The changes underway at Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG) begin with the spectacular new physical space.
“But the new space also reflects a system-wide effort to enhance patient access and improve care at ZSFG. Physicians from the Department of Anesthesia and Perioperative Care area have been instrumental in the transition and in driving change in a number of key areas,” says Jim Marks, MD, PhD, the hospital’s chief of the medical staff.
The stories below offer a few examples.
Complex Transition to the New Operating Rooms Proves Successful
As exhilarating as it’s been to move to the new hospital, preparing the clinical staff to smoothly transition its operations was an enormously complex challenge.
“When the clock flipped from 6:59 to 7:00 AM on May 21, 2016, we had to move from our last case in the old hospital to being ready to handle a potential major trauma – like an airplane crash – in the new hospital,” says the ZSFG’s medical director of the anesthesia workroom, Stefan Simon, MD.
Thankfully, there was no airplane crash that morning, but the transition in the operating rooms (ORs) and perioperative area was smoother than anyone could reasonably expect, in part due to the efforts of Simon, Perioperative Medical Director Jens Krombach, MD, and Krishna Parekh, MD, who took special assignments to work on a number of specific aspects of the transition.
“We were a team,” says Simon, noting that Parekh handled everything from setting up simulations in the new hospital to helping determine where to place various types of equipment and that Krombach created an extensive plan for patient flow in the new hospital’s many anesthesia work places.
The process began with a detailed analysis of how to achieve a safe and successful transition without a so-called “soft opening” of the new hospital. “With the flip of a switch, we had to be ready to run 6 or 7 ORs and every anesthesia provider had to be familiar with the new equipment – monitoring equipment, anesthesia machines and computer systems – as well as the layout of the new building, the new rooms, the new patient flow, how patient transport would work and the new communication system,” says Simon.
A Methodical, Multi-Pronged Approach
The team decided to take a multi-pronged approach over the course of the few months leading up to the day of the move. Once they had worked out the preliminary details about the layout of the ORs, the anesthesia workroom and patient flow – and had access to the new hospital – they designed three morning-long sessions where providers could move from station to station and receive training on all the new equipment. Part of the training involved simulations: What if a patient comes in with a gunshot wound to the chest? How to handle a pediatric patient who enters from the emergency department? How would a patient be transported to get an MRI? Which elevator would they use?
“The anesthesia equipment alone was a real challenge, because it is substantially different from what we’d been using in the old hospital,” says Simon. Therefore, the team didn’t stop at simulations, but created three new anesthesia workstations in the old hospital. This made it possible – once they’d completed their simulation training in the new facility – to use the equipment with live patients and fine-tune the setup. “Every anesthesia provider, including the anesthesia technicians, needed to fulfill the training for all new equipment,” says Simon.
In addition, the team created a “treasure hunt” in the new building, so that whenever work slowed in the old facility, providers could go to the new building to continue to familiarize themselves with the new rooms, layouts and workflow implications.
Finally, the team coordinated its work closely with the many different departments at ZSFG to troubleshoot any and all potential problems.
“Our goal was to eliminate as many hiccups as possible before we made the move,” says Simon. “It was a process of constant problem solving and working as a team and was important because every time we looked at a problem, something would arise that some of us had not thought about at all.”
When the first urgent case appeared for the new hospital – at 10 AM on May 21 – the team felt ready. Simon says, “Getting to a smoothly oiled machine will take months, but it was gratifying that we were fully functional and ready to safely operate at the time of the move.”
More Resources, Improved Design, Enhanced Access for Trauma and Preoperative Care
In addition to being the city’s safety net hospital, ZSFG is San Francisco’s trauma center. Marc Steurer, MD, director of Trauma Anesthesiology at ZSFG, says the new hospital does a remarkable job of accommodating modern patient flow in ways that simultaneously enhance efficiency and patient care. Among the improvements:
- The ambulance bay is just feet away from the trauma resuscitation room.
- The CT scanner is right next to the resuscitation rooms.
- A dedicated elevator transports patients to the operating rooms (ORs), interventional radiology or the intensive care unit (ICU).
- The trauma OR has a large footprint, state-of-the-art equipment and an adjacent blood bank.
- A hybrid OR gives clinicians the ability to do both surgical and interventional radiology procedures.
- The dedicated trauma ICU has larger, well-equipped and light-filled rooms.
“All of these resources eliminate a lot of hurdles and barriers, allowing us to focus more on our patients,” says Steurer.
Perioperative Process Improvements Center on Patient Needs
Other improvements have been in motion for a few years now – and the new facility enhances those improvements.
Take perioperative care. About three and half years ago, Laura Lang, MD, medical director of ZSFG’s preoperative clinic saw an opportunity to implement a number of innovations that could increase access to care for underserved patients while improving patient outcomes and patient satisfaction. Led by experienced attending physicians, nurse practitioners and registered nurses – and consistently one of the highest performing clinics at ZSFG, with only 8 percent no-shows per month – the clinic was well-positioned to identify opportunities for change and implement them.
