Quality & Safety Corner: Improving Health Care Delivery

reprinted from Issue 16, Spring 2013 of Frontiers of Medicine (PDF)

While many faculty are translating laboratory findings into patient treatments, other physician-scientists are studying health care systems themselves – often using UCSF as their "laboratory" to pioneer ways to improve health care delivery.

"UCSF has a number of faculty who are involved in what we call health services research," says Niraj Sehgal, MD, MPH, associate chair for quality improvement and patient safety. "They are well equipped to answer questions that are becoming increasingly important with health care reform, such as how do we provide the highest quality and safest care to patients with a limited set of resources?"

R. Adams Dudley, MD, MBA

R. Adams Dudley, MD, MBA, a pulmonologist and the associate director for research at the UCSF Philip R. Lee Institute for Health Policy Studies, has developed measures of quality of care and worked on initiatives to make quality matter in the market. One of the best-known is CalHospitalCompare.org, which includes ratings for clinical care, patient safety and patient experience for more than 232 California hospitals. "Health care has not been an industry to track its own performance," says Dudley. "Comparative information is very important. If you just tell a doctor or hospital, ‘The death rate in your ICU is 13 percent,’ they don’t know what to do with that. Helping them to understand where they fit in the spectrum of performance, with data they believe is accurate, enables them to get better."

Working in partnership with hospital executives, insurance companies, consumers and many other stakeholders, CalHospitalCompare developed a way of measuring and risk- adjusting mortality for ICU patients, then shared the data in a series of quality improvement collaboratives. "Improvements happened at a really rapid rate, and we lowered the statewide ICU death rate by about 2 percent over three years," says Dudley. Many other improvements were spurred by making accurate comparative information easily available. "It’s all about multiplication," he says. "Getting information all the way to key policymakers really extends your impact."

Ralph Gonzales, MD, MSPH

Ralph Gonzales, MD, MSPH, associate chair for ambulatory care and clinical innovation, is an expert in implementation science – the science of translating evidence into practice. "With the goal of designing a much better ‘1.0’ version of a health care intervention, implementation science provides a framework for understanding the patient, provider and systemic factors related to what we are trying to improve " says Gonzales. "Also, because no two places are alike, we tailor and adapt previous evidence to the local environment and circumstances."

Gonzales has developed strategies for reducing overprescribing of antibiotics. "Many years ago when I moonlighted at Kaiser urgent care, I found how hard it was to resist pressure from patients to give them antibiotics I didn’t feel were appropriate," says Gonzales. He and colleagues developed educational pieces for physicians and patients, including exam room posters emblazoned with the Centers for Disease Control and Prevention (CDC) logo explaining that antibiotics aren’t effective for bronchitis, and increase antibiotic resistance in the individual and the community. "Doctors told us that these interventions made it easier for them to do the right thing – it was no longer the doctor saying ‘no’, it was the CDC and poster saying ‘no’," says Gonzales. These education programs have been scaled up, the CDC now offers this content on their website, and total antibiotic prescribing for respiratory conditions has dropped by about 20 to 25 percent nationally over the last 15 years.

Urmimala Sarkar, MD, MPH

Urmimala Sarkar, MD, MPH, an internist at San Francisco General Hospital, is working to help people living at home with chronic conditions manage their health more safely. Patient safety has been a focal point in the hospital setting, but Sarkar is one of a handful of researchers studying patient safety in the outpatient setting – such as outpatient medication complications. "With patients who take 20 medications a day, there is the potential for confusion and drug interactions," says Sarkar. "For someone who is low-income, doesn’t speak English and can’t afford glasses, the likelihood that they’re going to experience medication problems is much higher."

She analyzes large data sets and interviews patients who recently visited the emergency room to determine the scope and underlying causes of the problem. "I envision there will be a multilayered solution, involving a combination of technology, care teams to support patients in their medication self-management, and workflow changes to allow providers to think about patients who are not right in front of them," says Sarkar. "This work requires a very supportive and forward- thinking enterprise, and I can’t imagine doing this kind of research anywhere else."

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