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[INTRO]

DoM Quality Leads Shift Towards Value-Based Care

As I have previously shared with you in musings on the health care business, our field is quickly moving towards value-based care. This welcome change emphasizes outcomes over volume — in other words, the quality of patient care over the quantity of patients who come through our doors.

DoM Quality positions us uniquely well to thrive amidst so much change. Unlike many quality programs that focus primarily on compliance and regulatory mandates, our quality program integrates evidence-backed improvement projects, faculty-led initiatives and innovative incentive structures to drive meaningful change. Take our peer coaching program, for instance, which you will learn more about below: It is designed not only to enhance patient care but to support physician well-being and retention, resulting in quality improvement efforts that are both sustainable and fulfilling. 

Another example My Action Plan (MAP), a centralized care gap closure program launched in February 2023 in collaboration with the Office of Population Health & Accountable Care (OPHAC) and the UCLA Nudge Unit at the Anderson School of Management. MAP creates and distributes personalized electronic action plans to help patients close care gaps. The initial results suggest resounding success: The program has reached more than 300,000 patients, achieving a 20% relative increase in care gap closure rates.

As policies change, the aims of DoM Quality will remain the same. The program is committed to its “Quadruple Aim”: First, improving the health of populations by advancing healthcare for all in alignment with the department’s mission; second, enhancing the patient experience; third, reducing costs by preventing unnecessary healthcare utilization, and fourth, creating a healthy work environment for healthcare teams. Early iterations of the program’s projects have led to quantitative improvements in patient care, increased faculty and staff satisfaction, reduced burnout and expanded team-based care models — and there is more to be excited about on the horizon.

“Moving forward, we aim to collaborate with operations teams to scale up these successful programs across the health system,” Dr. Dermenchyan said. “Additionally, we plan to expand partnerships with other UC health systems and share our work at regional and national conferences to drive broader healthcare improvements.”

Thank you, Anna, for your outstanding LEADERShip! Keep reading to learn about the many exceptional programs of DoM Quality.

Quality Incentive Programs Lead to Lasting Improvements in Patient Care

As anyone who has tried to form a new habit knows, long-term change is much easier said than done. The same is true for quality improvement initiatives in health care systems — but thanks to incentive programs, DoM Quality seems to be making significant strides. 

“Our program has demonstrated a sustainable change and cultural shift that aligns with the DoM’s goal of providing the highest level of evidence-based care for our patients,” Pooya I. Bokhoor, MD, an interventional cardiologist and a co-leader of the cardiology division’s quality incentive program, said. “It’s in line with an overall shift from financial-based models to value-based care models and acknowledging physicians for the quality of care they’re providing.”

UCLA Primary Care was the first division to launch a quality incentive program. Its program, the Primary Care Clinical Excellence Program, began in 2019 and is now directed by Nika Harutyunyan, MD. Over the past five years, this program has led to meaningful improvements in key clinical metrics and acknowledged dedication and excellence among our medical faculty and staff. 

“It’s been inspiring to see how this initiative has helped move the needle in the right direction — and we’re proud of the impact it’s had across our system,” Dr. Harutyunyan said.

More recently, DoM Quality has expanded incentive programs to our subspecialties as well. The cardiology program was the first to pilot an incentive program. Dr. Bokhoor and co-director David J. Cho, MD, MBA helped start the program in 2021 with the goal of helping to improve initiation and adherence to guideline-directed medical therapy that is known to help improve patient outcomes and save lives.

“This stemmed from our passion for objectively evaluating the care that physicians are providing in a way that shifts the focus from quantity of care to quality of care,” Dr. Cho said. “The majority of cardiovascular care is still delivered in the clinics, and we didn’t have a reliable way to truly know how well we were performing as physicians.”

Incentive programs are a way to encourage physicians to address care gaps by meeting guidelines set by national professional societies and organizations like CMS. These guidelines are designed with the aim of reducing patient morbidity and mortality; for instance, some are set around the appropriate treatment of heart failure or optimal blood pressure control among a physicians’ patients. Those who exceed average performance for each goal are rewarded with a financial bonus — and recognition of a job well done. That alone is a powerful way to boost physicians’ career satisfaction. 

