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value-based Chasing perfection in Neurosurgery 2015 clinical report

NEUROSURGERY key Achievements

Mortality: 1  Neurosurgery – Over the past 2 years, we have significantly reduced the UHC risk-adjusted mortality rate, passing from the 84th percentile (97/114) in Q1 2012 to the 13th percentile (18/128) for the most recent quarter of data, Q2 2015.  Spine – The SMUCLA Spine Program has the lowest risk-adjusted mortality among the US News and World Report Top 20 Best for and Neurosurgery, and is ranked 7th out of 89 in risk-adjusted mortality in UHC.

ReadmissionS: 2  Neurosurgery – RRUMC is ranked 2nd in all-cause readmission rates among the US News and World Report Top 20 Best Hospitals for Neurology and Neurosurgery.  Spine – The SMUCLA Spine Program is ranked 4th in all-cause readmisison rates among the US News and World Report Top 20 Best Hospitals for Neurology and Neurosurgery.

Stroke: The UCLA Center has been awarded the “Target: Stroke” Honor Roll Elite 3 Plus status for expedited stroke care in 2015. This quality award has only been given to approximately 30 out of 1000 stroke centers in the US.

Program Specific Dashboards: In collaboration with the Faculty 4 Practice Group and Quality Analytics, we have successfully developed automated dashboards for the majority of our programs. These dashboards will both facilitate and empower our program directors to lead targeted quality initiatives.

Value-Based Neurosurgery - COMPREHENSIVE 5 Care redesign: In the past year, we have successfully redesigned strategies and implemented process improvement initiatives targeting key care points throughout the episode of care. This care redesign has had widespread positive effects on numerous quality metrics and patient satisfaction.

Patient Satisfaction - management: 6 For both Neurosurgery and Spine, we have successfully improved during hospitalization.

Nursing Excellence: In 2015, RRUMC received its 3rd Magnet Certification. 7 This elite award of excellence has been awarded to fewer than 6% of all US hospitals.

December 2015 Department of Neurosurgery 2015 CLINICAL VALUE REPORT

Department chair 1 KEY achievements Neil A. Martin, MD 3 MessAge From the chairman

4 about neurosurgery Editors Jody Anderson 5 Value-based care delivery Gena Behnke Nancy McLaughlin, MD, PhD 6 surgical volume Neil A. Martin, MD 7 mortality Reduction

8 length of stay Acknowledgments Faculty Practice Group & 9 readmission reduction Office of 10 and Analysis discharge by noon Robin Clarke, MD 11 reTUrn to emergency department: Andrew Hackbarth root cause analysis

Patient Satisfaction 12 Stroke and Neurovascular (HCAHPS) Namgyal Kyulo 16 code brain initiative Xiangqun (Jennifer) Lu 17 spine program Tony Padilla 18 Program (CGCAHPS) Samuel Skootsky, MD 19 Lateia S. Taylor 20 Neuro-

22 Comprehensive Neurosurgery care redesign

24 patient satisfaction

25 patient and family advisory council (NPFAC)

26 nursing led initiatives

28 resident led initiatives

29 Technology and Quality Improvements

Cover Illustration: 30 dashboards

Medial sphenoid wing . 32 Value academics Image provided by Surgical Theater virtual reality Surgical Navigation Advanced Platform (SNAP.)

2 Message from the Chairman

Jody Anderson Barbara Anderson The faculty and staff of the Department of Neurosurgery are Director of Quality Analytics Unit Director delighted to present this update on the UCLA Department /Trauma ICU of Neurosurgery Quality Program. The Quality Program in Neurosurgery has continued to develop and includes in neurosurgery, neurological critical care, , and neuro-, along with our colleagues in the OR, ICU, and medical/surgical nursing. The team also includes physical therapists, pharmacists, case managers, social workers, and departmental administrative staff. We benefit from the engagement and insight of our Patient and Family Advisory Council. The program has been coordinated with and supported by Julie Byrd Marvin Bergsneider Administrative Nurse Professor the leadership and administrative teams of UCLA Health, the and Neurosurgery Co-Director, Pituitary Tumor Program Santa Monica UCLA Medical Centers, and the Faculty Practice Group.

Our previous report largely described the structure and agenda of our program. We are now primarily focused on reporting the quantitative measurements that define the results of our program. In the key metrics, in program after program, we have seen clear progressive year-over-year improvements. The measurements of our clinical performance, in the majority of critical areas, place our programs in the Langston Holly Steven Cohen Professor Chief Administrative Officer company of the nation’s most exceptional academic medical centers. Director, UCLA Spine Center Neurosurgery

The principal lesson of our efforts in quality program has been very clear: with sustained, creative team effort, major improvements in care are possible. And I want to emphasize - we are not done.

The program has been generously supported by our Health System, by the Office of the President of the University of California, and by visionary philanthropists. Without Nader Pouratian Nancy McLaughlin this support and the dedicated efforts of our entire team, the program would not Associate Professor Assistant Clinical Professor Director of Quality, Neurosurgery Neurosurgery have been successful. I want to acknowledge all the talented and dedicated participants in this program. Most importantly, on behalf of our patients and their families, who are at the center of this work and benefit most from these efforts – thank you all!

Through the last five years we have developed a vision for our program – to chase perfection in neurosurgical care. With the help of so many, this year we moved several steps closer to the ultimate goal of perfect neurosurgery. Barbara Van De Wiele Jeffrey Saver Professor, Executive Vice Chair Professor of Neurology Sincerely, Anesthesiology & Perioperative Medicine Co-Director, UCLA Stroke Center

Neil A. Martin, MD Professor & W. Eugene Stern Chair in Neurosurgery

Derek Wilcox Paul M. Vespa Unit Director Professor 6N Neurosurgery & Neurology Director, Neurocritical Care Program 3 About the UCLA DEPARTMENT OF Neurosurgery

The Department of Neurosurgery at UCLA delivers clinical care on two campuses: the Ronald Reagan UCLA Medical Center (RRUMC), dedicated to cranial neurosurgery, and the Santa Monica UCLA Medical Center (SMUCLA), dedicated mostly to spinal neurosurgery.

The Clinical Programs include: The Department of Neurosurgery strives to invent the future of neurosurgery by improving neurosurgical treatment of brain and spinal conditions through Cerebrovascular innovative research and development, by providing optimal value of care • & AVMs for our patients and training the next generation of neurosurgical pioneers. • Stroke

Brain Tumor The Research Programs in neurosurgery at UCLA include: • Neurosurgical ()

• Pituitary Tumors • Brain Research Center (BIRC) • Pediatric • • Brain Tumor • Peripheral • Base Tumor • Clinical Informatics • Spine Spine & Peripheral Nerve • Cerebrovascular • Stroke • Spine • Peripheral Nerve • Neurocognitive • VALUE Research

Epilepsy UCLA Neurosurgery Recognition and Awards: Stereotactic and Functional • Stereotactic (SRS)  No. 7 Neurosurgery Department according to U.S. News and World Report • Functional Neurosurgery  No. 2 in National Institutes of Health (NIH) research grants (2014) Neurotrauma & Critical Care • Brain Injury Research Center  No. 2 in the U.S. for scholarly research

• Neurocritical Care  Joint Commission National Quality Approval awarded to UCLA Stroke Center

Pain  The UCLA Stroke Center is a designated center of the NIH-funded Specialized Programs of Translational Research in Acute Stroke (SPOTRIAS)  Nine clinicians in total in the UCLA Neurosurgery Department have been voted BEST DOCTOR IN AMERICA.

