Healthcare Reform from the Inside

Neurosurgery Team

UCLA Neurosurgical Clinical Quality Program:
Healthcare Reform from the Inside

A Neurosurgical Quality Improvement Initiative: Enhancing Quality, Safety and Efficiency

It is widely recognized that the United States healthcare system has serious deficits in overall quality, patient safety, patient satisfaction, coverage, and access to care.

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1. Identifying the Department's QI and Patient Safety Priorities
2. Aligning Department's Priorities with Medical Center Goals
3. Finalizing the Goals for Improvement
4. Launching the QI Initiative Retreat
5. Sustaining the QI Initiatives
6. Celebrating success
7. Challenges

Concurrently, healthcare costs are increasing at a rate that will compromise the national economy, overburden many families today, and overwhelm our children tomorrow. While federal and state governments struggle to reform healthcare financing and healthcare coverage programs, we see it as the clinician's responsibility to expand our programmatic focus from the traditional tripartite mission of patient care, teaching, and research, to encompass a department-wide initiative to enhance quality, lower cost, and improve patient satisfaction. We as clinicians and leaders have to do our part to improve, even re-invent, healthcare in a broader sense: this is "Healthcare Reform from the Inside". Many, perhaps most, elements of the needed comprehensive restructuring of the U.S. healthcare system can only be accomplished through the insights, ingenuity, and interventions of the clinicians working every day on the frontlines of medicine.

While the United States has been a leader in health care advancement and innovation, there has been a growing national recognition of the deficiencies in quality, safety, access to care and cost. As illustrated by McGlynn in 2003, patients receive 54 - 56% of recommended preventive, acute and chronic care. Furthermore, the quality of care varies considerably based on the medical condition, ranging from 11 to 79% of recommended care. In addition, the Institute of Medicine report To Err is Human demonstrated that nearly 100,000 deaths occur annually due to medical errors. Moreover, access to care is challenging with more than 40 million uninsured Americans. The cost of health care has significantly increased, with management of chronic illnesses during the last two years of life accounting for 32% of all Medicare spending. The U.S. spends more money on health care than any other industrialized nation, while performing poorly on quality indicators. While health care reform is underway in Washington, it is critical for each hospital, department, and health care provider to work in a multidisciplinary manner to improve the quality of patient care.

In February 2009, the Department of Neurosurgery at Ronald Reagan UCLA Medical Center launched the "Quality Improvement (QI) Initiative: Enhancing Quality, Safety, and Efficiency". This Initiative emphasizes a multidisciplinary approach for improving health care at the departmental level. The goals of the Initiative were as follows: 1) To provide the appropriate care and ensure quality and safety for all patients, 2) To proactively create improvement instead of a reactive response imposed by governmental agencies, 3) To reduce the harmful economic and social impact of increasing health care costs, 4) To provide opportunities for fair "gain-sharing" that incentivizes positive change, and 5) To offer value-added mechanisms to replace clinician compensation lost through cuts in reimbursement. The QI Initiative focused on identifying departmental priorities, aligning priorities with the Medical Center, creating a culture and infrastructure for change, and sustaining improvement efforts.

This innovative Program is unique in a number of ways. It focuses on cross-functional and inter-disciplinary groups of providers. It is not the responsibility of one group, but the involvement of everyone, from the housekeeping staff to the CEO, that is integral in creating a successful program. These efforts span individuals in executive leadership positions to the faculty and staff at the frontlines of delivering care. Furthermore, the Program is quite comprehensive in scope, focusing on improving health care with projects in quality, safety, patient satisfaction, utilization, and cost. The Clinical Quality Program leverages the local culture. By focusing on one clinical department and utilizing established relationships, the Program encouraged a culture of collaboration. This, in combination with the comprehensive scope, creates a philosophy of thinking globally but acting locally. Most importantly, the Program emphasizes a data-driven and proactive management of quality improvement efforts. This differs from the traditional approach in improvement efforts: attending meetings, lacking data, no action plans, and no accountability for follow-up. The Program continuously and vigilantly requires active tracking and management of improvement projects.

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  1. Identifying the Department's QI and Patient Safety Priorities.

    The initial step in the implementation of the QI Initiative involves recognizing the Department's QI and patient safety priorities. An analysis of the performance data for quality indicators and patient satisfaction was reviewed. This step requires the vision and management of the departmental leadership to ensure a global and objective assessment of the various metrics and their performance. Furthermore, the departmental leadership has the ability to influence and guide clinical programs during the future evolution of the Initiative. Since each department is knowledgeable and involved in their respective metrics, the identification of critical indicators should occur at a departmental level. The scope and details of QI projects are too broad and vary substantially between departments and would not be appropriately covered by hospital-wide policies and initiatives. At this point, QI and patient safety will become an integral aspect of the departmental agenda.

