ATTACHMENT A
Laguna Honda Hospital
           &
 Rehabilitation Center
   Patient Demographics
LHH Distribution of Residents by
Race/Ethnicity as of 3/31/06 (n = 1044)


                                               ...
LHH Distribution of Residents by Gender
                                                                January 2000 - Jan...
LHH Distribution of Residents by Age
                                                2001 - 2005 and First Quarter of 2006...
ATTACHMENT B
LAGUNA HONDA HOSPITAL

                                                             Strategic Plan Report
                ...
GOALS


    1. Clinical Programs            Continue to enhance preventive and therapeutic clinical programs.
            ...
Objectives                    Indicators / Outcomes              Baseline                    Target                       ...
2. Safety and Security         Develop and implement an enhanced Safety/Security program that will provide a safe/secure e...
Objectives                 • Indicators / Outcomes                        • Baseline   • Target                     • Curr...
3. Finance                      Maximize revenue for all programs and services. --- October 2005 review post-Invision ---
...
4. Organizational Structure, Communication and Leadership                   Develop a hospital-wide organizational structu...
Health        • HealthStream Pilot program
                                                                               ...
5. Information Systems        LHH will participate in the design and implementation of a single DPH-wide clinical and fina...
Objectives              Indicators / Outcomes      Baseline            Target   Current Status


 4. Define the           ...
6. Performance Improvement, Licensing and Regulatory Preparedness                  Develop and implement the LHH Performan...
7. Human Resources               Ensure adequate and culturally competent staff
                                    * Robe...
Objectives            Indicators / Outcomes             Baseline                                    Target    Current Stat...
8. Laguna Honda Hospital Replacement Project                      Develop a systematic approach to successfully operationa...
Objectives                         Indicators / Outcomes           Target                        Current Status
    and an...
9. Operational structure of new hospital         Initiate the operational planning for moving into the new hospital.
     ...
ATTACHMENT C
Placement Unit Targeted Case Management Accomplishments
                              FY 2005-06

The Placement Unit Targe...
P e rio d : 7 /0 1 /2 0 0 5 - 0 5 /3 1 /2 0 0 6 *

Screenings Completed......................................................
ATTACHMENT D
LAGUNA HONDA HOSPITAL
                                                                                              Leader...
LHH Executive Administrator
  Medical Services Division Organizational Chart
                                             ...
John T. Kanaley
                                                                                                          ...
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ATTACHMENT A

  1. 1. ATTACHMENT A
  2. 2. Laguna Honda Hospital & Rehabilitation Center Patient Demographics
  3. 3. LHH Distribution of Residents by Race/Ethnicity as of 3/31/06 (n = 1044) African-American 25% Non-Hispanic White 38% Other Asian 12% Other Chinese 2% Filipino 8% Hispanic 13% 2% LHH Distribution of Residents by Payor 6/13/06 (n = 1033) Pending MediCal and/or Medicare 2% Private Pay Medically Indigent 1% 2% Medicare 2% MediCal 93%
  4. 4. LHH Distribution of Residents by Gender January 2000 - January 2006 120% Number of Residents 100% 80% 53% 53% 52% 52% 53% 51% 52% 51% 51% 50% 47% 47% 49% 60% 40% 20% 47% 47% 48% 48% 47% 49% 48% 49% 49% 51% 53% 53% 51% 0% 00 01 02 03 04 05 06 00 01 02 03 04 05 20 20 20 20 20 20 20 20 20 20 20 20 20 ry ry ry ry ry ry ry ne ne ne ne ne ne a a a a a a a Ju Ju Ju Ju Ju Ju nu nu nu nu nu nu nu Ja Ja Ja Ja Ja Ja Ja Males Females LHH Distribution of Residents by Age First Quarter of 2006 25% % of LHH Residents in Age Category 20% 15% 10% 5% 0% <30 30 - 39 40 - 49 50 - 59 60 - 69 70 - 79 80 - 89 90 - 99 >99 Age Decile
  5. 5. LHH Distribution of Residents by Age 2001 - 2005 and First Quarter of 2006 25% Percent of Residents in Age Category 20% 15% 10% 5% c 0% <30 30 - 39 40 - 49 50 - 59 60 - 69 70 - 79 80 - 89 90 - 99 >99 Calendar 2001 1% 4% 1% 1 15% 16% 19% 22% 1% 1 1% Calendar 2002 1% 4% 10% 15% 17% 20% 22% 1% 1 1% Calendar 2003 1% 4% 9% 16% 18% 19% 22% 10% 1% Calendar 2004 1% 4% 12% 18% 18% 17% 20% 9% 1% Calendar 2005 1% 4% 10% 19% 18% 18% 21% 9% 0% 1 Qtr 2006 st 1% 3% 9% 18% 18% 19% 23% 8% 1%
  6. 6. ATTACHMENT B
  7. 7. LAGUNA HONDA HOSPITAL Strategic Plan Report January 2005—June 2006 MISSION As part of the Department of Public Health safety net, the mission of Laguna Honda Hospital is to provide high-quality, culturally competent rehabilitation and skilled nursing services to the diverse population of San Francisco. Skilled nursing service includes long-term care for residents who cannot be cared for in the community and/or short-term care for those who can be rehabilitated and discharged to a lower level of care within the community. VISION Laguna Honda Hospital will be a center of excellence in providing a continuum of care that integrates residents in the least restrictive setting, thereby supporting their highest level of independence. Updated June 15, 2006 1 Shading indicates that goal was met.