44 On the forefront of Value-based care delivery

The UCLA Department of Neurosurgery has pioneered numerous safety and quality initiatives that have subsequently been implemented throughout the UCLA Campus and the University of California Health System.

In recent years, the concept of value of care has become the overarching framework guiding care delivery. In addition to delivering the best outcome and achieving a perfect patient experience, care needs to be delivered in a cost-conscious way.

The KEy features in the department of neurosurgery, essential to its leadership in value-based care delivery

One clear mission statement: Provide a perfect and flawless patient experience, every time, any time.

Exceptional dedication to delivering optimal care: By all care providers including faculty members, residents and fellows, nursing, care partners, therapists, pharmacists, and care coordinators.

Essential collaborations with new partners: Performance Excellence specialists, Patient Affairs liaisons, Quality Analytics, Quality and Patient Safety, Risk Management, and medical center finance department representatives.

Unique access to and critical review of electronic quality and financial data: Diligent review of data to assure appropriateness of patient population, specificity of informatic queries, and clinical pertinence of metrics. Various sources of data are utilized for verification purposes.

Outstanding collaborative care: Through various committees, frontline care providers and administrators review data together, identify areas that need improvement, prioritize quality initiatives, collaborate for action planning and implementation, monitor initiatives following implementation, and together assure sustainability.

This report presents the results of important initiatives undertaken in 2014-2015 to improve the value of delivered care. Metrics developed by the department for specific initiatives and measures collected by national organizations are presented.

NEUROSURGERY

5 Surgical Volume

Procedure Volume by Location Procedure Volume by Location UCLA Department of Neurosurgery - 2014 UCLA Department of Neurosurgery - 2015

20.2% 28.4%

71.6% 79.8%

RRUMC - Neurosurgery SMUCLA - Neurosurgery Spine RRUMC - Neurosurgery SMUCLA - Neurosurgery Spine

Source: Epic Clarity Database, custom query

The Department of Neurosurgery at UCLA performs over 2,000 procedures between the Ronald Reagan UCLA Medical Center and the Santa Monica Medical Center

Constant Growth in Neuroscience Tertiary and Surgical Volume has Increased 10% in 2015 Quaternary Case Volume

880

1400 860

840 1200

820 1000 800

800 780

600 Cases ofNumber 760 Number of Cases

740 400 720

200 700

0 680 RRUMC SMUCLA Spine Total TQ Cases* 2014 2015 2013 2014 2015

*Tertiary and Quaternary cases are comprised of adult patients treated at Ronald Reagan UCLA Source: UCLA Health System Decision Support Medical Center, almost all cranial cases, of particularly high acuity, requiring specialized clinical facilities and services 6 Mortality reduction

RRUMC Neurosurgery has Significantly Reduced its Risk Adjusted Mortality from 1.32 in Q1 2012 to 0.35 in Q2 2015 UHC Risk Adjusted Mortality: RRUMC Cranial Neurosurgery Service Line

2.50

2.00

1.50

1.00

0.50 Observed Mortality / Expected Mortality / Expected Mortality Observed Observed Mortality / ExpectedMortlaity Mortality Observed 0.00 Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2013 Q2 2013 Q3 2013 Q4 2013 Q1 2014 Q2 2014 Q3 2014 Q4 2014 Q1 2015 Q2 2015

UHC Cranial Neurosurgery Service Line Risk Adjusted Mortality UHC Neurology Service Line Risk Adjusted Mortality RRUMC and the US News and World Report Top 20 Best Hospitals for Neurology and RRUMC and the US News and World Report Top 20 Best Hospitals for Neurology Neurosurgery, Fiscal Year 2015 and Neurosurgery, Fiscal Year 2015

1.20 1.40

1.00 1.20

0.80 1.00

0.80 0.60 0.60 0.40 0.40

0.20 0.20 Observed Mortality / Expected Mortality / Expected Mortality Observed Observed Mortality / ExpectedMortality Mortality Observed Observed Mortality / Expected Mortality / Expected Mortality Observed 0.00 Mortality / Expected Mortality Observed 0.00

*UHC Neurology service line includes many patients managed by Neurosurgery and the Neuro-ICU

UHC Cranial Neurosurgery Service Line Risk Adjusted Mortality

RRUMC1.80 and Select US News and World Report Top 20 Best Hospitals for Neurology and Neurosurgery 1.80 1.60 1.60 RRUMC 1.40 RRUMC 1 1.40 1 1.20 2 1.20 2 1.00 3 1.00 3 0.80 4 0.80 4 5

Observed LOS / Expected LOS / Expected LOS Observed 0.60 5

Observed LOS / Expected LOS / Expected LOS Observed 0.60 6 0.40 6 0.40 7 0.20 7

Observed Mortality / Expected Mortality / Expected Mortality Observed 0.20 0.00 Q1 2014 Q2 2014 Q3 2014 Q4 2014 Q1 2015 Q2 2015 0.00 Q1 2014 Q2 2014 Q3 2014 Q4 2014 Q1 2015 Q2 2015 Source: UHC’s Clinical Database 7 Length of Stay

Average Length of Stay - UCLA Neurosurgery and Spine

10.0 10.0 9.0 9.0 8.0 8.0 7.0 7.0 6.0 6.0 5.0 5.0 4.0 4.0 3.0 3.0 2.0 2.0 Average Length of Stay (days) of Stay Length Average Average Length of Stay (days) of Stay Length Average 1.0 1.0 0.0 0.0 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 2008 2009 2010 2011 2012 2013 2014 2015 2008 2009 2010 2011 2012 2013 2014 2015 Source: Epic Clarity Database, custom query RRUMC - Neurosurgery SMUCLA - Neurosurgery Spine RRUMC - Neurosurgery SMUCLA - Neurosurgery Spine

UHC Length of Stay Index, RRUMC - Cranial Neurosurgery Service Line and Select US News and World Report Top 20 Best Hospitals for Neurology and Neurosurgery

1.90 1.901.90

1.70 RRUCLA 1.701.70 RRUMC RRUMC 2 1.50 2 2 1.501.50 4 4 4 1.30 1.301.30 5 5 5 1.10 1.101.10 6 6 6 Observed LOS Observed/ LOS Expected LOS

Observed LOS / Expected LOS Expected / LOS Observed 0.90LOS Expected / LOS Observed 0.900.90 7 7 7

0.700.700.70 Q1Q1 2014Q1 2014 2014 Q2Q2 2014Q2 2014 2014 Q3Q3 2014Q3 2014 2014 Q4Q4 2014Q4 2014 2014 Q1Q1 2015Q1 2015 2015 Q2Q2 2015Q2 2015 2015 Source: UHC’s Clinical Database

UHC Length of Stay Index, SMUCLA - Spinal Service Line and Select US News and World Report Top 20 Best Hospitals for Neurology and Neurosurgery

1.901.90 1.90 RRUCLA 1.701.70 t 1.70 SMUCLA 2 SMUCLA 1.501.50 2 1.50 2 4 4 1.301.30 4 1.30 5 5 1.10 5 1.10 6 1.10 6 6 Observed LOS Observed/ LOS Expected LOS 0.90 Observed/ LOS Expected LOS 0.90 7 7 Observed LOS Observed/ LOS Expected LOS 0.90 7

