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CATEGORY 1: Infrastructure Development
Project
Implement and Utilize
Disease Management
Registry

Description
Build disease management registry to identify,
monitor, manage, and communicate with high
risk patients
Y1:
Y2:
Y3:
Y4:
Y5:
Enhanced Interpretation
Services and Culturally
Competent Care

Gap analysis to determine baseline of language
access gaps, revise policies to assure meet JCHO,
HHS and other standards, integrate cultural
competency into staff training, and expand
technology used in interpretation services.
Y1:
Y2:
Y3:
Y4:
Y5:
5-Year Goals
(1) Have registry functionality at 2 practice sites (2) create protocols for
registry-driven reminders and reports for providers and nurses re: BP,
LDL cholesterol, liver and renal monitoring and management in
cardiovascular disease patients
(1) create protocols for breast and cervical cancer screening. Metric:
electronic process to correctly identify 95% of screening tests that
require followup. (2) staff training so that 75% of all outpatient primary
care and cardiology sites have at least 2 people trained.
(1) Generate at least 2 registry based reports for each provider for care
delivered outside office visit and peer comparisons for nurse-driven
protocols. (2) Hold 2 sessions for primary care providers to learn from
highest performing cardiovascular risk factor managers. (3) Add at least
2 specialty practices that can use registry.
(1) ) Generate at least 2 registry based reports for each provider for care
delivered outside office visit and peer comparisons for provider-driven
protocols (e.g blood pressure control, LDL cholesterol control) (2)
improve workflow to either reduce time it takes to manage registry or
add more patients using same resources. (3) Expand registry
functionality to have at least some registry activity for 75% of all
primary care providers.
(1) Deliver registries to 95% of all system practicing ambulatory care
providers. (2) At least 2 registry reports to every provider.
Develop organizational plan for patient and family centerdness and
cultural competencies.
(1) Gap analysis (2) Establish baseline of qualified health care
interpreter encounters per month.
(1) Increase number of qualified health care interpreter encounters per
month by 10% . (2) Implement audio/video conferencing interpreter
terminals in 80% of patient care areas. (3) 80% of staff trained to
appropriately use health care interpreters (via video, phone, or in
person.)
Increase qualified health care interpreter encounters per month by 30%
of baseline.
Increase qualified health care interpreter encounters per month by 20%
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of baseline.
Y1: Develop plan to establish UCSD Department of Telemedicine.
Expand current centralized specialty consult
Y2: (1) Telemedicine triage unit established for one specialty. (2) Pilot
telemedicine to be part of routine activity in any
telemedicine charting and communication tools within EMR.
clinical specialty and acute care/emergency
operations, and expand hours in specialty clinics, Y3: (1) Expand to at least one additional specialty. (2) Implement
telemedicine partnership with at least one additional remote clinical
and expand telemedicine use for emergency
site (SPOKES) (3) Establish baseline number of e-consultations.
evaluation services.
Y4: (1) Increase e-consultations by 10%. (2) Expand to at least one
additional specialty. (3) Expand to at least one additional remote clinical
site.
Y5: (1) Increase e-consultations by 20%. (2) Expand to at least one
additional remote clinic.
Y1: Gap analysis.
Transition all coding from ICD-9 to ICD-10
Y2: (1) Develop project plan for organization-wide transition. (2) Asses all
current info systems re: need for transition.
Y3: (1) Train 100% of coding staff. (2) Update clinical document
improvement tools for ICD-10.
Y4: (1) 100% of records coded using ICD-10. (2) Audit at least 50% of
records for accuracy.
Y5: Develop and implement improvement plan based on audit.
CATEGORY 2: INNOVATION AND REDESIGN
Introduce Telemedicine

Enhance Coding and
Documentation for
Quality Data

Redesign Primary Care

Improve and increase patient use of electronic
medical record to improve access for screening
and preventive services.
Improve Patient Flow in
the Emergency
Department

