Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG) is a 397-bed public safety-net hospital that experiences over 80,000 ED visits each year and nearly 16,000 admissions. They pride themselves on being a teaching hospital, a Level 1 Trauma Center, and a lean learning organization.
After adopting A3 Thinking as the organization’s primary problem-solving methodology in 2015, and faced with a worsening post-acute care crisis throughout the San Francisco Bay Area, ZSFG’s executive leadership identified improving patient flow and access as a key strategic priority in 2016-2017. Two physicians, Hemal Kanzaria, an Emergency Department physician and Kaizen Promotion Office fellow, and Jack Chase, a family physician and Medical Director of Care Coordination, troubled by the flow problems they saw in their own work as clinicians and leaders at ZSFG, developed an A3 and built up a multidisciplinary team to tackle this issue.
By asking why, going to see, learning from those who knew the work best, and continually seeking opportunities to improve value for staff and patients alike, Drs. Kanzaria and Chase began to understand the problem more deeply. They found that 1/3 of patients admitted to an inpatient unit from the ED had a length of stay of less than 2 days. They noticed that these patients often showed a pattern of high social complexity combined with low medical acuity and discovered that such admissions driven by social needs accounted for 10-15% of all hospitalizations at ZSFG. They realized that ED providers did not always have the resources, capacity, or the knowledge to connect such patients with the services they needed most and often admitted them out of concern for their wellbeing in the community.
In an effort to be “hard on process, easy on people” one countermeasure they decided to explore was convening a multidisciplinary team of providers, social workers, nurses, pharmacists, and patient navigators to work on improving the fragmented processes that were contributing to these “social” admissions from the ED.
Since the work began in August of 2017, the ZSFG Social Medicine team has continued to use lean tools and A3 Thinking to design and lead several improvement initiatives that have had positive impacts on flow, team cohesion, staff wellness, and patient outcomes. Under the leadership of Drs. Kanzaria and Chase, with the dedicated participation of the entire team, and with coaching support from the Kaizen Promotion Office, this group has helped improve ED team engagement, partnerships with community agencies, processes for linking patients with needed community resources, and the overall quality and effectiveness of care coordination from the ED, successfully averting over 195 “social” admissions and preventing over 30 readmissions in the first half of 2018.
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