0.700.70 0.70 Q1 2014Q1 2014 Q2 2014Q2 2014 Q3 2014Q3 2014 Q4 2014Q4 2014 Q1 2015Q1 2015 Q2 2015Q2 2015 Q1 2014 Q2 2014 Q3 2014 Q4 2014 Q1 2015 Q2 2015

Source: UHC’s Clinical Database 8 Readmission reduction

Rrumc is Ranked 2nd in All-Cause Readmission Rates UHC Percent All-Cause 30-Day Readmissions: RRUMC Cranial Neurosurgery Service Line and the US News and World The Department of Report Top 20 Best Hospitals for Neurology and Neurosurgery, Fiscal Year 2015 16.00 Neurosurgery is continuously 16.00 14.00 striving to eliminate all 14.00 preventable readmissions. 12.00 12.00 10.00 10.00 8.00 8.00 Cause Readmissions Our efforts to deliver - 6.00 Cause Readmissions Cause optimal care are supported - 6.00 4.00 4.00

by on-going of All Percent

Percent All Percent 2.00 readmissions with weekly 2.00 0.00 case reviews. 0.00

Smucla is Ranked 4th in All-Cause Readmission Rates UHC Percent All-Cause 30-Day Readmissions: SMUCLA Spinal Surgery Service Line and the US News and World Report Top 16.0020 Best Hospitals for Neurology and Neurosurgery, Fiscal Year 2015

14.008.00

12.007.00

10.006.00

8.005.00 Cause Readmissions - 6.004.00 Cause Readmissions - 4.003.00 Percent All Percent Percent All Percent 2.002.00

1.00 0.00

0.00

Source for all graphs: UHC’s Clinical Database

RR16.00UMC Cranial Neurosurgery Service Line SM16.00UCLA Spinal Surgery Service Line Percent All-Cause 30-Day Readmissions Percent All-Cause 30-Day Readmissions 14.00 14.00 25 12.00 12.00 20 10.00 10.00 15 8.00 8.00 Percent 10 Cause Readmissions Cause Readmissions - 6.00 - 6.00

5 4.00 4.00 Percent All Percent All Percent 2.00 2.000

0.00 0.00 9 Discharge by noon

The Department of Neurosurgery is improving patient flow by targeting discharge by noon at both RRUMC and SMUCLA. Our initiatives have addressed the causes of discharge delays, improved communication with patients and their families regarding the date and time of discharge, and resolved delays due to transportation and incomplete paperwork.

Percent Discharge by Noon per Month, RRUMC – Neurosurgery

70%

70% 60%

60% 50%

50% 40%

40% 30%

30% Percent D/C D/C by Noon Percent

Percent D/C by Noon D/C by Percent 20%

Percent D/C D/C by Noon Percent 20% 10%

10% 0% 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 0% 1 3 20085 7 9 11 1 3 20095 7 9 11 1 3 20105 7 9 11 1 3 20115 7 9 11 1 3 20125 7 9 11 1 3 20135 7 9 11 1 3 20145 7 9 11 1 20153 5 2008 2009 2010 RRUMC - Neurosurgery2011 RRUMC - 2012All 2013 2014 2015 RRUMC - Neurosurgery RRUMC - All

The UCLA Department of Neurosurgery has had sustained improvement in discharge by noon, and consistently outperforms RRUMC and SMUCLA hospital-wide discharge by noon performance

Percent Discharge by Noon per Month, SMUCLA – Neurosurgery Spine

100% 100% 90% 90% 80% 80% 70% 70% 60% 60% 50% 50% 40% 40% Percent D/C by Noon Percent

Percent D/C by Noon D/C by Percent 30%

Percent D/C by Noon Percent 30% 20% 20% 10% 10% 0% 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 0% 1 3 20085 7 9 11 1 3 20095 7 9 11 1 3 20105 7 9 11 1 3 20115 7 9 11 1 3 20125 7 9 11 1 3 20135 7 9 11 1 3 20145 7 9 11 120153 5 2008 2009 2010 SMUCLA - Neurosurgery2011 Spine SMUCLA2012 - All 2013 2014 2015 SMUCLA - Neurosurgery Spine SMUCLA - All

Source: Epic Clarity Database, custom query

10 RETURN TO EMERGENCY DEpartment: root cause analysis

57% of Neurosurgery ED Visits Occur within the First Month

In 2015, the Hospitalist service, 90 in collaboration with the 80 70 Department of Neurosurgery, 60 aimed to characterize the 50 incidence and etiology of 40 Emergency Department visits 30 Number of Patients Number of Patients of Number within six months following 20

an index admission to UCLA 10

Neurosurgery. 0 1.39% 30 60 90 120 150 180 > 180 1.39% Days from discharge to ED visit

1.39% 42% of Patients with ED Visits are Readmitted to the Hospital Reasons for ED Visits within the First Month after Discharge

Reasons for Return to the ED New/worsening pain issue 21 New/worsening neurological 41.67% 14 41.67%1.39% symptom or sign Infectious disease 12 41.67% 1.39% 41.67% 56.94% Miscelaneous 10 56.94% Rule-out medical issue 7 Cardiovascular - vascular 6 41.67% 56.94% 56.94% Surgical complication 6 56.94% Abnormal imaging/laboratory 3 41.67% Iatrogenic 3 56.94% Psychiatric 2 1.39% Total number of patients 84 Discharged from ED Readmitted DischargedDischargedDischarged from from ED ED from EDLeftReadmitted AgainstProcess MedicalReadmitted Advice improvements under implementation ReadmittedLeftLeft Against Against Medical MedicalAdvice Advice 1. Improve coordination of post-operative care before patient discharge: Discharged fromDischarged ED from ED ReadmittedReadmittedLeft Against Medical Advice Left Against Medical Advice a) Coordinate appointment with primary care within one week of discharge Left Against Medical Advice b) Coordinate appointment with neurosurgeon within one week of discharge 2. Improve patient education regarding: a) What to look out for after surgery b) Pain management 3. Establish easy access pathways for rapid clinical assessments Source: Epic Clarity Database, custom query 11 STROKE and Neurovascular

ISCHEMIC STROKE: Mortality

ACCREDITATIONS RRUMC and the US News and World Report Top 20 Best Hospitals for Neurology and Neurosurgery, Q1-Q21.60 2015

 Comprehensive Stroke Center, certified 1.40 by the Joint Commission, since 2012 RRUMC is 2nd in risk adjusted 1.20 mortality for ischemic stroke  Primary Stroke Center, certified by the 1.00

Joint Commission, since 2005 0.80

 Get with the Guidelines Stroke Gold Plus, 0.60

recognized by AHA/ASA since 2010 0.40

0.20  Target: Stroke Honor Roll Elite Plus, Mortality / Expected Mortality Observed recognized by AHA/ASA since 2015 0.00

innovations RRUMC and the US News and World Report Top 10 Best Hospitals for Neurology and Neurosurgery

1.60

 First mechanical thrombectomy device 1.40

for acute ischemic stroke: 1.20

stent and coil retrievers—invented/ 1.00 developed at UCLA. 0.80 0.60  First clinical cellphone PACS system for 0.40 Ischemic Stroke Mortality O/E 1.80 remote review of CT and MRI scans in 0.20 1.60 Observed Observed Mortality / Expected Mortality acute stroke developed at UCLA. Mortality / Expected Mortality Observed 0.00 1.40 2012 2013 2014 2015