“If the only measure of how good of a physician you are is the number of patients you see every day, it’s very exhausting,” Dr. Bokhoor said. “This is a new, innovative way to show that leadership acknowledges and values that physicians aren’t just getting patients through the door but are being thoughtful in providing high-level evidence-based care.” 

There are also current incentive programs in primary care, nephrology and hospital medicine, with plans in place to launch incentive programs in other divisions in the near future. Meanwhile, the cardiology division’s quality incentive program is in the process of publishing a manuscript that quantifies its durable success with statistically significant improvements in GDMT in heart failure patients, improved blood pressure control, and improvement in lipid lowering therapies in at-risk populations. For example, mineralocorticoid receptor antagonist prescriptions in heart failure patients improved from 55.9% to 79.5% during the study period. 

“This is one of the first specialty programs to show that when you combine financial incentives with the right culture and IT infrastructure, you can create lasting change,” Dr. Cho said. 

Peer Coaches Help Faculty Stay at the Top of Their Game 

All-star athletes turn to coaches to keep them in top form, even at the height of their careers. So why shouldn’t all-star physicians?

That was the logic behind the creation of DoM Quality’s nama Program, a unique initiative that pairs faculty with peers who help them navigate the many unique personal and professional challenges faced by physicians. Founded in 2019 to combat burnout among UCLA doctors, it has since expanded from four to 11 peer coaches — four primary care doctors, six specialists and one hospitalist.

“There’s a lot of pressure on physicians nowadays, both from a clinical and a personal standpoint,” Yaroslav A. Gofnung, MD, director of the Peer Coaching Program, said. “I think one of the advantages of having the coaching being done by physicians in the DoM is that we’re all going through the same thing.” 

Dr. Gofnung and Associate Director Carolyn Goh, MD were among the first couple waves of coaches to join the program. They feel that the physicians who serve as coaches stand to benefit as much as the peers they coach. 

“I think as coaches we gain a lot from this program, and all of us feel that we’ve been able to mitigate our own burnout by learning some of the tools that we have, working with like-minded peers, and giving back,” Dr. Goh said. 

Given how multifaceted burnout can be, coaches within the program are diligent about understanding exactly what challenges each individual is facing. The source can range widely, but often the problem can be addressed by improving practical skills associated with electronic health record management, or by smoothing out clinical workflows. Once again, having internal coaches who work in the same system is of tremendous benefit in coming up with solutions. 

“Clinical workflows can differ between clinics, but fortunately, some of us have worked in different clinics also, so we can help identify where a physician might be able to intervene or would have to discuss changes with their manager or staff on how to make things run more smoothly,” Dr. Goh explained. 

The Peer Coaching Program is currently available to ambulatory and inpatient physicians, including those who go through the DMPG onboarding program. In the short term, it’s looking to further expand its services in the inpatient setting.

The program’s long-term direction will be determined through self-evaluation. The Peer Coaching Program is in the process of publishing the results of a randomized control trial that will demonstrate whether or not coaching reduces burnout among participants at a statistically significant level. Those results will inform what happens next. 

“Anecdotal testimonials and some data we’ve reviewed so far seems to show that we do make a difference,” Dr. Gofnung said. “We want to do something scientific to prove that, and once we do, the plan would be to potentially expand a similar approach to other departments across the health system.” 

DoM Quality Peer Review Program Expands with Department Growth

One of DoM Quality’s most important functions is peer review, a process where medical staff audit clinical operations to identify areas for improvement among individuals and the greater health system. 

“Peer review is crucial for maintaining high standards of practice and ensuring high-quality patient care,” Lisa N. Kransdorf, MD, MPH, medical director of ambulatory peer review, said. “The goal is continuous improvement in the care we provide to our patients. 

Currently more than 70 DoM faculty serve as peer reviewers, with representation from all of our divisions. 

“I am always impressed by their engagement, thoughtfulness, objectivity and empathy,” Wendy M. Simon, MD, medical director of inpatient peer review, said. “I am grateful to them for their committee service.” 