Analyze ED for improvement opportunities,
initiate care per protocol and triage to expedite
exam and treatment, expand physical patient
care areas to increase capacity, and implement
electronic health info exchange with pre-hospital
Y1: Establish mechanism for patient self-enrollment in EMR
(MyUCSDChart), without provider referral.
Y2: (1) Establish baseline for patient enrollement. (2) Develop marketing
strategy to encourage patient enrollment. (3) Develop protocol for
automatic patient reminders.
Y3: (1) Increase enrollment by 5% over baseline. (2) Develop protocols for
screening alerts sent to patients.
Y4: (1) Increase enrollment by 10% over baseline. (2) Develop protocols for
reminders for lipid and glucose screening in CVD and diabetes
screening.
Y5: (1)Increase patients by 15% over baseline
Y1: (1) Develop care initiation protocols, (2) establish baseline for patients
who leave ED without being seen, and (3) establish ED wait time
baseline.
Y2: (1)Decrease % patients who leave ED without being seen by 5% (2)
Develop health info exchange link with pre-hospital and community
clinic care. (3) Reduce ED wait time for admitted patients by 5%.
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care
Y3: (1) Decrease % patients who leave ED without being seen by 10% (2)
Reduce ED wait time by 10%
Y4: (1) Decrease % patients who leave ED without being seen by 15% (2)
Reduce ED wait time by 15%
Y5: (1) Maintain 15% below baselines for ED leavers (2) Maintain 15%
below baseline for ED wait time
Y1: (1) Develop criteria and mechanism for automatic triggers for palliative
Increase number of patients receiving palliative
care consult and (2) establish baseline for palliative care consults
care by expanding teams, creating automated
Y2: (1) Increase palliative care consults by 25% over baseline (2) establish
triggers to identify patients needing palliative
baseline of patients who died in hospital and received palliative care
care, monitor patient transitions from ICU or
consult
code status changes to increase appropriate
Y3:
(1) Increase palliative care consults by 50% over baseline (2) Increase
transitions to palliative care, and monitor and
palliative care consults among patients who died in hospital by 5%
evaluate cost and symptom impacts
Y4: (1) increase palliative consults by 75% (2) Increase palliative care
consults among patients who died in hospital by 10%
Y5: (1) increase palliative consults by 100% (2) Increase palliative care
consults among patients who died in hospital by 15%
Use of Palliative Care
Programs

Conduct Medication
Management

Establish medication management program for
high risk patients
Implement/Expand Care
Transition Programs

Improve transition from inpatient to outpatient
care and prevent readmissions, improve
followup, and increase and improve use of
collaborative and electronic medical records and
health information technology for effective
transitions and continuity of care
Y1: Develop plan.
Y2: (1) Develop criteria and identify targeted patient populations. (2)
Implement program via written plan to provide medication
reconciliation as part of transition from acute to ambulatory care
Y3: Increase number of patients that consistently receive medication
management by 100%
Y4: Increase number of patients that consistently receive medication
management by 200%
Y5: Increase number of patients that consistently receive medication
management by 300%
Y1: (1) Develop staffing and implementation plan. (2) Develop care
transition protocols for community with patients and families during
and post-discharge (3) Designate team to manage project.
Y2: (1) Identify top chronic conditions and patient characteristics
characteristic of readmission (2) Create patient stratification system to
enable resources to be targeted to highest risk patients (3) Pilot care
transitions process for patient/family communications and
interdisciplinary rounds on 2 wards (4) Achieve completion of discharge
summaries within 48 hours of discharge in 80% of hospital medical
services discharges (5) Establish baseline percent of medical surgical
inpatients discharged to home who are assigned a medical home.
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Y3: (1) Pilot care transitions protocols on 4 wards (2) Establish hospitalbased case manager process for discharged patients who have top
chronic conditions, to include standardized discharge instructions and
education and provide additional coaching as needed (3) Achieve
completion of discharge summaries within 48 hours of discharge in 80%
of all medical and general surgical patients (4) assess and establish
linkages with community-based organizations to create support
network for targeted discharged patients (5) increase percent of
medical inpatients discharged to home who are assigned a medical
home by 15%.
Y4: (1) Achieve completion of discharge summaries within 48 hours of
discharge in 90% of all medical and general surgical patients (2) increase
percent of medical inpatients discharged to home who are assigned a
medical home by 30%.
Y5: (1) Share learnings with peer organization audiences in at least two
venues (2) increase percent of medical inpatients discharged to home
who are assigned a medical home by 50%.
Implement Real-Time
Healthcare Associated
(HAI) Systems

Establish HAI surveillance system that is
integrated with electronic medical records
system, includes prompting tools for physicians,
and provides just-in-time education tools and
resources for clinicians when HAIs are identified.
Improve Severe Sepsis
Detection and
Management

implement Sepsis Management and Resuscitation
Bundle
Reduce avoidable harm or deaths due to severe
sepsis to patients receiving inpatient services

