Quality and Safety

Neurosurgery Quality Improvement and Patient Safety Program

 

Our Vision

The vision of the Department of Neurological Surgery’s Quality Improvement and Patient Safety 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 initiatives aimed at improving the quality of patient care and the patient experience at UCSF Medical Center.

Thanks to our intense focus on providing high quality, safe care, UCSF Medical Center was ranked #3 for Neurosurgery and Neurology in 2024-25, and Best in the West.

Aims

Our Neurosurgery Quality and Safety Program has five primary aims:

  1. To Provide High Quality Care
  2. To Provide Safe Care
  3. To Provide Patient-Centered Care
  4. To Provide Efficient Care
  5. To Maintain Academic Excellence

Providing High Quality Care

We aim to:

  • Decrease mortality rates
  • Decrease readmission rates
  • Decrease craniotomy and spine surgical site infection rates
  • Reduce hospital acquired conditions such as post-op venous thromboembolism, urinary tract infections, ventilator associated pneumonias, central line infections, pressure ulcers and falls

​Providing Safe Care

We aim to:

  • Monitor all adverse events and deaths and provide root cause analysis when warranted
  • Reduce medication errors
  • Provide safe OR care
  • Investigate patient safety events reported by multi-disciplinary team members

Providing Patient-Centered Care

We aim to ensure the best possible experience by:

  • Improving communication between providers and patients
  • Responding to patient concerns and giving time and space for answering patient questions and concerns
  • Providing a safe and comfortable hospital experience for patients
  • Improving communication between multi-disciplinary team members

Providing Efficient Care

We aim to:

  • Provide a smooth and efficient discharge process
  • Prioritize early mobilization and feeding post-operatively
  • Reduce unnecessary laboratory and radiological testing

Maintaining Academic Excellence

Our Neurosurgery housestaff:

  • Lead author a quality/safety publication before graduation
  • Participate in the annual housestaff incentive project, leading to improvement in areas such as documentation of neurosurgical drains, ICU rounding practices, and delirium management in post-op patients
  • Participate in a quality and safety curriculum that includes patient communication workshops, quarterly lunchtime seminars, and a quality and safety orientation every July

 

Our Tools
  • Quarterly Attending Dashboards: these dashboards are disseminated to the attendings quarterly to give them personalized data about their metrics, including mortality, infection rates, and lengths of stay
  • Quarterly Attending Quality Meetings: we meet with the Neurosurgery attendings quarterly to deep dive into the departmental quality data and discuss one aspect of quality or safety
  • Unit Based Leadership Teams (UBLT): Our multi-disciplinary Unit Based Leadership teams meet weekly to discuss quality initiatives on the Neuro units
     
Patient Experience
  • Improving Patient Communication: Residents receive intensive training from the Center for Enhancing Communication in Health Care to hone their patient communications skills, and attending physicians receive quarterly reports of their patient communication data. In addition, unit based initiatives are underway to improve nursing communication of medications to patients and to address other patient experience issues.
Current Initiatives
  • ERAS Crani pathway: Our ERAS Crani pathway is piloting in February 2019, and is a novel “Enhancing Recovery After Surgery” pathway that standardizes high quality care at pre-op, intra-op and post-op stages with an emphasis on optimizing medications and early feeding and mobilization post-operatively.
  • Opioid Stewardship: We are working with UCSF Health to ensure that we are following evidence-based guidelines for dispensing opioids. Our providers are verifying home opioid regimens before prescribing them and we are working on ensuring that every patient discharged on high morphine equivalents receives naloxone on discharge
  • Spine Pathway: We are working with our Orthopedics Spine colleagues to standardize spine surgical care across specialties and standardize pain medication regimens on discharge.
Quality and Safety Publications

Reflect Newsletter

Reflect is quarterly Quality and Safety Newsletter that updates members of the department on the various projects and initiatives that we are involved with. 

 

Team

Armond Esmaili, MD
Director of Quality and Safety
[email protected]