To accommodate our larger department, DoM Quality has recently added new ambulatory and inpatient physicians as well as an additional RN to serve as lead peer reviewers. The peer review program at Ronald Reagan and other UCLA clinics will soon be expanded to DoM physicians at UCLA West Valley Hospital as well. 

Physicians who are interested in serving as peer reviewers may contact DOMQuality@mednet.ucla.edu to inquire about openings. Thank you to all of our peer review faculty and staff who help make our mission successful! Meet them by visiting this link. 

THINQ teaches students to think — and act — on healthcare challenges 

Among the most unique of DoM Quality’s many programs is The Healthcare Improvement and iNnovation in Quality (THINQ) Collaborative, an organization that gives undergraduates and recent graduates the opportunity to participate in a wide breadth of healthcare quality improvement projects before they officially start their healthcare careers. 

“The THINQ program exposes students to hospital medicine, primary care and various medicine sub-specialties — and most importantly introduces them to quality improvement concepts that at least when I was an undergraduate many years ago, I had no idea about,” Russell B. Kerbel, MD, who co-leads the program alongside Dr. Dermenchyan, said. “The THINQ students are way ahead of the curve in terms of active pre-medical experiences that undergraduates would have outside of volunteering, shadowing or scribing.”[FH2] 

THINQ was originally founded in 2014 by UCLA hospitalist Aram A. Namavar, MD, MS just prior to starting medical school. He and former UCLA Chief Quality Officer Nasim Afsar, MD, MBA wanted to find a way to integrate college, masters and medical students into the DoM Quality program. Dr. Namavar’s experience taught him that there is much more to hospital medicine than patient care, and even today will leverage what he learned from THINQ in his new role as the co-director of hospitalist services at UCLA West Valley Medical Center. 

“One can impact care delivery at the system level to create a wide impact,” he said. “I learned how to build and motivate a team that would lead to positive results, whether that be scientific productivity or improvements in outcome measures.” [FH4] 

Today, THINQ is a competitive program that accepts only 10 to 15 students per year out of the roughly 200 that apply. Its robust initiatives include a journal club, physician shadowing, student-led research initiatives on quality improvement, a Shark Tank-style case competition and leadership development activities. They also take part in extensive community outreach and engagement, such as the this past November’s inaugural LA Walk for Alopecia and the creation of a guide to help people with addiction find accessible treatment and services.

Given the extensive nature of THINQ’s research projects — the latest of which include systematic literature reviews on AI scribes, data collection to improve nursing recommendations for discharge, and much more — it is no surprise that it is equally prolific when it comes to tracking its own progress. Members have even published studies so the organization’s success can be replicated at other institutions; given that more than half of them over the past 10 years have gone on to pursue more healthcare education or careers, it seems to be working well.

“They do a lot of internal evaluation about how the program is going,” Dr. Kerbel said. “It’s basically quality improvement doing quality improvement on themselves and holding themselves accountable.”

Sristi Palimar, a fourth-year undergraduate and associate director of THINQ, has been most impacted by the program’s biweekly general meetings, shadowing opportunities and workshops, the teachings from which help them make the most of their experiences in the clinic. 

“For example, our social justice and leadership development workshops identify strategies students can use to more effectively shadow patients who may represent variable socioeconomic backgrounds,” Sristi said. “Thus, THINQ students learn the importance of cultural sensitivity and holistic patient care, which they are then able to identify in their observations of patient care.” [FH9] 

Andre Fabian, a project policy analyst for DoM Quality who was a member of THINQ before he graduated from UCLA in 2024, continues to be inspired by the undergraduates he works with in the program. As he prepares to enter a dual MD/MPH program this fall, he is grateful for all that THINQ taught him. 

“Fields such as medicine, public health and education are evolving at a rapid rate,” Andre said. “The ability to identify ways to adapt to new changes within a system, as well as understanding the tools to identify when and how changes occur, are two invaluable skills I learned from THINQ that will help me reach and exceed my goals.” [FH10] 

Drs. Leuchter, Kahn and Mafi uncover troubling trend in ED use among economically disadvantaged populations

The DoM has a long history of impactful quality research that influences national healthcare policies, improves treatment outcomes for patients and, in some cases, reveal significant new patterns in population health. One recent example of this is a study led by a team of UCLA internists and health services researchers who demonstrated that the COVID-19 pandemic may have altered care patterns in emergency department (ED) use among patients from socioeconomically disadvantaged backgrounds. Their research was published online March 3 in Health Affairs. 