One of the first things Lang and her colleagues did was opt to see every patient scheduled for elective surgery in person, rather than only seeing high-risk patients in clinic and doing the rest of their screening by phone, as is common in other hospitals.
"In person screening is more effective for many of our patients,” says Lang. “For example, we can be much more effective in preparing patients for surgery who don’t speak English or need pre-operative testing. And for those who have had limited access to healthcare, we can do a full work-up and then get them connected to health care providers and, where necessary, social services.”
Such an approach also has a financial advantage in that it decreases cancellations and their associated costs, while reducing patient wait times. Lang and Steurer believed the reduced wait times would increase patient satisfaction.
To find out – and to give patients a voice – in January 2016 they implemented a survey in the clinic to close the loop on patients’ experience. “The data shows a direct correlation between how likely a patient is to recommend us with how satisfied they are with their wait time and instructions,” says Steurer.
Larger Space, Creative Solutions
All of this work will bear even more fruit when the preoperative clinic moves into a larger, self-contained space in the fall of 2016 to accommodate increased volumes. At the moment, it shares space with other surgical services where the waiting room and check-in process is centralized. “When we have our own waiting area and check-in desk, we expect to be able to improve workflow and further improve wait times,” says Steurer.
But he and Lang have not limited their innovations to onsite services. “One of the things we've discovered is that sometimes our patients can’t show up due to limited transport – they don’t have a car and can’t afford bus fare on any given day,” says Lang. “So we’ve created a partnership with Lyft where we will offer department-sponsored rides back and forth to our patients who need it on the days of their preop exam and surgery.”
In fact, the Lyft program is part of a comprehensive effort to provide services across the entire spectrum of care. “The preop clinic is a logical connection point in the perioperative episode,” says Steurer. “We are in a position to become more of a perioperative guiding entity by doing everything from helping to decrease infections to coordinating postoperative respite at home.”
Bringing Comprehensive Pain Management to ZSFG’s Underserved
It’s an interesting time to be a pain physician.
On the one hand, demand is intense. With about 100 million Americans suffering from chronic pain, outpatient clinics are overflowing. Meanwhile, inpatient settings are under regulatory pressure to ensure adequate pain control.
Yet even as physicians try to address these demands, epidemic levels of opioid abuse and overdose deaths have dominated the headlines. An article in the August 2015 issue of the Journal of Urban Health reported that from 2010 to 2012, 331 people in San Francisco died from accidental opioid overdose, most of them from prescription opioids – and these cases disproportionately affected the city’s poorest residents.
Anesthesiologist and pain physician Arthur Wood, MD, is determined to offer his patients access to a full menu of pain relief options while minimizing addiction risks. He leads what is rapidly becoming a comprehensive pain management center at ZSFG, where many of the city’s poor receive their care.
Expanding Capacity
Wood arrived at UCSF in 2015 as the first physician on the ZSFG staff to have completed the Accreditation Council for Graduate Medical Education’s (ACGME’s) anesthesiology pain fellowship. His vision was to extend ZSFG’s pain clinic hours beyond a half-day a week and to bring together a full complement of pain management services in one place, including medications, injections, integrative medicine approaches, cognitive-behavioral therapies and procedures. He has moved quickly to realize this vision.
“We’ve co-located our pain clinic with our already established outpatient preoperative clinic and extended it to two half days a week, which has already reduced wait time,” says Wood. “And we’ve successfully recruited and hired two pain-fellowship trained anesthesiologists who will enable us to move to five full days a week some time in the fall of 2016.”
He is confident that demand will justify that level of expansion, in part because transitioning to an electronic referral system – which has made it easier for primary care physicians to get their patients into the clinic – quickly resulted in a doubling of volume.
“We are monitoring whether those increases continue, but given the number of people that suffer from chronic pain in San Francisco, I believe they will,” says Wood.
A Larger Space With More Services
In anticipation, the pain clinic has secured a new and larger space, which will facilitate an improved patient experience that includes more reductions in wait times and the ability to see multiple providers in one visit.
“We also can do ultrasound guided pain injections in the new space – and will continue to do fluoroscopic-based injections in the operating rooms,” says Wood.
At the same time, he is looking to bring additional services into the clinic, so providers can more easily communicate about complex patients. The possibilities include: the Healthy Spine Clinic, which is staffed by two experienced nurse practitioners; a pharmacist who is helping to develop medication tapers; addiction medicine physicians; onsite physical therapists; and, possibly in the future, the department’s expert in neurostimulation.
In addition, Wood and his colleagues are capturing patient-reported outcomes using the NIH’s PROMIS measures of pain, function, sleep and anxiety to help refine the services they offer to patients.
“We expect this to be a one-stop shop that offers our often underserved patients access to all of the latest treatments for pain,” says Wood.