  8. 8. GOALS 1. Clinical Programs Continue to enhance preventive and therapeutic clinical programs. *Paul Isakson, MD, Monica Banchero, MD, Hosea Thomas, MD, Mivic Hirose, RN Objectives Indicators / Outcomes Baseline Target Current Status 1. Establish a unified • Program development • N/A • Training The following PI processes and systems have been behavioral health and QI Process. • QI process implemented: program. • Resident-to-resident altercations review team. • Staff Incident Review Team • SMART Training • QI data sent to appropriate department heads, chiefs of service, programs/cluster staff for analysis and action. • Reallocation and increase in nursing staffing on units identified with behavioral management opportunities. • Use of 6th floor as open space for dementia residents. • Improved satisfaction • 2003 data to be • Press Ganey benchmark • Contract in progress for Press Ganey surveys. surveys from residents, aggregated into • As part of QI program, Nursing interviewed 152 families, staff. single score. residents, using a quality of life assessment resident interview tool and observed care of 71 residents (not interviewable). Analysis in progress. 2. Enrich culturally • Increased number of • 76 employees • Increase the number of • 90 employees eligible for bilingual pay as of focused programs. bilingual and bicultural eligible for employees eligible for 5/06. staff. bilingual pay as of bilingual pay by 10%. 1/05. • Improved satisfaction • 2003 Data. • Press Ganey benchmark • Establishing pt. sat. survey with Press Ganey. surveys from residents, • As above, quality of life assessment is in families, staff. progress. 3. Integrate ID/DD • 100% assessment • N/A • 7/05 • Completed 7/05 program with completed for ID/DD • Open ID/DD unit. • Opened ID/DD unit in 12/05. community. clients. Updated June 15, 2006 2 Shading indicates that goal was met.
  9. 9. Objectives Indicators / Outcomes Baseline Target Current Status • Increased activity • MDS N2 Avg Pt. • Increase in activity • MDS N2 Avg Pt. Score* participation of ID/DD Score* = 0.97 participation by 10% as o All ID/DD = 0.982 (6/05 – 5/06) clients. (1/1/05-6/1/05) evidenced by reduction o Excl. E3 = 0.986 (12/05 – 5/06) of score in section N2 of o E3 = 0.974 (12/05 – 5/06) the MDS. 4. Expand rehabilitation/ • Increase rehabilitation • In FY 04-05: • Acute = 2 ADC • 12/05: Acute= 2.4 ADC community reentry census by 25%. Acute=1.6 ADC • SNF = 21.63 ADC SNF = 16.6 ADC program. SNF = 17.3 ADC • CHCF grant. (L4A & L4S) * Based on a scale of 0-3, 0 being the highest amount of activity and 3 being the least amount of activity. Updated June 15, 2006 3 Shading indicates that goal was met.
  10. 10. 2. Safety and Security Develop and implement an enhanced Safety/Security program that will provide a safe/secure environment for residents, staff and visitors. *Gayling Gee, Serge Teplitsky, Cheryl Austin Objectives Indicators / Outcomes Baseline Target Current Status 1. Physical Plant • Cardkey exterior door locks. • N/A • 6/05 • Design completed. Installation Enhancement in progress. • Improve lighting. • 12/05 • CH West entrance and rear loading dock entry completed 12/05. • Add duress alarms in North and East • 12/05 • System design completed parking lots. 12/05. Pending P.O. to initiate installation in 6/15/06. 2. Visitor ID • Extend program to day shift at least 3 • Eves, 2 posts, 5 • Extend program to day • Completed cadet program 3/06. Enhancement posts, 7 days per week. days per week. shift—at least 3 posts, Hours been extended to 4 posts 7 days per week. throughout main building and Clarendon. 3. Workplace Violence • Establish a violence vulnerability • N/A • 7/05 • Complete 7/05. Prevention Program analysis for high-risk units: C3, K6, (WVPP) O7, L4, O4, M5, 2nd Floor of CH. 4. Increased Security • Improve response time to incidents. • N/A • Emergency < 10 min • Cadet recruitment on-going, Personnel – • Intra-campus Escort Service for staff.. Urgent < 30 min with successful staffing of 7 • Enhanced Floor/Unit presence (foot Other < 60 min day/week coverage of 4 posts. patrols). • Deputy recruitment in process. • Escort PM & AM shift. • Completed 12/05. • One foot • Completed 6/05. patrol/shift/day. 5. Education and Training • Education and Training regarding the • Minimal • SMART training for • Train-the-Trainer complete management of patients with training. high risk units by 8/05. aggressive behavior. 1/1/06. Updated June 15, 2006 4 Shading indicates that goal was met.