1.20 RRUMC 2 13 4 5 18 6 21 9 7  First Neuro ICU-adjacent comprehensive stroke imaging center with CT, PET, 3T, get with the guidelines/ and MRI. performance achievement award

 First cerebral blood flow (CBF) laboratory Defect Free Measure of the 7 Consensus GWTG/PAA* Measures

to use bedside xenon CBF studies and 100% for stroke critical 98% care and research. 96%

94% TOP GRAPHS Source: UHC Clinical Database; Ischemic stroke - primary ICD9 92% diagnosis codes: 433.01, 433.1, 433.11, 433.21, 433.31, 433.81, 433.91, 434, 434.01, 434.11, 434.91 90% Percent of Patients LOWER GRAPH *GWTG: Get with the Guidelines 88% PAA: Performance Achievement Award This composite is made from these seven measures: IT rt-PA 2 Hour, Mortality / Expected Mortality Observed 86% Early Antithrombotics, Antithrombotics, Anticoagulation for Atrial Fibrillation, DVT Prophylaxis, LDL 100 or ND, and Smoking Cessation. Q3 2014 Q4 2014 Q1 2015 Q2 2015 Source: UHC’s Clinical Database RRUMC All Hospitals 12 ISCHEMIC STROKE: Length of stay

RRUMC and the US News and World Report Top 20 Best Hospitals for Neurology and RRUMC and the US News and World Report Top 10 Best Hospitals for Neurology Neurosurgery, Q1-Q2 2015 and Neurosurgery 1.30 1.90 1.901.30 1.40 1.60 1.20 1.70 1.701.20 RRUCLA RRUCLA 1.20 1.40 1.10 1.10 2 2 1.501.00 1.20 1.50 1.00 1.00 1.00 4 4 1.300.80 1.30 0.80 0.90 0.90 5 5 0.60 1.10 0.60 1.10 0.80 0.80 6 6

Observed LOS / Expected LOS Expected/ LOS Observed 0.40 Ischemic Stroke Mortality O/E 0.40 / Observed Expected LOS LOS Observed LOS Observed/ LOS Expected LOS Observed LOS Observed/ LOS Expected LOS 0.90 1.80 0.90 7 7 0.70 0.70 0.20 0.20 2012 2013 2014 1.60 0.70 Observed Mortality / Expected Mortality 0.700.60 RRUMC UCSF Northwestern Memorial Johns Hopkins 0.00 Brigham & Women's Mayo (MN) New York Presbyterian NYU 0.00 Q1 2014 Q2 2014 Q3 2014 Q4 2014 1.40Q1 2015 2012 2012Q1 2014Q2 2015 20132013Q2 2014 2014 2014Q3 20142015 2015Q4 2014 Q1 2015 Q2 2015 RRUMC 2 13 4 5 18 6 21 9 7 1.20 RRUMC 2 13 4 5 18 6 21 9 7

ISCHEMIC STROKE: all-cause 30-day readmissionS

RRUMC and the US News and World Report Top 20 Best Hospitals for Neurology and RRUMC and the US News and World Report Top 10 Best Hospitals for Neurology Neurosurgery, Q1-Q2 2015 and Neurosurgery

16.00 16.00 12 14.0 12.00

14.00 14.00 10.00 10 1.60 12.0 12.00 8.00 1.40 12.00 8 10.0 10.00 1.20 10.00 6.00

1.00 8.0 4.00 8.006 8.00 Cause Readmissions Percent

0.80 - Cause Readmissions 2.00 - Cause Readmissions 6.00 - 6.006.0 4 0.60 0.00 4.00 2012 Ischemic2013 Stroke Mortality O/E 2014

0.40 All Percent 4.00 4.0 RRUMC UCSF Northwestern Memorial Johns Hopkins 1.80

Percent All Percent Mass General Brigham & Women's (MN) New York Presbyterian

2 All Percent 0.20 2.00 NYU Cleveland Clinic 1.60 2.00 Observed Observed Mortality / Expected Mortality 2.0 0.00 2012 2013 2014 2015 0.000 1.40 0.00 2012 2013 2014 2015 RRUMC 2 13 4 5 18 6 21 9 7 1.20 RRUMC 2 13 4 5 18 6 21 9 7

Direct Cost of neuroscience tertiary and Quaternary cases

Over the past two years, direct cost of $30,000 Neuroscience TQ cases has decreased $25,000

$20,000

$15,000 Direct Cost

$10,000 TOP GRAPHS Source: UHC Clinical Database; Ischemic stroke - primary ICD9 diagnosis codes: 433.01, 433.1, $5,000 433.11, 433.21, 433.31, 433.81, 433.91, 434, 434.01, 434.11, 434.91 $0 BOTTOM GRAPH Brain Tumor Unruptured Stroke Source: UCLA Health System Decision Support

2013 2014 2015 13 RRUMC is 2nd in Risk Adjusted Mortality and 3rd in Length of Stay for Patients

UHC Intracerebral Hemorrhage Risk Adjusted Mortality: RRUMC and the US News and UHC Intracerebral Hemorrhage Length of Stay: RRUMC and the US News and World Report World R eport T op 20 Best Hospitals for Neurology and Neurosurgery, Fiscal Year 2015 Top 20 Best Hospitals for Neurology and Neurosurgery, Fiscal Year 2015 1.20 2.00

1.80 1.00 1.60

1.40 0.80 1.20

0.60 1.00

0.80 0.40 0.60 Observed LOS / Expected LOS / Expected LOS Observed

Observed LOS / Expected LOS Expected / LOS Observed 0.40 0.20 Observed Mortality / Expected Mortality / Expected Mortality Observed Observed Mortality / Expected Mortality Expected / Mortality Observed 0.20

0.00 0.00

The Department of Neurosurgery is dedicated to offering cutting edge care for patients with intracranial hemorrhages. For spontaneous intracerebral hemorrhage, the Department of Neurosurgery is perfecting minimally invasive surgical techniques to evacuate intracerebral hematoma in specific patients. UCLA is one of the seven sites for the Intraoperative CT-guided Endoscopic Surgery for ICH (ICES) trial.

RRUMC is Actively Working on Improving Risk Adjusted Mortality and Length of Stay for Patients

UHC Subarachnoid Hemorrhage Risk Adjusted Mortality: RRUMC and the US News and UHC Subarachnoid Hemorrhage Length of Stay: RRUMC and the US News and World Report World Report Top 20 Best Hospitals for Neurology and Neurosurgery, Fiscal Year 2015 Top 20 Best Hospitals for Neurology and Neurosurgery, Fiscal Year 2015

1.40 1.40

1.20 1.20

1.00 1.00

0.80 0.80

0.60 0.60

0.40 0.40 Observed LOS / Expected LOS / Expected LOS Observed

0.20 LOS / Expected LOS Observed 0.20 Observed Mortality / Expected Mortality Expected / Mortality Observed Observed Mortality / Expected Mortality / Expected Mortality Observed 0.00 0.00

Source: UHC Clinical Database; ICH - primary ICD9 diagnosis code 431, SAH - primary ICD9 diagnosis code 430 14 indirect vascularization

Encephaloduroarteriosynangiosis commonly refered to as (EDAS) is a form of indirect revascularization that has been employed for the treatment of pediatric . At UCLA, we have pioneered the use of EDAS for adult patients with intracranial stenoocclusive disease such as moyamoya disease or intracranial atherosclerosis.

