Neurosurgery Patient Safety and Quality Improvement


The vision of the Department of Neurological Surgery’s Patient Safety and Quality Improvement program is to provide the safest and highest quality patient care based on the principles of clinical, operational, and academic excellence with the overall aim of being a national leader in neurological surgery quality and patient safety.

Since the inception of the program in 2011, we have convened a multi-disciplinary team of faculty members, residents, nurse practitioners, physician assistants, clinic practice managers, nurses, pharmacists, Infection Control specialists, Service Excellence liaisons, and Medical Center quality improvement and service line representatives through a multitude of projects aimed at improving the quality of patient care and the patient experience at UCSF Medical Center. We have made significant strides towards this goal, and for the first time in departmental history, the Department of Neurological Surgery received the 2012 Healthgrades Neurosurgery Excellence Award, which recognizes hospitals for superior patient safety outcomes in neurological surgery.

The aims of the Neurosurgical Patient Safety and Quality program focuses on four key areas:

Clinical Effectiveness


• Reduce craniotomy and spine surgical site infections
• Reduce medication errors
• Reduce other Hospital Acquired Conditions: Post-op VTE, CA-UTI,   VAP, CLABSI, HAPUs, falls
• Lower mortality observed/expected (O/E) ratios
• Improve hand hygiene rates
• Reduce 30-day readmission rates

Clinical Efficiencies


• Improve discharge before noon
• Improve discharge summary completion timeliness
• Reduce unnecessary laboratory and radiologic testing

Patient Experience


• Improve inpatient HCAHPS and Press-Ganey scores
• Improve outpatient HCAHPS and Press-Ganey scores

Resident Engagement


• Quality Improvement (QI) Resident Curriculum
• Resident participation in case review and ongoing departmental QI   projects
• Quarterly QI Resident Lunches
• Annual participation in UCSF Graduate Medical Education QI   Incentive Project