemphill credited these improvements to additional personnel from the hospital and the Dean’s Office, particularly the hiring of the first Neurology Outpatient Director with dedicated leadership and time for attention to tasks. Dr. Hemphill highlighted the Service’s outstanding young faculty who are the future of ZSFG, and have made significant difference in terms of patient car and flow. Dr. Hemphill stated that H34 is the “NeuroICU of the Future”, and should serve as destination center that highlights ZSFG. H34 provides advance neuromonitoring, data integration, precision medicine approach, and is the focal point of teaching/training staff best practices. Members thanked Dr. Hemphill for his excellent report, and commended the Neurology Clinical Service, under his leadership, for its outstanding services of residents and faculty to the hospital, and collaborative work with other Clinical Services.
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Commissioner Comments: Commissioners Singer and Sanchez requested that the Action Items be deferred until the next meeting so that a Health Commissioner who is a physician can be present to review the medical action items.
9) OTHER BUSINESS
This item was not discussed.
14) PUBLIC COMMENT
There was no general public comment.
15) 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
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).) (Action item)
Action Taken: The Committee approved December 2016 Credentialing Report; and the
Performance Improvement and Patient Safety Reports. The Committee voted not to disclose other discussions held in closed session.
16) ADJOURNMENT The meeting was adjourned at 4:49pm.
