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Edward A. Chow, M.D. 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, February 28, 2017 3:00 p.m. 1001 Potrero Avenue, Building 25, 7th Floor Conference Room H7124, H7125 and H7126

San Francisco, CA 94110

1) CALL TO ORDER Present: Commissioner David J. Sanchez, Jr., Ph.D. Commissioner David Pating, MD Excused: Commissioner Edward A. Chow, M.D., Chair Staff: Barbara Garcia, Roland Pickens, Susan Ehrlich MD, Terry Dentoni, Troy Williams,

Todd May MD, Jeff Critchfield MD, Tosan Boyo, Alice Chen MD, Karen Hill, David Woods, Dan Schwager, Aiyanna Johnson, Valerie Inouye, Ron Weigelt,

Commissioner Sanchez chaired the meeting, which was called to order at 3:12pm. 2) APPROVAL OF THE MINUTES OF THE FEBRUARY 28, 2017 ZUCKERBERG FRANCISCO GENERAL

JOINT CONFERENCE COMMITTEE MEETING Action Taken: The Committee unanimously approved the minutes.

3) REGULATORY AFFAIRS REPORTS Troy Williams, Chief Quality Officer gave the report. Commissioner Comments: Commissioner Pating asked for clarification of the location of the ZSFG skilled nursing unit. Mr. Williams stated that unit 4A is in building 5. Dr. May stated that the unit is a short term acute facility.

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4) ZSFG A3 OPTIMIZING A CARE EXERIENCE MODEL Aiyana Johnson, Chief Patient Experience Officer, gave the presentation. Commissioner Comments: Commissioner Pating asked if ZSFG is utilizing national best practices to improve food services. Ms. Johnson stated that there are fiscal issues involved in improving food services. She added that there are industry experts that can improve “cook and chill” methods. She also stated that currently ZSFG dietary staff only interact with patients that have therapeutic dietary orders; ZSFG is exploring options to expand this service. Commissioner Pating asked if any hospitals are getting patient satisfaction ratings above 50%. Dr. Critchfield stated that hospitals offering food “on demand” receive higher patient scores. Dr. Ehrlich stated that ZSFG will study what it can improve in its current system which may result in a combination of “cook and chill” meals and “on demand” snacks. She added that the “cook and chill” method is more predictable and fits in better with a unionized work environment. “On demand” systems requires re-training staff and a different work flow. Commissioner Sanchez noted that the ZSFG population is one of the most diverse and meeting food needs is a challenge. Dr. Critchfield stated that ZSFG will continue its efforts to work with families to honor cultural preferences and tastes.

5) HOSPITAL ADMINISTRATOR’S REPORT Susan Ehrlich M.D., Chief Executive Officer, gave the report. California Department of Public Health Surveys CALIFORNIA DEPARTMENT OF PUBLIC HEALTH SKILLED NURSING FACILITY LONG TERM CARE SURVEY On February 27th, the Health Facility Evaluator Nurse (HFEN) Surveyors from the California Department of Public Health (CDPH), arrived at ZSFG to conduct the CDPH/CMS Skilled Nursing Facility (SNF) Long Term Care Relicensing/Recertification Survey. The survey took approximately four days to complete. During the visit, surveyors visited the following areas: the Building 5 kitchen, power plant, laundry services, conducted resident and staff interviews, and conducted medical record reviews. There were only three minor findings identified during the exit conference. The team immediately addressed them. These are outstanding survey results, considering the intensity of the review by five surveyors for four days. Many thanks to Anna Calderon, RN, Nurse Manager of the Skilled Nursing Facility and her staff for being well-prepared. CALIFORNIA DEPARTMENT OF PUBLIC HEALTH SKILLED NURSING FACILITY FIRE LIFE SAFETY CODE SURVEY On March 9th, one CDPH Health Facilities Evaluator arrived on campus to conduct a one-day unannounced Fire/Life Safety Code survey of the 4A Skilled Nursing Facility (SNF). They surveyor conducted a walkthrough on 4A to check for Fire/Life Safety Code compliance and reviewed Life Safety Code documentation with Fire Marshall Rich Elliot. There were two minor findings that were corrected in real time. Many thanks to Rich Elliott, Greg Chase, and the Facilities Team for ensuring a successful Fire/Life Safety Survey. Mardi Gras Celebration News Coverage on SF Chronicle On February 23rd, ZSFG hosted a Mardi Gras and Black History Month celebration. The Mardi Gras celebration featured Southern food cooked by Executive Chef Michael Jenkins, and as a bonus for Black History Month, a lunchtime concert by the Marcus Shelby Trio.