  11. 11. Objectives • Indicators / Outcomes • Baseline • Target • Current Status 6. Traffic and Parking • Implement Paid Parking. • No paid • 3/1/05 • Complete. Paid parking Enforcement parking. • $563,740 revenue target implemented 3/1/05. Per • Per diem parking by diem parking in design. 11/05. • Budget for FY 05-06. • In place by 10/05. 7. Designation of Campus • Develop a safety officer position. • N/A • Budget FY06 • Position posted 8/05. Safety Officer • In Place 10/05 Difficulty recruiting. 8. Clean up 3 reported • Behind Clarendon. • N/A • 4/30/05 • Clean-up behind Clarendon, problems areas on 3rd and 5th floors complete. campus. • 5th Floor breezeway closed 1/06. Completed due to closure. • Clean, trash-free 3rd and 5th floor areas. • N/A • 7/05 • Work initiated on smoking shelters; estimated completion date 6/15/06. 9. Clean up homeless • Relocate homeless camps, clean up • N/A • 6/05 • Plan completed 4/05. camps on campus. campsites and patrol. • Undergrowth removal • Camps removal completed by 1/1/06. 4/05. • Goat project complete 8/05. • Debris removal completed 9/05. Updated June 15, 2006 5 Shading indicates that goal was met.
  12. 12. 3. Finance Maximize revenue for all programs and services. --- October 2005 review post-Invision --- * Valerie Inouye Objectives Indicators / Outcomes Baseline Target Current Status 1. Submit specific plans • Increase net per capita patient revenues • N/A • Budget by 1/05. • Complete in the FY 06 budget from one year to next. • Staff by 10/05. • Positions posted for known • 10/05 opportunities. • 11/05 • Fund position(s) • Staff position(s) 2. Convert from the • Obtain proposal from Siemens. • N/A • Conversion by 7/05. • Complete current ADL system • Develop a comprehensive conversion to Invision for patient plan, including a realistic time line. billing as a short-term • After conversion, report on reasons for solution. unbilled services and where reimbursement can be improved. • Implement operational improvements to capture revenue for the opportunities identified. 3. Increase revenue. • Continue to review current operations to • N/A • After completion of • On-going identify additional opportunities. number 2 above. 4. Improved Reporting. • Obtain better reporting from the billing • N/A • After completion of • On-going system on services performed where number 2 above. reimbursement can be improved. 5. Improve reporting to • Obtain consulting engagement to help • N/A • 7/06 • Planning for improved help manage FTEs with nurse model. reporting will take and operating • Develop the reports needed by nursing to place in FY 06-07. expenses. manage by nursing unit Labor reports, i.e. position control. Updated June 15, 2006 6 Shading indicates that goal was met.
  13. 13. 4. Organizational Structure, Communication and Leadership Develop a hospital-wide organizational structure for operations, leadership, communications, and training. * John T. Kanaley, Gayling Gee, Arla Escontrias Objectives Indicators / Outcomes Baseline Target Current Status 1. Define and develop • September 2005 - Nursing, Clinical • N/A • 7//05 • Completed 7/05. infrastructure. & Support Services • Organizational charts. • Completed 7/05. • Staffing plans - • FTE’s in FY 04-05 • 12/05 • Complete. Developed benchmarks o Nursing and needs assessments for Nursing, o DET DET and Housekeeping. Submitted o Housekeping Budget request. o Others? • Benchmarks Nursing = 4.1 HPPD • 12/05 • Complete DET = 8 FTE Housekeeping = 115 FTE 2. Develop programs to • Health Stream, Workplace Safety, • N/A • Assess for • DET established 8/1/05. train staff. Harassment Free Workplace, training • DET strategic goals and objectives Cultural Awareness, Abuse, needs. established 11/05. Uniform Discipline, Investigations • Develop • Complete. Hospital-wide orientation and Report Writing, Standard of training program updated and revised. Pilot in Conduct, Managers’ Training, program. 5/06. HIPAA, Compliance, Change Management. • LHH Education Council established 2/06 with multidisciplinary, hospital- wide representation. • Quarterly and monthly hospital • Implement education calendar established 11/05. Updated June 15, 2006 7 Shading indicates that goal was met.
  14. 14. Health • HealthStream Pilot program Stream established 10/05. Sixteen LHH program departments enrolled as of 4/06. with 90% Barcode reader technology compliance, established 3/06. Compliance rates of June 2006. enrolled departments for 2006 classes ranges from 70-100%. Full roll-out will go into FY 06-07. Objectives Indicators / Outcomes Baseline Target Current Status 3. Define and develop a • Policy approval and review process • N/A • Policy and • Complete. Policy Approval developed. Implementat • Reviewed at Exec staff 7/12/05. Process. ion by 6/05. • P&P Committee established. 4. Define leadership • • SYMLOG Baseline • 6/06 • Complete. training program, Assessment • Symlog Assessment fund, and agree on • Exec staff Review. focus. • Budget for training FY06 5. Performance • • 19% in 2004 • 80% by 6/05 • 82.19% for calendar year 2005 on Appraisal Process. • 90% by 6/06 1/20/06. 6. Design and • Internal Website. • N/A • 6/05 • Complete 8/05. implement a • External Website. • 6/05 • Complete 6/05. communication plan. • Internal Communication Plan. • 1/06 • Plan complete 3/06. Roll out in FY • Daily Nursing Report. • 6/05 06-07. • Complete 10/05. 7. Build relationships • TCM Meetings. • N/A • • TCM meetings continue. within DPH and • Medical staff from both GH & • 2 medical staff meetings conducted other CCSF LHH. and I.S.C meetings begun 9/7/05. Departments. • HMA report on leadership. • HMA Report to HC. Updated June 15, 2006 8 Shading indicates that goal was met.
