DSRIP Plan: NativIdad Medical Center (NMC)
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CATEGORY 1: Infrastructure Development
Project
Increase Training of
Primary Care
Workforce Through
Expansion of the Family
Medicine Residency
Program and Serving as
a Training Site for
Medical Students and
Physician Assistants
Enhanced
Interpretation Services
and Culturally
Competent Care
through Investment in
Infrastructure to
Identify Language
Access Needs, Increase
Capacity to Provide
Qualified Interpreter
Services, Train Staff
Related to Language
Access and Cultural
Sensitivity, and Insure
Timely Access to
Qualified Interpreter
Services
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Description
Increased training and primary care capacity
through the expansion of the Family Medicine
Residency Program, a UCSF affiliation, by two
residency slots per year in Years Two, Three,
and Four (increasing a class from 8 to 10
Residents for a total of 30 residents in training
at NMC)
5-Year Goals
Y1: Expand Family Medicine Training Program by hiring two new
Family Medicine faculty members
Y2: Expand Family Medicine Training Program by recruiting two
additional first year Residents to begin training July 1 2012 thus
expanding residency program to 26 total residents
Y3: Expand Family Medicine Training Program by recruit two additional
first year Residents to begin training July 1 2013 thus expanding
residency program to 28 total residents
Y4: Expand Family Medicine Training Program by recruiting two
additional first year Residents to begin training July 1 2014 thus
expanding residency program to 30 total residents
Y5: Increase the number of primary care trainees by providing training
to at least six Touro University Medical Students each academic year.
Expanded capacity to provide qualified health
care interpreter encounters and an increase in
the number of interpreter encounters as
evidenced by a 100% increase in our qualified
interpreter workforce,
The deployment of HCIN in 100% of
departments identified in a language access
services gap analysis, and
A 60% increase in the number of qualified
interpreter encounters per month over
baseline.
Y1: Action plan development based on gap analysis which identified gaps in
language access services and baseline data
Y2: Establish baseline data for number of encounters facilitated by qualified
interpreters and number of departments utilizing video and audio
conference terminals
Y3: Expand qualified health care interpretation technology to 30% of
departments indentified in gap analysis
Y4: Expand qualified health care interpretation to 75% of departments
identified in gap analysis
Y5: Expand qualified health care interpretation technology to 100% of
departments identities in gap analysis
CATEGORY 2: INNOVATION AND REDESIGN
DSRIP Plan: NativIdad Medical Center (NMC)
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Improve How the
Patient Experiences
the Care and the
Patient’s Satisfaction
with the Care Provided
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Implementation of at least three organizational
strategies to improve the patient experience
resulting in a 15% improvement over baseline
of Percent Excellent score in patient
satisfaction survey’s overall quality of care
question.
Y1: Develop regular organizational display of patient experience data and
provide quarterly updates to employees on the efforts the organization
is undertaking to improve the experience of its patients and their
families
Y2: Conduct focus groups in one targeted clinical area to establish the
baseline patient experience and report findings
Y3: Conduct focus groups in one targeted clinical area to establish the
baseline patient experience and report findings
Y4: Implement at least one organizational strategy that includes the patient
in shared decision making aimed at improving patient and family
centeredness
Y5: Implement at least one organizational strategy that includes the patient
in shared decision making aimed at improving patient and family
centeredness
Apply Process
Improvement
Methodology to
Improve
Quality/Efficiency as
Evidenced by
Achievement of
Milestones in
Categories 3 & 4 and
Achievement of
Performance Goals in
our Targeted
Improvement Projects
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Improved quality of care as evidenced by
achievement of milestones in DSRIP Category
4,
Improved patient satisfaction reflected in
patient satisfaction scores
Achievement of performance goals in our
targeted improvement projects.
Y1: Train management staff and physician leaders in the Model for
Improvement methodology
Y2: Train process improvement advisors/champions
Y3: Train process improvement advisors/champions
Y4: Convene training events conducted by designated process improvement
trainers
Y5: Convene training events conducted by designated process improvement
trainers
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CATEGORY 4: URGENT IMPROVEMENT IN CARE
Improve Severe Sepsis
Detection and
Management
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Reducing harm or death to patients seeking
care due to sepsis
Reduce avoidable harm or deaths due to
severe sepsis to patients receiving inpatient
services
Y1: Establish baseline data for Sepsis Mortality
Y2: Implement the Sepsis Resuscitation Bundle
Y3: Achieve X% compliance with Sepsis Resuscitation Bundle, where “X” will
be determined in Year 2 based on baseline data
Y4: Achieve X% compliance with Sepsis Resuscitation Bundle, where “X” will
DSRIP Plan: NativIdad Medical Center (NMC)
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be determined in Year 2 based on baseline data
Y5: Achieve X% compliance with Sepsis Resuscitation Bundle, where “X” will
be determined in Year 2 based on baseline data
Central LineAssociated
Bloodstream Infection
Prevention
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Prevent central line-associated bloodstream
infections
Y1: Establish baseline data for Central Line Bundle Practices
Y2: Implement the Central Line Insertion Practice (CLIP)
Y3: Achieve X% compliance with CLIP, where “X” will be determined in Year
2 based on baseline data
Y4: Achieve X% compliance with CLIP, where “X” will be determined in Year
2 based on baseline data
Y5: Achieve X% compliance with CLIP, where “X” will be determined in Year
2 based on baseline data
Hospital-Acquired
Pressure Ulcer
Prevention
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Make improvements in the management of
patients in order to prevent pressure ulcers.
NMC will prevent pressure ulcers by
establishing and implementing standard
processes of care as outlined in IHI’s
Improvement Map.
Y1: Form a multidisciplinary Performance Improvement Team to coordinate
and oversee the implementation of the Pressure Ulcer Prevention
strategies
Y2: Share data, promising practices, and findings with SNI to foster shared
learning and benchmarking across the California public hospitals
Y3: Achieve hospital-acquired pressure ulcer prevalence of less than 2.5%
Y4: Achieve hospital-acquired pressure ulcer prevalence of less than 1.5%
Y5: Achieve hospital-acquired pressure ulcer prevalence of less than 1.1%
Improve Venous
Thromboembolus
(VTE) Prevention &
Treatment

Reducing harm or death to patients by
assessing all hospitalized patients for VTE risk
on admission in order to start needed
prophylaxis
Y1: Form a multidisciplinary Performance Improvement Team to coordinate
and oversee the implementation of the VTE Prevention and Treatment
strategies
Y2: Put in place measurement/data management systems
Y3: Increase the rate of patients who receive VTE prophylaxis or have
documentation why no VTE prophylaxis was given the day of or the day
after hospital admission or surgery end date for surgeries that start the
day of or the day after hospital admission by X, where “X” will be
determined in Year 2 based on baseline data
Y4: Increase the rate of patients who receive VTE prophylaxis or have
documentation why no VTE prophylaxis was given the day of or the day
after hospital admission or surgery end date for surgeries that start the
day of or the day after hospital admission by X, where “X” will be
determined in Year 2 based on baseline data
Y5: Increase the rate of patients who receive VTE prophylaxis or have
documentation why no VTE prophylaxis was given the day of or the day
after hospital admission or surgery end date for surgeries that start the
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DSRIP Plan: NativIdad Medical Center (NMC)
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day of or the day after hospital admission by X, where “X” will be
determined in Year 2 based on baseline data