UCSF Medical Center Strives to Improve Patient Care Quality, Safety

By Lisa Cisneros

UCSF Medical Center is boosting its efforts to ensure that patients receive the highest-quality patient care and service through a number of efforts, medical center leaders say. "UCSF Medical Center and UCSF Children's Hospital are committed to providing the safest and highest-quality care to our patients," says Ernie Ring, chief medical officer. "To achieve this goal, we constantly refine our practices to meet the highest standards of care through experience as well as rigorous clinical research. UCSF strives to stay at the leading edge of health care by providing consistently reliable, evidence-based care to all of our patients 100 percent of the time." UCSF defines quality as superior care and outcomes, outstanding patient safety, and excellent service and patient satisfaction. To improve quality and safety of care at UCSF, the medical center continuously evaluates its performance against rigorous internal standards as well as industry benchmarks. The medical center also responds promptly to regulatory reviews, and works to implement recommended changes to improve quality and safety for its patients. For example, surveyors from the state Department of Health Services, representing federal regulators at the Centers for Medicare and Medicaid Services (CMS), recently concluded a seven-day survey of UCSF Medical Center's performance in regard to 23 CMS "conditions of participation." These conditions are the health and safety standards required to participate in the Medicare and Medicaid programs. The surveyors found that the medical center doesn't fully comply with three conditions in pharmacy, nursing and quality improvement related to medication management. "We believe this is a reasonable outcome of the survey, given that there were some patient care issues identified that indeed need correcting," says Mark Laret, chief executive officer of UCSF Medical Center. Because these issues are resolved when identified, "our hospital is safer for patients today than it was last week, and it was safer last week than it was a year ago," he adds. Laret and Ring thanked the pharmacy, nursing and medical staffs for their hard work in advance of and during the survey. The CMS conditions cover virtually the entire patient care environment, ranging from anesthesia services to emergency services to organ procurement to staffing and delivery of care. Within three months, surveyors will again visit UCSF to ensure that these conditions are met.

Championing Patient Safety

Since taking the helm of UCSF Medical Center seven years ago, Laret has championed a culture of care and safety. The medical center has engaged the entire leadership, including department chairs, service chiefs, nursing managers and others leaders involved in clinical care, to focus on quality and safety through consistent communication as well as annual retreats. Progress in maintaining the highest standards of care is reflected in accreditations, rankings and activities. Recently, UCSF Medical Center:
  • Received full accreditation from the Joint Commission, a nonprofit agency that evaluates and accredits health care facilities nationwide.
  • Ranked No. 7 among the nation's top 10 hospitals in the 2007 annual ranking by US News & World Report.
  • Ranked in the top 10 out of the nation's premier academic medical centers in overall quality in a study by the University Health System Consortium (UHC).
In fact, UCSF Medical Center is recognized by UHC for making significant improvements, rising steadily in the overall rankings in the study, which examines data such as safety, effectiveness, equity of providing care, efficiency and patient-centered care from top academic medical centers. UCSF Medical Center also ranked first in the UHC study in serving a diverse patient population in gender, race and socioeconomic status, and eighth in offering patient-centered care. "This work reflects our renewed commitment to quality and safety as our top priority and our consistent efforts to improve care, partner with the medical staff and assign accountability," says Brigid Ide, director of Patient Safety and Quality Services. "It also reflects that we are delivering evidence-based care to our patients." Ide points out that the annual medical center workplan and individual achievement program goals continue to make care quality and patient safety the medical center's highest priorities. The UCSF Strategic Plan, a blueprint for the next 20 years, makes providing top-notch patient care a campuswide priority. To achieve this vision, the plan outlines three goals: provide high-quality, patient-centered care leading to optimal outcomes and patient satisfaction, improve access to care, and set the standard for patient safety. A summary of the plan is posted here. Laret, who served on the Strategic Planning Board, is now beginning to implement the recommendations, which run the gamut from establishing quality and safety standards for departments, divisions and individual providers to using the expertise of faculty who are involved in research on health care quality to help improve operations. "The strategic plan is important because it highlights the importance of the clinical enterprise to the whole academic mission of UCSF," Laret says. As a follow-up to the strategic planning process, the medical center will be updating its 2001 strategic plan to integrate it with the campuswide plan, Laret says. "This will be a broad-based exercise involving everybody from the clinical enterprise," he says. Key to ensuring progress on patient safety and quality of care is ensuring that the medical center is financially strong. Since the medical center is largely self-supported, it must generate income to invest in new equipment and technology as well as employee training. UCSF Medical Center ended the 2007 fiscal year on June 30 with a record $107.4 million in net income. Much of this income is being invested in safety and quality improvements such as electronic health records and in recruiting and retaining high-quality physicians, nurses and staff. While thanking employees for another outstanding financial year, Laret emphasizes that "the medical center's first priority is and always will be to care for patients safely and effectively. The medical center's most important responsibility is delivering the highest-quality care and providing the best customer service possible."

