Management of quality improvement (QI) and safety programs within the neurosciences at UNC is a collaborative effort between the UNC Departments of Neurosurgery and Neurology. These efforts include:

  • Oversight by the Neurosciences Quality Council,
  • Development of educational resources and training, and
  • Establishment of departmental QI initiatives.

The Neurosciences Quality Council is a multidisciplinary team that includes physician and nursing clinical leadership as well as departmental administrators. Council members meet bimonthly to receive quality improvement coaching from clinician leaders, hospital organizational experts and project managers.

Purpose:

To provide a structure and process to prioritize and support focused quality and safety improvement activities within the departments.

Goals:

  • Align with UNC Health Care and UNC School of Medicine organizational and quality improvement goals.
  • Develop an integrated framework for QI prioritization and initiatives within the departments.
  • Promote a culture of QI and safety through multidisciplinary, collaborative, transparent, and data-driven activities.

Responsibilities:

  • Set yearly departmental quality goals.
  • Foster integration and collaboration between clinical QI work groups.
  • Review work group progress and execution of short and long-term departmental QI activities.
  • Maintain and disseminate a Neurosciences QI dashboard.
  • Inform the UNC Medical Center Improvement Council of ongoing initiates, progress and opportunities.
Educational resources and training opportunities are described on the UNC Institute for Healthcare Quality Improvement’s website.

A sampling of the Neurosciences Quality Council’s active projects are listed below:

  • IPASS hand-off project
  • Neurosciences bounce back and preventable readmission initiative
  • Opioid stewardship
  • Hospital-acquired infection prevention
  • CT reduction in children project
  • Congress of Neurological Surgeons Quality Improvement and Patient Safety
    CNS sponsors a yearly NeuroSafe Conference.
  • The American College of Surgeons’ National Surgical Quality Improvement Program® (ACS NSQIP) is a nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care in the private sector. ACS NSQIP offers tools, training, customization options and data.
  • American Association of Neurological Surgeons (AANS) actively participates in efforts to measurably improve patient safety and quality of care, including advocacy related to the Patient Safety and Quality Improvement Act. This law created a voluntary reporting program through which health care providers can share information relating to patient safety events with patient safety organizations (PSOs) on a confidential basis to improve patient safety.
  • PROMIS Tools for patient reported health status. Patient Reported Outcomes Measurement Information System (PROMIS), funded by the National Institutes of Health (NIH), is a system of highly reliable, valid, flexible, precise, and responsive assessment tools that measure patient–reported health status.

Key contacts for more information:

Kathleen Bradford, MD
Department of Pediatrics, General Pediatrics and Adolescent Medicine
Department of Neurosurgery, Quality Improvement

Casey Olm-Shipman, MD
Departments of Neurology and Neurosurgery
Neurocritical Care, Child Neurology