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Innovation Profile: Elizabeth Turner

An (ultra)sound decision.

Name: Elizabeth Turner
Title: UCLA director of bedside ultrasound, Division of Pulmonary and Critical Care Medicine; previously UC Irvine assistant professor of pulmonary and critical care, director of the medical intensive care unit and director of bedside ultrasound for the Department of Medicine
Education: M.D., M.S., Wake Forest University
Project: Implementation and assessment of a formal curriculum for bedside ultrasound training

Innovation Profile is a monthly feature highlighting the work of a UC Center for Health Quality and Innovation fellow or grantee.

By Alec Rosenberg

Ultrasound isn’t just for pregnant women. The portable device, best known for giving expectant parents a first glimpse of their babies, has spread to critical care. Dr. Elizabeth Turner is helping lead the charge.

Turner received a grant from the UC Center for Health Quality and Innovation to develop a curriculum for bedside ultrasound training. She began the project while at UC Irvine and now plans to expand her efforts at UCLA, where she just joined as director of bedside ultrasound in the Division of Pulmonary and Critical Care Medicine.

“This is quality improvement for patient care,” Turner said. “You can get the right therapy to the patient early. You can make the decision appropriately. Their outcomes are going to be better. There are direct cost savings. And patient satisfaction will improve if we can implement this as part of our practice.”

Bedside ultrasound involves portable ultrasound exams – which use sound waves to see inside the body – performed and interpreted by the physician at the point of care. Turner emphasizes that ultrasound is not meant to replace the work of cardiologists or radiologists. Instead, it’s about trying to identify quickly the appropriate test from the appropriate person.

“We’re not trying to take anyone’s business,” Turner said. “We’re just trying to give the business to the right person.”

A former ballet dancer, Turner got a late start in medicine, applying to medical school at age 25. With a dancer’s focus and dedication, she leapt forward as a physician, following medical school at Wake Forest University with a residency at UC San Francisco and a critical care fellowship at Stanford University, where she first received training in ultrasound.

A powerful tool

“It just made so much sense, especially in critical care where minutes make a big difference in a patient’s life,” Turner said. “I realized what a powerful tool it was and got excited about it.”

It’s estimated that every $1 spent on ultrasound saves $3 in patient care. For example, the typical legal settlement on a collapsed lung is about $150,000, but using ultrasound dramatically reduces the risk of a patient suffering that problem. “One lawsuit will pay for three ultrasound machines,” Turner said.

But standardized training in point-of-care ultrasonography is lacking. Enter Turner’s innovation center project.

She tested her training (which combined e-learning and hands-on supervision) on critical care and cardiology fellows at UC Irvine. It turned out to be a quick and efficient method – the fellows gained knowledge and confidence equal or superior to that of experts and apprentice-based learners. And they did so in less than four months, compared with other training pathways that can take two to four years.

Under Turner’s direction, UC Irvine increased its use of bedside ultrasound; a preliminary assessment of trends shows that length of stay in the intensive care unit has declined by approximately a day while patient satisfaction has improved. “They like that the doctors are hands on,” Turner said. “Hands on means we’re at the bedside scanning them.”

Here to stay

Turner now is working to expand bedside ultrasound at UCLA and hopes to scale up training to spread its use across UC. Also, she has had abstracts about the project accepted to two national conventions.

“The national societies feel this is a relevant topic,” Turner said. “Bedside ultrasound is here to stay. We need to do it properly.”

For example, one afternoon, Turner gave a team of UC Irvine residents an hourlong training session on using bedside ultrasound to look at the heart. That night, one of those residents used the machine to examine a patient with low blood pressure and found a huge sac of fluid around the heart. “If he hadn’t picked that up, the patient could have died,” Turner said. “That was after a one-hour lesson. Imagine what you could do after an organized program.”

Related links:

View Elizabeth Turner’s talk at the UC Center for Health Quality and Innovation colloquium

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Innovation Profile: Rebecca Smith-Bindman

Setting the standard.

