Too many times we are addressing problems in a healthcare setting that are far too advanced for minimal or non life altering treatment because they simply were not caught early enough. My idea is to implement a reward system that encourages rountine checkups with your healthcare provider insead of only when there is a "problem" this system would also reward healthy behavior. In doing this we would substaintially save in healthcare costs overall and greatly reduce rescources needed. This would apply to the UCSF Health sysrtem and its Clinics. 

Public transportation is the best way to get around San Francisco and is what most of our patients use.  Although we have the UCSF shuttle service that could be used between locations, there are only 2 routes that stops at a BART station, and neither one goes to Parnassus or Mt. Zion.  Therefore, our patients have to rely on Muni, which unfortunately is very unreliable.  If we could provide shuttle service from the BART station to Parnassus and Mt. Zion locations, it would make it easier for patients to make it to the hospitals, thus help lower no shows and late shows for appointments, not to mention higher patient satisfaction.

I would suggest to provide some additional training to  SFGH Pharmacy staff snd  Billing Departement in order to start providing services to our Medicare population. Currently those patients are being re-directed to private pharmacies. I am sure that revenues  from Medicare could find a good use at SFGH and UCSF.

During ophthalmology procedures, eye drops are used that are patient specific and required post-op.  However, they are not appropriately labeled for discharge and thus thrown away.  If these medications were ordered as discharge meds, thus would be appropriately labeled, they could be given to the patient post op and send home with them.  There would not be any wastage of the eye drops post op, they would be labeled for discharge and patient will not have to wait for discharge medications, nor go out via pharmacy to pick up medications.

Using scribes in clinic setting to increase efficiency and thus improve speed with which referring physicians receive consultation reports as well as increase volume of patients seen. 

I've been notified that this idea is currently being implemented, and therefore will withdraw it from the contest. Thanks.

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Ordering an outpatient laboratory test in APEX triggers automatic printing of a paper requisition form. The outpatient laboratory should be able to see these orders electronically, making the paper requistion an unnecessary waste of paper, ink, and electricity (printer use). In my experience, sending a patient to the lab with or without the printed requsition in hand makes no difference in the outcome: the lab will perform the appropriate test regardless. Fixing this in APEX should be easy. If patients want documentation of the test ordered, they can have their provider mention the tests in the AVS, or check MyChart for results.

Eliminate city provided cars, cell phones, credit cards.

All patients are given print out of the after visit summary. I often write detailed patient instructions and have often found that patietns would forget the details of instructions ( even though it was written down and a print out was given). I think its often misplaced after few days. Many physicians often get Mychart  questions after few weeks about the issues that were written down on the AVS but patients forgot because they lost the AVS.

I propose we should be able to make some changes in the APEX in a way that AVS should be created but pushed /emailed to patient via MyChart at the time of check out (instead of printing) and they can access it in their email inbox anytime. In my experience many patients would prefer to have it in their email than get a paper print out. 

Of course, this would not apply to certain patients who do not use email or MyChart or who prefer a paper print out.

Summary of benefits:

1) Saving paper

2) Saving printer ink/electricity

3) Increase patient retention of instructions

4) Patients can get the procedure instructions ( like for colonoscopy preparation instructions) added in AVS as dot phrase and emailed. There are several times, they call back as they lost it and takes a lot of time for office staff to work on arranging it send it to them again

5) Will save time of physicians and office staff as it will reduce some of the phone calls/messages

All physicians in California are legally required to report any disorder "characterized by a lapse in consciousness" to the Department of Public Health, who in turn notify the Department of Motor Vehicles. The goal is to make sure that people with seizures, cardiogenic syncope, etc. are treated appropriately before they resume driving. Whether mandatory reporting really reduces patient morbidity is an area of active debate in the neurology community. However, the law is clear - physicians' failure to report these diagnoses in a timely fashion may lead to significant liability, should the patient continue to drive and suffer another loss of consciousness.

At present, physicians and staff must locate the Confidential Morbidity Report form (http://sfcdcp.org/document.html?id=322), print it, fill it out by hand, scan it into APEX (for medical documentation purposes), and then FAX it to the DPH. This system can break down at any point in the chain, leaving many patients unreported. It is also quite inefficient and resource-intensive.

We propose that the CMR PDF form be available through APEX - perhaps through a "CMR" tab in the visit navigator, available to all physicians in all clinical contexts/environments. If it is possible to autopopulate the patient's demographic information, autopopulate UCSF "reporting facility" information (with the address and phone number changing in response to the clinical context used for login) and route the form to be FAXed via APEX, we would conserve a variety of resources: physician time, staff time, and the ink, paper, and electricity required for printing and scanning. Most importantly, compliance with state law would improve, better protecting our physicians and patients.

- Manu Hegde and Ellen Weber

Many patients, particularly at SFGH, are non-native English speakers.  Unfortunately, there few live translators available, and none after hours.   Translator phones are often few and far between or malfunctioning.  Furthermore, many patients are cognitively impaired or have hearing impairment, which makes the use of a translator phone difficult and ineffective.  Language barriers contibute to costs and adverse events: 1. Patient may misunderstand discharge instructions, leading to readmissions  2. Patient may misunderstand safety instructions, leading to falls or other adverse in-hospital events  3.  Patient satisfaction is impaired when not understanding the care plan

Given the above problems, I propose forming language-based hospital units.  As Spanish and Cantonese are likely the two most common non-English primary languages spoke at SFGH, I propose starting with those two languages and forming the Chinese and Spanish Service Programs.  As part of these progams, MDs, RNs, CNAs, unit clerks, therapists, and other ancillary staff who speak Spanish and Cantonese should be assigned preferentially to a certain unit (eg 5A), and patient who speak that language should be preferentially admitted to that unit.  This simple and free grouping of patients and staff into language-based units will save money and improve outcomes with only minimal administration efforts.  This same language-based service program could easily occur at UCSF as well depending on the number of non-native English speakers admitted to that hospital.

UCSF operates the clinical labs for Parnassus and MZ and a separate lab at SFGH.  Given that the average age of clinical lab scientists is north of 55 and the fact that few are graduated in California each year, why not consider consolidating the labs Parnassus, MZ, SFGH and the new Benioff Hospitals?  This could increase efficiency and address labor pool shortages.

Create an internal website maybe on Care links where departments can list and search for office or medical supplies that they need or have extras of.  Instead of ordering right away, employees or practice managers can see what might be available on the website.  Also, departments can list things they may be looking for,(i.e. wish list items).The small items can be delivered via inter-office mail.  It would be a form of recycling and money saving because inevitably, offices end up with extra 3inch binders, an extra ink cartridge for a printer that no longer exists and even color paper.  These items accumulate over time and take up space that can be used more efficiently.  This is especially sad, if it could be used by someone else for free!  It could be divided by specific groups or even UCSF locations.  Maybe there is a better way to implement this but it just seems like such an easy way to save money. 

Thanks for reading!

Ariana Amidi

In the operating room, there are many supplies that are opened BEFORE the surgeon actually needs them.  This includes implants (patch materials, etc) and sutures.  The scrub nurses try to "stay ahead" but the could stll stay ahead if they would open things more "on demand" rather than in batches which results in tremendous waste.  I understand their desire to make sure they have everything just when the surgeons need it, but with better communication between the surgeons and their scrubs and a conscious effort to avoid opening too much product and once, we can have a significang impact on reducing wasted expensive materials.

For UCSF Benioff Children's Hospital - integrate surgical services (orthopedics, urology, surgery) into primary hospitalist (purple and orange) teams.  This will enable physicians whom are on the pediatric floors to serve as the primary teams, with the surgical services consulting. This change would allow for easier RN communication with physicians whom are more readily accessible than our busy surgeons. Surgeons would, of course, continue to be involved in decision making for their patients but it would reduce the burden of needing to make medication changes and meet regularly with families. This could also enable faster discharges. Our families would also have a physician more readily accesible to answer questions and provide support, improving patient satisfaction. 