Y1: (1) Develop real-time intervention system in EMR to track patients with
organisms known to increase HAI risk. (2) Develop electronic system for
real-time feedback to clinicians re potential HAI events (3) Implement
prompts for prevention and risk identification for CLIP and daily line
necessity.
Y2: (1) Expand HAI EMR system to other areas such as ICU, non-ICU, or
specialty care, and generate report (2) Develop electronic system for
real-time education to clinicians (3) Expand prevention and risk
identification prompts to include urinary catheter necessity
Y3: Expand HAI system to all inpatients.
Y4: Initiate chlorhexidine bathing in non-ICU adults with central lines,
urinary catheters, or recent surgery
Y5: Measure HAI rate for urinary catheter associated infections
CATEGORY 4: URGENT IMPROVEMENT IN CARE
Y1: Participate in San Diego Patient Safety Collaborative on Sepsis to learn
and share best practices.
Y2: (1) Implement the Sepsis Resuscitation Bundle: (2) Report at least 6
months of data to SNI for baseline / benchmarks; (3) Report the results
to the state.
Y3: (1) achieve TBD% compliance with sepsis resuscitation bundle; (2) share
Central Line Associated
Blood Stream Infection
(CLABSI) Prevention

Surgical Site Infection


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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)
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 the Central Line Insertion Practices (CLIP)
improve compliance with central line insertion
Y2: (1) Report at least 6 months of data collection on CLIP to SNI for
bundle
baseline / benchmarks; (2) Report at least 6 months of data collection
Reduce avoidable harm or deaths and costs of
on CLABSI to SNI baseline / benchmarks; (3) Report CLIP results to the
care due to central-line associated blood stream
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: Redesign and implement antibiotic delivery documentation within the
improve surgical site infection prevention
inpatient EMR
Y2: (1) Report at least 6 months of data collection on SSI to SNI for
baseline/benchmarks; (2) Report result to state (3) Achieve 92%
compliance in SCIP Core Measures: post-operative glycemic control in
CT surgery and urinary catheter removal by post op day 2 (4) Achieve
85% compliance with combined SCIP Core Measure for ambulatory
antibiotic administration.
Y3: (1) Reduce the rate of surgical site infection for Class 1 and 2 wounds by
X (2) share data and practices with SNI (3) Report results to the state (4)
Achieve 93% compliance in SCIP Core Measures: post-operative
glycemic control in CT surgery and urinary catheter removal by post op
day 2 (4) Achieve 90% compliance with combined SCIP Core Measure for
ambulatory antibiotic administration.
Y4: (1) Reduce the rate of surgical site infection for Class 1 and 2 wounds by
X (2) share data and practices with SNI (3) Report results to the state (4)
Achieve 95% compliance in SCIP Core Measures: post-operative
glycemic control in CT surgery and urinary catheter removal by post op
Hospital-acquired
Pressure Ulcer (HAPU)
Prevention

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day 2 (4) Achieve 95% compliance with combined SCIP Core Measure for
ambulatory antibiotic administration.
Y5: (1) Reduce the rate of surgical site infection for Class 1 and 2 wounds by
X (2) share data and practices with SNI (3) Report results to the state (4)
Maintain or exceed 95% compliance in SCIP Core Measures: postoperative glycemic control in CT surgery and urinary catheter removal
by post op day 2 (4) Maintain or exceed 95% compliance with combined
SCIP Core Measure for ambulatory antibiotic administration.
Y1: Implement wound ostomy nurses documentation of skin assessment in
Improve prevention of pressure ulcers using
EMR
evidence-based recommendations from the
Y2: (1) Share data, promising practices and findings with SNI to foster
national Pressure Ulcer Advisory Panel
shared learning and benchmarking across the California public hospitals;
(2) Report hospital-acquired pressure ulcer prevalence results to the
state.
Y3: (1) Achieve hospital-acquired pressure ulcer prevalence of less than
1.1%; (2) Share data, promising practices and findings with SNI; (3)
Report hospital-acquired pressure ulcer prevalence results to the state
Y4: (1) Maintain hospital-acquired pressure ulcer prevalence of less than
1.1%; (2) Share data, promising practices and findings with SNI (3)
Report hospital-acquired pressure ulcer prevalence results to the state
Y5: (1) Maintain hospital-acquired pressure ulcer prevalence of less than
1.1%; (2) Share data, promising practices and findings with SNI (3)
Report hospital-acquired pressure ulcer prevalence results to the state