  15. 15. 5. Information Systems LHH will participate in the design and implementation of a single DPH-wide clinical and financial information system and will upgrade the hospital infrastructure to support advanced technology. ---October 2005--- * Pat Skala, Mivic Hirose Objectives Indicators / Outcomes Baseline Target Current Status 1. Develop and • Document and prioritize the • Need two • 6/06 • Completed walk-thru of main building. Walk-thru of implement a replacement of CAD3 wiring additional wires Clarendon Hall will be done to identify locations of second cable throughout the areas that will pulled to each device. management use Soarian. unit. • Working with Facilities to identify closest closet. project plan. • Add data ports (or use wireless • May require • Have 17 devices on hand to install as soon as wiring is access points) to each nursing wireless devices pulled. station to support a minimum in cramped areas. • New wiring has been pulled to 14 nursing stations. IS is of three workstations per working with Nursing to prioritize the rollout of 17 net new nursing unit. workstations on the units. We are in the process of installing • Place a second and third these devices now. However, we have reached a point where workstation on each unit as we can no longer use the existing distribution system to add ports become available. additional wire. The conduits are full. To avoid the expense of installing a new raiser system in buildings that will be torn down as part of the rebuild project, we will use a combination of wireless technology and Category 3 extenders as we move forward. 2. Staff Training • Partner with the Information • Computer • 6/06 • As of 5/16/06, currently on a 4th cohort of staff training. Technology Consortium of San training needed Approximately 250 nursing have completed the training. Francisco, City College of San for 85% of Francisco and Labor to nursing staff. • Currently on the 4th cohort of staff training. Approximately develop a computer-skills 250 nursing staff have completed the training. training curriculum for staff. 3. Siemen’s LTC • Ensure that the Siemens Long • N/A • 4/05 • Completed 2/05 Programing Term Care Requirements document is reviewed, modified and approved by LHH clinical and financial managers. Updated June 15, 2006 9 Shading indicates that goal was met.
  16. 16. Objectives Indicators / Outcomes Baseline Target Current Status 4. Define the • Monitor the work plan. • Project of the • 9/06 • Brief discussions-have received suggestions. Need to metrics to be LHH IS Steering formalize. used to measure Committee. • Several proposals have been submitted as possible the success of the benchmarking projects. Key from a clinician’s perspective Soarian is the need to reduce the amount of time currently spent implementation. looking up information in the paper chart and reducing the number of times the information cannot be found. Updated June 15, 2006 10 Shading indicates that goal was met.
  17. 17. 6. Performance Improvement, Licensing and Regulatory Preparedness Develop and implement the LHH Performance Improvement Plan. --- September 2005 --- * Serge Teplitsky, Paul Isakson, MD Objectives Indicators / Outcomes Baseline Target Current Status 1. PI Program • Clearly define organization, line • LHH Performance • 6/05 • Complete. Program approved authority, responsibility and Improvement Policy. and implemented April 2005. accountability for performance improvement. 2. Develop Indicators • • CHSRA • Identify • Complete. Indicators are trended • UOs significant and presented at the LHH JCC, • CMS Quality clinical, Hospital Wide Performance Indicators financial and Improvement Committee and organizational Medical QI Committee outcomes. 3. PI Monitoring • Develop monitoring indicators that • CHSRA • Baseline and • Complete. Indicators are trended allow organization to track its • UOs Performance and presented at the LHH JCC, progress over time and demonstrated • CMS Quality measures to be Hospital Wide Performance the value of care we provide to our Indicators determined by Improvement Committee and residents. 1/06. Medical QI Committee 4. Staff Education on • Design presentation of data and • Education through • Hospital-wide • PI Plan presentation developed. Performance information to be shared with various PI committees. completion by Presented to Exec. Committee. Improvement (PI) employees, the medical staff and the 10/05. • Education has been done through community and to maintain presentations at the hospital confidentiality of protected health performance improvement information involved. committees and management forums. Training is being designed for Health Stream educational system • PI Plan was incorporated into LHH new employee orient-ation program on 5/12/06. 5. Program Evaluation • Provide for evaluation of the plan on • N/A • 6/05 • Complete, evaluation component the regular basis. in PI plan. Updated June 15, 2006 11 Shading indicates that goal was met.