I believe that MYChart has the capability to send reminders to patients.  They can get reminders via text message,  email, US Mail, and phone call. The calls and email Often people schedule appointments so far in advance they often forget the appointments.  In my department we call the patients to remind them of the appointments.  We request a call back and if they do not call back the appointment is cancelled. The patient is given multiple opportunities to make contact. If the fail to return the call, we document in APEX in Phone Encounters the attempts we made to  contact the patient. If the patient has not returned the call by the day prior, I would say  cancel the appointment.

We communicate very clearly what our expectation is and if we have not heard from the patient by a certain date and time, the appointment will be cancelled. It helps to free up appointments for same day urgent patients. Patients who fail to respond are usually the patients who no-show. Responsible people call us back. We message this out to our patients so it does not come as a surprise. It can be labor intensive, but if everyone takes a few patients it makes the work not so daunting.

Reminder notices are helpful.... If you can automate them it's even better, then the process is automatic and not labor intenstive. It would be great if the patient could receive several reminder options, for instance a patient could choose phone call and text message. It is difficult to  get to 100%, but I think this would significantly reduce the number of no-show visits and help effectively utilize our resources.

Having service contracts could make sense on the short term.  But looking at expenses invested in maintenance for medical equipment through service contracts, and looking at the market using inhouse services how much they are saving, enforces the idea of investing in hiring personnel, training them, and then getting rid of the contracts.  Though, this idea does need some other low cost logestics to assure its success.

I have serveral ideas that would take time to implement, but would yield valuable results from a cost savings perspective and a patient satisfaction/customer service perspective.

Now that the UCSF has one system (EPIC/APEX) and the current "Funds Flow" model is changing , I would consoliate the following units:

1.  Consolidate the payment posting units associated with the Hospital (PFS) and the Medical Group (MGBS).  Currently both units are sending information back and forth to each other in attempts to balance ERAs (Electronic Remittance Advices) and bank lockbox payments.  Having both units under one roof improves communication, reduces posting errors, reduces the need to post to undistributed/unidentified Work-queues and ultimately can reduce staffing levels through economies of scale.

2.  Consolidate the Package/Transplant billing units associated with PFS and MGBS.  Currently both units shuffle paper back and forth via campus mail.  When MGBS has a global type transplant bill, they have to print the claim forms and send them to PFS.  Consolidating both units would improve on communication and would improve billing by at least one or two days.  The sooner the claims go out the sooner payment can come in.

3.  Centralize registration.  Today our registration process is decentralized and when there are changes due to payors (Covered-California rings a bell), training these changes is extremely difficult because the training has to be coordinated with hundreds of registration staff at various clinics.  Attempting to decipher insurance cards today requires an indepth knowledge of insurance acronyms and sending a bill to an incorrect insurance address will delay payment and causing much back-end work to correct.  Reimbursement rates are continuing their downward spiral, so getting it right the first time is imperative.   Having a centralized registration unit improves on having staff that specialize in registraion only that have time to ask the right questions and gather accurate information.  Today our clinic staff are burdened with collecting co-pays, posting money in the system, answering phones, answering nursing and/or physician quesitons, dealing with unruly patients and/or a long line of patients.  The front end staff, although do a good job, UCSF needs to understand that we need to do a great job.  We must do better to improve the "Patient Experience".  When incorrect information is in the system, things go wrong and ultimately the patient experience suffers and all the apologies and letters of apology just can't heal the bad experience.

4.  The following is extremely futuristic.  Since many of the UC Medical Centers have or are jumping onto the same system (EPIC), the consolidation of various departments/units can drive endless economies of scales.  Imagine one massive billing entity for two or three or five UC Medical Centers (this particular entity could perform these services anywhere).  Also, imagine one reimbursement contracting body for all UC's

Thank you for listening....Lupe Galvan 415-353-3816      

I doubt this is a novel concept, but it pains me to see hundreds of dollars unnecessarily charged to patients because of provider lack of awareness on the costs of medications.

The proposal is to have a small parenthetical (charge-to-patient) amount listed within the Apex medication orders.  While I do understand the markup between charge-to-hospital to charge-to-patient is signficant, in this era of bundled care, it is time to be transparent about these costs and consider this as a fourth, fifith, sixth consideration in choosing a particular drug.  Cost of course, should not be the primary reason to choose a drug.  

I do understand that this cost may not be imposed on the particular patient, and may be "picked up" by the insurer, but the entire system is impacted by higher cost drugs even if the direct impact is nil.  

For example, IV acetaminophen cost-to-patient is $150 while oral acetaminophen is a few pennies.  As the Director of the Acute Pain Service, I periodically see IV APAP unnecessarily adminsitered when PO APAP could be.  Another example: aprepitant. A single dose costs >$850 to a patient without their knowledge.  These drugs have signficant utility, but could be used more judiciously.  

Might this lead to desensitization to these costs?  Maybe-- but often when I relay this type of information to individuals, their awareness for such costs increases, and their behavior adapts.  

Transparent is the new black.  

-Ramo

Providers who order ambulatory radiology tests receive paper reports, as well as receiving results in APEX.  I frequently receive paper reports of results I have already reviewed in APEX, resulting in a huge, expensive paper and envelope waste when multiplied by all the providers at UCSF.  

If I could figure out whom to contact in order to stop these mailed reports, I would do it.  I recommend setting up a mechanism for "opting out" of paper reports for those with regular access to APEX. This might also decrease the risk of HIPPA violation by minimizing the risk of these reports not being shredded or disposed of in a safe manner. 

An email notice could be broadcast to all providers intermittently to instruct them how to opt out.  

Another option would be to just not send paper reports for tests that were ordered in APEX, since those who ordered the tests must be able to use the system to get results. 

Lisa Hannegan

Neurosurgery NP

Excessive imaging of patients increases health care costs and the risk for cancer. It also may create needless delays in disposition decisions. The idea: when a physician opens an order for a CT scan, prior CT's done in the last 3 years would be listed, allowing the physician to consider alternative means of testing or deciding not to image at this point at all. Additionally, the approximate amount of radiation and its risk for that study would be displayed. (Currently radiation information appears on the reading, but not in the order).

If UCSF scheduling staff is required to be well-versed in insurance types (PPO vs HMO, for example) and schedule appointments accordingly, the university may have fewer write offs.

For example:

I schedule appointments and obtain authorizations for the Voice & Swallowing Center, a subdivision of Otolaryngology. I identify whether a patient needs authorization prior to confirming an appointment date with them; for those with HMO-type plans, they are scheduled ~1-2 weeks out, depending on the insurance company, to ensure there is adequate time to obtain an authorization.

On the other hand, our General Otolaryngology department sometimes accepts walk-in appointments, and the staff is able to schedule next-available appointments (oftentimes within the next couple days) without checking to see if an authorization is needed. This results in the need to request retro auths, which certain insurance companies do not allow, and it leaves ambiguity when determining whether or not a visit will be covered if it was scheduled during the timeframe the authorization is pending.

Unless an appointment is medically-urgent (as determined by a RN or provider), patients who require authorization for routine services should be scheduled out with enough time to obtain such authorization. This still offers excellent patient care while increasing the likelihood of an insurance company paying the university for the billed services.

Hi,

 CPMC at 3838 California St has a LAB open on Sat , I think 9- 3PM, which is  very helpful for people who cannot go to the lab during the week because they cannot take time off from work. I also think more revenue would be generated by doing this. It also might cut down on traffic, and parking.

No. 2 Ideal   Do not send bills for 15. dollar or 20.  dollar copays, Collect all copays  and monies due at the front desk at the time of the visit.  It cost much more to send  bills for  co pays and monies due.

3rd Ideal  We at OHS have a short  huddle  meeting every morning when we all arrive at 7:30 AM.

