Quality Improvement
We are constantly looking to improve the care we provide patients in the most impactful and cost-efficient manner. Every day we strive to understand how we can do better with patient outcomes, while reducing costs if possible, and sticking to best practices and evidence-based medicine. With this in mind, Stanford Health Care Tri-Valley continues to invest significant time and resources into Quality Improvement. We have begun many different projects across our growing number of departments to identify areas where we can accomplish this goal. It is an exciting time to be involved with Quality Improvement. We have a growing number of initiatives led by our Quality improvement / Performance Improvement Medical Directors, Silvia Loica-Mersa, MD, Ginger Yang, MD, and Kathleen Carrothers, MS MPH, and we are just getting started! Feel free to reach out to Silvia if you are interested in being involved with Quality Improvement Projects, please contact Dr. Loica-Mersa.
Here are a few programs we are working on:
MD-RN Communication Committee
Minjoung Go, Jeff Ketchersid, and Silvia Loica-Mersa are leading an effort to improve communication between physicians and nurses at Stanford Health Care Tri-Valley. The MD-RN Communication Project is a collaboration between the hospitalist group, nursing leadership, and bedside nursing staff. The committee has initiated a monthly MD-RN Grand Rounds around topics of interest that were identified through nursing and physician surveys. Topics so far have included respiratory deterioration, delirium management, and inpatient management of diabetes. Upcoming classes will focus on improving communication using TeamSTEPPS and ARCC.
Clinical Deterioration Index
Alex Chu and Silvia Loica-Mersa are participating in the Stanford Health Care Tri-Valley implementation of the Clinical Deterioration Index (CDI). The CDI is an AI model that uses Epic data to predict the risk of clinical deterioration (RRT, Code Blue, ICU transfer, or mortality). The CDI is currently being piloted on multiple units at Stanford Palo Alto and for all hospitalist patients at Stanford Health Care Tri-Valley.
Silvia Loica-Mersa, MD
Co-Medical Director
Programs and Projects
The Cost Savings Reimbursement Program (CSRP)
Ginger Yang, MD
Co-Medical Director
The CSRP was started at the Stanford school of medicine/Stanford healthcare organization in Palo Alto. This program looks to improve the delivery of high-quality clinical care while reducing costs and improving efficiency. Areas of improvement identified, studied, and implemented by physician led teams, with a portion of the cost savings returning to the department to find a research, education, supplies. If you are interested in learning more, please contact Dr. Yang.
Ongoing and upcoming projects include:
Reducing inappropriate magnesium ordering
-DONTcusate: eliminating low value docusate in favor of more effective laxatives
-A Menu Without Prices - Closing the Gap with Medication Cost Transparency: Medication costs to the organization will be displayed to the ordering provider, allowing the provider to make higher value choices while continuing to consider what is best for the patient. The initiative will also target high cost IV medications and encourage switching to the PO equivalent.
-Reducing Inappropriate and Repetitive Ordering of Hemoglobin A1c, Lipid panel, Thyroid function test, and Phosphorus levels
-Orthopedic Trauma Spend Reduction Program: Joint efforts between SHC Tri-Valley and SHC-PA orthopedic surgeons in negotiating vendor prices and standardizing prostheses
-Orthopedic Lab Cost Reduction: reducing unnecessary pre-operative labs for patients undergoing orthopedic procedures.
More information regarding CSRP and how providers can submit proposals for their projects can be found on our intranet page (need Stanford log-in) https://shcconnect.stanfordmed.org/sites/vc/ImprovementTeam/CSRP/Pages/default.aspx
RITE: Realizing Improvement through Team
This innovative training program involves medical staff from many different disciplines (from nurses to physicians to therapists, etc), to provide the tools to start and implement performance projects in real time.
Interested in submitting a project? Submit the project proposal here.
Cohort 4 Projects (2023)
CLABSI reduction
Given significant morbidity, mortality, and costs associated with CLABSIs, this project's goal was to reduce overall CLABSIs in the hospital to less than or equal to 2. Interventions targeted toward standardization of line evaluation and management. As of graduation of the program, there had been 138 CLABSI free days within the hospital.
Improving the ICU to floor hand off process
This project aimed to decrease the number of missed intensivist to hospitalist handoffs prior to the patient leaving the ICU. After implementation of a standard workflow with standardization of communication points, missed handoffs decreased to near 0.
Improving RN communication
This was a project initiated in the 1W unit of the hospital with the aim to increase HCAHPS RN communication scores by 2%. Interventions included pain management rounds and implementing the 5 Ps into the hourly rounding process (ie plan of care, pain, prevention of falls, positioning, and personal needs). Surveys conducted of patients noted a increase in RN communication from <70% to >80% on average.