Reporting Results

Setting the standard for patient safety is ever more important in today's era of accountability and transparency, in which accreditation and government agencies are raising the standards and patients and the public at large are demanding consistent, high-quality care, Laret says. Increasingly, that demand is driving the proliferation of web-based report cards which publish hospitals' quality and satisfaction scores and outcomes, so that consumers and purchasing organizations can make informed health care choices. Ring says that patients should consider many factors when reviewing these online surveys. When were the data compiled? Is the information current? Academic medical centers like UCSF Medical Center often care for the most seriously ill patients, as well as newborns and the elderly, who are transferred from community hospitals that don't have the resources and expertise to care for these patients. Some patients come to UCSF for its nationally renowned palliative care program. Do the surveys take into consideration these factors when evaluating hospitals?
Cecelia Glennon treats a patient

Cecelia Glennon, a clinical research nurse for the UCSF Clinical and Translational Science Institute Pediatric Clinical Research Center, treats a patient at UCSF Children's Hospital.

Among the hospital evaluation websites is one created by the California Hospital Assessment and Reporting Taskforce (CHART). CHART rates 210 hospitals across the state that account for 70 percent of all hospital admissions. It also rates the top five conditions and procedures - heart attack, heart failure, heart bypass surgery, pneumonia and maternity - that are the most common reasons why people are admitted to a hospital. Like many key national and statewide quality initiatives, the methodology behind CHART was developed by UCSF researchers, led by R. Adams Dudley and colleagues at the UCSF Philip R. Lee Institute for Health Policy Studies. Both UCSF Medical Center hospitals, Moffitt-Long at Parnassus and Mount Zion, received a "superior" for overall patient service on CHART. A superior rating means that the hospital performed well above average compared with the other hospitals on this measure. Importantly, UCSF Medical Center is recognized for its participation in several national or regional patient safety and quality public reporting initiatives, such as CMS, the Joint Commission and the California Office of Statewide Health Planning and Development. Laret says the mere fact that the medical center is being held to heightened scrutiny is "motivating us to do better." He also says the medical center's collaboration and cooperation, particularly with other UC hospitals, in discussing quality and safety measures are helping them learn from each other.

Leading the Way

One way that UCSF has led the nation in improving patient safety is by employing hospitalists, the doctors who coordinate the array of treatments a hospitalized patient may receive. Hospitalists are well-positioned to see where errors begin and how to correct them, says Robert Wachter, professor of medicine, chief of the Medical Service and chair of the Patient Safety Committee at UCSF Medical Center. "At UCSF, we were the first to recognize the potential value of hospitalists," says Wachter, who coined the term in 1996 with Lee Goldman, former chair of the Department of Medicine. "Last year, we looked at what other patient populations would benefit from the enhanced quality and safety of care, and put hospitalists in the bone marrow transplant unit and neurosurgery." Wachter says that today, an internist-hospitalist is helping co-manage dozens of patients on the neurosurgery service who have medical problems like diabetes, infections and heart failure. It is really a critical position, since most neurosurgeons spend a huge amount of time in the operating room. Now, the hospitalist manages emergencies, tries to anticipate and prevent problems, and provides early response treatment when necessary. From its hiring of two hospitalists in 1995, UCSF Medical Center now employs 38. Today, more than 20,000 practice in hospitals across the nation, making the hospitalist field the fastest growing specialty in the history of American medicine, Wachter points out. "We have really pushed our hospitals - and those across the country - to not only focus on providing terrific care to individual patients, but also to be leaders in making their hospital system work better," says Wachter, who wrote a best-selling book on patient safety, Internal Bleeding, and recently published the field's leading textbook, Understanding Patient Safety. "It's no coincidence that hospitalists so often emerge as the leaders in areas like patient safety and quality." Wachter also believes improved human interaction among practitioners is making a big difference in patient safety. "Placing a greater emphasis on interdisciplinary collaboration is pretty unique. Hospitalists recognize that providing high-quality, safe care is a team sport," he says. Recently, the Medical Service hosted a program supported by a grant from the Gordon and Betty Moore Foundation to the UCSF schools of nursing, pharmacy and medicine to train 400 nurses, doctors, pharmacists, social workers and others in teamwork and collaboration. Feedback has been very positive from this experience and has led to improved communication and collaboration, Wachter notes. UCSF also hosted the second annual Interprofessional Education Day on Sept. 19 to bring students from all four professional schools, physical therapists and dietetic interns from the medical center together to learn about the importance of teamwork. Recently, the medical center implemented an electronic medical records system. As part of that system, UCSF Medical Center also developed a sign-out module for better transition of care between shifts of health care providers. The module, called Synopsis, provides a practical, up-to-date summary of the condition of each patient, such as what medications were last given or what his or her temperature was, but also communicates to the next shift what antibiotics to give if a patient develops a fever or when to call a family member. Next, UCSF will implement even more advanced clinical information systems for provider order entry and prescribing drugs in the inpatient setting, and will bring electronic medical records into the outpatient setting in clinics across the clinical enterprise. All told, the medical center's investment in information technology will top $100 million. Among other efforts, the medical center has improved the process and protocols of transferring patients from their hospital rooms to other departments, such as radiology, to better ensure their safety while en route, and continues to stress the importance of hand washing to prevent the transmission of germs, including bacteria, viruses and infections. Lastly, the medical center has appointed Joy Pao, a seasoned quality leader from Kaiser Permanente, as the new director of Quality Improvement for the medical center. Pao is responsible for implementing programs and initiatives as outlined in the UCSF Performance Improvement Plan; improving systems and meeting standards for all quality reporting; and maximizing integration among the inpatient, outpatient and home care quality programs. Pao is also directing staff to provide expert support to the quality and safety committees and clinical departments within the medical center. "All of these efforts will help UCSF Medical Center continue to put the quality, safety and care needs of our patients first in everything we do," Laret says. Photo by Susan Merrell

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