Our wonderful director, manager,  and our team always has a  voice and discuss what is happening and what is needed during the day and week.  We always know if we have any urgent workers comp appointments and if we do not what we need to do so that employees may avoid  the ER which saves employees time and the hospital revenue. It is a real pleasure to work with the OHS team

With Respect,

April Andrews

For whatever reason patients will occasionally call the wrong department, this is usually already frustrating for the patient who has had to sit through the intro to the wrong department and when someone does pick up they’re told to call a different number or they’re sent to the trunk line to start from the very beginning. Instead of doing that we can use the tools available to us (ORGR, the global Directory, and even the internet). By creating a more direct path by simply getting them to the department they want. This will also free up others who would have had to do the same thing, keep the patient from having to explain themselves to multiple people, and lower the stress of the patient so that they don’t spend the first part of their conversation with the person in the correct department discussing how difficult it was trying to reach them.

If there is one thing that stays the same at SFGH, it is constant change. We change the way we perform our work duties on a monthly if not weekly basis. There is usually a looming imperative driving immediate change that eclipses all other previous practices, working or not. The drive for change far exceeds our institutional agility to respond in a meaningful way.

Patient care occurs via a complex chain-reaction machine that has evolved over time and is highly complex and variable. Its success comes not from its sytematic nature, but by the constant corrections of skilled healthcare workers. Many of the rule-based interventions that have been created as regulation bears down on us add complexity and expense to the requirments of patient care. They are static in nature and often obstructive in dynamic situations. They hindering the capability of humans to play their crucial role in providing quality care.

Simulation can and should be used extensively to test new work environments, processes and policies before patients are subjected to them. Simulation is used successfully and integrally in many other high hazard industries. We use it primarily for education at SFGH, often to rehearse for rare events. I propose that we use simulation to refine everyday practice, much of which we could be doing better, but don't have an effective way to engage multiple disciplines around a common goal. Simulation engages the people who know what they actually have to do to take care of patients and can create a more functional link between administration and front line workers.

Patients/visitors/family members often find it challenging to literally navigate the SFGH campus.  They get lost, miss appointments, waste their time walking around, etc.  It can be a potentially daunting, off-putting, or frustrating experience.

Having trained volunteers who can help these visitors in terms of directions, language, culture, navigation of the health care system, etc. would be a patient-centered welcome to SFGH which would engender increased good will and collaboration between patients and their SFGH providers, as well as have a positive impact on their healthcare in terms of improved compliance and decreased no-shows, missed appointments, patient frustration, etc.

Two (low-hanging fruit) measures which can be implemented in a cost-effective manner:

1.  "Patient concierges" (volunteers) on each floor which has significant numbers of visitor traffic, in the hospital(s) and clinic buildings, who actively, warmly, and eagerly welcome visitors and offer assistance in navigating our campus.  This is akin to concierge services provided at larger hotels, other hospitals, etc.

2.  "Patient welcome staff" (volunteers) who meet patients/visitors at the SFGH curb/roundabout (e.g. the wheel-chair bound) and help escort them to their sites.  This is akin to the welcome services provided at the airport for the physically disabled.

Web 2.0 developers can create a program that alerts doctors, administrative staff, and patients to unmet goals on a checklist. For example, hospitals can reduce cancellations due to uncompleted pre-op appointments. Further, alerts can be sent out to patients via email or sms if an appointment changes due to emergency schedule conflicts. Finally, this system can work with insurance companies to verify that the procedure is authorized and will be reimbursed.

The cost of running an operating room is significant - it is estimated that the cost of the use of a routine operating room at UCSF Health System is $69/minute. This means that any unused operating room time is a significant loss of money. On any given day, an operating room is used for multiple cases. Once one case finishes, a cleaning staff comes into the OR to clear away trash and the OR staff takes away supplies from the previous case and sets up supplies for the next case. The anesthesia team also must prepare for their next case in having all of their supplies and medications ready.

Despite the fact that this "turnover" happens multiple times a day in every operating room in the hospital, turnover times vary widely. At times, turnover can happen in 10 minutes, whereas at other times (but under the same circumstances/same cases), those turnover times can exceed an hour. The cost from these lost minutes of OR time is astounding. That extra 50 minutes of unused OR time costs the hospital $3,450 - and this lost time is occurring in every operating room, multiple times per day. For example, choosing one random day to look at the Parnassus OR schedule, the mean turnover time for scheduled cases was 52.2 minutes, with a total of 1776 minutes of turnover time, costing $122,544 (if using the $69/minute cost). We know that turnover can happen much faster when people are properly incentivized.

I propose using a monetary incentive program to reward staff to decrease turnover times by providing a monetary reward for turnover times that are below a goal number of minutes. This incentive should be directed towards all members of the team to encourage buy-in and participation. This has been done in other hospitals and has been shown to significantly reduce turnover times and costs related to unused OR time. We could institute this at either San Francisco General Hospital, or UCSF Health System, or both.

Patient ER visits and readmissions after discharge incur many costs, both to the patients and their families and to the hospital, which can often be quite substantial. Often, these readmissions occur because after a patient is discharged home, they are unsure of what to do about symptoms they experience and rather than talking with their providers, they wait too long to seek help so that problems that could have been handled with a visit to an outpatient provider or a phone call must then be dealt with in the emergency room or a hospital admission. Anything we can do to reduce patient readmission after discharge or hospital-based procedures would help our patients avoid further visits to the hospital, would reduce our hospital costs, and would likely improve patient satisfaction.

Some departments make routine phone calls to patients the day after discharge in order to address these issues and solve problems before they become a reason for a visit to the hospital. Often these phone calls also help to ensure that patients know the best way to contact providers if they do have questions or problems in the future, so that patients call and talk with a provider rather than showing up to the emergency room.

I propose that the medical center designates adequately-trained individuals to call every patient within 24 hours after discharge from the hospital or after a hospital-based procedure at the UCSF Health System. To evaluate the efficacy of the program, we can track readmission/ER visit rates to determine if rates of readmission or ER visits decrease after instituting the routine phone calls. In each phone call, any problems/difficulties that the patient was experienced would be addressed and would be passed on to someone qualified to address them, and the patients would also be asked if they knew the appropriate way to contact their provider and would be given this contact information again if needed. This would not only work to save costs by avoiding readmisisons, but would also likely result in improved patient satisfaction and patient experience with our health system as well.

No-shows for clinic visits are hugely costly and lead to inefficient clinic practices. While there are many root causes, a signficant contributor is pre-appointment engagement (or lack thereof). I propose the development of a patient-centered, low-cost, online pre-appointment portal, which promotes active engagement and personalizes the experience for the patient. Patients can learn about the MD they are going to visit, have the opportunity to ask questions, fill out questionnaires, and have tools to facilitate the doctor communication. Through this portal, patients can be notified automatically pre-appointment (via text, emails, or automated phone calls).

UCSF Health System

Create an environment where conservation is part of every units culture, in regards to; electicity and costly medical supplies.

-Often lights are left on in infrequently used rooms i.e. staff bathroom, linen room, and room where we store belongings/walkers-turn off lights when exiting, investigate use of motion sensing switches in infrequently used rooms.

-Investigate alternatives to costly medical supplies-i.e. use of clean cotton ball vs sterile 2x2 gauze after fsbg

-Simple reminder signs to staff as they prepare to go off shift, to empty pockets of unit pens, penlights, dry erase markers etc

-Educate staff re: cost of a full linen change, make it ok to re-use a non-soiled heavy blanket on patients beds, and to avoid the automatic placement of chux to every pt. bed

-Avoid distributing basin and kidney pans to all patients on admission.

Hello,

Any clinics that spend over $40 a month on water bottles with Arrowhead or other companies could get a better price through Macke Water.  Their monthly rental is $34.95 with no bottles to store and change out.  Installation is $75 to hook the water system to a water source.

This could potentially save a lot of money PLUS decrease the chances of employees hurting themselves changing out the bottles.

Hello.  I'm suggesting that there is a need for a JCAHO-like entity to be created to oversee ethical financial management of UCSF and UC wide institutions.  An independent body made up of people with financial expertise and a proven track record of ethical financial management and high integrity to evaluate, survey, and study the various proposals that UC management 'implements' to the University. 