  18. 18. 7. Human Resources Ensure adequate and culturally competent staff * Robert Thomas, Mivic Hirose, Gayling Gee, Paul Isakson, MD Objectives Indicators / Outcomes Baseline Target Current Status 1. Facilitate a • Review recruiting and • LHH employee demographics were • 4/05 • Recruitment practices were evaluated on diverse hiring practices. reviewed on 4/18/05. LHH is under- 8/1/05. The newly designated nursing workforce by represented in relation to our program director has implemented new target resident makeup and Bay Area recruitment strategies to expand the recruitment. population. applicant pool. • Prepare a target recruitment • 7/05 Targeted recruitment via: plan that promotes a diverse “ • Job Fairs • Meetings w/ schools workforce. • Newspaper Ads of Nursing and • Yellow Pages community leaders • Partner with schools and • 9/05 universities to enhance “ “ diverse recruitment. • Monitor statistics of new Employee Racial Demographics 2005 • Increased Employee Racial Demographics 3/8/06 employments against LHH White – 14.6% recruitment of White – 13.8% (-0.8%) and SF populations to Black – 11.9% bilingual/bi- Black – 11.6% (-0.3%) achieve a balance. Hispanic – 8.3% cultural staff Hispanic – 8.4% (+0.1%) Asian or Pacific Islander – 15.1% by 5% to Asian or Pacific Islander – 16.6% (+1.5%) Filipino – 50.0% reflect resident Filipino – 49.54% (-0.5%) Native American – 0.1% population. Native American – 0.0% (-0.1%) Nursing Racial Demographics 2005 Nursing Racial Demographics 5/06 White – 4.7% White – 5% (+0.3) Black – 9.9% Black – 11% (+1.1%) Hispanic – 4.6% Hispanic – 5.2% (+0.6) Asian or Pacific Islander – 6% Asian or Pacific Islander – 7.4% (+1.4%) Filipino – 74.7% Filipino – 71.2% (- 3.5%) Native American – 0% Native American – 0% (same) 2. Enhance the • Review/survey LHH • Nursing and HR are currently • 6/05 • Department of Education & Training will skills of current resident population to analyzing data to determine the provide training where there is a staff to provide determine cultural, social, language preference of our resident language/cultural competency need. culturally clinical care needs. population. Updated June 15, 2006 12 Shading indicates that goal was met.
  19. 19. Objectives Indicators / Outcomes Baseline Target Current Status competent care. • Prepare an education and • 12/05 training plan. “ • Provide education and • training for staff to enhance “ “ their abilities to provide a diversity of care. 3. Minimize staff • Facilitate staff replacement • LHH has historically had a low • • Working to improve requisition approval vacancies and especially in nursing. turnover rate. It is anticipated that process. attrition rates. attrition will increase dramatically in • Survey conducted on expected turnover the next few years. (1/06): 20% next 3 yrs, 20% next 5 yrs, 34% next 10 yrs. • Review staff to predict “ • 6/05 “ attrition rates. • Conduct personal exit • interviews to determine why “ “ employees leave. 4. Retain a • Develop a retention and • With attrition estimated at 20% over • • Working to improve positive relationships diverse advancement plan. the next 3 years, there is an with current staff to enhance morale. workforce. opportunity to enhance recruitment • Working to enhance cultural awareness and retention. and values of current staff. Updated June 15, 2006 13 Shading indicates that goal was met.
  20. 20. 8. Laguna Honda Hospital Replacement Project Develop a systematic approach to successfully operationalize the Replacement Project. --- October 2005 --- *Lawrence Funk Objectives Indicators / Outcomes Target Current Status 1. In collaboration with the LHH • LHHRP scope: no less • The East Residence along • The City has authorized construction of the South, Replacement Project Team, than 780 licensed beds. with the South Residence Link and East Resident Buildings which will City/DPH Leadership, and and Link Building will provide 780 licensed beds. The decision regarding major stakeholders review the provide 780 licensed beds the ultimate scope of the project is a policy issue project construction bids and for the LHHRP. for City Leadership. budget, and determine the • Decide on remaining scope (the West Wing = 420 scope of work to be built. • beds). 2. Define FF&E Budget and • Based upon the final scope • Refine budget estimate and • Completed. The total preliminary FFE cost for Procurement process. of work, review the FFE produce plan for approving 1200 costs is $36M, of which $29M is required for budget, and develop a plan specifications. 780 beds. The Project Team, consultants, City for procurement. Purchaser, and LHH staff will collaborate in the procurement process. 3. Develop a Donor Recognition • Program Developed in • 6-9 months after city makes • The development of a Donor Recognition program Policy and Program to conjunction with the decision on scope of project. has been deferred until ’06-07, pending decision support the FFE fundraising Laguna Honda Foundation. on scope of project and reactivation of the Laguna effort. Honda Foundation. 4. Continue efforts to integrate • To integrate through • 1 year prior to opening the • Completed 05-06 objective technology in the new facility collaboration LHHRP, facility—8/07. Ongoing in 06-07. as appropriate. hospital staff, DTIS, DPH, IT staff, consultants, optimize integration Every Opportunity. • Integrate a package from point of care to business systems. 5. Initiate financial planning for • Planning process defined. • By 1/06. • A draft pro forma operating budget has been the new facility including a completed. A final product will be produced when pro-forma operating budget, the ultimate scope of the project is determined by Updated June 15, 2006 14 Shading indicates that goal was met.
