QUALITY PROGRAM UPDATES

WELCOME

In July 2022, we welcomed Monique Trinh as Quality Program Project Manager. Monique is an extremely engaged team member with strong analytic, project management and people skills. She is also currently enrolled at the UCLA Fielding School of Public Health, where she is pursuing her Master of Healthcare Administration (expected to graduate June 2023). Since joining us, Monique has been instrumental in advancing QI project management throughout the department.

I am so delighted by the great strides we have taken in our quality activities over the past two years! I would like to thank and recognize our leaders who have worked tirelessly on expanding our activities and on improving the quality of our quality program:

Dr. Michelle Hickey, Director, Pathology and Laboratory Medicine Quality Improvement Program & Chair of the Quality Leadership Committee

Dr. Yuna Kang, Chair of the Quality Culture/Education/Resident Projects Committee

Dr. Alyssa Ziman, Co-Chair of the Quality Utilization and Improvement Committee

Alexander Martin, PA(ASCP), MHA, Co-Chair of the Quality Utilization and Improvement Committee

2023 QUALITY IMPROVEMENT DAY AND DALJIT S. AND ELAINE SARKARIA KEYNOTE LECTURE ON QUALITY IMPROVEMENT

Please join us for the 2023 Quality Improvement Day and Daljit S. and Elaine Sarkaria Keynote Lecture on Quality Improvement, which will be hosted virtually via Zoom from 8 a.m. to 1 p.m. on 2/10/2023. Our keynote speaker is Kate Hilton from the Institute for Healthcare Improvement. Quality Improvement Day will also feature DGSOM faculty, DGSOM trainees, and other clinicians. Detailed information about the agenda and speakers can be found on the website we created for the program. If you can join, please register here.

PATHOLOGY – HUB OF THE HOSPITAL

This year, we had a goal to broaden our QI footprint and partner with other Health System QI teams to improve diagnostics, operations and patient safety. Therefore, we added a new committee to our QI Program structure - the Quality Leadership Committee (QLC). The QLC was established to identify cross-departmental projects in alignment with UCLA Health, FPG, and DGSOM quality goals. In essence, Pathology and Laboratory Medicine is the hub of the hospital as samples from almost every patient seen in the hospital pass through the laboratory.

Since the specimens received are from patients from every clinical department, we think it’s important to partner with other clinical departments in quality improvement efforts. Thus, our strategic pillars at large are to:

• Increase partnerships with key stakeholders systemwide.
• Transcend silos and foster interdisciplinary collaboration through continuous quality improvement.
• Strengthen internal operations with refinement & alignment.
• Optimize efficiencies (patient safety, operations and workflow improvements, or increase cost-savings).

CURRENT PROJECTS

We have identified four projects to support this fiscal year:

1. Develop test order pathways for the first diagnosis of multiple sclerosis

This project is led by Dr. Michelle Hickey (Immunogenetics) and Dr. Melle Reider-Demer (Neurology). The project team consists of Dr. Michelle Hickey (Immunogenetics), Dr. Melle Reider-Demer (Neurology), and Dr. Kevin Patel (Neurology). Together, they are working to develop standard test order pathways for the first diagnosis of Multiple Sclerosis. The project endeavors to enhance patient safety and quality, improve access to care, and ensure financial sustainability. The Department is providing project management and data analysis support to achieve the following goals:

• (a) Retrospective review of test/scan utilization in first diagnosis of MS to create test ordering pathway.
• (b) Work with key stakeholders to refine test ordering pathway and create an educational process for training faculty/staff/trainees.
• (c) Evaluate impact.

2. Improving discrete reporting of clinical/diagnostic data for transplant patients

This project is led by Dr. Michelle Hickey (Immunogenetics). The project team consists of Dr. Michelle Hickey (Immunogenetics), Dr. John Zuckerman (AP), Dr. Jitin Makker (AP), and Dr. Erik Lum (Nephrology). Together, they are developing a dashboard to efficiently synthesize and analyze quality assessment information. The project endeavors to enhance patient safety and quality. The Department is providing project management and informatics support to achieve the following goals:

• (a) Improve clinical ordering of appropriate serum testing at the time of renal biopsy (to comply with current national guidelines).
• (b) Create a Tableau dashboard of data for patient management and QA needs.

3. Increase blood culture fill volumes

This project is led by Dr. Omai Garner (LM) and Allison Nomura (LM). The project team consists of Jennifer Zhang and Jonathan Aquino. Together, they are working to develop methodologies to increase blood fill volumes, increasing the accuracy of sepsis diagnosis. The project endeavors to enhance patient safety and quality, improve access to care, and ensure financial sustainability. The Department is championing the project with leadership, providing financial support for additional staffing for additional data collection, project management, and informatics support to achieve the following goals:

• (a) Improve data collection to improve data from our middleware.
• (b) Interventions – a. physically mark blood collection bottles with “fill line”; b. targeted education to providers who are consistently collecting low blood volumes.
• (c) Education – general education and onboarding education.
• (d) Consistent, constant feedback to providers regarding the blood volumes they are collecting.

4. Reference lab optimizations 

This project is led by William Werre (LM), Alex Martin (AP), Marivic Visico, Dr. Josh Deignan (AP), and Dr. Alyssa Ziman (LM). The project team consists of the Lab Stewardship Task Force, Lab Support Services Management Team, and Dr. Eric Cheng (CMIO). Together, they are working to streamline the development of built tests to enhance ordering practices for reference laboratories. The project endeavors to enhance patient safety and quality and ensure financial sustainability. The Department is providing project management and informatics support to achieve the following goals:

• (a) Will create specific new test builds for ~150 tests, to create additional discrete data fields and to limit provider choices to approved non-UCLA reference labs. 
• (b) Create a Tableau dashboard to be able to monitor outside lab usage. 
• (c) Monitor data to determine if any testing should be brought in house, consolidated, or investigated further for appropriateness. 
• (d) Monitor impact of interventions (utilization of test builds versus Misc. Ref Lab orderable, TAT, troubleshooting/result management by send out staff, etc). 

UPDATES & EVENTS

Enhancements have been made to the submission processes for QLC and Q-CEP, as outlined above. From now on, submissions can be submitted via the links below:

• QLC Submission Portal
• Q-CEP Submission Portal