Since the 'implementation' style of management has taken effect at UCSF within the last couple years, the results have generated aggressive, reactionary responses.  There have been more worker strikes than ever before within a short duration of time and much upheaval due to this 'implementation' aggressive, non-negotiating style of management.  The justification for this style of management is always due to fiscal responsibility and financial savings for the University.  However, the people that generate the supposed financial savings are people who are politically tied by their occupations to ensure that the University accepts their data.  In other words, those people who present the financial incentives toward convincing management to 'implement' decisions in the University work for the University and are invested in making sure their numbers are accepted....with no objective analysis to ensure that those numbers are in fact true, valid and correct.

I'm calling for the creation of a JCAHO-like entity to be created and to be responsible for total financial evaluation of UCSF and UC institutions to provide this objective financial analysis on all levels.  The committee should be made up of local and national experts that are citizens and people of proven integrity.  They should be in no way politically tied to the University to stand to gain any professional or financial benefit whatsoever.  It should be run similar to JCAHO which is the Joint Commission that evaluates the safety and accreditation of hospitals.  A financial analysis counterpart should be created and independent of the University to ensure the financial ethics and integrity are upheld.

This would be different than a government audit.  This idea would actually be the governing decision-maker when the University management wishes to implement impactful changes to the University and there is inherent controversy about whether the decision will in fact save the University money. 

One current example is the issue of transforming the Interpreter Services Department from an all in-person system to a Video Monitor system that depersonalizes the service.  The University insists that this would save them money.  Interpreter Services disagrees and has much data to support their claims that it would not save the University money.  It would cost more in fact to implement this.  As it stands now, the University would simply 'implement' their decisions with no independent financial overseer to act as judge in the decision of these two points of view.  Because they can. The University takes the viewpoint that they do not need any financial overseers other than the State in designated territories.  The workers and most likely the taxpayers strongly disagree.  This new entity of a JCAHO-like financial overseer would act as judge and decision maker to ensure that the financial data was accurate or inaccurate.  This independent body would benefit both the University and opposing groups questioning the financial data proposed by the University by providing the truth. 

I think it's an idea who's time has come.

Respectfully yours,

Freya Magnusson, HUSC III 

UCSF's current policy is medication cannot be transferred with patients. Medications, especially insulin pens get wasted which is costly to the patient and the hospital. My proposal is that the transport team can bring a locked box with them with a lock that each floor has a copy of the key that opens the box. The RN on the sending floor places the meds (to be transferred with the patient) in the box and locks it. The box travels with the patient/transport. On the receiving floor the receiving nurse unlocks the box and retrieves the meds and the empty box stays with transport.

Additonally a checklist or another form of documentation  can be added to apex so the sending RN can document which meds and time they were sent with the patient and the receiving nurse document the meds were received and the time.

Denise Kuri,RN 11NICU

At SFGH, children come to the ER at night for problems that could certainly wait until the morning when they can come to Urgent Care.  A refrigerator magnet with the number of the advice line to hand out to patients might allow more people to come to urgent care of the ER and reduce costs.

This idea was raised during a patient panel in support of Mission Bay operations & transition planning efforts.

As a way to encourage patient sleep as part of the healing process, the patient requested that morning phlebotomy draws be reduced or eliminated. 

As a follow up, and when discussed anecdotally with clinicians--including physician representation--we learned that in most cases, the morning labs are not part of the daily physician rounding work up & process, and therefore a wasteful exercise.

The proposal is to have morning draws ordered, instead of defaulted in Epic. Changing this practice could save the medical center money and improve patient satisfaction.

More investigation has not taken place due to lack of bandwidth, and so that is why I put forward this idea.

Thank you,

I schedule the liver outreach clinics for Reno, Modesto and Fresno. Every month about two weeks prior to clinic is send them a courtesy reminder letter. The letter reminds them of the date, time, location, make sure lab work is done, and to reschedule after the appoinment.

I also take the time when I first register them for outreach that our liver clinics are only once a month, that it is important to try to keep appointment, but that we do understand that emergencies do happen.

The patients tell me that the appoinment reminder letters help them a lot.

I usually don't have very many no shows.

Cindy Gardner

Admin asst/Hepatology

353-2156

I recently was vacationing on a cruise ship and was greeted continually  by a  smiling person who sanitized every person's hands when entering restaurants, bars, or when entering the ship after going ashore.  I was very impressed with  the way this necessary activity was handled.   This was the practice for the entire ship during my entire stay.    In a hospital situation this would be possible on entering the hospital for visitors making it a  pleasant reminder rather  than an opptional activity.

I am currently a PCA, but will be part of the new grad rn program.  Policies and procedures are not always followed by even experienced nurses.  Ex.  I have observed two expereinced nurses at UCSF clamping chest tubes for transport.  Our nurses needed to be aware of changes in policies and procedures in order to provide safe care for our patients and to prevent costly lawsuits.  Podcasts could make the policies less laborious and more accessable.   CEs would provide an additional motivation.  John Hopkins and other major universities already provide educational podcasts for nurses and medical students online.    

There are multiple elevator systems at the Moffit/Long hospital, however, they are very slow and inefficient. This causes delays in patient transport to procedures and tests and also a delay in healthcare providers reaching patients and creates a domino effect where there is a delay in care and timely decision-making. Elevators should be streamlined so that one elevator only accesses certain floors and the neighboring elevator accesses the remainder of the floors (e.g. Elevator A goes to Basement through 7th floor + 15th floor; Elevator B goes to 8th floor through 14th floor).

I think it would be great if instead of printing all the lab requisitions, a bar code could be printed that when scanned would have the labs that need to be resulted.  That would save the environment and and in turn save money by not having to buy as much paper.  The lab reqs often print an extra page that is nearly blank that is not needed as well. 

When I was a case manager on the floors, it became apparent to me that patients had no idea that the hospital encouraged them to leave before 12 noon. There is nothing in their admit paperwork that addresses this idea and I have yet to hear a physician push for this when discussing discharge with their patients. Yet, this is a goal year after year of the hospital. There are several simple fixes for this problem.

1. Include the language in the admit paperwork (which patient usually read after they are discharged), if ever. I used to do home infusion visits to visit patients after their discharge from UCSF and none of the patients had ever even looked at their paperwork.

2. When the case manager makes initial contact with the patient, address the feasibility of a noon discharge. The patient can then call family and give them advance notice that this is the expectation. The nurse caring for the patient should also advise a pick up before noon when the patient discusses discharge with her/him.

3. Since patient don't remember that much that we present to them, how about a neon or brightly colored laminated sign on their wall next to the clock in their room? It could be a funny cartoon showing them in a wheelchair going out the door with 12:00 Noon displayed prominently. That way when they look at the clock when determining what time they will be leaving, they will see the reminder.

One way or another, we need to find idea's to inform patients that a morning discharge is expected. Of course this means that the teams have to get their discharge paperwork together but most services know this from the case manager on rounds. We can't have patients waiting around until 6:00 when their friend gets off work to pick them up. I know they can be discharged and sent down to the waiting room/lobby but wouldn't it be a more pleasant experience if they went home instead of hanging out for hours? Or we could pay for a taxi voucher (which we do sometimes) but really a patient should be responsible for getting themselves home when physically able. 

Personally I like the sign idea.

The majority of test ordering now occurs directly by providers entering orders on computer screen, from simple labs up to MRI and Nuclear Medicine imaging. I believe that simply having the cost of that test on the screen might have a profound impact on ordering of unnecessary or reflexive testing. A prime example would be of coagulation studies that residents still routinely order on moderately ill admissions and on pre-op patients without bleeding histories. Where educational awareness has failed a simple remdinder of the cost may well succeed without inappropriately limiting use where indicated. This is appropriate for all clinical environments from clinic to ICU. 

As it stands now, per diem healthcare workers have to provide for their own private health insurance.  I would like to see a UC sponsored health insurance option catered to provide for our per diem healthcare workers, especially our per diem RN's.  Ideally it would be a win-win situation if well-devised and may possibly earn the University money as well as provide for the per diems.  I am not a financial expert, but there are many out there. 

It seems neglectful and unjust that our hardworking per diems be left to their own devices to pay costly out-of- pocket health insurance when the University could come up with a statewide program to look out for them.  They may be required to pay more than non per diem workers, but providing nothing to them is not just.  Especially to the nurses.

