DSRIP Plan: UC San Francisco Medical Center / UCSF Benioff Children’s Hospital
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CATEGORY 1: Infrastructure Development
Project
Increase Primary Care
Capacity
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Implement and Utilize
Disease Management
Registry Functionality
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Description
Expand existing practices
Opening at least one new UCSFMC primary care
practice
Recruiting the primary care clinicians needed for
this expansion
Implement the new EPIC EMR at UCSFMC
5-Year Goals
Y1: (1) Appoint primary care strategic planning group to plan and
implement UCSFMC primary care expansion; (2) Relocate General
Medical Clinic to larger space at UCSFMC Mt. Zion Campus
Y2: (1) Recruit 2 additional primary care provider FTEs; (2) Increase patient
encounters at UCSFMC primary care clinics by 2,5000 relative to FY10
encounters
Y3: (1) Recruit 2 additional primary care provider FTEs (total of 4); (2)
Increase patient encounters at UCSFMC by 5,000 relative to FY10
encounters
Y4: (1) Recruit 2 additional primary care provider FTEs (total of 6); (2)
Increase patient encounters at UCSFMC by 7,500 relative to FY10
encounters
Y5: Increase patient encounters at UCSFMC by 10,000 relative to FY10
encounters
Y1: Review current registry capability and assess future needs
Y2: (1) Populate registry with patient data at 2 of 5 (40%) primary care
practices to create registry for patients enrolled in those practices; (2)
Enter patient data into registry at these 4 practices for at least 75% of
patients at the practice with diabetes and 75% of patient eligible for
colorectal cancer screening (aged 50-75)
Y3: (1) Populate registry with patient data at 4 of 5 (80%) primary care
practices to create registry for patients enrolled in those practices; (2)
Enter patient data into registry at these 4 practices for at least 75% of
patients at the practice with diabetes and 75% of patient eligible for
colorectal cancer screening (aged 50-75)
Y4: (1) Populate registry w/ patient data at 5 of 5 primary care practices to
create registry for patients enrolled in those practices with final practice
included being pediatrics; (2)In addition to adult patient data entered in
previous 4 primary care practices, enter patient data into registry at
pediatrics practice to track immunization status, including registry data
for at least 75% of active young children in the practice
Y5: (1) Expand child immunization registry to include young children cared
with medical homes at family medicine practice, so that 100% of UCSF
primary care practices serving children have an immunization registry;
Enhance Performance
Improvement and
Reporting Capacity
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DSRIP Plan: UC San Francisco Medical Center / UCSF Benioff Children’s Hospital
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(2) Enter patient data intro registry at all practices serving children to
track immunization status, including registry data for at least 75% of
active young children in the practice.
Y5: Enter patient data into the registry for at least 65% of patients with
diabetes who are assigned to a KMC primary care clinic as their medical
home
Y1: (1) Develop reporting methodologies that will enable continuous quality
Conduct an inventory of the key data sources,
improvement; (2) Participate in a collaborative
reporting efforts and platforms
Y2:
(1) Hire/ train 2 staff in well proven quality and efficiency improvement
Select an information technology solution to
principles, tools and processes; (2) Implement quality improvement (QI)
support data management and production of
data systems, collection and reporting capabilities
balanced scorecards
Y3:
(1) Hire/ train 1 staff in well proven quality and efficiency improvement
Produce meaningful reports and templates
principles, tools and processes; (2) Implement QI data systems,
utilized to reflect performance and drive change.