“The positive story is that we found an overall persistent reduction in avoidable ED visits throughout the pandemic,” Richard K. Leuchter, MD, first author, said. While this has long been a goal of policymakers, it was coupled with a concerning observation: The number of non-avoidable ED visits dropped as well, particularly among Medicaid and dual-enrolled Medicare-Medicaid patients — a group that has low incomes and, often, complex health needs. While the figures for most groups rebounded to pre-pandemic levels, they remained low for these vulnerable populations. 

“The fact that they stayed down only for the socioeconomically disadvantaged patients, but rebounded for the patients who are more well-resourced, raises concern for a kind of emerging disparity,” Dr. Leuchter added. This suggests a reversal in the historic trend of under-resourced patients using the ED for non-emergent care in lieu of a primary care physician, but not necessarily because resources were being used more efficiently. 

The findings build upon a study published in 2022 by some members of the same team behind the new research. That paper was first authored by John N. Mafi, MD, MPH, who served as a senior author on the new work; both studies was led by Katherine L. Kahn, MD, MPH, a storied UCLA health services researcher with a track record of spearheading influential national evaluations on the impact of health policies. Dr. Mafi, Dr. Kahn and the rest of the team behind the 2022 study was one of the first in the country to demonstrate that ambulatory care service use did not rebound over the course of the pandemic among Medicaid and Medicare-Medicaid patients. 

The new findings suggest that those earlier results were part of a larger pattern, even as absolute use of ED facilities for non-emergent care remains higher among Medicare and Medicare-Medicaid patients. Dr. Mafi noted that they might serve as a warning of risks associated with some types of policies to dissuade unnecessary emergency room visits are enacted. There are reports of cases where state Medicaid programs have tried to deny payment or increased co-pays for avoidable ED visits, along with a case where one major payer, UnitedHealthcare, denied healthcare coverage for “unnecessary” ED use during the COVID-19 pandemic. 

“There’s now an increased risk of this kind of negative spillover effect where not only do you have diminished returns on targeting a reduction in avoidable ED visits, but you’re also at risk of discouraging unavoidable or non-avoidable ED visits in the most vulnerable groups for life-saving needs,” Dr. Mafi said. “That could cause further inequities and harm to population health.” 

Dr. Kahn noted that at a population level, there are many reasons why low-resource patient populations might improperly use ED services — or not use them at all when they should. One challenge lies in knowing what counts as an emergency in the first place. 

“There’s variation among people in terms of their understanding of what is an emergency and when it is helpful to stay home and have soup,” she said. “This is an issue about access, but access is tied to understanding when it’s necessary to receive emergency care.” 

“We're enthusiastic about decreasing emergency room use if it's not necessary, but we’re also enthusiastic about making sure that all populations are aware of the opportunity to visit an emergency room if it is an emergency,” Dr. Kahn added. 

Congratulations to Rich, Katherine and John on an outstanding study! 

Anjay Rastogi, MD, PhD, Leads Effort to Make March Kidney Health Awareness Month in Santa Monica

Last month, Santa Moncia Mayor Lana Negrete and the Santa Monica City Council issued a proclamation recognizing March as Kidney Health Awareness Month. The effort behind the proclamation was led by UCLA Clinical Chief of Nephrology and professor of clinical medicine Anjay Rastogi, MD, PhD, the founding director of the UCLA CORE Kidney Health Program.

Dr. Rastogi sets a new standard when it comes to community engagement. He is also the creator of the Bruin Beans Health Club (BBHC), an undergraduate organization that collaborates with nephrologists in the CORE Kidney program and was involved with the Santa Monica proclamation (BBHC member Disha Yadav, a kidney recipient, spoke on behalf of the club at the proclamation event). Dr. Rastogi is also behind CORE Kidney’s Rose Parade float.

“QUOTE,” Dr. Rastogi said. “QUOTE.”

Thank you, Anjay, for your LEADERShip in our mission to advance health for all!

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