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A podium was draped with balloons and the packed room was lively with conversation. Stella Landry began a soaring rendition of “Lift Every Voice and Sing”. There was stirring poetry; informative history pointers; a speech from Supervisor Malia Cohen, two students describing the goals of White Coats for Black Lives and its work against “race-based medicine” and “medical apartheid”, and then a hearty thank-you “to all the African American employees who work in this institution.” Many thanks to our CHEARS committee, ZSFG’s employee recognition group, and Food and Nutrition Services, for continuing to plan events that support and recognize our staff. Emergency Department Improvement Workshop During the week of March 3rd, the Emergency Department team conducted a week-long improvement event focused on the front-end flow in the Emergency Department. This improvement workshop was an extension from a previous December 2016 workshop. During the improvement workshop, the team focused on four improvement ideas: (1) Quick Sorting at Greet "Quick Triage", (2) Optimizing Fast Track, (3) Improving Patient Property Management, (4) Upgrading Physical Space and Materials in Triage. After testing three combinations of Quick Sort/Triage and Fast Track, the team reduced mean greet to triage time for non-ambulance patients by 25% and lead time for greet to provider for all ESI 3/4/5 patients by 26%. Many thanks to the improvement team for another successful workshop! Lean Certification Module Marathon In March, ZSFG concluded a third cohort of lean leadership certification. The purpose of the training is to internally develop leaders with the lean knowledge and skills. The lean leader certification process is not only rigorous but requires the commitment of leaders to spend the time necessary to gain the knowledge and skills to learn how to lead differently. Rona Consulting, ZSFG’s coaches throughout the process, guided 22 participants through a nine week training module. Participants were expected to participate and pass the final session by teaching back. ZSFG is happy to share that all 22 leaders who participated in cohort 3 passed and are certified to train others. Thus far, ZSFG has now trained and certified 49 total leaders! Congratulations, team.

March is National Nutrition Month March is Nutrition Month! It was also Registered Dietitian Day March 8th. On March 22nd, our dietitians and dietetic technicians registered (DTR) held the Nutrition fair in the cafeteria. ZSFG would like recognize our outstanding team of Registered Dietitians and Dietetic Technicians who ensure our residents are nutritionally optimized. National Patient Safety Awareness Week During the week of March 13th, ZSFG celebrated National Patient Safety Week. The celebration aims to increase awareness of patient safety on a national level. ZSFG proudly participates in many measures to improve patient safety and reduce error rates. To promote this, the ZSFG team participated in the AHRQ Culture of Safety Survey last week and reached a record high response rate of 1600 individual responses, this represents a 30% response rate for all staff and providers working here at ZSFG. This is an outstanding accomplishment as it is an important and valuable tool we use to measure perceptions of patient safety every 2 years. ZSFG expects to share results by early April, as well as a plan to respond to the results in order to improve our culture of safety.

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On March 14th and 16th, ZSFG celebrated National Patient Safety in the cafeteria with Roulette, sweets and drawings to win one of three $10 gift cards for Subway Sandwiches. Many thanks to our safety team! March is Social Work Month The National Professional Social Work Society celebrates social workers across the country in order to highlight the important contributions they make to society. ZSFG Social workers stand up for our patients every day. These include patients who are experiencing devastating illnesses and mental health crises, children, families and communities. Social workers are invaluable and continue to make our community a better place. ZSFG celebrates the contributions of social workers during National Social Work Month in March. Patient Flow Report for February 2017

A series of charts depicting changes in the average daily census is attached to the original minutes.

