Neurosurgery Team

UCLA Neurosurgical Clinical Quality Program:
Implementation Guide

I. Identifying Areas of Priority

Areas of focus should be based on the quality priorities in the department, the specialty, and national initiatives. A number of factors should be considered in identifying areas of priority:

a. Strength of evidence for improvement efforts

  • Based on available literature or expert consensus

b. High clinical significance and impact from the improvement initiative

  • Relevance to the challenges faced by the specialty and national organizations
    • IHI, TJC, CMS
  • Publically reported quality measure, pay for performance, or metrics used in hospital grading/ranking

c. Appropriate metrics (measurements) easily available and accessible for process or outcome measures

  • Consider ease of obtaining data from the department/institution

d. Established or available benchmarks

  • Based on national standards, literature, or baseline data

e. Appropriate expertise available to lead the improvement efforts

  • This can include expertise within the
    Institution: quality department, other clinical departments
    National: through mentored-implementation projects

f. Diverse group of projects

  • Areas of priority should include a variety of projects, including easily achievable low-hanging fruit, as well as more challenging and long-term initiatives.

II. Aligning the Quality Agenda with the Priorities of the Medical Center

This alignment will reveal potential hospital-wide resources that can be utilized to advance the department's quality agenda. This can also ensure that if there are available resources in the future, the leadership team can help create synergies.

III. Creating and Leading a Culture of Change

a. Identifying leaders and champions: for each area of priority, assign a leader who will be accountable and ensure progress. The leader should clearly identify:

  • Specific aims for improvement
  • Interventions that will be implemented
  • Timeline for completion of aims

This process should also include:

  • Metrics: for processes or outcomes
  • Balancing measures: unintended consequences of implementing the quality initiatives
  • Barriers to accomplishing the goal

These parameters should be closely followed by the champion. Various tracking methods such as the one proposed below can be used:


Individual Accountable

Educational Package

- Lives saved
- Dollars saved
- Satisfaction
- Ranking

Metrics and Baseline Data


Outcomes and Timeline (long and short term)







b. Creating a dashboard to track improvement:

  • Ensure appropriate metrics have been identified
  • Obtain baseline data
  • Establish benchmarks for improvement

c. Recognizing early adopters: proactively identify health care providers (attendings, residents, nurses, pharmacists) who are engaged in quality improvement efforts and work with them toward achieving objectives.

d. Creating teams: align projects with interests of other health care providers by illustrating direct benefit to the provider - this can be in time savings and simplification of work processes to help address demanding schedules.

e. Empowering staff to see themselves as leaders: can be accomplished through launching a QI Retreat, actively celebrating and highlighting success, and establishing monthly Care Coordination meetings

f. Provide incentives (financial and/or recognition) for leaders and key champions of the quality program: this should be build into the cost savings that will occur from establishing the quality program

IV. Sustainability

a. Track results by monitoring progress

  • Monthly: by review of dashboard in monthly care coordination meetings
  • Quarterly: for data available every 3 months
  • Annually: via the faculty annual quality reports

b. Address barriers to improvement in real-time

c. Create a position dedicated to ensuring progress of the department's quality priorities: director of quality (RN, NP, MD)

d. Actively re-assess progress, set new goals and celebrate success