Los Angeles-based UCLA Health System, which includes three acute-care hospitals and a neuropsychiatric hospital, has three primary focus areas in patient safety and quality. While the health system works on more than 50 initiatives simultaneously, the recent focus has been on readmissions, mortality and sepsis. Nasim Afsar-manesh, MD, SFHM, associate CMO of UCLA Hospitals (the hospital arm of the health system) and executive director of quality and safety in the departments of medicine and neurosurgery at UCLA, shares innovative strategies hospital leaders are using to improve safety and quality and ways the system teaches quality improvement techniques to providers.
Readmission reduction initiative
UCLA Health System set the audacious goal of eliminating all preventable readmissions. To understand this problem, UCLA Hospitals conducted a retrospective chart review to determine the causes of readmissions in each department. "The etiologies of readmission for internal medicine are going to be different than for orthopedic surgery," Dr. Afsar says. "Prior to designing interventions, it's important to understand the specific cause for the readmissions in a particular group." UCLA approached readmissions in a patient-centered way by interviewing patients who were rehospitalized.
In one department's pilot program, physicians are notified in real time when their patients are readmitted, and they discuss possible causes of the readmission. "The idea is that as the last physician who cared for the patient, you should know the patient best and be able to provide a unique insight into why the patient would be readmitted," Dr. Afsar says.
UCLA Hospitals are piloting a similar concept with accountable care units, a team that includes all providers caring for the patient — from the hospital discharge and readmissions providers to the providers who cared for the patient in the outpatient clinics. The team is notified when a patient is readmitted, discusses possible causes and develops plans to prevent future readmissions.
In addition to improving inpatient care, UCLA Hospitals focus on providing adequate support after patients are discharged to prevent readmissions. One of the departments developed an Evaluation and Treatment Center to offer services that are difficult to provide in a primary care setting, but do not require an emergency department visit. For example, an infusion, which may take between six and eight hours, can be safely administered in an outpatient setting. In the past, patients who needed this service would likely have gone to the ED, which is less comfortable and more costly to the patient, according to Dr. Afsar. "We have a number of interventions focusing on pain management or close and frequent outpatient follow-up to ensure patients are safe during this vulnerable transition time," she says.
Mortality and sepsis
Other key focus areas of UCLA Hospitals are mortality and sepsis. Leaders examined mortality rates and determined the vast majority of deaths were expected due to the severity of illness in the patients. There were not many cases where deaths were unexpected or preventable, according to Dr. Afsar. However, there were opportunities to improve end-of-life care for patients with terminal illnesses to ensure patients and families are fully supported during this challenging period. The system is expanding hospice and palliative care services to help meet the needs of patients and families, particularly in the outpatient setting.
UCLA Hospitals' sepsis initiatives have centered around evidence-based management. These bundles include protocols for timely administration of antibiotics, fluids and other key processes. To date, the team has been able to make significant improvement in compliance with best practices, Dr. Afsar says.
Quality improvement training
To engage all providers and staff in quality improvement, Dr. Afsar trains residents and fellows in quality improvement techniques. She developed a QI curriculum in 2009 to teach residents and fellows tools to increase quality of care. Trainees have an opportunity to develop QI projects, some of which have been presented nationally and published. She says, "It's a [way] to engage and empower trainees to look at the environment and say 'How can I make an improvement? How can I be part of the solution?'"
UCLA Hospitals are also piloting a QI incentive program that pays residents for meeting a threshold of performance on some key metrics. For example, physicians can earn incentive payments if more than 90 percent of patients rate physicians as "always" communicating understandably with them, according to Dr. Afsar. "We strive for this measure to be at 100 percent," Dr. Afsar says.
In addition to the training program, more than 40 residents and fellows have created the Housestaff Quality Improvement Council aimed at proactively evaluating and improving care. "They're at the front lines of delivering care to patients every day. Their input and insights on how we can do things better is really important, so we really value the thoughtfulness of this group," Dr. Afsar says.