collection and reporting capabilities
Starting with one or two initiatives, this
Y4:
(1) Participate in / present to quality performance improvement
intervention will ultimately provide information
conferences, webinars, learning sessions or other venues; (2)
for all key initiatives in the “Bridge to Reform”
Implement QI data systems, collection and reporting capabilities
project set and other key organizational
Y5: Create a quality dashboard or scorecard to be shared with
initiatives. This will enable front line staff as well
organizational leadership on a regular basis that includes patient
as executive stakeholders to manage against
satisfaction
data, increase assigned accountability, adjust
interventions/approaches based on data and
celebrate success
Retrain / recruit / hire / train staff to assist in
achieving the plan
Shift the manpower effort from data collection
and manipulation to performance improvement
activities
CATEGORY 2: INNOVATION AND REDESIGN
Expand Medical Homes
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Expand and redefine the roles of the primary care
team members, focusing on training medical
assistants to function in an expanded role as
panel managers and training nurses in care
management of high risk patients in all UCSFMC
primary care clinics
Link high need patients to primary care medical
homes, focusing in particular on SPD patients,
Y1: (1) Develop protocols for effectively communicating with patients and
families during and post discharge to improve adherence to discharge
and follow-up instructions; (2) Begin monthly data collection and
reporting for chosen metrics
Y2: (1) Develop a staffing and implementation plan to accomplish the goals/
objectives of the care transitions program; (2) Implement standard care
transition processes in one additional patient population;
Y3: (1) Conduct an assessment and establish linkages with community-
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Increase Specialty Care
Access / Redesign
Referral Process
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DSRIP Plan: UC San Francisco Medical Center / UCSF Benioff Children’s Hospital
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including young adults with childhood-onset
based organizations to create a support network for targeted patients
disabling conditions who use UCSFMC specialist
post-discharge; (2) Implement standard care transition processes in two
services but do not have a primary care medical
additional patient populations;
home
Y4: (1) Train 3 additional MEAs / health workers in panel management and
health coaching, deploy in UCSFMC clinics; (2) Train 1 additional RN case
Perform population health management by
manager in case management of high risk patients and deploy in
identifying and reaching out to patients who
UCSFMC primary care clinics; (3) Link at least 75 additional SPD patients
need preventive and chronic care services, with
without UCSFMC primary care visits in FY10 to primary care medical
an emphasis on newly trained panel managers
homes; (4) Panel managers / health coaches actively managing registries
and nurse care managers using the registry
for colorectal cancer screening for at least 1,500 UCSFMC primary care
functionality as a tool for more effective
patients and registries for chronic care for 1,000 UCSFMC primary care
population management and outreach
patients with diabetes; (5) 150 high risk HCSFMC primary care patients
have assigned care manager teams
Y5: (1) Train 1 additional RN case manager in case management of high risk
patients and deploy in UCSFMC primary care clinics; (2) Link at least 50
additional SPD patients without UCSFMC primary care visits in FY10 to
primary care medical homes; (3) Panel managers / health coaches
actively managing registries for colorectal cancer screening for at least
2,000 UCSFMC primary care patients and registries for chronic care for
1,500 UCSFMC primary care patients with diabetes; (5) 250 high risk
HCSFMC primary care patients have assigned care manager teams
Y1: Designate personal / team to support and manage the specialty access
Redesign the specialty referral process for a
process
subset of UCSFMC specialty clinics in order to
Y2: (1) Develop and implement standardized referral evaluation and
reduce the appointment scheduling lag to less
processing guidelines for 4 specialty clinics; (2) Complete a planning
than and reduce the 3rd available appointment
process and submit a plan to implement electronic referrals; (3) Develop
time, thus improving access for new patients
the technical capabilities to facilitate electronic referrals
Develop and implement an e-referral program in
Y3: (1) Develop and implement standardized referral evaluation and
a subset of UCSFMC specialty clinics
processing guidelines for 2 additional specialty clinics; (2) Measure wait
times for specialty care appointments in the 4 initial specialty clinics; (3)
Implement specialty care access programs; e-referral in at least 2
specialty clinics
Y4: (1) Measure wait times for specialty care appointments in 2 additional
clinics%; (2) Develop and implement standardized referral evaluation
and processing guidelines for 2 additional specialty clinics; (3)
Implement specialty care access programs; e-referral in at least 2
additional specialty clinics
Y5: (1) Measure the number of specialty care referrals that result without a
clinic visit; (2) Achieve standards for specialty care access
Implement / Expand
Care Transitions
Program
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Y1: (1) Develop protocols for effectively communicating with patients and
Early identification of needs: enhanced
families during and post discharge to improve adherence to discharge
assessment for post-discharge needs will be
and follow-up instructions; (2) begin monthly data collection and
conducted at the time of admission by a case
reporting for chosen metrics
manager
Multi-disciplinary teams with clearly defined roles Y2: (1) Develop a staffing and implementation plan to accomplish the
goals/objectives of the care transitions program; (2) Implement
will prepare the patient for discharge
standard care transition processes in one additional patient population;
Individual target plans will be developed for high
Y3: (1) Conduct an assessment and establish linkages with communityrisk patients to mitigate risks and crease post
based organizations to create a support network for targeted patients
discharge care plans that will be communicated
post-discharge; (2)Implement standard care transition processes in two
and coordinated without patient partners
additional patient populations
Revision of discharge materials and education will
Y4:
(1) Redesign the process in order to be more effective; incorporating
be addressed
learnings, at least one new element into the process based on the
Medication reconciliation will be done for every
assessment, using the process modification process to include the
patient
specificity needed as learnings are discovered in Year 3; (2) Begin
Post discharge appointments will be made within
monthly data collection and reporting for chosen metrics
7-14 days or as appropriate for the patient
Y5:
(1) Report shared learnings of the care transitions program to local or
condition
national
stakeholders; (2) Begin monthly data collection and reporting
Routine directed post discharge phone calls will
for chosen metrics
be the standard of care
Earlier introduction of Palliative Care
Consultation as a care option
Leverage technology to standardize transition of
care information flow and reports.
