DSRIP Plan: UC Davis Medical Center
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CATEGORY 1: Infrastructure Development
Project
Implement and Utilize
Disease Management
Registry Functionality
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Collection of Accurate
Race, Ethnicity and
Language (REAL) Data to
Reduce Disparities
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Description
expand chronic disease management programs in
the ambulatory setting
design care coordination strategies to optimize
care across a continuum
incorporate decision-support for chronic disease
management into team-based practice
5-Year Goals
Y1: (1) develop a plan (identify current patient volume, assess new patients
with chronic disease diagnoses, plan expansion of services and sites,
plan expansion of current programs to all primary care clinics); (2)
develop patient experience metric question; (3) use paper-based
companion survey for on-site clinic use
Y2: (1) implement system to manage newly diagnosed chronic disease
patients at 1 primary care clinic; (2) develop tethered registry to
capture patient enrollment in chronic disease management program;
(3) design patient experience report
Y3: (1) expand chronic disease management program team to 2 additional
clinic sites; (2) implement tethered registry for chronic disease
management; (3) compare patient experience metric against team
integration at sites
Y4: (1) expand chronic disease management program/registry team to at
least 4 additional clinic sites; (2) compare patient experience metric
against team integration at sites
Y5: (1) expand chronic disease management program/registry team to at
least 6 additional clinic sites; (2) compare patient experience metric
against team integration at sites
Develop ability to collect patient demographic
data that can be compared to quality and health
outcomes data
Stratify patient, demographic data by outcomes
to identify disparities
engage in quality improvement projects to
reduce health care disparities
Y1: (1) develop Ambulatory plan to assess collection of REAL data; 92) report
on preliminary REAL data collection
Y2: (1) develop plan to stratify patient outcomes using REAL data and
strategy to link to quality data; (2) patient experience questionnaire
to be designed and tested using sample set of patients across
demographics
Y3: (1) Record designated REAL data fields for at least 50% of unique
patients; (2) analyze Patient experience questionnaire
Y4: (1) Record designated REAL data fields for at least 70% of unique
patients; (2) analyze patient experience questionnaire
Y5: (1) Record designated REAL data fields for at least 90% of unique
patients; (2) perform REAL data analysis and identify at least 2
specific health care disparities; (3) analyze patient experience
questionnaire
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CATEGORY 2: INNOVATION AND REDESIGN
Implement/Expand Care
Transitions Program
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Conduct Medication
Management
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Create mechanism to identify within the
emergency department and track in all settings,
patients with specific chronic diseases
create “intensive care management” (ICM)
registry and management system
increase staffing in the ED to provide ICM
optimize patients’ medications prior to discharge
reconcile medications at time of discharge
provide after-discharge follow-up
provide patient education
configure alerts within EHR to ensure outpatient
prescriptions comply with criteria for use of Black
Box warning medications
fully implement bedside barcode scanning and
smart infusion pumps
Y1:
Y2:
Y3:
Y4:
Y5:
Y1:
Y2:
Y3:
Y4:
Y5:
Expand Medical Homes
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expand preventive immunizations programs
design care coordination strategies
incorporate decision-support for immunization
prevention and wellness education into teambased practices
Y1:
Y2:
Y3:
expand current ICM within the ED (hire 2 additional Care Managers)
expand ED case management to 7 days/week (4 case management
FTEs 10 hours/day)
implement ICM registry and use it for more than 50% of all ED casemanaged patients and for all patients admitted from ED into hospital
implement ICM egistry use it for more than 90% of all ED casemanaged patients and for all patients admitted from ED into hospital
(blank)
(1) implement pilot of bedside barcode scanning (2) initiate
implementation of smart infusion pumps
(1) implement services to improve continuity of medication use for
patients with heart failure or on warfarin (hire pharmacist and nurse
and provide continuity of medication use services to at least one
patient); (2) provide services to improve continuity of medication
use to at least 50% of patients with heart failure or on warfarin; (3)
implement safeguards in EHR to ensure compliance with criteria for
safe use of Black Box Warning medications; (4) implement more
smart infusion pumps; (5) complete planning for full implementation
of bedside barcode scanning
(1)provide services to 75% of heart failure and warfarin patients; (2)
implement clinical pharmacist services for COPD pneumonia and AMI
patients; (3) fully implement bedside barcode scanning of
medications
provide clinical pharmacist services to 75% of heart failure and
warfarin patients and 50% of COPD, pneumonia and AMI patients
provide clinical pharmacist services to 75% of all targeted patients
(1) develop timeline and plan to submit application for Patient
Centered Medical Home (PCMH) recognition by NCQA; (2) apply for
at least one primary care site; (3) develop plan to identify new and
existing ambulatory patients requiring influenza vaccination
(1) develop timeline and plan for submission of PCMH application for
primary care sites; (2) develop patient experience survey using
PCMH criteria; (3) design seasonal influenza notification system; (4)
design MyChart influenza notification report for provider use