Standardized processes developed to reduce variability in patient care and ultimately improve patient clinical outcome

The introduction of standardized checklists, structured specific perioperative briefings, strict management, and open -anesthesiologist communication systems has significantly reduced the variability of care for this patient population and favorably impacted the rates of perioperative complications. The clinical outcomes we have obtained are notably better than previously reported studies, with a reduction in the rates of stroke from 42% at 1 year to 6% at 2 years.

15 code brain initiative

In 2014, a multidisciplinary interdepartmental collaborative was created to optimize the initial assessment and care provided for intracerebral hemorrhage patients. The multidisciplinary team developed the Code Brain Initiative, aiming to: 1) rapidly identify patients with potential life threatening neurologic emergencies, 2) expedite their medical management, Key Achievements and 3) coordinate initial . in the past year include: An automated dashboard to monitor the Code Brain Initiative is being developed.  Defining the target patient population  Process mapping the ideal care pathway Dashboard Metrics Time from ED arrival to being seen by a physician  Defining process and outcome metrics Time from ED arrival to neuroimaging Time from ED arrival to arrival in ICU  Developing an ICH care protocol for Time from arrival to blood pressure target met the Emergency Department Time from arrival to initiation of INR reversal (if needed)  Hardwiring the ICH care protocol in the Time from arrival to ICU bed request orders electronic Time from bed request to orders written ICU LOS  Educating all involved care providers Mortality within 30 days

Code Brain Pathway

1416 Spine PROGRAM

SMUCLA Spine Program has the Lowest Risk-Adjusted Mortality among the US News and World Report Top 20 Best Hospitals for Neurology and Neurosurgery

1.40 rate 1.20 0.58% 1.00 Re-operation rate 0.80 1.16% 0.60

0.40 Readmission rate 2.53% 0.20 Observed Mortality / Expected Mortality / Expected Mortality Observed

0.00 16 3 9 18 12 7 4 14 2 10 6 21 19 11 5 17 13 20 SMUCLA. SpineEST LET Source: UHC Clinical Database, Spinal Surgery Service Line, Fiscal Year 2015 ACTUAL Title:. . UCLA patients have better pain relief outcomes following lumbar surgery than the national UCLA patients have better pain relief outcomes Improving HCAHPS Patient Satisfaction Percentile Rank benchmark following lumbar surgery than the national benchmark for “Pain Well Controlled during Stay” 100 (Mean SMUCLA National Time + SD) Spine Benchmark 80 Back Baseline 6.0 + 2.9 6.5 + 2.8 60

Pain 3 Month 2.1 + 1.9 3.0 + 2.8 40

Baseline 7.7 + 2.1 6.9 + 2.7 Rank Percentile Leg 20 Pain 3 Month 1.8 +2.2 2.4 + 3.0 0

Source: The National Neurosurgery Quality and Outcomes Database (N²QOD), April 2014 – June 2015 01/2014 - 06/2014 7/2014 - 12/2014 01/2015 - 06/2015

Patients’ Satisfaction following Lumbar Surgery is above the National Benchmark

100 98.2 88.3 90 80 72.7 70 67 60 50 40 SMUCLA Spine 30 25.5 Percent Satisfaction 21.3 National Benchmark 20 10 4.9 6.7 1.8 0 0 Surgery met my I did not improve as Surgery helped but I I am the same or worse Top 2 selections expectations much as I hoped but would not undergo the as compared to before would undergo the same same operation for the the surgery operation for the same same results Source: The National Neurosurgery Quality and Outcomes results Database (N²QOD), April 2014 – June 2015 17 Brain tumor PROGRAM RRUMC Brain Tumor Program is currently 5th in Risk UHC Brain Tumor risk adjusted mortality* Adjusted Mortality RR U MC and the US News and World Report T op 20 Best H ospitals for Neurology and Neurosurgery, Fiscal Year 2015 1.80 1.80 1.60 1.60 1.40 1.40 1.20 1.20 1.00 1.00 0.80 0.80 0.60 0.60 0.40 0.40 ObservedMortality / Expected Mortality 0.20 ObservedMortality / Expected Mortality 0.20 0.00 0.00 10 16 9 6 RRUMC 3 13 17 11 18 7 14 4 12 5 19 20 21 2 10 16 9 6 RRUMC 3 13 17 11 18 7 14 4 12 5 19 20 21 2

Source: UHC Clinical Database, primary ICD9 diagnosis codes: 191, 191.1, 191.2, 191.3, 191.4, 191.5, 191.6, 191.7, 191.8, 191.9, 192.1, 225.0, 225.2, 225.3, 225.4, 225.5, 225.6, 225.7, 225.8, 225.9, 237.5, 237.6, 198.3

LENGTH OF STAY for Brain Tumor Patients*

Source: Value Analytics report Implementation of a detailed OR Inpatient Tumor Resection Surgery and Hospitalization Direct Variable COST* checklist has resulted in reducing cost variability

Source: Value Analytics report

Brain Tumor Integrated Practice Unit initiatives:  Process mapping of a brain tumor patient throughout the entire episode of care within various tracks  Streamlined pre-operative and intra-operative checklists to maintain consistency in OR procedures for brain tumor patients  Nurse Navigator assuring coordination of care and support to patients and families throughout their treatment

*The data presented is specifically for the Meningioma--Metastasis patients, representing the largest subpopulation of brain tumor patients. 18 Deep Brain stimulation

The vast majority of elective DBS patients go home iNpatient DBS surgery admission length of stay the day after surgery

In the last 15 months, only one elective DBS patient DBS surgery 30-Day Readmissions was readmitted to the hospital within 30 days

DBS 30-Day EMERGENCY Department only visits

DBS surgery admission direct variable costs (includes both unilateral and bilateral stimulator implantations)

Source for all graphs: Value Analytics report 19 NEURO-Intensive care unit

The ICU of the Future Mission Statement: To deliver state-of-the-art, evidence-based care using advanced techniques and approaches to guarantee high quality care, best possible outcomes, and lowest risks for the patient

Ventilator-associated pneumonia prevention initiative

A new Ventilator-Associated Pneumonia initiative was launched in July 2015 throughout UCLA intensive care units. This new initiative, termed utilization of subglottic suction ETT, targets , polytrauma, and prolonged patients.