CATEGORY 4: URGENT IMPROVEMENT IN CARE
Improve Severe Sepsis
Detection and
Management
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implement Sepsis Management and Resuscitation
Bundle
Reduce avoidable harm or deaths due to severe
sepsis to patients receiving inpatient services
Y1: (1) Conduct and report a gap analysis of recommended practices
compared to UCSFMC practices; (2) Establish UCSFMC sepsis mortality
baseline using the Integrated Nurse Leadership Program (INLP)
definitions
Y2: (1) Implement the Sepsis Resuscitation Bundle; (2) Report at least 6
months of data to SNI for baseline / benchmarks; (3) Report results to
the state
Y3: (1) achieve TBD% compliance with sepsis resuscitation bundle; (2) share
data and practices with SNI for benchmarking across public hospitals; (3)
Report results to the state
Y4: (1) achieve TBD% compliance with sepsis resuscitation bundle; (2) share
data and practices with SNI for benchmarking across public hospitals; (3)
Central Line Associated
Blood Stream Infection
(CLABSI) Prevention
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Surgical Site Infection
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DSRIP Plan: UC San Francisco Medical Center / UCSF Benioff Children’s Hospital
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Report results to the state
Y5: (1) achieve TBD% compliance with sepsis resuscitation bundle; (2) share
data and practices with SNI for benchmarking across public hospitals; (3)
Report results to the state
Y1: Implement a process of care to improve performance
improve compliance with central line insertion
Y2: (1) Implement the Central Line Insertion Practices (CLIP); (2) Report at
bundle
least 6 months of data collection on CLIP to SNI for baseline /
Reduce avoidable harm or deaths and costs of
benchmarks; (3) Report at least 6 months of data collection on CLABSI
care due to central-line associated blood stream
to SNI for baseline / benchmarks ; (4) Report CLIP results to state
infections
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
Y1: Establish an institutional surgical site infection and complication profile
improve surgical site infection prevention
baseline for general surgery, vascular surgery and selected specialty
surgical cases using the American College of Surgeon’s National Surgical
Quality Improvement Program (NSQIP)
Y2: (1) Report at least 6 months of data collection on SSI to California
Health Care Safety Net Institute (SNI) for purposes of establishing the
baseline and setting benchmarks ; (4) Report results to state
Y3: (1) Reduce the rate of surgical site infection for Class 1 and 2 wounds by
X, where “X” will be determined in Year 2 based on baseline data; (2)
Share data, promising practices and findings with SNI to foster shared
learning and benchmarking across the California public hospitals;
(3)Report results to the state.
Y4: (1) Reduce the rate of surgical site infection for Class 1 and 2 wounds by
X, where “X” will be determined in Year 2 based on baseline data; (2)
Share data, promising practices and findings with SNI to foster shared
learning and benchmarking across the California public hospitals;
(3)Report results to the state.
Y5: (1) Reduce the rate of surgical site infection for Class 1 and 2 wounds by
X, where “X” will be determined in Year 2 based on baseline data; (2)
Share data, promising practices and findings with SNI to foster shared
learning and benchmarking across the California public hospitals;
(3)Report results to the state.
Hospital-acquired
Pressure Ulcer (HAPU)
Prevention
Stroke Management
Venous
Thromboembolism (VTE)
Prevention & Treatment
Falls with Injury
Prevention
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Y1: Educate at least 100 nurses on pressure ulcer prevention and wound
Use a multi-disciplinary team approach to the
care. Education will focus on prevention, identification, treatment and
prevention of pressure ulcers using evidencecase review analysis
based recommendations from the national
Y2:
(1) Share data, promising practices and findings with SNI to foster
Pressure Ulcer Advisory Panel
shared learning and benchmarking across the California public hospitals;
(2) Report HAPU prevalence results to the state
Y3: (1) Achieve HAPU prevalence of less than 2.2%: (2) Share data,
promising practices and findings with SNI to foster shared learning and
benchmarking across the California public hospitals; (3)Report HAPU
prevalence to the state.
Y4: (1) Achieve HAPU prevalence of less than 1.7%: (2) Share data,
promising practices and findings with SNI to foster shared learning and
benchmarking across the California public hospitals; (3)Report HAPU
prevalence to the state.
Y5: (1) Achieve HAPU prevalence of less than 1.1%: (2) Share data,
promising practices and findings with SNI to foster shared learning and
benchmarking across the California public hospitals; (3)Report HAPU
prevalence to the state.
Not a selected intervention by UCSF Medical Center
Prevent VTE by checking patients for risk of blood Not a selected intervention by UCSF Medical Center
clots and taking appropriate prevention steps
Not a selected intervention by UCSF Medical Center