Name: Rebecca Smith-Bindman
Title: UC San Francisco professor in the departments of radiology and biomedical imaging, epidemiology and biostatistics, and obstetrics, gynecology and reproductive sciences
Education: M.D., UC San Francisco
Project: Standardization and Optimization of Computed Tomography Patient Radiation Dose Across the University of California Medical Centers (UC DOSE)

Innovation Profile is a monthly feature highlighting the work of a UC Center for Health Quality and Innovation fellow or grantee.

By Alec Rosenberg

When you take a pill, you know what dose to take. But when you get a CT scan do you know how much radiation you are supposed to receive?

Chances are you don’t, and neither does your doctor.

UC San Francisco professor of radiology and biomedical imaging Rebecca Smith-Bindman hopes to change that.

She leads a project funded by the UC Center for Health Quality and Innovation to standardize and optimize computed tomography radiation doses for patients across UC medical centers.

Computed tomography (CT) exams have become increasingly common, quadrupling nationwide between 1994 and 2007. About 1 in 5 patients receives a CT scan each year. While an important medical advance, CT exams also deliver much more radiation than conventional X-rays. It’s estimated that 2 percent of cancers may be caused by CT radiation exposure. And without standards for CT radiation amounts, Smith-Bindman has found that doses vary widely.

“The doses are way higher than they need to be,” she said.

A critical eye

Smith-Bindman nurtured her critical eye on exams early in her career. After studying architecture and structural engineering at Princeton University, she conducted osteoporosis research at UCSF, but realized the test she was using to measure backbones and osteoporosis didn’t work well. “It was like flipping a coin in terms of accuracy,” she said. So she developed a better way of defining osteoporosis, a better test.

After attending medical school at UCSF and becoming a doctor, she realized how many tests patients were receiving. Excessive testing can cause multiple problems such as high-dose radiation exposure, false positives that lead to further testing and overdiagnosis that leads to unnecessary treatment. There’s also an emotional toll – something Smith-Bindman witnessed with a sister who died of a brain tumor. Before her sister would take a test, “the amount of anxiety was indescribable,” she said. And it’s costly: Medical imaging is a $100 billion-a-year business in the United States.

Smith-Bindman’s innovation center project seeks to standardize and reduce the doses used for CT at UC medical centers. The amount of radiation is affected by how often an area is scanned and the size of the area scanned. Evidence suggests the radiation dose from each CT scan could be reduced by 50 percent or more without reducing diagnostic accuracy. UCSF has successfully lowered its CT doses by 40 percent in the past two years, Smith-Bindman said, improving patient safety and the quality of care.

Smith-Bindman’s grant has enabled her to work with colleagues across UC to make a bigger impact.

“It’s really worthwhile,” Smith-Bindman said. “We have amazing faculty across UC medical centers and this grant has allowed us to take the time to collaborate and bring together our expertise.”

The group created a single server where all systemwide CT dose data can be collected and analyzed. It’s already helping UC comply with SB 1237, California’s first-in-the-nation requirement to report radiation doses.

Spreading the word

The project also could help set benchmarks and standards for others to follow. “Our plan is to make what we learn from this collaboration widely available outside the UCs,” Smith-Bindman said.

Smith-Bindman and her UC colleagues are organizing a large virtual symposium in May to help educate the public, referring physicians, technologists, physicists and radiologists across the country on strategies for assessing and then lowering the radiation doses to which patients are exposed. As part of this meeting, facilities will be able to upload their actual CT data and receive audits of how they are doing with respect to the doses they are using for CT.

“CT scanning overall has more benefit than harm, and in the right clinical settings can improve health care quality and patient outcomes,” Smith-Bindman said, noting that her project focuses on reducing the potential harm from radiation. “The goal of my work is not to make people afraid of imaging, but to raise awareness that everything we do in health care has risks and benefits, and to help reduce the risks by lowering the doses used. Whenever a test is ordered, you need to ask yourself and your doctor, ‘Do I really need this?’ If the answer is yes, then the risk is small and shouldn’t dissuade you from necessary imaging.”