Ventilator-Associated Pneumonia Implemented at UCLA Efficiency Issues .(VAP) Prevention Method Head of bed up 45 Yes Patients slip, angle is less PEEP Yes Consistently done Chlorhexidine mouth wash (SOD) Yes Consistently done Daily sedation interruption Yes Pentobarbituric coma / deep sedation used Daily weaning trials Yes Delayed in coma patients Saline prior to suctioning Yes Consistently done Early tracheostomy Yes Day 7-10, some variability Selective gut decontamination No Controversial Silver coated ETT No Enterprise approach needed Subglottic suction No NEW TRIAL JULY 2015 ETT biofilm removal devices No Never trialed at UCLA Probiotics No NEW TRIAL - DEC 2015

Infection Control Protocol

 Admission screening for MRSA and MDR  ‘Sterile Precautions’ Protocol: – All transfers from outside hospitals/SNFs – Nurses and Physicians treat the unit like a sterile field  Isolation for MRSA, MDR, C. difficile  rounding with ICU team to facilitate  New bed/room cleaning protocol antibiotic selection – New cleaning protocol for high contact areas  Quarterly meeting between ICU QA team and – Prospective cleaning/waxing during vacancy times Hospital Epidemiology  Neuro-Infectious Disease Service January 2015  Probiotics to prevent C. difficile (December 2015)  Foley Removal Protocol Sept 2015

20 UCLA’s Neurocritical Care One Call- Diagnoses for These Patients were: Immediately Accept Policy

6% This initiative, implemented in March 2015, provides all Emergency 12% Departments in the region with the ability to rapidly and efficiently 6% 12% transfer by ground or by air acutely brain-injured patients to UCLA Ronald 45% 12% 45% Reagan Medical Center for advanced emergent care. 12% A bed is kept always open 24/7/365 for immediate intake of acute

(under 12 hour) ischemic stroke, , and traumatic 25%25% brain injury patients.

In the first 6 months after inception, the Neurocritical Care One Call - Acute ischemic stroke Subarachnoid hemorrhage Acute ischemic stroke Subarachnoid hemorrhage Immediately Accept Policy was used for transfer of 58 patients to UCLA. Intracerebral hemorrhage Traumatic brain injury Intracerebral hemorrhage Traumatic brain injury Other Other

Early mobility initiative

A new multidisciplinary early mobility initiative is being launched, encouraging safe mobility as tolerated by each patient. It involves utilizing specialized equipment to maximize mobilization even in patients that may have profound neurological impairments.

In the Last 6 Months, the Percentage of Elective Adult Cranial Neurosurgery Patients Passing all Early Mobility Goals has Doubled, Reaching 60%

100% 90% 80% 70% 60% 50% 40% Percent Passed Percent 30% 20% 10% 0% .1-9 .10-19 20-29 30-39 40-49 50-59 60-69 70-76 Weeks Post Implementation of NERVS Care Redesign

Goal 1 Goal 2 Goal 3 All Goals Goal 70%

Goal 1: Sit upright at bedside for 5 minutes, by 10pm POD0 Goal 2: Walk 5 feet to chair & sit in chair for 5 minutes, by 9am POD1 Goal 3: Ambulate 50 feet with RN assistance, by 12pm POD1

Source: manual chart extraction 21 comprehensive neurosurgery care redesign IN June 2014 NEUROSURGERY began the implementation of redesigned care for the top 4 care items: The Department of Neurosurgery is leading a  Communication between care providers comprehensive care redesign initiative called  Pain management NERVS (Neurosurgery Enhanced Recovery  Patient education after surgery, Value, and Safety)  Physical exercise and mobilization

key to continuous high performance in delivering redesigned care included:

 Support by leadership that the redesigned care is the standard of care for neurosurgical patients  Real-time auditing by NERVS nurses enabling identification of goals of care that need completion by a specific time to keep patient on track to early recovery  Bimonthly data review by the core NERVS team, making sure performances are circled back to the various care providers, celebrating successes, and reviewing circumstances having prevented completion of goals  Continuous education to assure various elements of the redesigned care are performed per protocol: huddles, bathroom literature, NERVS dashboard in 6ICU and 6N, etc.

Patient education We engage patients early-on regarding their recovery, informing them before and during their hospitalization what to expect after surgery. Standardized discharge information is now provided early on, preparing patients and families for their return home.

We Aim to Have 90% of NERVS Patients Satisfy Their Education Goals on Time - Wherever They Are! (PACU, ICU, Floor) 100% 100% 100% 90% 90% 90% 80% 80% 80% 70% 70% 70% 60% 60% 60% 50%50% 50% 40%40% 40% Percent Passed Percent 30%30% 30% Percent Given on TimeonGivenPercent 20%TimeonGivenPercent 20% 20% 10%10% 10% 0%0% 0% 1 31 53 157 379 1159 11137 13159 111517 131719 151921 172123 192325 212527 232729 252931 273134 293436 313638 343840 364042 384244 404446 4246484448504650524852545054565256585458605660625862646064666266686468706670726872747074767276787478 76 78 WeeksWeekWeeks Post Post Implementation Implementation Post Implementation of of NERVS NERVS of CareNERVS Care Redesign Redesign Care Redesign

Goal 1 Goal 1Goal Goal1 Goal2 2Goal 2 GoalGoal 33Goal 3 Goal 90%Goal 70%90%

Goal 1: Patient received education related to POD0 Road to Recovery on POD0 Goal 2: Patient received education related to POD1 Road to Recovery and POD1 Discharge information on POD1 Goal 3: Patient received education related to POD2 Road to Recovery and POD2 Discharge information on POD2 22 Sample of process improvements integrated in care delivery to improve pain experience

We strongly believe NERVS will be THE care redesign model of integrated optimal surgical care delivery throughout the patient’s entire episode of care.

Pain management When patients are involved in their pain assessment and management, their pain experience may be significantly improved. The table above highlights some of the process improvements coordinated across the continuum of care.

Early mobilization Before NERVS, post-operative mobilization was inconsistent and impossible to track. After implementation of the redesigned care process, more than 70 percent of our NERVS patients are mobilized early on, without any falls related to early ambulation.

We aim to have at least 70% of NERVS Patients Pass Their Mobilization Goals on Time - Wherever They Are! (PACU, ICU, Floor)

100% 90% 80% 70% 60% 50% 40%

Percent Passed Percent 30% 20% 10% 0% 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64 66 68 70 72 74 76 78 Week Post Implementation of NERVS Care Redesign

Goal 1 Goal 2 Goal 3 Goal 70%

Goal 1: Sit upright at bedside for 5 minutes, by 10pm POD0 Goal 2: Walk 5 feet to chair & sit in chair for 5 minutes, by 9am POD1 Goal 3: Ambulate 50 feet with RN assistance, by 12pm POD1

Special thanks to the NERVS multidisciplinary team for their dedication to the care redesign initiative and thank you to Mr. Richard Rodstein, Consultant in Quality, for his valuable guidance. 23 CGCAHPS* Survey - Calendar Year 2014 Patient 100% 90% SATISFACTION 80% 70% 60% 50% 40% 30%

Percent Positive Response Positive Percent 20% Percent Positive Response Positive Percent Patient satisfaction is a major component 10% 0% of improved value of delivered care, a Would you recommend this Quality of Patient-Doctor Rate this doctor doctor to your family and Interaction priority for the Department of Neurosurgery. friends?