Currently some UCSF outpatient clinics do not open their scheduling until one month prior ie - you have to call in late January or early February for a clinic appointment in March. This results in multiple calls to the clinic to see if the appointment schedule has been released yet. Recommend tracking the number of calls for appointments that cannot be made due to the schedule not being released as well as patient clinic call wait times. Then recommend releasing the clinic schedules earlier for patient appointments and tracking calls and call wait times. This intervention should reduce patient hold times for clinic appointments and improve patient satisfaction.  

Having used MyChart as both a provider and patient, I think it's a pretty user-friendly system that can be quite useful for communicating about non-urgent issues, requesting appointments, and requesting medication refills. We can increase the number of patients using MyChart by setting up sign-up stations in our outpatient clinics - either in the waiting room or some other common area where patients can use it while waiting. Having the ability to sign up in clinic will eliminate people forgetting or "not having time" to do it at home. This could greatly reduce the number of outpatient phone calls - and frustration about dealing with phone trees, etc. It also helps ensure patients have an electronic way to communicate with providers without us having to give out our personal email addresses, and documents the communication in their chart (I think). Some practices are sending AVS's through MyChart rather than printing them - and this is a way to save paper and phone calls as well.

  I am sometimes amazed at the number of blankets placed on a patient to try to keep them warm during transportation (as many as 5 - 6!).

In the past, I have worked at a hospital that did a study of how to keep our patients warm while being transported on gurneys. In summary, they found that by placing a bed-sheet on the patient retains much more heat than a blanket alone (tighter weave of the fabric?). So, the recommendation of the study suggested placing a warm blanket on the patient which is then covered by a bed-sheet. Simple.

I'm sure we can cut way down on laundry costs by being a little smarter about how we warm our patients.

One of the many factors that prevent patients from being discharged before noon is their preference to stay for lunch.  While lunch is often not delivered until 12:30 or 1, we could instead implement a policy of providing a brown bag lunch at 11 am on the day of discharge.  This could lead to a discharge time that is 1-2 hours earlier, improve patient flow, and would likely decrease food costs.  This idea could be applicable to both UCSF and SFGH.  

Overuse of telemetry monitoring is a target of the ABIM Foundation’s “Choosing Wisely” campaign, which recommends that hospitals develop a protocol to limit telemetry use. It is associated with ER overcrowding, over-testing and over-treatment of clinically irrelevant events, limited patient mobility and sleep due to frequent adjustment of equipment, and the cost of nurse and physician time responding to false alarms. A staggering statistic from the UCSF Medicine Service is that 44% of our patients are on telemetry until the moment they are discharged. We propose a four-part campaign to reduce unnecessary telemetry use at UCSF Parnassus - an educational campaign for housestaff, a messaging campaign with pocket cards and posters, a monthly feedback campaign to ward teams about their telemetry use, and a change to Apex to link the monitoring indication to an expiration time for the order.

“Caring wisely” is a phrase loaded with a profound responsibility – to thoughtfully do the right thing with respect and dignity for all. Wisdom is the ability or result of an ability to think and act utilizing knowledge, experience, understanding, common sense, and insight. Patient to patient, medical knowledge, experience, and common sense are constants for any given health care provider. When health care providers learn each of their patient’s sets of expectations, hopes, and fears, they can develop an understanding of their patients’ unique goals of care and gain insight into what care each patient values. It is this second part of wisdom on which I wish to focus. My idea is to engage patients in defining their values and care goals in a standardized manner at the time of hospital admission or pre-operative evaluation. Establishing this guide for patient care early should reduce the number of future decision-points, improve efficiency of future decision-making, lower hospital costs by reducing wasteful care, and make “caring wisely” a simple choice.

Problem: Poor/inadequate design of procedural kits for paracentesis, thoracentesis, and lumbar puncture at UCSF

Issue: The current procedural kits for the above procedures are inefficiently packaged with either excess items not frequently used (and often wasted, despite efforts to partner with the medical school's REMEDY chapter to repurpose these items in other settings) or do not have adequate supplies of more necessary, higher-yield items, leading to excess medical waste and provider time getting additional supplies.  For example:

(1) paracentesis/thoracentesis kits: have plastic drainage bags/associated tubing that, when adequate vacutainers are available (recognizing there is a current shortage), never get used (we save these for a rainy day, but rarely use them--much more time-intensive/not practical for large volume procedures, and so have a large unused stockpile)

(2) paracentesis kits: as above, as well as: include extra 22-gauge needle and spinal needle that are rarely used and often tossed out; include glass top vials but no filter needles; do not include Chloraprep (which is preferentially used over iodine for several reasons); do not include Tegaderm. There are similar suboptimal design issues with the alternative Turkell kits.

(3) LP kits: have inadequate lidocaine included for the vast majority of LPs, inadequately sized syringes, inadequate gauze, has sponges included (but no iodine) and no Chloraprep.

Idea: UCSF has significant purchasing power and could discuss with the kit manufacturers redesigning the kits we currently use tailored to our local practices to reduce medical waste, wasted provider time searching for extra supplies required, and improve work flow. 

In addition, as director of the Hospitalist Procedure Service, I would favor discontinuing use/stocking of the Turkell kits for several reasons (including that the "safety" mechanisms are impractical) and using one, properly designed kit to be for all paras/thoras. This would also streamline the ordering/stocking process and standardize provider familiarity/ease with learning only one kit (hopefully improving procedural quality/safety).

Issue: To evaluate for possible intraabdominal fluid infection in pts with ascites, providers typically will send cell ct/diff and cultures (innoculated in aerobic/anaerobic blood culture bottles).  However, a positive culture representing true infection in the absence of the cell count revealing >250 PMNs is quite rare (often representing inadvertent contamination).  As the cell count is typically processed within a few hours, a provider will know the whether a pt meets cell count criteria for bacterial peritonitis: if it has <250 PMNs, this rules out infection in the vast majority of hospitalized pts and thus the pending cultures are clinically unnecessary (since they nearly always return negative) (recognizing there may be sub-populations where providers may still prefer to be conservative, esp in the immunocompromised or with atypical pathogens).

As we charge patients approx $200 *each* for aerobic and anerobic processing (as well as lab/staff/resource time), this represents a high-yield clinical situation to target waste. 

Idea: Work with the lab/micro and APEX to standardize a protocol of when to process the submitted culture bottles.  From a proceduralist work flow standpoint, providers can draw the necessary samples and submit to the lab, holding the culture bottles until further ntoice.  If the cell count returns "positive" (ie: >250PMNs), then Micro automatically processes the culture bottles. If the cell count does not, then the provider would have the option (either by automated page/in APEX somehow) to process or not (I would assume the most providers would select not). If there is no response from the provider, then the samples are automatically discarded within a certain time frame (ex: 24hrs).

Problem: A significant portion of pts have no listed PMD or preferred pharmacy in APEX.

Issue: Recognizing that providers share the responsibility to know this information, other clinical duties often lead to inconsistent asking/entering of these two basic/vital pieces of information for safe, appropriate discharges.  Many patients who actually have a PMD but don't have this info entered into APEX (or have the incorrect provider listed) won't have their discharge summaries/pertinent clinical info routed to the appropriate outpt provider, leading to suboptimal communication btwn intpt/outpt providers and care continuity and potential for unnecessary risks to care quality/safety (esp with pending tests at discharge or issues requiring close f/u). Similarly, the pt's preferred pharmacy info is sometimes missing/incorrect, potentially leading to electronically misrouted discharge prescriptions, gaps in care, or pt dissatisfaction.

Idea: When a pt is admitted to the hospital, the Admissions staff routinely confirms basic demographic/insurance/etc information w/ the pt/family This seems like the optimal time to standardize collecting/confirming PMD/pharmacy, without unduly adding to their work flow or requiring additional resources.

Create a High Value Care Committee at SFGH such as the one created by Chris Moriates and his colleagues at UCSF Medical Center.