  2. Aligning the Department's Priorities with the Medical Center Goals.
    The departmental leadership should work with the medical center to align mutual QI and patient safety priorities. Discussions with the hospital administration will focus on clinically significant indicators for quality, safety, patient satisfaction, efficiency and cost. A negotiation will then occur for selection of high impact targets, considering a combination of easily obtainable goals and more challenging metrics. Inclusion of purely challenging projects will lead to improvement efforts appearing futile and unachievable, which will dissipate the motivation and momentum for change. Metrics for evaluation of success should be chosen based on clinical relevance and ability to be easily measured. Benchmarks for these indicators can be obtained through historic performance data or national standards for care. At this point, the departmental leadership's responsibility and accountability for the chosen improvement measures is created.

    The discussions between departmental leadership and hospital administration can be facilitated by the history of successfully working on mutual projects. Prior to the QI Initiative, the UCLA Neurosurgery Department had been actively involved and successful in improving the percentage of patients discharge-by-noon and therefore hospital throughput. These efforts led to intra-departmental team building and the establishment of the Department's credibility in improvement initiatives.
  3. Finalizing the Goals for Improvement.
    The discussions between the Neurosurgery Department and the Medical Center administration resulted in agreement on five major areas for improvement. A QI dashboard was created to reflect the historic data and to continue to track improvement efforts. Metrics and benchmarks, based on national standards or the literature, were chosen. Leaders for each initiative were assigned based on their areas of interest and clinical involvement, experience with previous QI projects, and interest in the improvement process. Each leader was charged with creating an agenda for their respective improvement measure:

    A) Reduction of medication errors and costs
    - Identifying the more effective and less costly alternatives in choosing medications for patients
    - Reducing waste in medication utilization (i.e. proactive discontinuation of medication when not necessary)
    - Educating practitioners on more appropriate medication use (i.e. appropriate transitions from intravenous to oral)
    B) Reduction of hospital-acquired infections
    - Increasing hand hygiene compliance rates
    - Reducing C. difficile rates by proactively identifying and isolating patients with diarrhea and sending stool cultures
    - Reducing foley catheter-associated urinary tract infections and catheter-associated blood stream infection
    C) Reduction of operating room (OR) supply costs and waste
    - Educating health care providers regarding cost of OR supplies and comparable more cost effective options
    - Recognizing OR supply waste (i.e. opening packages that were not utilized during surgery)
    - Reducing defective or unusable OR supplies
    D) Improving patient flow at Santa Monica-UCLA Medical Center (community hospital of the Health Systems)
    - Improving the Spine Service discharge-by-noon rates
    E) Improving patient satisfaction
    - Identifying the areas of improvement in the current patient satisfaction data
    - Improving daily communication with patients and families regarding the plan of care
    - Obtaining real-time weekly data on improvement interventions with feedback to residents and attendings
  4. Launching the QI Initiative Retreat.
    In order to generate departmental support and promote participation in improvement projects, a retreat was organized to launch the QI Initiative. The goal of the retreat was to create a community dedicated to QI and patient safety and establish common goals for improvement. An agenda was set for the retreat and included: an introduction by the Department Chair and the Chief Operating Officer about the QI Initiative and the five areas of priority; the division of attendees into five groups based on expertise in each of the five areas of priority; the reconvening after an hour of group discussion with the group leader reporting on the action plans for that area; and conclusion of the program with the date for the follow-up meeting.

    All health care providers and staff were invited to attend including, physicians, residents in training, the Chief Executive Officer, the Chief Medical Officer, the Chief Operational Officer, hospital epidemiology, nurses and nurse leadership, therapists, pharmacists, and housekeeping and patient transport services. In planning the retreat, individual health care providers and staff were invited to sign-up and participate in a break-out session for one of the five priority areas. This allowed the attendees to research and learn about their respective break-out session and ensure engaged discussions during the session. Each break-out group was balanced and included subject matter experts and sufficient attendees to promote a dynamic discussion. During these sessions, the group leaders worked on building a team of dedicated staff to ensure advancing the improvement goals. While the overall objectives of the retreat were decided by the leadership, the direction and details of how to proceed was left to the discretion of the group leaders and participants. This emphasized a sense of ownership by the front-line providers while the leadership was accountable for the improvement process. After the break-out sessions, the attendees reconvened and each group leader presented their respective plan of action and accountability with personal assignments and due dates for their priorities. The leaders were then charged with ensuring the desired improvements were implemented.

    The retreat promoted team building, an opportunity for education of the staff about the QI initiatives, and created momentum for the improvement efforts. Furthermore, it allowed for members to voice concerns and have questions answered, which helped decrease apathy and cynicism. The retreat helped align the departmental priorities with the institutional goals. It strengthened the administration's support due to the enthusiasm generated and it outlined a course of action for achieving improvement.