Learning about QI isn't just for residents and fellows, however. UCLA Health System holds an annual quality forum for all providers in the health system to learn from successful QI projects and enhance the performance of medicine. Sharing best practices across the organization supports continuous improvement at UCLA Health System, she says.
As the system continues to focus on readmissions, mortality and sepsis, it will build upon past successes and look to trainees for fresh ideas and perspectives on quality improvement.
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Readmission reduction initiativeUCLA Health System set the audacious goal of eliminating all preventable readmissions. To understand this problem, UCLA Hospitals conducted a retrospective chart review to determine the causes of readmissions in each department. "The etiologies of readmission for internal medicine are going to be different than for orthopedic surgery," Dr. Afsar says. "Prior to designing interventions, it's important to understand the specific cause for the readmissions in a particular group." UCLA approached readmissions in a patient-centered way by interviewing patients who were rehospitalized.
In one department's pilot program, physicians are notified in real time when their patients are readmitted, and they discuss possible causes of the readmission. "The idea is that as the last physician who cared for the patient, you should know the patient best and be able to provide a unique insight into why the patient would be readmitted," Dr. Afsar says.
UCLA Hospitals are piloting a similar concept with accountable care units, a team that includes all providers caring for the patient — from the hospital discharge and readmissions providers to the providers who cared for the patient in the outpatient clinics. The team is notified when a patient is readmitted, discusses possible causes and develops plans to prevent future readmissions.
In addition to improving inpatient care, UCLA Hospitals focus on providing adequate support after patients are discharged to prevent readmissions. One of the departments developed an Evaluation and Treatment Center to offer services that are difficult to provide in a primary care setting, but do not require an emergency department visit. For example, an infusion, which may take between six and eight hours, can be safely administered in an outpatient setting. In the past, patients who needed this service would likely have gone to the ED, which is less comfortable and more costly to the patient, according to Dr. Afsar. "We have a number of interventions focusing on pain management or close and frequent outpatient follow-up to ensure patients are safe during this vulnerable transition time," she says.
Mortality and sepsis
Other key focus areas of UCLA Hospitals are mortality and sepsis. Leaders examined mortality rates and determined the vast majority of deaths were expected due to the severity of illness in the patients. There were not many cases where deaths were unexpected or preventable, according to Dr. Afsar. However, there were opportunities to improve end-of-life care for patients with terminal illnesses to ensure patients and families are fully supported during this challenging period. The system is expanding hospice and palliative care services to help meet the needs of patients and families, particularly in the outpatient setting.
UCLA Hospitals' sepsis initiatives have centered around evidence-based management. These bundles include protocols for timely administration of antibiotics, fluids and other key processes. To date, the team has been able to make significant improvement in compliance with best practices, Dr. Afsar says.
Quality improvement training
To engage all providers and staff in quality improvement, Dr. Afsar trains residents and fellows in quality improvement techniques. She developed a QI curriculum in 2009 to teach residents and fellows tools to increase quality of care. Trainees have an opportunity to develop QI projects, some of which have been presented nationally and published. She says, "It's a [way] to engage and empower trainees to look at the environment and say 'How can I make an improvement? How can I be part of the solution?'"
UCLA Hospitals are also piloting a QI incentive program that pays residents for meeting a threshold of performance on some key metrics. For example, physicians can earn incentive payments if more than 90 percent of patients rate physicians as "always" communicating understandably with them, according to Dr. Afsar. "We strive for this measure to be at 100 percent," Dr. Afsar says.
In addition to the training program, more than 40 residents and fellows have created the Housestaff Quality Improvement Council aimed at proactively evaluating and improving care. "They're at the front lines of delivering care to patients every day. Their input and insights on how we can do things better is really important, so we really value the thoughtfulness of this group," Dr. Afsar says.
Learning about QI isn't just for residents and fellows, however. UCLA Health System holds an annual quality forum for all providers in the health system to learn from successful QI projects and enhance the performance of medicine. Sharing best practices across the organization supports continuous improvement at UCLA Health System, she says.
As the system continues to focus on readmissions, mortality and sepsis, it will build upon past successes and look to trainees for fresh ideas and perspectives on quality improvement.
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