UCLA NEUROSURGERY
CLINICAL QUALITY PROGRAM THE PERFECT PATIENT EXPERIENCE, EVERY TIME, ANY TIME, 24-7 s clinicians and leaders on the frontlines of medicine at UCLA, we have the experience, ingenuity and most importantly, the responsibility to reform healthcare from the inside. UCLA is one of the premier academic medical centers that set the standards for medical care in the country and the world. In the Neurosurgery Department’s three-part mission dedicated to patient care, teaching, and research, we endeavor to develop a system to standardize quality that can be implemented throughout the Ronald Reagan UCLA Medical Center, UCLA Health, UC campuses and beyond. We believe that by diagnosing the deficits in healthcare through our experience in the trenches, we can contribute to repairing the U.S. healthcare system with a strategic approach to quality care. For over a decade, we have ranked in the top five hospitals in the country and “Best in the West” according to U.S. News and World Report. We are in a unique
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position to be an example for the rest of the medical community, while understanding that upholding the highest standards also means refining our internal systems and innovating new systems. Neil A. Martin, MD, Professor & W. Eugene Stern Chair in Neurosurgery, formed the UCLA Neurosurgery Clinical Quality Program to improve our patient care, enhance patient safety, increase efficiency and reduce costs for our patients. Our program involves the specialties and combined disciplines of faculty members, nurses, care partners, therapists, pharmacists, infection control specialists, patient affairs liaisons and medical center finance department representatives. By working together as a team to evaluate overall performance, we have created more efficient systems in our daily operations.
THE NEUROSURGERY CLINICAL QUALITY PROGRAM IS FOCUSED ON THE FOLLOWING INITIATIVES: 1: INFECTION PREVENTION
2: BLOOD PRESSURE CONTROL PROJECT The Blood Pressure Control Project was designed to determine the safest and most effective oral blood pressure medications for Neurosurgery patients and to reduce the time required to get blood pressure to target levels.
The Infection Prevention Program works with UCLA Health’s Antimicrobial Stewardship Program to identify and correct improper antibiotic use. Surgical site infections for spinal fusions and laminectomies have been reduced to just 8 in the last 30 months. Blood stream infections have been virtually eliminated, with only 1 in the last 66 months.
3: THE READMISSION REDUCTION INITIATIVE 1 1 5 4 3 2 4 8 3 4 0 0 6 3 6 3 2009
2010
2011
30-Day Readmissions
2012
The team has conducted an extensive three-year chart review of readmissions, categorizing preventability and common causes of re-hospitalizations. Interventions have been designed and are being implemented to address the most common causes of readmissions.
4: NEUROSURGERY QUALITY IMPROVEMENT DASHBOARD The Neurosurgery Dashboard collects metrics for overall care, quality, safety, patient satisfaction and efficiency, allowing the team to continue providing the highest quality health care.
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UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND