In February 2009, the Department of Neurosurgery at Ronald Reagan UCLA Medical Center launched the "Clinical Quality Program: Enhancing Quality, Safety, and Efficiency".
This initiative emphasizes a multidisciplinary approach for improving health care at the departmental level. The goals of the Program were as follows:
The Quality Program 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 Departmental leadership worked with the Medical Center to align mutual QI and patient safety priorities. Discussions with hospital administration focused on clinically significant indicators for quality, safety, patient satisfaction, efficiency and cost. A selection can then occur of the high impact targets, considering a combination of easily obtainable goals and more challenging outcomes. Inclusion of purely challenging projects will lead to improvement efforts appearing futile and unachievable, which will dissipate of the motivation and momentum for change. Metrics for evaluation of success should be chosen based on clinical relevance, as well as the ability to be easily measured. Often times, administrative data that is already collected and reported can be utilized to reduce the burden of measurement. Benchmarks for these indicators can be obtained through historic performance or national standards for care.
For more information about the UCLA Neurosurgery Quality Dashboard, please contact our Director of Quality, Dr. Won Kim at WonKim@mednet.ucla.edu.