UCLA Neurosurgical Clinical Quality Program:

Neurosurgery Team


UCLA Neurosurgery Clinical Quality Program
Active projects:

Clinical Care Initiatives: Quality and Safety

  1. Readmission Reduction Initiative
    The team has conducted an extensive three-year chart review of readmissions, categorizing preventability and common etiologies of re-hospitalizations. Interventions have been designed and are being implemented to address to the most common causes of readmissions.
  2. Mortality Reduction Initiative
    A three-year review of mortality has been conducted by the team and specific interventions are being designed and implemented to improve patient care.
  3. Infection Prevention
    The Infection Prevention Program has focused on collaborating with the Health System wide Antibiotic Stewardship Program, identifying inappropriate antibiotic utilization and making recommendations to improve use.
  4. Blood Pressure Control
    The Blood Pressure Control project was designed to determine the most safe and effective oral blood pressure medications for Neurosurgery patients and to reduce the amount of time it takes to get the patient's blood pressure to the target blood pressure.
  5. Neurosurgery Quality Improvement Dashboard
    The Neurosurgery Dashboard collects metrics for overall care, quality, safety, patient satisfaction, and efficiency/throughput, allowing the team to track metrics and continue providing the highest quality health care.

    Patient Centered Care and Satisfaction
  6. Transitions of Care
    The Transitions of Care project was designed to evaluate the discharge process and improve care during this vulnerable time. This has involved a formal process to ensure appropriate follow-up for patients and clarification of discharge paperwork.
  7. Patient and Family Advisory Council (PFAC)
    The Neurosurgery PFAC is co-led by a family member and a representative from the Department with the objective of creating a partnership between physicians, nurses, staff, patients and families. Members of the council provide input and feedback on patient care, services provided, new policies, and also recommend new programs and strategies. One such program is the development of a peer support group.

    Efficiency and Throughput
  8. Improving Through-put
    Eliminating inefficiencies that lead to late discharge will help ensure that patients can pick up their medications, settle at home in a timely manner, and get answers to any questions that may arise while their primary providers are available to help answer questions.
  9. Health Care Sustainability and Waste Reduction
    The team is reducing waste by implementing the following programs: green IT, green office, green labs, water waste reduction, recycling of plastic and cardboard containers on the unit, discarding linens, re-stocking unused supplies, re-packaging intubation trays, and evaluation of lab utilization.