Improving Staff Responsiveness
The aim of this project was to increase HCAHPS Staff Responsiveness
scores by 2 % The project focused on the 2W unit in the hospital and focused on key drivers that contributed to patient calls including pain concerns, bathroom requests and RN specific calls. Specific interventions worked included identification of patients who needed more frequent rounding, implementation of a "no pass zone", and modifications of the welcome letter for patients in terms of expectations of rounding frequency. This led to a 17% decrease in time to respond by staff.
Cohort 3 Projects (9/2022-1/2023)
Reconstruction of the Inpatient Stroke Alert Process
This project aimed at improving the compliance rate for the metric of inpatient stroke alerts to CT scanner in 25 minutes or fewer. It ultimately led to an increase in compliance from 57% to 88% within the 3-month period of the project. This was accomplished through improvements in education surrounding stroke identification, clearer delineation of roles and responsibilities, and improving communication
CAUTI Reduction Project
CAUTIs This project aimed at reducing CAUTIs through a combination of decreased foley use, decrease urinary culture ordering of foley samples, many of which have colonized bacteria, as well as improved care of patients with foleys through creation of foley care kits
Earlier Mobilization of Patients
Decrease patient mobility often results in complications such as HAPIs (hospital acquired pressure injuries), patient deconditioning, and longer length of stay. This project created a method of accurately documenting patients' BMAT (Bedside Mobility Assessment Too) level as well as interventions that lead to improvements in these methods such as implementation of visual cues for ambulation and the creation of a BMAT algorithm. This ultimately lead to an increase in patients who were able to progress in their BMAT levels during their hospitalization from 52% to 71%.
Safe Patient Handling Injuries
Injuries amongst staff while mobilizing patients have been a significant source of morbidity, loss of productivity, and decrease in staff morale and patient experience, particularly as these injuries have increased at SHC-TV by 60% over the last three years. We have improved education regarding right equipment usage, increased lift coach usage, and increased availability of equipment such as Hovermatts.
Cohort 2 Projects (11/2021-5/2022)
Improving Patient Flow on 1W
Aimed at making discharges on 1W more efficient so that beds would be available for patients from the PACU from elective cases as well as the ER. Interventions included visual wall and performing earlier assessments on discharge readiness in multiple domains: ie medication, rides, PTOT evaluation. Overall improved median discharge time by 47 min.
Improving Quiet at Night on 3W
Aimed at improving quietness on the unit to allow for better patient experiences. The team created quiet kits and partnered with multiple groups within the hospital to improve the quietness measure.
Improving Sepsis Mortality
This project focused on improving sepsis mortality for patients that present to the emergency room. Some of the measures implemented include early rooming of patients that screen positive for sepsis, using nursing triage order sets, and improving antibiotic delivery to the bedside.
Cohort 1 Projects (2021)
Decreasing ED length of stay for discharged patients
This team worked on improving LOS for ED discharged patients. They have implemented a training program through Healthstream aimed at increasing RN utilization of triage protocol to improve workflow. Additionally, they are trialing additional a second RN to triage during peak flow times.
Decreasing CLABSIs in the ICU
The goal of this project was to decrease CLABSIs in the ICU with the goal of reducing the SIR (standardized infection ratio) from 2.05 to ≤0.633. To this goal, the team has implemented a new dressing trial, provided RN education, and revised the ICU rounding checklist. Additionally, they have collaborated with the SHC-PA campus to align IV therapy policies and gained approval for EPIC changes. Since the start of these interventions, there have been 0 CLABSIs in the ICU.
Improving Patient Flow
The overall aim of this project was to improve patient flow in the 2W nursing unit of the hospital. The team implemented an afternoon check in between CM, Charge RN and physicians. The team also worked on improving the standardization of communication between different disciplines. This led to an overall reduction of length of stay and improved likelihood to recommend by patients. In the future, the team hopes to develop additional improvement project A3s based on key learnings from this current project and also expand successful interventions to other nursing units.
Improving Communication to Patients about Medications
This project was developed with the goal of improving HCAHPS communication about medications domain score for the 3W nursing unit. The team has developed a training protocol to educate RNs regarding the use of Lexicomp to discuss side effects with patients. This training protocol will also be implemented for new hire nurses during nursing orientation. In the future, the team has the goal of developing a pharmacy discharge education improvement project and potentially trialing a discharge pharmacist.
ICDP: Improvement Capability Development Project: Improving General Surgery Mortality at SHC Tri-Valley
This Improvement Capability Development Project (ICDP) focuses on improving the Vizient mortality index for general surgery at SHC Tri-Valley by identifying opportunities to improve the peri-operative care of general surgery patients, as well as improve clinical documentation so that it more accurately reflects the state of illness and co-morbidities of the general surgery patients treated at SHC Tri-Valley. John Gahagan is the physician champion for this project, which is funded through the Stanford Department of Surgery.