  21. 21. Objectives Indicators / Outcomes Target Current Status and an analysis of the impact City Leadership. of SB1128. 6. Initiate planning for the • Planning Group • Begin planning as soon as • Completed objective for 05-06 Assisted Living Program on established. scope of Replacement ongoing in 06-07. the LHH campus. project is determined. 7. Continue to provide public • Develop external website. • By 9/05 • Completed objective for 05-06 information and advocacy for • Rebuild website. • By 9/05 ongoing in 06-07 the Replacement Project. • Community meetings. • Bi-monthly • Develop communication • By 1/06 plan. Updated June 15, 2006 15 Shading indicates that goal was met.
  22. 22. 9. Operational structure of new hospital Initiate the operational planning for moving into the new hospital. --- November 2005 --- * John T. Kanaley Objectives Indicators / Outcomes Baseline Target Current Status 1. Policy and Procedures To be determined Transition Steering Committee established and meeting monthly. This will be a 3-yr goal. 2. Operational Plans a. Nursing b. Operations c. Medical Staff d. Information Systems e. Pharmacy f. Resident/Family g. Licensing/Certification h. Out patient Updated June 15, 2006 16 Shading indicates that goal was met.
  23. 23. ATTACHMENT C
  24. 24. Placement Unit Targeted Case Management Accomplishments FY 2005-06 The Placement Unit Targeted Case Management (TCM) program officially began operations in March 2004. It was implemented to help residents of Laguna Honda Hospital transition back into the community and to divert LHH admissions by providing intensive support in securing the resources necessary to remain in the most integrated setting. The TCM program screens, assesses, and develops individual service/discharge plans for LHH residents and San Francisco General Hospital patients who are interested in discharge, and provides limited ongoing case management as appropriate. The TCM Screening identifies candidates eligible for more intensive assessment by case managers for the purpose of possible transitioning back into the community. The TCM Screening criteria include: Level of Cognitive Skills for Daily Decision-Making; Level of Dressing and Personal Hygiene Ability; Suspected Presence of DD or Mental Illness (PAS/PASSR State screening); Availability of Persons Supportive of Discharge; Preference to Return to the Community; and Projected Duration of Stay at LHH. Screening also helps to determine timeframe for potential discharge of those eligible for TCM. In FY 2005-06, as of June 1, 2006, 611 clients were screened for eligibility. The next step in the TCM process is assessment by case managers who evaluate the client’s eligibility for the TCM program through the completion of the RAI-HC. Individual Service Linkage Plans have been developed and are now being processed for each client. In FY 2005-06, as of June 1, 2006, 572 clients were assessed. Once accepted, each client is assigned a case manager who provides discharge planning, makes referrals, and follows the success of the client in the community for a period of time after discharge. In FY 2005-06, as of June 1, 2006, 185 clients were accepted into TCM. A total of 269 clients were served throughout the fiscal year. For these clients, 353 referrals were made to ensure successful community placements. In FY 2005-06, as of June 1, 2006, 119 clients were discharged from LHH and SFGH by TCM staff.
  25. 25. P e rio d : 7 /0 1 /2 0 0 5 - 0 5 /3 1 /2 0 0 6 * Screenings Completed.......................................................... 611 100 90 80 70 60 50 40 30 20 10 S c r e e n in g s 0 Ju l A ug Sep Oct No v De c Ja n Fe b Ma r A pr May 2005 2005 2005 2005 2005 2005 2006 2006 2006 2006 2006 Assessments Completed...................................................... 572 90 80 70 60 50 40 30 20 10 A s s e s s me n ts 0 Ju l A ug Sep Oct No v De c Ja n Fe b Ma r A pr Ma y 2005 2005 2005 2005 2005 2005 2006 2006 2006 2006 2006 Clients enrolled into TCM...................................................... 185 Discharges from SFGH and LHH by TCM ........................ 119 30 25 20 15 10 5 0 Jul A ug S ep Oct N ov D ec Jan F eb M ar A pr M ay 2005 2005 2005 2005 2005 2005 2006 2006 2006 2006 2006 TC M A dm is s ions D is c harges Community, Wavier and Housing-Related Referrals......... 353 * Ju n e 2 0 0 6 TC M d a ta se t u n a v a ila b le a t th e tim e th is re p o rt w a s p ro d u ce d .