Related links:

View Rebecca Smith-Bindman’s talk at the UC Center for Health Quality and Innovation colloquium

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Innovation Profile: Lisa Gibbs

Standing up for senior health.

Name: Lisa Gibbs
Title: UC Irvine clinical professor of family medicine, associate director of the Program in Geriatrics, medical director of the SeniorHealth Center
Education:  M.D., Stanford University
Project: Transformation of the Primary Care Practice to the Patient-Centered Medical Home Model

Innovation Profile is a monthly feature highlighting the work of a UC Center for Health Quality and Innovation  fellow or grantee.

By Alec Rosenberg

It’s not easy growing old. The golden years can be challenged by a myriad of conditions such as arthritis, heart disease and memory loss that often overlap and are increasingly costly to treat.

UC Irvine’s Dr. Lisa Gibbs has seen the toll that time can take on the health of older adults and their caregivers – and she has dedicated her career to improving geriatric care.

Gibbs became interested in working with older adults during medical school at Stanford, where she became involved in research on Alzheimer’s disease. She nurtured that interest at UC Davis, where she completed her residency in family medicine and then a fellowship in geriatric medicine. “I realized how vulnerable this population is,” Gibbs said.

She pointed to a couple married for 50 years. The wife had dementia, but then her caregiver husband developed prostate cancer. “His care was probably delayed because he was so focused on caring for her,” Gibbs said. “Caregivers also need our care and attention.”

Gibbs leads a team dedicated to providing the best in geriatric care as medical director of the UC Irvine SeniorHealth Center and clinical professor for the Program in Geriatrics. She was granted a UC Center for Health Quality and Innovation fellowship to enhance that care by turning the center into the UC system’s first patient-centered medical home (PCMH) for seniors.

A patient-centered medical home is a physician-led team approach to providing comprehensive primary care. Unlike traditional primary care, the PCMH model proactively manages all levels of care for an entire patient population, rather than focusing only on patients when they seek care for illness or injury.

“We’re hoping that with an interdisciplinary team approach and improved care coordination that we’ll be able to increase the quality of care, improve patient satisfaction and reduce overall health care costs,” Gibbs said.

The SeniorHealth Center already places the patient and family at the center of care, coordinating in teams with geriatricians, psychologists, pharmacists, nurses and social workers, Gibbs said. The fellowship will help lead the center to enhance its services by adding key features:

  • Open access to care, leaving time slots available for same-day appointments. “This should reduce visits to the emergency room,” Gibbs said. “Patients will be able to be seen right away by physicians who know them instead of going to urgent or emergency room care.”
  • Electronic medical records to help track patient outcomes and population data.
  • Self-care support and resources.
  • Care management, including individualized care plans.
  • Referral tracking and follow up.
  • Continuous quality improvement.

UC Irvine plans to apply next year for National Committee for Quality Assurance certification as a patient-centered medical home. Then educators will develop related curriculum for medical students, residents and fellows to learn how to optimally care for older adults and share its findings throughout UC Health.

“UC is a leader in developing innovations,” Gibbs said. “We’re willing to look at different models and newly developed models of health care because we truly do care about delivering the best care and service.”

View Lisa Gibbs’ talk at the UC Center for Health Quality and Innovation colloquium (begins at 8:46)

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Innovation Profile: Ulfat Shaikh

Improving quality on the front lines.

Name: Ulfat Shaikh
Title: UC Davis associate professor of pediatrics
Education: M.D., Goa Medical College, India; M.P.H., University of Medicine and Dentistry of New Jersey; M.S., UC Davis
Project: Integrating Patient Care and Health Professions Education to Improve Care Transitions: The UC Health Quality Improvement Network

Innovation Profile is a monthly feature highlighting the work of a UC Center for Health Quality and Innovation fellow or grantee.