    The Neurosurgery QI Initiative Retreat occurred in February 2009. Over 100 engaged participants attended and contributed to the development and advancement of the Department's improvement priorities. The initial scope of the QI priorities included:

    A) Reduction of medication errors and costs
    - Converting intravenous medications to oral
    - Identifying lower cost equivalents for commonly used medications
    - Creating a safety plan for high risk medications
    B) Reduction of hospital-acquired infections
    - Improving hand hygiene in health care providers in the intensive care unit and on the floor
    - Screening for and eliminating resistant pathogens
    - Decreasing device use: foley catheters and central venous catheters
    C) Reduction of operating room (OR) supply costs and waste
    - Providing education on the top ten most costly items
    - Addressing high cost items by renegotiating contracts with vendors
    - Reducing waste in the OR by having items available but not opened
    D) Improving patient flow at Santa Monica-UCLA Medical Center
    - Addressing causes of discharge delays (i.e. pain not adequately controlled)
    - Increasing awareness about discharge day and time
    - Facilitating authorization for patient transfers to skilled nursing facilities or rehabilitation centers, resolve delays in transportation and incomplete discharge paperwork
    E) Improving patient satisfaction
    - Improving the resident-patient interaction by creating a standardized rounding protocol
    - Creating a care coordination communication tool

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  1. Sustaining the QI Initiatives.
    After the retreat, active engagement of individual team leaders and retreat participants is a critical component of on-going improvement. The department chair can encourage, support, and monitor progress. Another alternative is to create a new position for a director of quality. The director can be responsibility for ensuring continued improvement, managing barriers, and providing support for all health care providers and staff involved in the QI initiatives. As QI projects progress, the metrics have to be monitored regularly and reviewed by all members of the department. In areas where there is a lack of improvement, there needs to be a formal discussion and plan for advancement of the project.

    A follow-up retreat should be scheduled to encourage the improvement process and reinforce accountability. The UCLA Neurosurgery Department reconvened to review the improvement projects two months after the initial retreat:

    A) Reduction of medication errors and costs
    - Converting intravenous medications to oral with pre-printed order sets: drugs identified included pantoprazole,
    famotidine, levetiracetam, phenytoin, and dexamethasone
    - Substituting lower cost equivalents for antibiotics, anti-emetics, and anti-hypertensive medications. For example,
    metoprolol costs about $0.07 per tablet compared to carvedilol at $1.97 per tablet.
    - Evaluating adverse medication effects on a weekly basis, creating warning signs and surveillance programs
    B) Reduction of hospital-acquired infections
    - Improving hand hygiene in health care providers by obtaining accurate hand washing data in the intensive care unit
    and on the floor, creating educational posters about the importance of hand washing, surveying trainees regarding methods used for reminders, talking to ancillary services with poor hand hygiene compliance
    - Screening for and eliminating resistant pathogens by evaluating the methodology for cleaning patient rooms
    - Decreasing device use (i.e. foley catheters and central venous catheters) by educating health care providers about the appropriate use
    of catheters and integrating these practices into existing orders sets
    C) Reduction of operating room (OR) supply costs and waste
    - Addressing high cost items by renegotiating contracts with vendors led to a 60% decrease in OR supply costs
    - Reducing waste in the operating room by having items available but not opened
    D) Improving patient flow at Santa Monica -UCLA Medical Center
    - Evaluating the options for creating a discharge lounge: many concerns about patient safety were voiced
    - Increasing awareness about discharge day and time through patient education
    - Facilitating authorization for patient transfers
    E) Improving patient satisfaction
    - Developing a resident-patient communication tool to provide more consistent daily communication with patients and families
    - Providing residents with real time patient feedback on their performance

    The performance goals and metrics of the QI Initiative should be renegotiated with the group leaders and hospital administration at the end of the year to eliminate impractical goals and add new objectives.
  2. Celebrating success.
    Positive improvements should be celebrated during departmental meetings and at an institutional level. Incentive payments from the financial gain of the quality measures, accompanying a letter from the chief of the department, will help emphasize the important role of the program in ensuring high quality of care for patients. With each success, the chair of the department and the director of quality should plan for the next cycle of improvement. Proposals for new projects or advancement of existing projects can be drafted and presented to the department chair for discussion and approval.
  3. Challenges.
    There are a number of challenges in establishing a departmental agenda for QI initiatives. Clinicians often have demanding schedules and dedicating the necessary time for QI projects can be challenging. Therefore aligning improvement projects with the work that the providers are already involved in can create more appropriate objectives. Moreover, selecting projects that can illustrate direct benefit for the faculty and staff, in time saving or simplification of work processes, can be encouraging to busy health care providers. The hierarchical nature of medicine further poses a barrier to the creation and maintenance of multidisciplinary teams. It is critical for the department chair and the group leaders to continually emphasize the importance of teamwork and a multidisciplinary approach to improvement. Lastly, while many faculty member and staff have been involved in improving their clinical areas, most health care providers are not trained in QI methodology. Continued QI education through hospital and outside resources is important in advancement of the quality agenda. Providing support for providers is critical to ensure sustainability of the QI initiatives.

The UCLA Neurosurgery QI Initiative illustrates a multidisciplinary approach to enhance quality of care and reduce costs in the health care system. As one department effectively illustrates improvement, other departments can utilize their methodology and experience to create their own QI agenda. This Initiative has been continually maintained by the departmental leadership with performance metric reviews, establishment of an ingrained behavior, and dedication to improvement. For the long-term durability of this program, continuous advocacy and encouragement of the teams is critical for sustaining change from the inside.

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