Overview

UCLA's neurosurgery department improved risk-adjusted mortality by engaging leaders and clinicians.

Member Profile

The cranial neurosurgery program is located at 540-bed Ronald Reagan UCLA Medical Center, which is also a Joint Commission/American Heart Association Certified Comprehensive Stroke Center. The spinal neurosurgery program is based at Santa Monica UCLA Medical Center.

Challenge

UCLA, a U.S. News & World Report leader in neurosurgery, ranked in the bottom quarter of hospital peers for risk-adjusted mortality in that specialty during late 2011 and early 2012, according to Vizient data analysis. Neil Martin, MD, chair of the department of neurosurgery, suspected that the neurosurgery mortality ratio did not appropriately reflect the quality of care provided by the service line. But he recognized the opportunity to gain a better understanding of the metric. That’s when he turned to Vizient and the Clinical Data Base.

Solution

As an improvement accelerator, Vizient provides not only transparent comparative data but also strong support and expertise. After multiple conversations with Vizient’s data and performance improvement experts, Martin launched UCLA’s Clinical Quality Program in Neurosurgery with an interdisciplinary focus on understanding and improving risk-adjusted mortality. His energy and accountability were vital to this effort, which also engaged physicians and analytic support staff.

Realizing he needed help understanding UCLA’s risk-adjusted mortality in order to develop the appropriate interventions, Martin enlisted the support of Nasim Afsar-Manesh, MD, chief quality officer; Tom Rosenthal, MD, chief medical officer; and Molly Coye, MD, chief innovation officer.

Afsar-Manesh already had a good grasp of Vizient’s methodologies. She worked with Vizient to understand the drill-down capabilities, networking opportunities, and best practices for improving risk-adjusted mortality. This work revealed that the important, but understated, role of hospitalists was crucial to reducing neurosurgery mortality. Neurosurgeon Nader Pouratian, MD, and hospitalist Wendy Simon, MD, collaborated with Afsar-Manesh in using Vizient’s Clinical Data Base to retrospectively review three years’ worth of mortality data.

After working with Vizient to understand the risk-adjustment methodology, these clinicians realized the importance of focusing on both observed and expected mortality rates. They aimed to create a collaborative environment where this information could be transparent within UCLA and used for performance improvement initiatives. Several interventions were implemented:

  • Using hospitalists
    Hospitalists achieved good results by managing comorbid conditions in other specialties, so UCLA emphasized the importance of using their expertise within neurosurgery.
  • Developing a “code brain” protocol
    Patients with neurological deficits who did not meet specific stroke protocols often experienced delays in obtaining a CT scan. To address the problem, the emergency, neurological critical care, radiology, and neurosurgery departments created a more general protocol for acute neurological cases called “code brain.”
  • Conducting weekly mortality reviews
    Mortality review is now a weekly process under the direction of Martin and the service line leaders. This change allows for more rapid implementation of action plans and specific follow-up activities to improve care. The review process also substantially improved clinician engagement. Pouratian, for example, points to these reviews as a learning experience.
  • Creating documentation templates
    The Vizient risk-adjustment models showed clinicians the importance of appropriate documentation that helps coding specialists capture the severity of cases. The team turned documentation practices into standard templates to make clinicians’ workflow easier.
  • Updating practices and software
    Vizient helped identify the fundamental mechanics of coding and documentation at UCLA. The team members discovered they were using old software that submitted no more than 25 diagnoses per case to the Vizient Clinical Data Base.
  • Increasing use of palliative and hospice care
    This type of care was seen not only as a mechanism to improve risk-adjusted mortality but also as a best practice.

Results

Steady improvements have occurred in neurosurgery since early 2012—both in observed mortality (from 7.37% to 3.57%) and in expected mortality (from 5.69% to 6.43%).  Similar trends were seen in the neurology service line, where the mortality index decreased from 1.12 in first quarter 2012 to 0.47 in first quarter 2014.

Patients in the neurology service line are often shared with neurosurgery and neurological critical care. UCLA ranked 17th of 112 academic medical centers in Vizient risk-adjusted mortality for neurosurgery in first quarter 2014. UCLA learned several lessons: Leaders who focus on quality can influence teams and promote new initiatives. Streamlined communication across multidisciplinary teams is crucial to success in quality initiatives. And bench marking is imperative to track performance, identify opportunities, and see the results of positive change.

One benefit of neurosurgery focusing on mortality was that it served as an example but also an incentive for other services to address mortality.
Neil Martin MD Chair, Department of Neurosurgery David Geffen School of Medicine Director, Quality Council UCLA Health System