Can apply to both UCSF Medical Center and SFGH.  SFGH is hampered to a greater degree given the lack of an integrated EMR system.  Efforts should be taken to standardize the location of advance care planning documenation in the EMR.  Often a great deal of time may be taken by providers to obtain ACP documentation, but then there is no standard place or processes around documenting such materials.  Or if there is a place, processes and practice are not standardized to ensure that information is recorded in a reliable fashion and location.  This leads to inaccessibility of important information at critical points of care across the care continuum (Ex. ED, after a hospitalization back in the PMD office, ICU, etc...)

Every day (particularly on weekends and holidays) patients on the Medicine service have clinically improved and are ready for discharge, yet remain in the hosptial because of difficulty in finding an appropriate skilled nursing facility where they can continue their rehab.  Each non-indicated day in the hospital needlessly costs thousands of dollars, occupies provider time that could be spent caring for acutely ill patients, and subjects patiens to many of the harms and infection risks that we know exist in the hosptial setting.  Many other hospitals (including SFGH) already have integreated non-acute care facilities affiliated with their main hospitals that can be used for helping to place patients in more appropriate care levels. Perhaps a ward of Mt. Zion or other similar UCSF facility could be modified to accomodate such patients.

This idea is applicable to UCSF Medical Center.  Specimen labeling errors are a significant patient safety risk in addition to causing increased costs and clinician and patient dissatisfaction.  Specimen mislabeling is due primarily to human and system errors.  Through the use of Lean/Six Sigma methodologies this project is aimed at identifying process defects and testing and implementing process and technology improvements.

In both the inpatient and outpatient setting, we often order labs that are indicated but tend not to change quickly over time. Often, if our patient has had these labs drawn recently, we may not need to repeat it.

We could reduce unnecessary duplicate labs AND increase efficiency if our ordering system (Apex) helped us know when a lab we ordered had been drawn recently and what its last value was. Ideally, this alert system we not require an extra click to OK our orders. For instance, imagine you could split your screen so you could 'manage orders' on the right and see simultaneous 'recent labs' on the left. As you ordered labs, the 'recent labs' view would show the last value in the system for each lab being ordered and the date at which it was last drawn. If a lab had never been ordered, apex could instead display "lab never ordered". This way, you could delete the labs that did not need to be redrawn before signing orders, and quickly see (in one display view) all of the previous relevant lab values. 

This intervention would decrease the duplicate ordering and help us quickly see previous results of labs such as: TSH, hgbA1C, cholesterol, hepatitis serologies, HIV, ESR/CRP, ANA/RF, PTH, etc. 

UCSF should pioneer in using BIG DATA to bring out the best innovative healthcare solutions.

It should leverage its proximity to the Silicon Valley to tap into its computing industry and come up with data which can help provide better solutions and reduce waste in the health care industry; and set up benchmarks in the process.

The old buildings (and many of the newer ones) on the SFGH campus are incredibly energy IN-efficient, and mostly for very basic structural reasons - windows that simply do not close completely, windows and doors that close but leak, etc.  Summer cooling and winter warming of areas with these problems, for one thing, must be expenisve.  Addressing these issues could potentially save a lot of money on annual overhead costs for the hospital, and the costs of repairs or building upgrades would not necessarily need to be passed onto hospital health consumers.  Addressing these things could also have little to no impact on patient care, as many of these old buildings are in use for research or administrative purposes.  

Purchase of a Mass Spec would help in ID of difficult organisms freeing up a lot of time in the lab and possibly freeing up FTE for possible transfer to the new hospital.

The Mass Spec will increase productivity and the turn around time of Microbiology Results. 

My suggestion is to have our Apex medical record talk to the billing department for nursing driven charges. Each day in Perinatal Services we lose a lot of money in revenue because nurses do not have time to act as billers. Nursing is busy providing excellent patient care then documenting this care but Apex will not talk to the charges department. The OB nurses then have to go back into the EMR to enter the charges they just documented about. As this activity is not critical for patient safety or patient care, it is often the piece that is not done in a timely manner or at all. I think this is a waste of nursing time and seems wrong to me that our electronic medical record cannot electronically speak to the charges but we have been told it cannot happen. Fixing this would result in a huge gain in revenue and could lead to better patient care as a competing activity would be off of nursings’ task list.

I find that a lot of times on the medicine and cardiology services, volume status is a large part of patient care.  Whenever we are removing volumes with diuretics, "lyte check" often follows - and often signed out to the overnight team to check.  

More often than not, really what is check is the K > 4 and Mg > 2, but often the lytes are ordered as a full BMP panel in the evening.

What would be very helpful and promote limiting the unnecessary full chem panels sent is to have some sort of "pm lyte" order which only orders potassium and magnesium.  What would also be helpful and streamline patient care for the overnight housestaff is to have the time autoset for 9pm or some standardized time so that there's not random times for each patient on each team that the cross over housestaff needs to comb through (and sometimes can miss the lyte check).

This can be implemented at UC or SFGH to help decrease unnecessary lab tests.

UCSF Medical Center is the only hospital that I have worked at that does not employ Respiratory Care Patient-Driven Protocols. I was surprised to learn this as I know that UCSD Medical Center pioneered PDPs over 15 years ago. 

It is well documented in medical literature that Respiratory Care PDP use reduces costs and improves patient outcomes. It is also held that Respiratory Care PDP use elevates the profession of Respiratory Care and enhances job satisfaction. 

Thank you you for this opportunity.

Best,

Jennifer Delaroderie RCP

Unexpectedly long waiting times contribute to patient anxiety and poor satisfaction, and lead many patients to leave without being seen or to begin their healthcare experience upset and frustrated. Posting average waiting times (either static or dynamic) in the ED waiting room can help patients manage their expectations (as well as self-titrate flow and arrival patterns). This could be expanded to include posting waiting times in other outpatient clinics and urgent care clinics, as well as average waiting times for certain procedures (i.e. signs that say "Blood work: 1-2 hours, CT scan: 2-3 hours, etc." and perhaps even average discharge times from various services on inpatient services. It could be as simple as a printed sign or as complicated as a screen that automatically updates to reflect current volume.  

With the large expense of installing a large quantity of large screen tv's over the last several years, it would only make sense to use them to the fullest capacity. Designate one specific channel to Discharge teaching only, which can be designed to specific needs or departments. We can make patients aware of this option at time of admssion to reduce the time spend at discharge. Many patients are given a limited choice of channels which are watched for many hours a day, to pass the time.  Many questions or information can be provided to the patient during the hospitalization which in turn will lead to earlier discharge times. Adding a Discharge Teaching Channel would keep patients and family informed about the expectations at time of discharge.

As an EM resident, I often call the radiology resident for a verbal wet read as do many of my fellow co-resident. We are encouraged and expected to review our own films, but during period of high clinical activity or when the patient is unstable, it is not possible to get to a PACS computer to sit and review all chest x-rays and CT scans on our own while medically managing the patient. In the last few months, I've called for a read on a CXR. Sometimes, the resident or attending in radiology will pull up the last image, and give a wet read. However, I will find out that the patient's image has not yet loaded, so I receive a read on an old Xrays, and have discharged or administered a medication based off an old chest xray read. Thus far, no adverse outcomes or patient harm occured in these 2 instances, but I can imagine that it could result in great patient harm. 

The typical Radiology/EM resident interaction will entail me asking for a wet read, and the resident will provide it and then the radiology resident will always ask for my last name, so they can dictate, "verbal read given to Dr. Amin." I propose adding one extra step in this interaction which the radiology resident is expected to say the date and time of the image when asking for my last name.

For example, if the radiology resident or attending used the exact phrase, "this is for CXR take on 2/6/14 at 1:30pm...patient has bilateral interstitial infiltrates with mild cardiomegaly... no pneumothorax... etc.... Can I please get your last name?"

In the ED we use the IPASS system for sign out to help prevent loss of information or misinformation during patient hand off. I beleive creating a formal interaction process between the radiology department and emergency department will improve communication of imperative medical information. 

