AGENDA

• Introduction and Executive Leadership

• Year in Review • Environment of

Care Report and Policy Approvals

3

San Francisco General Hospital and Trauma Center – Executive Leadership

• Roland Pickens, Interim Chief Executive Officer

• Brent Andrew, Chief Communications Officer

• Jenna Bilinski, Kaizen Promotion Office Director

• Max Bunuan, Associate Hospital Administrator for Facilities & Support Services

• Margaret Damiano, Associate Dean of Administration, UCSF

• Terry Dentoni, Chief Nursing Officer

• Karen Hill, Departmental Personnel Officer HR/SFGH

• Valerie Inouye, Chief Financial Officer

• Shermineh Jafarieh, Associate Hospital Administrator

• Aiyana Johnson, Associate Hospital Administrator / Chief Care Experience Officer

• Winona Mindolovich, Acting Associate Chief Information Officer

• Iman Nazeeri-Simmons, Chief Operating Officer

• Kimvan Nguyen, Director, Administrative Operations & Government Affairs

• Basil Price, Director of Security

• Terry Saltz, Rebuild Director

• Baljeet Sangha, Associate Hospital Administrator

• Troy Williams, Chief Quality Officer

• David Woods, Chief Pharmacy Officer

Executive Medical Staff Leaders

• Sue Carlisle, M.D., UCSF Vice Dean

• Todd May, M.D., Chief Medical Officer

• James Marks, M.D., Chief of Medical Staff

• Jeff Critchfield, M.D., Medical Director, Care Experience and Risk Management

• Lukejohn Day, M.D., Chief Integration Officer

• William Huen, M.D., Associate Chief Medical Officer

A Year in Review

Achieving excellence is an ongoing journey.

Mission• The mission of the San Francisco General Hospital & Trauma Center is to

provide quality health care and trauma services with compassion and respect.

Vision• Our vision is to be the best hospital by exceeding patient expectations and

advancing community wellness in a patient-centered, healing environment.

Values

• Learn by going to see

• Improve using Plan, Do, See, Act (PDSA) problem-solving

• Engage through teamwork and collaboration

• Care by showing respect and developing staff as leaders

True North

True North Category True North Metric Owner Goal Target FY1415

Safety Patient Harm Will Huen & Troy Williams By July 2016, reduce the annual number of harm events to 169 events

169 238

Quality Observed to expected mortality ratio

Will Huen & Troy Williams By July 2016, reduce observed to expected mortality ratio to 0.80

0.8 0.85

30-day readmission rate

Michelle Schneiderman By July 2016, reduce SFGH 30 day readmission by 10%.By July 2019, reduce SFGH 30 day readmission by 15%

10% 12%

Care Experience Measure of Patient Satisfaction

Jeff Critchfield & Aiyana Johnson

By Q1 2017, improve HCAHPS “Likely to recommend SFGH to friends” from 60 to 80th percentile

80% 62%

Access and Flow Terry Dentoni & Jim Marks By July 2016, reduce ED Patient Left without being seen (LWBS) rate from 8% to 6%

6% 8%

Access and Flow Terry Dentoni & Jim Marks By July 2016, reduce ED Arrival to Departure Time or Patient Discharge

210 mins 249 mins

Access and Flow Terry Dentoni & Jim Marks By July 2016, reduce ED Arrival to Departure Time or PatientAdmission

360 mins 492 mins

Develop People Staff Satisfaction Iman Nazeeri-Simmons By July 2016, train additional 200 staff and physicians in A3 problem-solving

200 75

Developing Problem-Solvers

Iman Nazeeri-Simmons By July 2016, 100% of executives have authored at least two A3's

100% 35%

Financial Stewardship FY1415 Salary Budget vs Actuals

Valerie Inouye By July 2016, meet labor & salary budget goals

$320,780,334 $317,942,087

Length of Stay Will Huen Decrease inpatient length of stay to 6.2 days

6.2 6.5

Daily Management System

“It really strengthens our ability to improve.”- Director of Surgical Services

• Operating Room

• Medical/Surgical

• Post-Anesthesia

Model Cells

Model Cell Improvement Work

Baseline Current Goal

OR Reduce average room turnover time by 25% by

November, 2015.

45 mins 38 mins 30 mins

PACU Reduce Pathology Specimen Slip

Defects

20% 1.4% 0%

5D Reduce percent of peripheral IVs

that have a defect to less than 15%.

80% 10% 15%

Model Cell Improvement Work

Value Stream Improvement WorkOutpatient Pharmacy

Outpatient pharmacy has reduced the time to refill a prescription from over 2 hours to less than 30 minutes.

Value Stream Improvement WorkSurgical And Procedural Services

In May 2014, patients needing cataract surgery had a 300 day wait. Through improvement work, the number of patients receiving cataract surgery increased from 4 to 11 cases per block time.

6.3 6.25.6 5.75 6

6.5

4.25

5.46.25 6

6.57

7.758.2

11

0

2

4

6

8

10

12

Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May

Cas

es/b

lock

Month

Cataract Surgery Cases

FOR APPROVAL

• Environment of Care Report

• Performance Improvement and Patient Safety Program

• Provision of Patient Care

QUESTIONS?