By Alec Rosenberg

How do you get better health outcomes? It’s a question that drives Ulfat Shaikh, UC Davis associate professor of pediatrics.

While working at a telemedicine obesity clinic when she first arrived at UC Davis seven years ago, she had success in treating childhood obesity at rural California clinics but couldn’t keep up with demand. With 30 percent of kids in the state overweight or obese, she wanted to have a bigger impact.

Her solution: Take a systemwide approach.

Shaikh received a career development award from the federal Agency for Healthcare Research and Quality three years ago. The award enabled her to design and study a quality improvement network of rural clinics in California. She wanted to see if clinics could work together to improve preventive care for childhood obesity and get children to eat better and exercise more. Energized by the success of this learning network, she reached out to colleagues at other UC campuses to brainstorm how to apply the concept across UC’s academic medical centers.

So when the UC Center for Health Quality and Innovation issued its first request for proposals last year, “we were ready,” Shaikh said. She received an innovation center grant to develop the infrastructure for a UC Health Quality Improvement Network involving medical residents. The aim of the systemwide network is to improve transitions of care during hospital discharges for adult and pediatric patients.

By improving communication at discharge, Shaikh hopes to reduce readmissions. Almost 20 percent of Medicare patients are readmitted to the hospital within 30 days of discharge, with Medicare spending $12 billion annually on potentially preventable readmissions.

The twist is involving medical residents, who receive supervised, hands-on training in clinical specialties such as pediatrics or surgery at teaching hospitals like UC academic medical centers. Residents serve on the front lines, playing a key role in the discharge process – and as potential leaders.

“We could multiply our quality improvement workforce by thousands,” Shaikh said. “Residents are seeing this as a critical area to be trained in. They have unique insights into system problems.”

Shaikh doesn’t have to start from scratch. UC medical centers already have launched quality improvement efforts. Shaikh and co-investigators Alpesh Amin of UC Irvine, Nasim Afsarmanesh of UCLA, Brian Clay of UC San Diego and Sumant Ranji of UC San Francisco will build on those efforts to create a common curriculum to train physicians in quality improvement.

The project also will lead to a discharge toolkit for pediatrics that will be used nationally and will set the ground for future quality improvement educational efforts aligned with UC Health priorities.

“We have this untapped network of colleagues,” Shaikh said. “It’s exciting.”

Related links:

View Ulfat Shaikh’s talk at the UC Center for Health Quality and Innovation colloquium

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Innovation Profile: Daniel Uslan

Resistance isn’t futile for this infection fighter.

Name: Daniel Uslan
Title: UCLA assistant clinical professor of infectious diseases, director of the Antimicrobial Stewardship Program
Education: M.D., University of Southern California; M.S., Northwestern University; B.S., UC San Diego
Project: Development of a UC-wide Antimicrobial Stewardship Program: Benchmarking and Beyond

Innovation Profile is a monthly feature highlighting the work of a UC Center for Health Quality and Innovation fellow or grantee.

By Alec Rosenberg

Daniel Uslan has cultivated his curiosity about the big impacts of tiny bugs into a career as an infection fighter.

Uslan, a UCLA assistant clinical professor of infectious diseases, was smitten by science at an early age. At 5, he made sourdough bread in a class with his father in Los Angeles called “It’s a Small World.” “I was so fascinated by these microscopic bugs being able to create food,” Uslan said.

That fascination led Uslan into the field of medicine, where he has focused on fighting the improper use of antibiotics in treating infections. Up to half of antibiotic use is inappropriate or unnecessary, he said. The consequences are steep: Antibiotic-resistant infections cost the U.S. health care system more than $20 billion a year, with problems including a dramatic rise in potentially deadly drug-resistant bacteria such as MRSA.