Medical/Surgical Average Daily Census was 225.93 which is 111% of budgeted staffed beds level and 90% of physical capacity of the hospital. 10.80% of the Medical/Surgical days were lower level of care days: 1.19% administrative and 9.61% decertified/non-reimbursed days. Acute Psychiatry Average Daily Census for Psychiatry beds, excluding 7L, was 42.96, which is 98% of budgeted staffed beds and 64.3% of physical capacity (7A, 7B, 7C). Average Daily Census for 7L was 5.93, which is 84.7% of budgeted staffed beds (n=7) and 49.4% of physical capacity (n=12). Latest Utilization Review data from the INVISION System shows 61.89% non-acute days (61.06% lower level of care and 0.83% non-reimbursed). 4A Skilled Nursing Unit ADC for our skilled nursing unit was 27.14, which is 96.9% of our budgeted staffed beds and 90.4% of physical capacity. Salary Variance to Budget by Pay Period Report for Fiscal Year 2016-2017 For Pay Period ending January 24, 2017, Zuckerberg San Francisco General recorded a 2.83% variance between Actual and Budgeted salary cost – actuals were $402,390 over budget. For variance to budget year-to-date, San Francisco General Hospital has a negative variance of $6,302,675 /2.7%.

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Commissioner Comments: Commissioner Sanchez noted that over the past twenty-five years, SFDPH employees have received many SPUR awards due to their ground breaking work.

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Commissioner Pating stated that he is proud that ZSFG has led the way for other SFDPH sections to utilize the Lean methodology. Director Garcia stated that the current SFDPH budget has over $1M designated to SFDPH-wide Lean activities.

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6) PATIENT CARE SERVICE REPORT Terry Dentoni, Chief Nursing Officer, gave the report.

Professional Nursing for the Month of February 2017

Nursing Professional Development The first week in March, the Emergency Department team held an Improvement (Kaizen) workshop to develop a quick sort process that will reduce the time a patient waits to see a provider. They also looked at ways to optimize fast track flow. Maternal Child Health nursing had their two day Breastfeeding Basics course for newly hired staff from the past 6 months. The course is a requirement to maintain our baby friendly status. Nursing Recruitment and Retention Six nurses are enrolled in the Critical Care training program’s didactic portion where they attend classes every other week in addition to their preceptor orientation. A total of 8 experienced nurses just finished their orientation and training to the SICU (2) and MICU (6). The Emergency Department training program has had 8 nurses successfully complete all phases of the department orientation. Their Winter 2016-17 group of 8 new nurses, have successfully completed their orientation and training to the ED pods A, B and C. Interviews are being scheduled this month for a brand new group start in the ED Spring training program. Maternal Child Health has 6 staff that finished their training to the labor & delivery process. They will be training to postpartum next month. Another group of new staff completed their post-partum orientation and training in March and now they will be training on the labor and delivery portion of the department. Medical Surgical nursing has hired three P103 nurses and is in the process of transitioning 13 new P103 staff in the orientation and training program to 2320 positions. Psychiatry has just hired one nurse who will begin orientation soon. Nursing Community Awards Supervisor Melia Cohen awarded Brenda Barros a certificate of honor at the February 28, 2017 Board of Supervisors meeting for her leadership, community support and work with SEIU 1021 during the Board’s Black History Month celebration.

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Emergency Department (ED) Data for the Month of February 2017

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February | 2017 Diversion Rate: 68%

ED diversion – hours 309 (46%) + Trauma override - hours 149 (22%) Total ED Encounters: 5723 ED Admissions: 932 ED Admission Rate: 16%

Psychiatric Emergency Service (PES) Data for the Month of February 2017

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Psychiatric Emergency Service (PES) Data for the Month of February 2017…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).

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ANALYSIS Inpatient admissions increased slightly this month, which likely led to the decrease in Condition Red and Average Length of Stay.

Commissioner Comments: Commissioner Pating thanked Ms. Dentoni for continuing to report diversion rates. He noted that this is an issue that the Health Commission continues to monitor.

7) ZSFG RN HIRING AND VACANCY REPORT Ron Weigelt and Karen Hill, Human Resource Department, gave the report. Commissioner Comments: Commissioner Pating encouraged the SFDPH to include customer service skills in its screening of new employees. He noted that these skills are important and can be gained in a myriad of life experiences.

8) MEDICAL STAFF REPORT James Marks, M.D., Chief of Medical Staff, gave the report.

Action Items: The following items were unanimously approved:

CTSI Privilege List Revisions

Ophthalmology Clinical Service Rules and Regulations, Policies, and Procedures

9) OTHER BUSINESS This item was not discussed.

10) PUBLIC COMMENT There was no public comment.

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11) 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 Taken: The Committee approved March 2017 Credentialing Report and Performance

Improvement and Patient Safety Report. The Committee voted not to disclose other discussions held in closed session.

12) ADJOURNMENT The meeting was adjourned at 4:01pm.