  26. 26. ATTACHMENT D
  27. 27. LAGUNA HONDA HOSPITAL Leadership Team EXECUTIVE ADMINISTRATOR John T. Kanaley DEPUTY CITY QUALITY ADMINISTRATIVE REPLACEMENT COMMUNITY PHARMACY OPERATIONS PROJECT AFFAIRS ATTORNEY MANAGEMENT David Woods Rowena Tran Larry Funk Arla Escontrias Adrianne Tong Serge Teplitsky MEDICAL SERVICES Paul Isakson, M.D. Clinical & Support Services INFORMATION NURSING SERVICES FINANCE HUMAN RESOURCES Hosea Thomas, M.D. Gayling Gee SYSTEMS Mivic Hirose Valerie Inouye Bob Thomas Monica Banchero- Cheryl Austin Pat Skala Hasson, M.D. Physician Staff Clinical Program Outpt & Clin Support See DPH See DPH Labor Relations Medical Education Information Systems Finance Asian Focus PT/Rad/RT Mental and Behavioral Organization Chart Organization Chart Payroll Acute Health Med surg Clinic Palative Workers' Compensation IC/CPD Rehabilitation Services Bed control/ Recruitment Social Services Operations Clinical Program Physician Services Department of Merit Systems Complex Education / Training Consult Services Rehab Clinical Dietitians HiV See DPH Hematology/Oncology Clinical Program Human Resources Health & Safety Organization Chart Cardiology/EKG Dementia Urology High support/Chronic Support Services Nephrology Operations HIS Plastic Surgery Telecom RAI / MDS Department Surgery Security Dental Parking/Tran Therapeutic Activities Pulmonary Housekpng Laundry Activity Therapy Podiatry Sr Nutrition Spiritual Care ADHC Vascular Surgery Volunteer Services Altzheimer's Endocrinology Vocational Rehab Vocational Rehab Materiels Management UCSF Service Agreements Materiels Mgmt Nutritional Services Plant Services February 2006
  28. 28. LHH Executive Administrator Medical Services Division Organizational Chart John Kanaley as of February 1, 2006 Secretary II 1446 – (1) MSSD: Medical Staff MSSD Specialist Medical Director Services Department 2106 – (1) 2235 – (1) Chief of Staff Clerk Typist 2232 (1) 1424 – (.90) Chief of Rehabilitation Vice Chief Chief of Psychiatry/ Neuropsychology Chief of Medical – LHH/SFGH Psychosocial C&L Coord. Chief of Medicine Consult Services SATS Informatics (UCSF Physician) Hospital Acute Cluster 2232 – (1) 2576 – (1.0) 2232 – (.5) (See Page 2) Screening 2576 – (.05) 2576 – (1.0) Hematology/Oncology Ancillary Acute Cluster SATS Services Psychosocial Rehabilitation Contract 2574 – (.6) Daytime Nights/Weekends (See Page 2) Cluster/ADHC (.5) 2574 (1.25) AIDS/M5 (.5) 2232 Cardiologist 2232 Senior Physician Specialist 2230 Physician Specialist 2430 MEA Admitting (32.82) (0.13) Dementia (1) (EKG Tech.) (2) 2574 – (.06) Cluster 2574 – (.65) Neuropsychology 2232 Urology Consult & Liaison Nephrology 2574 – (1.0) SATS Contract Sr. Occupational 2930 Therapist — Psychiatric SATS 2232 Plastic Surgery Psychosocial Social Worker 2588 R.A.S. (0.13) 2550 – (1.0) (SATS) (1.0) (SATS) (1.0) 2232 Surgery 2232 Psychiatric Senior (0.14) Physician Specialist Dental Michael Coleman, MD UOP Contract Charles Stinson, MD 2230 Pulmonary (0.13) Podiatry Contract Vascular Surgery Contract • Radiology • Neurology UCSF Service • Gynecology Agreements • Rheumatalogy • Orthopaedic 2230 Endocrinologist (0.13) • Dermatology Ophthalmology Contract ENT (1)