“Overuse or misuse of antibiotics leads directly to patient harm. It leads directly to bacterial resistance,” Uslan said. “We are really at a crisis right now. We are now seeing bacteria for which we have no effective antibiotics.”

Uslan, who joined UCLA in 2007, has worked to improve clinical outcomes of patients with infections. He directs UCLA’s Antimicrobial Stewardship Program, which has reduced antibiotic use 15 percent and saved more than $1 million over the past two years by focusing on giving the right antibiotic at the right dose for the right duration. Now Uslan is working to spread those efforts throughout the system: He received a UC Center for Health Quality and Innovation fellowship in December to explore development of a UC-wide antimicrobial stewardship program.

“These programs are absolutely essential. They provide value by increasing quality of care of patients with infections and by decreasing costs,” Uslan said.

Each UC medical center has an antimicrobial stewardship program in place, but they differ in how they are implemented. Uslan is analyzing what’s working and what could be changed. The goal is to provide substantial value. “We’re trying to learn from each other,” Uslan said. “By improving antibiotic use, you limit resistance. You limit antibiotic-associated toxicity. You improve patient outcomes. That’s sustainable.”

A successful program requires a lot of coordination, from infectious disease physicians and pharmacists to microbiologists, project managers and infection control professionals, Uslan said. Doctors have to be comfortable with someone looking over their shoulder while prescribing, he said.

While change can be uncomfortable, momentum is building to address the antibiotics issue. In 2010, California developed the only statewide antimicrobial stewardship initiative to promote appropriate antibiotic use in health care facilities. A UC-wide antimicrobial stewardship program could help set standards for other California hospitals to follow.

“The only solutions are for drug companies to develop new antibiotics or for physicians to use antibiotics appropriately,” Uslan said. “This is a really tremendous opportunity for UC to lead in the state of California. UC can be a model for the rest of the state.”

Related links:

View Daniel Uslan’s talk at the UC Center for Health Quality and Innovation colloquium (begins at 22:33)

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Innovation Profile: Wendy Anderson

Championing palliative care.

Name: Wendy Anderson
Title: UCSF assistant professor of medicine, clinician-investigator with the Division of Hospital Medicine and Palliative Care Program
Education: M.D., UC San Diego; M.S., University of Pittsburgh
Project: Nurse-initiated multidisciplinary patient- and family-centered communications in the ICU

Innovation Profile is a monthly feature highlighting the work of a UC Center for Health Quality and Innovation fellow or grantee.

By Alec Rosenberg

When patients find out they have a serious illness, it’s a stressful time for them and their families.

For Wendy Anderson, it’s also an inspiring time, an opportunity to build relationships with patients and their families and provide support. The UC San Francisco assistant professor of medicine is making a difference by expanding palliative care – specialized care for seriously ill patients focused on quality of life for patients and their families.

“Patients and their families have a huge need for good communication with their providers at this time,” Anderson said. “There are a lot of questions. You’re very worried about what’s happening. By giving clear information and emotional support, providers can help decrease stress.”

Anderson saw firsthand the importance of emotional support when she helped care for her grandfather while he received home hospice. “We accomplished what he wanted,” Anderson said. “That showed me the power of communication.” As a resident in the intensive care unit at Duke University Medical Center, she gained more perspective on issues involving care for patients with serious illness. “I saw the power of achieving patient and family goals as opposed to our goals as providers,” she said.

Palliative care is effective for any age or stage of serious illness, from cancer to kidney failure. Research shows it improves quality of life for families and helps ensure patients get the type of care they want.

“Do they want to be looking out their bedroom window?” Anderson said. “Do they want to try an experimental therapy, even if it has high risks?”

Each of the five UC medical centers has a palliative care team. UCSF also has trained more than 180 teams of doctors, nurses, chaplains and social workers nationally to care for seriously ill patients and their families. But access to palliative care often is limited, particularly in the ICU, where terminal stays account for significant costs to the health care system.