UCLA RRUMC - Neurosurgery SMUCLA - Spine Patient satisfaction has been a pillar in the development of our redesigned care program termed NERVS (Neurosurgery HCAHPS* Survey, RRUMC-Neurosurgery, Fiscal Year 2015 Enhanced Recovery after surgery, Value, Question: Would you recommend this hospital to your friends and family?

and Safety: see pages 22 & 23), resulting 100% in improved performance regarding 90% 80% specific HCAHPS questions. 70% 60% 50%

Percentile 40% *Clinician and Group Consumer Assessment of Healthcare 30% Providers and Systems 20% *Hospital Consumer Assessment of Healthcare Providers and Systems 10% 0% Q3 2014 Q4 2014 Q1 2015 Q2 2015 Quarter 75th percentile = National Hospital Average

HCAHPS Patient Satisfaction is Improving following Implementation of NERVS Care Redesign

100%

90%

80% * 70%

60%

50% NERVS

40% Non NERVS Satisfaction Scores Satisfaction

30% *Statistically significant Percent Positive Response Positive Percent

20%

10%

0% Rate hospital Likelihood to Nurses explained Pain well controlled Told what medicine Talked about help Received info re: recommend things during stay was for you would need symptoms to look understandably during discharge for during discharge 24 NEUROSURgery Patient and family advisory council

The voice of our patients and their families is essential to the Department of Neurosurgery. The Neurosurgery Patient and Family Advisory Council (NPFAC) was launched in the spring of 2012 as an opportunity to facilitate collaboration between the Neurosurgery physicians, staff, patients and families. The NPFAC is co-chaired by Wendy Tucker, the wife of a former patient, and Steve Cohen, the Chief Administrative Officer for the department. It is composed of a number of former patients and family members (spouses and parents) treated for a variety of conditions as well as members of the Depart- ment of Neurosurgery, including several nurse practitioners and the Director of Quality Analytics.

The mission of the Neurosurgery PFAC is to create an active partnership based on mutual respect between physicians, nurses, staff, patients and families to enhance the patient and family experience

The NPFAC is one of the first PFACs formed within UCLA Health. Significant achievements in 2015 include:  Developing a Peer Support Program  Developing the patient-oriented UCLA Neurosurgery app  Evaluating a telemedicine pilot for post-operative clinical evaluations  Revising standardized pre-operative patient information packet as well as discharge education  Revising the Neurosurgery pre-operative video  Providing input to UCLA Department of Nursing application to renew Magnet Certification

Members of the Neurosurgery Patient and Family Advisory Council

25 Nursing Led initiatives

Since June 2014, the % of Handoffs with Joint Neuro Check LEGEND Shift Bedside handoff: (6ICU and 6N) has been constantly increasing

100% In 6ICU, it is the standard of care to 90% 80% 6ICU complete a shift bedside handoff. 70% 60% 50% 40% In 2014, 6N adopted the same 30% practice, integrating patients and 20% 6N 10% Percent Handoff with Neuro Check Neuro with Handoff Percent families into the healthcare team. 0% 2 5 8 11 14 17 20 23 26 29 32 36 39 42 45 48 51 54 57 60 63 66 69 72 75 Week Post Implementation of NERVS Care Redesign

% Handoffs with Joint Neuro Check Done Both

Cauti Reduction: Magnet Recognition: Successful reduction of the CAUTI rate from initiatives undertaken in the past year have successfully lowered the rate of CAUTI from RRUMC just received our 3rd magnet a baseline average rate of 3.92 in fiscal year 2014 to a current certification. Magnet Recognition is the average rate of 2.97 for fiscal year 2015. highest honor an organization can receive for nursing excellence and is the gold Neuro-ICU has been selected as a pilot unit to test two new peri- standard for professional nursing practice. care products with the potential to further reduction of CAUTIs.

Pain board/tolerable pain: In 2014, 6N nursing has developed a pain board to help empower patients regarding the management of their pain. Patients note their pain goal, medication name, and next dosage time.

Medication cards:

To help improve patients’ understanding concerning their medication, large print medication cards were designed, explaining the purpose of the medication and the potential .

26 OR to ICU direct Urban zen training: admission: In 2014-2015, nurses from 6N have 6ICU implemented a protocol for been trained in Urban Zen, a toolbox direct admissions/transfers from the of non-pharmaceutical techniques to operating room to the ICU. The protocol help anxious patients or those in pain includes a standardized handover tool decrease their perception of pain. and huddle between anesthesia, the Urban Zen relaxation techniques such surgeon, intensivist, and ICU nurse as aromatherapy oils have become a to ensure patient safety and flawless favorite among our patients. communication between providers.

RN engagement and satisfaction results: Neurosurgery nurses report great job satisfaction: The 6ICU outperforms the national Magnet benchmark in ALL of the 7 categories measured, and 6N outperforms the national benchmark in 5 of the 7 categories.

4.6

4.4

4.2

4 Average 3.8

3.6 Likert Scale 3.4

3.2

3 Adequacy of Autonomy Fundamentals of Interprofessional Leadersip access Professional RN to RN teamwork resources and quality nursing care relationsips and responsiveness development and collabortation staffing

6ICU 6N Magnet benchmark

Trauma to 6ICU Rapid trauma to ICU: Median ED TraumaArrival to to 6ICU ED Depart Time 1/2013Median-12/2013 ED Arrival toand ED 6/2014Depart Time-2/2015 In partnership with the Emergency 1/2013-12/2013 and 6/2014-2/2015 7.0 7.0 Department (ED), the 6ICU decreased 6.0 6.0 5.0 the amount of time trauma patients spend 5.0 4.0 in the ED through better communication, 4.0 3.0 admission orders being written earlier, and 3.0 Hours in Time 2.0 1.0 Time in Hours in Time 2.0 by having a bed on standby for emergency 0.0 patients. 1.0 0.0

27 RESIDENT Led initiatives

Assessing Value of Care of Intracerebral Hemorrhage Patients This project aimed to identify possible improvements in treatment algorithms to ultimately improve value of care for these critically ill patients. Patients were retrospectively identified using ICD-9 coding. Clinical data was collected via chart review. Cost data was provided by the Ronald Reagan Financial Services Department. The project is led collaboratively by the Department of Neurosurgery and the Department of Medicine Statistics Core. Daniel Hirt, MD

“These kind of analyses are crucial in the future, within a healthcare system that is in constant flux. Patient care should always be of the utmost importance, but value must be taken into account, especially when resources are being utilized without rendering any benefit to the patient’s care and outcome.”

Standardizing the discharge summary The standardization of the discharge summary is intended to assure complete and consistent communication between the patient’s surgical team and their outpatient physicians. The project included: 1) surveys of intern classes, residents, and nurse practitioners regarding current discharge summary practices; 2) review of essential content determined by various stakeholders (hospital, neurosurgeon, hospitalist, ); 3) elaboration of a standardized discharge summary template; 4) review by quality improvement staff; 5) hardwiring of the template in the ; 6) implementation. Jos’lyn Woodard, MD

“Creating communication tools, decision-making tools, and transparent assessment of our interventions will be the intended focus of my clinical research over the next few years. This project reinforced the need for such aims.”

Improving care processes by examining adverse events in a tertiary neurosurgical department

This project’s goal was three-tiered: 1) improve documentation of adverse events (readmissions, reoperations, morbidity and mortality); 2) document the discussion held after each event; 3) elaborate action plans to prevent further incidents. Every week adverse events were compiled electronically and the list was updated by the chief

resident. Discussions with the residents, faculty, and the chairman were documented as well as Matthew Garrett, MD quality improvement propositions.

“I learned that attempting to identify weaknesses or possible improvements in the neurosurgery care process is challenging in the single center setting as adverse events were too varied and too infrequent. If I were to attempt this project again I would look into compiling data from a consortium of large volume centers.”