  29. 29. John T. Kanaley Executive Administrator Mivic Hirose Hospital Associate Administrator (2145) LHH Nursing Division Chief Nursing Officer Nora Wong Pamlea Ketzel 1.0 FTE Secretary I (1446) 1.0 FTE Nurse Manager (2322) Safety Training Bronwyn Gundogdu Bronwyn Gundogdu Mozettia Henley Mozettia Henley Esperanza Sorongon Debbie Tam William Frazier Nursing Director (2324) Nursing Director (2324) Nursing Director (2324) Nursing Director (2324) Nursing Director (2324) Nursing Director (2324) Health Program Coordinator (2593) 1.0 FTE 1.0 FTE 1.0 FTE 1.0 FTE 1.0 FTE Rosario Enriquez Ellen Apolinario Lolita Caceres Teresita Baluyut Mercedes Devasconcellos Ghodsi Davary Refer to Activity Therapy, 1.0 FTE Nurse Manager (2322) 1.0 FTE Nurse Manager (2322) 1.0 FTE Nurse Manager (2322) 1.0 FTE Nurse Manager (2322) 1.0 FTE Nursing Supervisor (2324) 1.0 Nurse Manager (2322) Spiritual Care Services, Units F4 & G6 Units D5 & E6 Units S300 & W300 Units C3 & G3 AM Shift Admissions Screener/Bed Control Vocational Rehabilitation and Volunteer Services Org Chart Gigi Ipac 1.0 Nurse Manager (2322) 2320 - 9 FTEs 2320 - 9 FTEs 2320 - 9 FTEs 2320 - 9 FTEs 2320 - 3 FTEs Units M5 & M7A 2312 - 3 FTEs 2312 - 3 FTEs 2312 - 3 FTEs 2312 - 3 FTEs 2312 - 2 FTEs 2302 - 18 FTEs 2302 - 18 FTEs 2302 - 18 FTEs 2302 - 18 FTEs 2302 - 15 FTEs 1428 - 1 FTE 1428 - 1 FTE Nahidi Mansoureh 1.0 Nurse Manager (2322) Kathleen Maxwell Oliva Ignacio Daisy Corral Natividad Dullas Lenora Jacobs Unit C2 1.0 FTE Nurse Manager (2322) 1.0 FTE Acting Nurse Manager (2320) 1.0 FTE Nurse Manager (2322) Acting Clinical Nurse Specialist (2323) 1.0 FTE Nursing Supervisor (2324) Hospice Unit & Palliative Care Program Units E3 & F5 Units K6 & L6 Unit F3 & TTWA Coordinator 1.0 FTE PM Shift Units E200, S200 & W200 2320 - 9 FTEs 2302 - 18 FTEs 2320 - 9 FTEs 2320 - 9 FTEs 2320 - 9 FTEs 2320 - 9 FTEs 2320 - 3 FTEs 2312 - 3 FTEs 2312 - 3 FTEs 2302 - 18 FTEs 2312 - 3 FTEs 2312 - 2 FTEs 2302 - 18 FTEs 2302 - 18 FTEs 2302 - 18 FTEs 2302 - 15 FTEs 1428 - 1 FTE Stella Yim 1.0 Nurse Manager (2322) Peter Rapadas Josephine Rapadas Lilia Hendrix Madonna Valencia Sophie Mace Units C4 & G4 1.0 FTE Nurse Manager (2322) 1.0 FTE Nurse Manager (2322) 1.0 FTE Nurse Manager (2322) 1.0 FTE Nurse Manager (2322) 1.0 FTE Nursing Supervisor (2324) Units D6 & F6 Units O5 & L7 E100, W100 & E300 Units L4A & L4S, Float Staff AM Shift 2320 - 9 FTEs 2312 - 3 FTEs 2320 - 9 FTEs 2320 - 9 FTEs 2320 - 9 FTEs 2320 - 21.8 FTEs 2320 - 3 FTEs 2302 - 18 FTEs 2312 - 3 FTEs 2302 - 18 FTEs 2312 - 3 FTEs 2312 - 3 FTEs 2312 - 2 FTEs 2302 - 18 FTEs 2302 - 18 FTEs 2302 - 75 FTEs 2302 - 15 FTEs 1428 - 1 FTE Anne Hughes 1.0 FTE Clinical Nurse Specialist (2323) Muriel White Cristina Reyes Dorothy White Roland Zepf Monica McGuire 1.0 FTE Nurse Manager (2322) 1.0 Acting Nurse Manager (2320) 1.0 FTE Nurse Manager (2322) 1.0 FTE Nurse Manager (2322) 1.0 FTE Nursing Supervisor (2324) Units M7S & K7 Units K5 & L5 Unit O4 PM Shift Bea Gunn 2320 - 1.0 FTE Clinical Resource Nurse 2320 - 9 FTEs 2320 - 9 FTEs 2320 - 9 FTEs 2320 - 9 FTEs 2320 - 3 FTEs Clinical Educator 2312 - 3 FTEs 2312 - 3 FTEs 2312 - 3 FTEs 2312 - 3 FTEs 2312 - 2 FTEs 2302 - 18 FTEs 2302 - 18 FTEs 2302 - 18 FTEs 2302 - 18 FTEs 2302 - 15 FTEs 1428 - 1 FTE Elisa Ramirez 2320 - 1.0 FTE Orientation Coordinator Gail Cobe Amparo Rodriguez Christine Winkler Vacant Mary West Clinical Educator 1.0 FTE Clinical Nurse Specialist (2323) 1.0 Acting Nurse Manager (2320) 1.0 FTE Nurse Manager (2322) 1.0 FTE Clinical Nurse Specialist (2323) 1.0 Nursing Supervisor (2324) Dementia Program Units E5 & M6 Units E4 & G5 AM Shift Vacant 2320 - 1.0 FTE Recruitment and Retention Coordinator Vacant 1.0 FTE Clinical Nurse Specialist (2323) 2320 - 9 FTEs 2320 - 9 FTEs 2320 - 3 FTEs Wound Care/Geriatrics Program 2312 - 3 FTEs 2312 - 3 FTEs 2312 - 2 FTEs 2302 - 18 FTEs 2302 - 18 FTEs 2302 - 15 FTEs Beautician Services 7324 - 2.0 FTEs Salary Savings Nursing Office 2320 - 1.0 FTE, 2302 - 1 FTE 1408 - 1.0 FTE, 1424 - 2.0 FTEs 2302 Nursing Assistant (37.10) 1429 - 2.0 FTEs MDS/RAI Program 2312 Licensed Vocational Nurse (2.80) 2320 - 7.0 FTEs 2320 Registered Nurse (14.06) February 2006 Vacant Positions 2320 - 15 FTEs 2312 - 2 FTEs 2302 - 7 FTEs

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