Choosing Wisely Inspires Quality Improvement Initiatives at UCSF

Three years ago a team of residents and hospitalists at the University of California, San Francisco (UCSF) began thinking of ways to improve care across the institution. Led by then-resident Dr. Christopher Moriates, the High Value Care Committee set out to:

• raise awareness of the cost of health care;
• reduce unnecessary resource utilization;
• increase efficiency and patient throughput; and,
• create and support stewards of high-value, responsible health care in the Division of Hospital Medicine at UCSF.

“When the Society of Hospital Medicine [SHM] Choosing Wisely® list came out in early 2013 it fit in very well with what we were doing. We wanted to move from simply educating physicians about these concepts to operationalizing them into projects,” said Dr. Moriates, Assistant Professor, UCSF School of Medicine and Co-Chair of the High Value Care Committee.

Staff at UCSF reviewed SHM’s recommendations and determined how well they performed in five areas. A review of baseline data revealed good performance related to some of the recommendations, such as avoiding urinary catheterization for non-critically ill patients. Other areas, such as unnecessary blood transfusions or continuous telemetry outside the ICU, were identified as opportunities for improvement.

Baseline data revealed that 30 percent of patients admitted to the hospital medicine service had blood transfusions when their hemoglobin level was above 8g/dl, despite increasing evidence that a strategy limiting most blood transfusions to lower hemoglobin levels is better for patients. To reduce unnecessary blood transfusions, the committee created a campaign for better Blood Utilization Stewardship.

The committee educated physicians about when transfusions are appropriate – using real case examples from their hospital and summaries of the current evidence – and provided regular feedback on blood utilization via a monthly newsletter to all staff. Over a 12-month period, the rate of blood transfusions given to patients with hemoglobin levels above 8g/dl decreased to well under 20 percent, and in several months had fallen below 10 percent.

Reducing unnecessary use of telemetry proved to be a more difficult area to define.

“We can all quibble about exactly how long people should be on telemetry, but it’s pretty hard to argue that someone should be on real-time cardiac monitoring one hour and then be at home relaxing the next. That just doesn’t make sense,” said Dr. Moriates.

SHM’s Choosing Wisely recommendation states, “Don’t order continuous telemetry monitoring outside of the ICU without using a protocol that governs continuation.” Baseline data revealed 44 percent of patients admitted to the hospital medicine service at UCSF for more than 48 hours were on telemetry until they were discharged.

Led by hospitalist Dr. Nader Najafi, resident champions were enlisted to create and disseminate materials among their colleagues explaining the initiative and how decreasing telemetry usage benefitted patients. Similar to the Blood Utilization Stewardship campaign, clinicians received monthly reports showing rates of telemetry and how the institution was performing as a whole. After implementing the initiative, rates consistently fell below 30 percent.

“We’re continuing to work on systems solutions. For both telemetry and transfusions we have changes to our electronic ordering system that we’ve proposed that will help support the improvements that we have seen with our educational and data feedback campaigns,” said Dr. Moriates. “So we teach our clinicians why they should be doing it, we teach them how to do it, and then we need to create systems that support that work.”

Beyond the tangible metrics of reducing unnecessary interventions, the committee’s work and the Choosing Wisely campaign have inspired others to think about new ways to improve patient care.

A new campus-wide program called Caring Wisely, also led by Dr. Moriates, supports front-line clinicians in creating their own health care value improvement projects by providing funding and resources. For example, a group of surgeons is leading a price-transparency initiative and standardization of operating room supply lists, while in the emergency department work is being done on decision support tools for physicians in decreasing unnecessary CT scans.

“What started as a personal mission amongst a few of us has now become a movement. When we had our first meeting of this academic year, the room was full with resident physicians, fellows and faculty members that brought their own ideas of projects they wanted to drive forward. By far the biggest metric of our success is seeing the enthusiasm coming forward from other clinicians,” said Dr. Moriates.