Add a cover to the code blue / staff assist lights in each patient room. This will prevent visitors and cleaning staff from inadvertently initiating a Code Blue. When a Code Blue is called there is significant mobilization of resources and increase in staff and visitor stress levels. Preventing false alarms would save resources by preventing the Code Team from having to drop what they're doing in order to respond. This would also improve productivity as a false Code Blue is stressful and disrupts the work flow of everyone involved.

Currently in the Family Health Center, RN visits are available to use for blood pressure checks and medication titration, however there is no standardized process for these visits and no standardized way for providers to communicate to the RNs their instructions for the visit, and no standardized way for RNs to record/communicate the outcome of the visit. Some providers are not aware that these visits are available, and other providers have not had success using them. RNs have had difficulty recieving instructions for the visits and difficulty with the variability and lack of standardization of the visits. These visits are an incredible resource that can reduce the number of encounters required with a provider, optimize patient care and treatment of hypertension, and do so in a more efficient and clinically appropriate time frame. A standardized format for these visits, along with standardization of provider instructions for the visits and standardization of RN documentation of the visits, would be a huge resource to the Family Health Center and to our patients.

Cellulitis and community acquired pneumonia are common admitting diagnoses at SFGH. Blood cultures, even if obtained before antibiotics, are low yield and unlikely to change management in most cases where the patient is admitted to the floor. Similarly, patients admitted to the floor with cellulitis seldom have true positive blood cultures, particularly when the patient is afebrile. Reducing unnecessary blood cultures not only reduces the costs associated with the test itself but also reduces costs (and potentially adverse outcomes) associated with blood cultures that are positive due to skin contaminants.

Proposed site: San Francisco General Hospital

Continuous Pulse Oximetry is a valuable resource at San Francisco General Hospital, limited primarily to one medical/ surgical inpatient unit (4B). Overuse of continuos pulse oximetry can create unecessary bottle-necks in flow from the emergency room for newly admitted patients or out of the intensive care unit for patients ready to transition to the step-down unit. We aim to create a standardized order set with clear indications for continuous pulse oximetry use as well as automatic discontiuation within set-time frames shoulw providers not re-evaluate and renew the orders. We plan to employ a multidsiciplinary group of physicians, pulmonary subspecialists, respiratory therapists, and nurses to create an evidence and experience based order set for use at San Francisco General Hospital to limit unecessary continuous pulse oximetry use.

So, this is ANYTHING but a new idea, but I'm proposing it again at this time in UCSF's history.  As medicine continues to evolve as a delivery care system, as our financial and work stresses increase, and as the expectation continually tends to focus on doing more in less time, the need for regular therapy for our physicans as a support system of self-care for them to undertake these challenges rises in urgency. 

It's time for the ancient divide between medicine and behavioral & psychological sciences to integrate and make friends with each other.  Because we are always better together than we are apart.  When self-care on all levels is advocated for by the hospital and prioritized as a cultural norm and expectation of our physicians, then we are truly putting are best foot forward in excellent care for our patients. 

There are some obstacles to overcome.  For physicians in their 50s and 60s, receiving therapy or psychological help to manage stress held an extreme stigma back in their time when if they openly admitted to receiving counseling, they could be looked upon by the general public as less than competent physicians.  Obviously, the exact opposite is true.  Those physicians who receive regular therapy have better tools with which to manage their stress effectively and have strong support in which they can lean on to help them process the many emotional issues affecting their personal and professional lives.

While the University has a sponsored mental health care plan available to all providers here...this is not what I am suggesting.  I'm suggesting that the culture now be created and advocated for and strongly encouraged to motivate our physicans to receive regular therapy.  The need is evident.  If you surveyed most of the hospital staff and asked them if they believed that our physicians would benefit by receiving regular therapy, I am betting most all would say a collective "Yes, please." 

So, I'm speaking on behalf of the silent majority.  Shame need not be a part of this process. Removing the stigma associated with receiving therapy should be an important part of the University's mission to improve our physician's performance and excellence.  We all know this to be true...but action has to be taken to manifest that knowledge into reality.  So I am doing my part by logging my suggestion on this site.  I hope it's seriously considered.  Thank you.

In the course of busy workflow it is difficult for providers to integrate cost:benefit analysis while writing orders.  In order to provide meaningful clinical decision support to providers in order to change ordering behavior, we propose to create a list of the 10-15 most expensive diagnostic and/or therapeutic orders which have equivalently effective, evidence-based, more cost-conscious alternatives.  An example: ionized calcium (an expensive lab test), which could be safely replaced in many cases by a calcium and an albumin level (inexpensive tests) and simple math.  We propose to create our list via discussion with colleagues in lab medicine, radiology and pharmacy, and use of the existing Choosing Wisely guidelines as a starting point.  Our SFGH Ordering Wisely list would be integrated into practice via educational posters in resident workrooms, pocket cards, and ultimately via clinical decision support on SFGH's computer provider order entry (CPOE) system with pop-up messages when the costly alternative is selected, and a pathway for rapid conversion of the order to the more cost-effective alternative.

Inpatient resident documentation on admission H&Ps, daily progress notes and discharge summaries is intimately tied to how SFGH, a publically funded safety net hospital that provides 20% of all inpatient admissions to the city, is reimbursed. More specific diagnoses are coded to heavier weighted drgs that lead to higher reimbursements. For example, there is a difference of thousands between simply writing congestive heart failure and acute on chronic systolic heart failure. Moreover, the way residents document becomes ultimately translated into how SFGH gets evaluated by numerous external agencies. The case mix index and expected mortality ratios are ways by which our hospital is compared to others. 

There is wide variation between resident documentation as well as varying degrees of awareness of the titanic implications of how the language residents use affects reimbursement and ultimately the hospital's public opinion, both among residents and seasoned attendings.

While the clinical documentation team has already been able to affect much change, there is still plenty more to be done. I believe there are very simple sustainable ways we can change how residents document because as the adage goes, "no money, no mission."

Email is the backbone of communications at UCSF Medical Center.  Virtually every UCSF clinical and administrative manager-level and above receives hundreds of emails a day, and most typically spend 30 minutes or more of their day "managing" their email by moving them from the Inbox into folders. I have used an email management software called Neo Pro for 10 years, and I can find any email that I sent or received in the last 10 years in 7 seconds or less.  Neo Pro gives me powerful search and organization tools that automatically and instantly organize my email for me - no effort required.  I think Neo Pro should be on the desktop of all UCSF managers. It will save UCSF hundreds of hours in wasted time spent in what is a futile effort to organize email. It will improve efficiency because people will actually be able to find email in seconds. It will improve resource utilization by removing the need to store email on the Exchange server so "I can find it." Exchange server hard drive space is very expensive. It will enable an cost-saving email management strategy to be rolled out to everyone so that they can efficiently manage all of their email and email archives. Best of all, Neo Pro frees you from "managing" your email so you can focus on doing your job instead. I have personally installed Neo Pro on the computers of 30 UCSF employees at their request.  Neo Pro can be found at www. caelo.com.  

Additional comments can be found on the UCSF Bright Ideas website at this shortened weblink http://alturl.com/5tupc

 In the Mt Zion OR we place water and saline in warmers. Our current practice is after 3 days this is considered expired and poured out.  It actually has an expiration date of 2 years.

We can still use the fluid. We just can't pre-warm it.

I propose putting this solution in a different location after it has been previously warmed and used in different ways.

For example:

   1.  Use the fluid for cases not requiring warm solutions.

   2.  Use a solution warmer for the field to warm your solution.

   3.   Use the water in your water basin.

    4.  PSA/PCA could use this water to dilute their cleaning solution.

We could also put only saline in the warmers, no water.

We could also extend the time in the warmers to 2 weeks.  This is the usual practice.  

We waste a lot of solution on a weekly basis. 

Retail or community pharmacy has a very tight integration between what is dispensed and what is re-ordered. At the end of each day, reports are generated as to what is short / out and reorder. Occasionally there are exceptions ... A manager or someone in purchasing would do special orders, or review the report and make adjustments, but a highly automated process. 

