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.
Jump to... 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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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.
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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.