A Shared Mission: UCSF Brings Clinical, Educational Enterprises Together with Quality

By Scott Harris

Value equals quality over cost. Seems pretty simple when you put it that way. In the real world, of course, the equation for delivering higher-quality care is anything but neat and tidy. Hospitals and care providers these days recognize the clinical and fiscal value of safety and quality improvement (QI), but it’s harder to see how and where it plugs in to daily operations.

That’s where medical schools and teaching hospitals come in. Or, more specifically, their workforce and their learners. A program in the University of California, San Francisco Medical Center’s (UCSF) Department of Medicine tries to apply academic medicine’s strengths — education, patient care, and research — to quality and safety by helping disparate groups work more closely together toward better care.

“We’ve been great at building expertise in our mission areas,” said Niraj L. Sehgal, M.D., M.P.H., associate professor of medicine and associate chair for quality and safety. “Quality improvement blends those missions together. But at the same time, the tensions between the clinical and educational enterprises have grown greater. How do we better marry them?”

The department of medicine’s Quality and Safety Program attempts to root out some of the barriers that hamper the full adoption of QI and safety measures. The program, described in the February issue of the journal Academic Medicine, helps providers share clinical data more effectively, offers faculty development, and gives learners a seat at the table.

Perhaps most important, however, is the program’s first step: setting clear roles and responsibilities.

“There needs to be a system that has some kind of centralized control at the top level, but also ownership and empowerment within individual departments,” said Naama Neeman, M.Sc., the department’s administrative director for quality and safety programs. “It starts with looking at an org chart and creating quality improvement champions at the unit level. Engage them to come up with projects that are important to them, not just things that are required by regulations.”

The program also looks to tap a particularly strong vein of QI energy: residents and fellows.

“I’m amazed by the number of students who say they want to work on systems change, sometimes even before they know how they want to specialize,” Sehgal said. “A colleague once told me that systems change is the pathophysiology of this generation. We should be leveraging trainees to help.”

Leaders regularly ask learners for proposals around QI. Case conferences focus not only on interesting or unusual conditions, but on “something that didn’t go so great, and how it could go better next time,” Sehgal said. 

The medical center’s Housestaff Incentive Program offers financial rewards for achieving specific goals. In July 2009, communication with primary care physicians was documented in only 55 percent of patient discharges. Within six weeks of beginning work to increase that rate, the figure jumped to 80 percent. As a result, each resident received $300.
The Department of Medicine is currently working with residents to raise awareness around costs, especially for radiology. Though Neeman and Sehgal stressed that data were still preliminary, Sehgal said early findings suggest that “just providing cost and utilization data can impact behavior.”

But learners aren’t the only ones in need of guidance. Faculty members who did not grow up with QI in the curriculum also receive training, so they can imbue charges and courses with a QI context.

“We need a deeper bench of faculty who are well-versed in this,” Sehgal said. “It’s important that we train the trainers.”

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