As UCSF inpatient pharmacy, we are out of Gelfilm for OR (absorbable gelatin film, NDC 09-0283-01) and I have to hand write it on a clipboard, so someone can order it Monday for it to come in Tuesday, maybe?? The problem is particulary acute when a weekend is involved. 

Another example, we are out of levothyroxine injectable Sunday morning. As I quickly go down the list of options: check pyxis, call Mount Zion, or borrow from OSH ... A technician saw some came in Friday night. What luck and the chance that the technician worked Friday night and Sunday morning!! The delivery came in Friday night but b/c have to log it into the inventory management system, the med were not put on the shelf yet?

Now early Monday morning, we are out of heparin lock flush 300units/3ml syringes. A very fast mover in the hospital. It would be nice to be able to see what was ordered and have some assurance that this was coming later in the morning? 

Monday morning - out of ambrisentan 5 mg tablet b/c there was a new start yesterday. None at Mount Zion and will have to borrow from an OSH.

When it comes to inventory management, there is room for improvement and better automation. APeX knows exactly what is dispensed and approxmately what gets returned. Much energy and time expended on resolving these stock out issues, and taken away from patient care.

+ One option is to empower more people the ability to order meds/supplies over the weekend so that it can arrive on Monday, possibly shortening the delay?

+ Another thought would be to assign someone to log any delivery then put on the shelf. This would alleviate missing meds that are sitting in delivery totes.

+ Have a purchasing person come in for a few hours on the weekend.

Patients requiring ophthalmic consultation often require eye drops such as proparacaine for numbing the eye as well as phenylephrine and tropicamide for a dilated eye exam for a total of 3 medications.  Due to CMMS regulations, each patient needs a new order and new bottles of each medication for what is most often a single use.  These bottles of medication are anywhere from 2mL to 15mL and each bottle retails between $1 to $50 depending on brand and size, which is a hefty cost when often only 2 drops are needed from the entire bottle.  Depending on what the cost of these drops are at UCSF, the hospital could consider re-packaging the drops into single-use vials similar to those of preservative-free artificial tears to reduce wastage and even storage space.  If these mixed vials are created, the drops can also be mixed together so that even less packaging and medication is wasted and patients require only one drop placed into each eye . 

Situation:

Handwashing is one of the most effective ways to reduce the spread of bacteria and reduce the risk for infection. Patients are encouraged to ask their providers if they have used gel or washed their hands but many are often timid or shy about asking not wanting to question a provider.

Background:

On 15Llong it seems we have seen an increase in chorioamnionitis (infection of the membranes and fluid) surrounding the baby. Providers are performing vaginal exams and placing internal monitors as needed with an increased risk of introducing bacteria into the vagina. A chorio diagnosis almost always results in treating the mother with antibiotics, lab testing on the infant (CBC, blood cultures) and increased frequencies of vital signs (using nursing resources) and treating the infant with IV antibiotics in some cases.

Assessment:

Handwashing is not consistent among providers (largely MDs on our unit), even when asked if they washed or used gel on their hands. Gel and sinks are immediately available when they walk into the room but are often not utilized properly upon entering/exiting the room. When prompted the providers gladly comply with the handwashing request but should not have to be prompted.

Recommendation:

A surveillance project to encourage providers to wash/gel in the view of patient and/or nurse and documentation of what was done. A similar project was enacted at UC San Diego after high chorio rates were noted and found a large decrease in the amount of cases of chorio. A flowsheet kept at the bedside with the notes of the time of the vaginal exams, if the provider washed or used gel and the patient temperatures were recorded and can be reviewed in the cases of chorio. There needs to be a more consistent system to track the incidence and likely cause of chorio would could greatly reduce nursing resources, infant admission to ICN, use of antibiotics or unnecessary tests on infants, and even reduce the length of stay.  

4A has a reputation among MDs as being incredibly difficult to refer patients to. There are idiosyncratic admission criteria that sometimes do not have clinical relevance (ie requesting pts on dialysis to get a repeat lab draw AFTER dialysis to ensure the potassium is ok, not allowing patients newly on O2 to be referred even if they've just recovered from ARDS 2/2 PNA in the ICU, only accepting patients on q8h antibiotics rather than q12h, etc). 4A certainly has a right to define its admission criteria but if SFGH as a system is to become more efficient, it seems LLOC patients should not occupy acute beds in the main hospital but instead take one of the 4A beds that often are available. 4A also seems a more appropriate place than acute hospital beds for patients awaiting placement or conservatorship.

Patient FLow Issue at SFGH

Current State

Hospital to community health care facility transitions involve input from Social Services and Utilization Management staff.  The process is non-standard, non-reliable, inefficient and opaque to the providers who interface with the system.

Idea

Bring LEAN strategies to map the process to provide foundation for increased efficiencies in the referral process.

Specialty clinics have designed a set of standing orders for lab tests for their patients. Although there may be some value in the initial evaluation of a referral, it is very wasteful to have repeat lab tests. For exampl, patients get fasting lipids every 4 months. Lab test orders should be based on what a patient presents with as a problem or anticipated from the previous visit and not left as routine standing.

Overall workflow and communication in the hospital could be significantly improved if the text paging system were more widely utilized.  One of the barriers to increased utilization of the text paging system may be the dual paging systems that are not well centralized - DPH employees who are on the DPH Central Paging system and UCSF residents/employees who are on the Pagerbox system.  If there is a way to better centralize this,perhaps more text paging may be used by all hospital staff to more efficiently communicate.  

[Submitted with Tina Quon, RN]

Background: To minimize CAUTI, we currently ask primary teams to assess, on a daily basis, need for ongoing indwelling urinary catheter use, and order removal when indicated.

Problem: Foley catheters are often removed late in the day, which often results in catheter replacement during or after night-shift transfer of care, despite actual need. 

Solution:  We alert primary teams to order removal by 10 am, daily, and nurses to remove Foley’s by noon, daily, to allow adequate time for patients to void and for PVR’s to be checked by evening change of shift. Fill-Pull-Void and PVR-check guidelines provided by GU (Garcia). 

[Submitted with Kimberlee Honda]

Albuterol is frequently given via nebulizer for treatment of acute asthma symptoms in both the Pediatric Urgent Care and Pediatric Asthma Clinic settings.

Administration of albuterol via nebulizer is significantly more costly than delivery via MDI, yet it has been established that delivery of albuterol via MDI is just as effective as nebulized treatment.  There may be specific patients for which nebulized treatments are indicated, but we are overutilizing nebulized treatments in both settings.  This reinforces a myth for parents that the asthmatic child with increasing symptoms requires a nebulizer at home.  As a result, parents often fail to understand proper MDI/spacer technique and will frequently request a nebulizer kit, along with additional Rx's for albuterol neb solution at home.  Eliminating or reducing the use of nebs in clinic could not only reduce overall hospital and pharmacy spending, but would help promote a consistent message for optimal use of MDI/spacer during acute or emergency situations at home.

For background/reference: http://www.sciencedirect.com/science/article/pii/S0736467908006665
A similar cost issue was addressed in the inpatient setting at UCSF through the "Nebs No More After 24" pilot: http://archinte.jamanetwork.com/article.aspx?articleID=1718442

For SFGH

I am a Physical Therapist in Acute care at SFGH. My idea revolves around Early Mobilization in the ICU. 3 years ago 5E/5R MICU did a study of mobilizing ICU patients as soon as they were medically safe, instead of the old model of letting the patient rest in bed while in ICU. From the study, we found that the patients health improved faster, the patients had less days in ICU, less days in hospital and higher chances of having a home discharge. All of the above findings equals a cheaper hospital stay and less cost for the consumer and our hospital. Since the study 3 years ago, we have continued the concept of Early Mobilization in the MICU and are also trying to move into the 4E SICU.

In order to make the Early Mobilization Project work correctly the ICU would need a full time PT dedicated to the units to support and implement the project. At this time I only am able to spend about .4 of my FTE in the ICU. This makes it difficult to successfully implement Early Mobility daily and consistently.

If you would like, we have a presentation and data that supports the success of this program.

So I suggest A full time PT position to help save money on all ICU hospital stays.