Quality and Safety
The University of Minnesota Department of Neurosurgery established the Quality and Safety Program in 2014 as part of its Vision 2033 plan. Our overarching vision states:
Neurosurgery patients in Minnesota receive the safest and best care in the nation. The University of Minnesota is a destination for comprehensive, collaborative, patient-centered care of the most complex neurosurgical diseases. Through research and education, we lead the discovery of new neurosurgical knowledge and improvement of patient care throughout the world.
As stated, safe high-quality clinical care provides the foundation for our vision and we are committed to developing a neurosurgical program that will pave the way in quality and safety for neurosurgical patients in Minnesota.
The University of Minnesota Department of Neurosurgery Quality and Safety Team involves a group of neurosurgery faculty, residents, nurses, and staff, working closely with the University of Minnesota Quality Department to achieve the highest standard of quality and safety. We use metrics to drive improvement and track progress. For many quality markers, we have aligned ourselves with our parent institutional goals of excellence in execution, implementation and outcomes. For example, our three-year goal in leading the nation in performance on mortality and readmissions includes achieving 50thpercentile in the first year, 75th percentile in the second year, and 90th percentile in the third year.
To track our progress, we have carefully chosen key quantifiable metrics that we feel are markers of quality and safety. Data chosen are those thought to be most clinically relevant, that are accurate and from a reliable source, and which are collected in an identical manner from neurosurgical departments at comparable academic institutions. These metrics are carefully measured monthly from our University of Minnesota Hospitals, as well as comparably from the top 33 academic neurosurgical programs in the nation. We use the most accurate and powerful available databases, including University HealthSystem Consortium (UHC) and Crimson™. UHC provides a scoring and ranking model for academic medical centers (UHC scorecard), while Crimson is a provider of specific quality, safety and efficiency measures.
Each month, we compare and benchmark ourselves to these top academic neurosurgical programs by presenting and critically scrutinizing the data in our monthly three-hour Neurosurgery Quality and Safety Update conference. During this meeting, which includes neurosurgical faculty, residents and students, we review many dashboards showing where we stand compared to other top programs, discuss pertinent problem areas in detail, and formulate plans to improve our metrics. We also review relevant morbidity and mortality cases from the prior month from our four major hospitals — University of Minnesota Medical Center, Hennepin County Medical Center, University of Minnesota Masonic Children’s Hospital, and the Minneapolis Veterans Affairs Medical Center. Our residents take turns presenting and updating the group as part of their Resident Quality Improvement Education.
We are also part of the NeuroPoint Alliance Quality Outcomes Database (QOD), formerly known as the National Neurosurgery Quality and Outcomes Database (N2QOD). QOD serves as a continuous national clinical registry for neurosurgical procedures and practice patterns. Its primary purpose is to track quality of surgical care for the most common neurosurgical procedures, as well as provide practice groups and hospitals with an immediate infrastructure for analyzing and reporting the quality of their neurosurgical care.
Our areas of quality improvement focus are based on several factors, including:
- Our standing compared to national standards
- Clinical impact for our patient population
- Improvements that are in alignment with our institution
- Areas for which we have a reliable method to measure, track progress, and compare to other institutions
- Measures that can improve our hospital grading and ranking.
Our Quality and Safety program continues to grow and expand. If you have any questions, please contact Daniel Guillaume, MS, MD, at firstname.lastname@example.org.
Current Quality & Safety Projects
- Lowering our mortality Index: the Mortality index is the observed-to-expected (O/E) mortality ratio based on a complex formula. A ratio of <1.0 equals a better than expected performance, whereas a >1.0 ratio is worse than expected. Our goal is to achieve the top decile (90th percentile) within three years.
- Reducing readmissions: one third of the roughly two billion dollars spent on health care in the United States is associated with hospital readmissions. While in a majority of these cases hospitalizations are necessary, there is a fraction where readmissions could and should be avoided. Readmission reduction tactics include: medication management, care coordination and transitions in care via development of clear communication pathways between inpatient and outpatient care coordinators and ensuring that post discharge calls and appointments are completed, identifying patients who require a higher level of care coordination, development of real time reporting and tools to support communication between the ED and inpatient areas.
- Using neurosurgical simulation for education and research: this program uses a virtual reality neurosurgical simulator for resident education and research. A curriculum has been developed that requires residents to complete and master several modules over the course of two years. Several research projects are also based on this simulator.
- External ventricular drain (EVD) placement accuracy: this project has two key parts: (1) Preventing Infections in External Ventricular Drains (EVDs) is a comprehensive, evidence-based program aimed to minimize risk of infection from EVDs. The program has been expanded to include other institutions and create a national consortium; and (2) Accuracy of EVD placement is a program aimed to assess the need for improvement in the placement of external ventricular drains at the bedside through a rigorous treatment of the evidence and understanding for improvements in grading systems. A new grading system is being proposed that integrates feedback, and a novel method of placement is being developed.
- Improving discharge instructions: this project is directed at streamlining and standardizing discharge instructions for patients at the University Hospital. This was done to minimize variability on what patients were told at the time of discharge regarding their care, and restrictions after leaving the hospital.
- Quality and Safety Dashboard refinement: the Quality and Safety dashboard is currently being improved in a way that will allow us to dive deeper into problematic areas, which are addressed in our conference and potential interventions are discussed.
- Reducing length of stay: we are working to improve length of stay through a series of interventions that include improved patient education, earlier discharge planning and other enhancements.
- Streamlining operating room setup: this project focuses on setting operating rooms for procedures in a timely fashion. The project aims to develop an automated tool to assist operating room staff to identify and set-up operating room equipment needed for specific surgeries. The project prototype with focus on specific neurosurgical procedures and will then be expanded to other surgical specialties and hospitals.
- Reducing surgical site infections: the Infection Prevention Program makes use of protocols and check lists, and collaboration with the Infection Control Department to identify and implement procedures which lower infection rates.