Anderson received a UC Center for Health Quality and Innovation fellowship to address that issue. Her project to train bedside nurses to provide palliative care in the ICU is expected to expand palliative care, increase training of palliative care providers, improve quality of care and decrease costs.

“Nurses really are patients’ closest bedside provider,” Anderson said. “If you don’t include nurses in quality improvement efforts, they won’t work very well.”

Palliative care can create an 8:1 return on investment – lowering costs to payers – by reducing unwanted care and decreasing length of stay in the ICU, all while increasing patient and family satisfaction. Anderson’s project aims to decrease length of stay in UCSF’s ICU by one to three days, which could reduce yearly expenses by more than $1 million. Also, she will analyze results of patients who receive Medicare coverage, helping to make the findings transferable to other hospitals.

“At UCSF, we have more than a decade of experience of understanding the impact of palliative care on patients, families, providers and payers,” Anderson said. “By building on that, using UCSF as a laboratory, that will demonstrate its benefits and teach us how it will be implemented at other institutions.”

View Wendy Anderson’s talk at the UC Center for Health Quality and Innovation colloquium (begins at 30 minutes)

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Innovation Profile: Greg Maynard

Stopping blood clots, saving lives.

Name: Greg Maynard
Title: Clinical professor of medicine in the Division of Hospital Medicine at UC San Diego; director of the UC San Diego Center for Innovation and Improvement Science
Education: M.D., University of Illinois; M.Sc., University of Michigan
Project: UC collaborative to reduce hospital-acquired venous thromboembolism: Stop the clot

Innovation Profile is a monthly feature highlighting the work of a UC Center for Health Quality and Innovation fellow or grantee.

By Alec Rosenberg

Greg Maynard is on the front lines of quality improvement. His target: stopping blood clots, a common, potentially fatal — and often preventable — problem.

Maynard is a hospitalist, a physician who specializes in caring for patients in the hospital.

When Maynard joined UC San Diego in 2003, he was one of its four hospitalists. Now there are nearly 40, and Maynard has become a national leader in the growing field. He is senior vice president of the Society for Hospital Medicine’s Center for Healthcare Innovation and Improvement. He and other UC hospitalists played a key role in the society winning the 2011 John M. Eisenberg Patient Safety and Quality Award for national efforts to increase patient safety, including reducing blood clots.

“Hospitalists are generally well-positioned to take a lead in quality improvement,” Maynard said. “They know when things don’t work.”

Case in point: the blocking of a blood vessel by a blood clot, or venous thromboembolism (VTE). In the U.S., up to 200,000 people die each year from VTE, the equivalent of one jumbo jet crash every day. But many cases are preventable through efforts such as education and implementing effective guidelines.

Maynard received a Center for Health Quality and Innovation grant to create a systemwide effort to reduce UC’s already low VTE rate by at least 20 percent through focusing on preventive measures in adult medical-surgical hospital patients. The stop-the-clot collaborative will employ an easy-to-follow protocol. UC San Diego has followed a similar program that has reduced hospital-acquired VTE by more than 35 percent over two years.

“The whole approach is based on making this a simple process. People can fill it out in a few seconds,” Maynard said. “If you create a complicated risk-assessment process, it won’t work.”

Maynard’s project is expected to pay off by saving lives and reducing costs.

“If you prevent a bad event from happening, you’re going to prevent costs overall for the system,” he said.

The UC-wide effort also will bring additional benefits, he said.

“I think it’s showing that collaboration across the UC sites is feasible and that collaboration results in accelerated improvement and innovation that wouldn’t occur otherwise,” Maynard said. “It’s the sharing of tools. It’s the sharing of data. This opens discussions of why things work. It also opens the doors for more collaborative research opportunities. I’m sure we’re going to have several research projects spin off from this.”

View Greg Maynard’s talk at the UC Center for Health Quality and Innovation colloquium

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