28 technology and Quality improvements

Information technology is the cornerstone to the optimization of care delivery effectiveness UCLA Neurosurgery App The UCLA Department of Neurosurgery strives to innovate in the field of healthcare informatics through several endeavors, including the In 2015, the Department of Neurosurgery design of hardware and software for mobile technologies. developed a patient-oriented app. The neurosurgery app provides our patients and their family members with a step-by-step education on the surgical process as well as reminders of how to prepare for surgery at different intervals leading up to the surgical date. The app also includes information on the care team, medical conditions, and hospital and area amenities.

Surgical Navigation Platform Since April 2014, the Department of Neurosurgery has implemented the use of a Surgical Navigation Advanced Platform (SNAP) for complex vascular and tumoral cases. The SNAP intra-operative guidance is connected to the BrainLAB navigation system and provides advanced imaging capabilities including detailed modeling and 3D virtual reality image manipulation. The SNAP enhances neurosurgeons’ preoperative consultations with patients, planning of complex surgical procedures, and navigational aid during surgery to improve treatment and outcomes.

Telehealth Patient visits In 2015, the Department of Neurosurgery has continued its pursuit of innovation by making visits available to patients. Telehealth visits enable patients and providers to take part in face- to-face video session within the comfort of their home or office, preventing long waits and decreasing potential financial burdens. Currently, telehealth visits are offered to pilot patients for their two week post-operative visits and post-operative wound checks.

29 Dashboards

The UCLA Department of Neurosurgery is at the forefront of data-driven value-based initiatives, leading the future of the digital and interactive dashboards, their utilization, and integration in daily care

NERVS Care Redesign Dashboard Over 150 metrics are collected automatically, reviewed bi-monthly by the NERVS core redesign team, and shared with the front line providers. Access to these data and real-time feedback to the clinical staff has been essential to the success of the initiative.

Data Components Included in the NERVS Care Redesign Dashboard Goal Measures Intermediate Outcomes Process measures Discharge home Mobilization goals Bedside swallow exam before 6am POD1 LOS IV pain med administered after 8am POD1 PT order on or before 9am POD1 Cost for surgical care admission before end of POD1 Foley removed by 7am POD1 Moderate or Severe Pain before end of POD5 Patient education POD0, POD1, POD2 Assessment of tolerable pain

Extract of the NERVS Care Redesign Dashboard

Care coordination Dashboard Over 100 metrics are collected for the dashboard and reviewed monthly by Neurosurgery administrative and clinical staff. Data in the dashboard allows staff to measure, track and maintain quality of care. Monthly review of the dashboard also provides time to both celebrate successes and identify and troubleshoot areas needing improvement.

Data Components of the NERVS Care COORDINAtion Dashboard

30 EXTRACT OF THE Care COORDINAtion Dashboard

PROGRAM SPECIFIC Dashboard Over the past year, the Neurosurgery Department has been developing dashboards for each clinical program. These dashboards use innovative methods such as natural language processing of providers’ notes in addition to CPT and ICD9/ICD10 codes to precisely identify the correct patient populations for each dashboard. This allows program directors to have unique access to data specific to their subspecialty, including process and outcome measures developed specially for their patient population. These dashboards can also be used to target and track improvement initiatives particular to their program.

Extract of the MIcrovascular compression Syndrome PROGRAM Dashboard

Extract of the stroke PROGRAM Dashboard

31 Value Academics

Selected Recent Publications :

Buchanan C, Hernandez E, Anderson Analysis J, et al. of 30-­‐day readmissions in neurosurgical patients: surgical complication avoidance is key to quality . improvement J Neurosurg. 2014 Jul;121(1):170-­‐5. 1. McLaughlin N, Rodstein J, Burke MA, Demystifying Martin NA. process mapping: A key step in neurosurgical quality improvement initiatives. Neurosurgery. 2014 Aug;75(2):99-­‐109; discussion 109 2. McLaughlin N, Upadhyaya P, Buxey Value F, Martin NA. -­‐based neurosurgery: measuring and reducing the cost of microvascular decompression surgery. J Neurosurg . 2014 Sep;121(3):700-­‐8. 3. McLaughlin N, Burke MA, Setlur NP, et al. Time-­‐driven activity based costing: A driver for provider engagement in cost containment initiatives and -­‐ value based redesign. Neurosurg Focus. 2014 Nov;37(5):E3. 4. McLaughlin N, Martin NA, Upadhyaya P, Assessing et al. the cost of contemporary pituitary care. Neurosurg Focus. 2014 Nov;37(5):E7. 5. McLaughlin N, Khalessi AA, Martin H NA. ealth care economics in neurosurgery: There is no turning back. Neurosurg Focus. 2014 Nov;37(5):Introduction. 6. McLaughlin N, Ong, M, et Tabbush V, al. Contemporary healthcare e conomics: An overview. Neurosurg Focus. 2014 Nov;37(5):E2. 7. Fallah A. Time to rethink postoperative outcomes for curative resective . Epilepsy Behav. 2014 Dec;6(41):53-­‐54. 8. Kaplan AL, Agarwal Setlur N, NP, et . al Measuring the cost of care in benign prostatic -­‐ hyperplasia using time driven activity-­‐based costing (TDABC). Healthc (Amst). 2015 -­‐ Mar;3(1):43 8. 9. McLaughlin N, Garrett MC, et Emami L, . al Integrating risk management data in quality improvement initiatives within an academic n eurosurgery department. J Neurosurg. 2015 Jul -­‐ 31:1 8. [Epub ahead of print] 10. McLaughlin N, Jin P, Martin NA. Assessing early unplanned reoperations in neurosurgery: Opportunities for quality improvement. J Neurosurg. 2015 Jul;123(1):198-­‐205. 11. Fallah A. Moving beyond vidence e -­‐based m edicine: Incorporating patient values and preferences. Epilepsy Behav. 2015 Nov. pii: S1525-­‐5050(15)00566-­‐1. 12. Presentations: Oral: 15 total – including 81th AANS (2013); CNS (2013); 25th Annual National Forum on Quality Improvement in – IHI (2013); UHC (2013); CANS (2013; 2014), NASBS (2014); CFNS (2014); CNS (2014); AANS (2014), Pituitary Centers of Excellence Conference 015) (2

Grants:

University of California Center for Health Quality and Innovation Quality Enterprise Risk Management (CHQIQERM); Delivering Value-­‐Based Neurosurgery: The Neurosurgery Enhanced Recovery, Value, and 1. Safety (NERVS) protocol; $250,000 over three years; 08/2013 – present

University of University of California Structured Redesign to -­‐ Achieve Value Based Care; $50,000/year for 3 years; 2014 – present 2. University of California Center for Health Quality and Innovation Quality Enterprise Management (CHQIQERM); UC Care Check: A standardized multidisciplinary approach to improve neurosurgical patient 3. outcomes and care experiences; -­‐ Five site collaborative; $1.25 million over three years; 08/3013 – present

32 NEUROSURGERY

For more information on the Neurosurgery Clinical Quality and Value Program, please contact:

Nancy McLaughlin, MD, PhD, frcsc Assistant Clinical Professor, Neurosurgery [email protected] or Neil A. Martin, MD Professor and W. Eugene Stern Chair in Neurosurgery [email protected]

The Department of Neurosurgery would like to acknowledge the support of the University of California Center for Health Quality, UCLA Health, and the David Geffen School of Medicine. We are particularly grateful for the essential and generous support provided by Ann and Jerry Moss.