(1) develop plan for submission of PCMH application for remaining
primary care sites; (2) develop plan and timeline to implement
Apply Process
Improvement
Methodology to
Improve
Quality/Efficiency
DSRIP Plan: UC Davis Medical Center
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patient experience survey in remaining sites; (3) develop plan to
integrate influenza vaccination at all primary care sites
Y4:
(1) develop timeline and plan to submit application for PCMH
recognition for hospital-based primary care clinics; (2) develp PCMH
Patient Experience Focus Groups; (3) develop EHR report for
provider, buy site and provider, on influenza vaccination rate
Y5:
(1) assign at least 40% of eligible patients to PCMH medical homes;
(2) report shared learning of medical home model; (3) develop plan
for ongoing patient engagement through Patient Experience Board;
(4) develop EHR rport for specialty care providers who provide
influenza vaccines, by site and provider, on influenza vaccination
rates
Using Lean Six Sigma:
Y1:
(1) develop designated unite responsible for Lean Six Sigma
implementation and assess processes; (2) LSS Just-in-time training to
 identify and eliminate waste within health care
at least 2 multidisciplinary teams for specific projects
delivery value system
Y2:
(1) develop early-warning systems within EHR to act on identified
 install mistake-proofing systems
problems;
(2) LSS Just –in-Time training to at least 2 multidisciplinary
 shift culture from accepting errors and defects to
teams for specific projects
trusting a perfect patient experience is possible
Y3:
(1) continue to use and further develop early-warning systems in the
 maximize the use of tools
EHR; (2) LSS Master Black Belts provide 4 LSS Green Belt courses per
 focus on reducing selected HACs
year; (3) LSS Just –in-Time training to at least 2 multidisciplinary
teams for specific projects
Y4:
(1) continue to use and further develop early-warning systems in the
EHR; (2) LSS Master Black Belts provide 4 LSS Green Belt courses per
year; (3) LSS Just –in-Time training to at least 2 multidisciplinary
teams for specific projects
Y5:
(1)real-time alerts of patient errors and problems; (2) LSS Master
Black Belts provide 4 LSS Green Belt courses per year; (3) LSS Just –
in-Time training to at least 2 multidisciplinary teams for specific
projects
CATEGORY 4: URGENT IMPROVEMENT IN CARE
Improve Severe Sepsis
Detection and
Mangement
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implement Sepsis Management and Resuscitation
Bundle
Y1:
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Y2:
(1) join Sepsis Improvement Collaborative and join Foundation to
learn and share best practices; (2) convene multi-disciplinary group
to develop goals and work plans for reducing severe sepsis; (3) use
Lean Six Sigma to optimize efficiencies in evaluating and
implementing improvement project
(1) implement best practice alerts within EHR for early sepsis
Central Line Associated
Blood Stream Infection
(CLABSI) Prevention
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Surgical Site Infection
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recognition; (2) report at least 6 months of data to SNI; (3) report
results to State
Y3:
(1) achieve TBD% compliance with sepsis resuscitation bundle; (2)
share data and practices with SNI for benchmarking; (3) report
results to State
Y4:
(1) achieve TBD% compliance with sepsis resuscitation bundle; (2)
share data and practices with SNI for benchmarking; (3) report
results to State
Y5:
(1) achieve TBD% compliance with sepsis resuscitation bundle; (2)
share data and practices with SNI for benchmarking; (3) report
results to State
Y1:
implement
Central Line Insertion Practices (CLIP)
improve compliance with central line insertion
Y2:
(1) report 6 months of data on CLIP to SNI; (2) report 6 months of
bundle
data to CLABSI to SNI; (3) report CLIP results to State
Y3:
(1)achieve TBD% compliance with CLIP; (2) share data and practices
with SNI; (3) report CLIP and CLABSI results to State
Y4:
(1) achieve TBD% compliance with CLIP; (2) reduce central line
bloodstream infections by TBD%; (3) share data and practices with
SNI; (4) report CLIP and CLABSI results to State
Y5:
(1) achieve TBD% compliance with CLIP; (2) reduce central line
bloodstream infections by TBD%; (3) share data and practices with
SNI; (4) report CLIP and CLABSI results to State
improve surgical site infection prevention
Y1:
Y2:
Y3:
Y4:
Y5:
Hospital-acquired
Pressure Ulcer (HAPU)
Prevention
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use a multi-disciplinary team approach to the
prevention of pressure ulcers using evidencebased recommendations from the national
Pressure Ulcer Advisory Panel
Y1:
Y2:
Y3:
(1) Validate TheraDoc software to streamline SSI surveillance; (2)
establish SSI baseline for reporting
(1) Install TheraDoc software and train staff; (2) report at least 6
months of data on SSI to SNI; (3) report results to State
(1) reduce rate of SSI for Class I and 2 wounds by TBD rate; (2) share
data and practices with SNI; (3) report results to the State
(1) reduce rate of SSI for Class I and 2 wounds by TBD rate; (2) share
data and practices with SNI; (3) report results to the State
(1) reduce rate of SSI for Class I and 2 wounds by TBD rate; (2) share
data and practices with SNI; (3) report results to the State
(1) implement EHR template for SWAT team for documentation of
skin assessment; (2) develop electronic dashboard to measure and
report/share HAPU prevalence to inpatient units
(1) share data and findings with SNI; (2) report results to the State
(1) achieve HAPU prevalence of less than 2.0%; (2) share date and
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findings with SNI; (3) report results to State
Y4:
1) achieve HAPU prevalence of less than 1.5%; (2) share date and
findings with SNI; (3) report results to State
Y5:
1) achieve HAPU prevalence of less than 1.1%; (2) share date and
findings with SNI; (3) report results to State