Residents & Fellows Leading Interprofessional Continuous Improvement Teams (REFLECT)

a row of poster boards on easels set up for display

REFLECT ANNOUNCEMENT FOR 2024-2025

UCSF Health All-Program Goals for 2024-2025

The all-program goals are determined by UCSF Health and UCSF School of Medicine GME leadership, based on clinical quality and operational priorities. The goals are focused on specific areas where physicians have the most impact and align with UCSF Health's organizational goals.

Eligible residents and fellows can earn a maximum of $1800 combined between the all-program goals and any program-specific goals.

GOAL: Why This Is Important	MEASUREMENT
Goal #1: Quality and Safety – Achieve Zero Harm. Decrease the total number of events that cause harm to patients. Harm events: CLABSI (Central Line-Associated Bloodstream Infection) CAUTI (Catheter-Associated Urinary Tract Infection) Patient falls with injuries Surgical site infections C. diff infection (Clostridioides difficile) HAPI (Hospital-acquired Pressure Injuries	Threshold: 3 of 6 harms achieve/exceed goal Target: 4 of 6 harms achieve/exceed goal Outstanding: 5 of 6 harms achieve/exceed goal
Goal #2: Patient Experience – Create an exceptional experience for our patients and their families. We evaluate the percent of hospital areas (units) and outpatient areas (practices/clinics) that improve performance from FY24 baseline on "How well everyone at UCSF Health worked together to care for you?” by at least:	.1 on mean score on Press Ganey or maintain high performance at or above 95 mean score: Threshold: 1 of 4 business units must have 60% of units improving or maintaining high performance Target: 2 of 4 business units must have 60% of units improving or maintaining high performance Outstanding: 3 of 4 business units must have 60% of units improving or maintaining high performance
Goal # 3: Financial Strength – Our goal is to improve our financial strength. Modified EBIDA Margin defined as (Operating Earnings before Interest, Depreciation, and Amortization/Operating Revenue) is a good representation of the financial performance of our organization’s core operations.	Threshold: 9.00% Modified EBIDA Margin Target: 9.95% Modified EBIDA Margin Outstanding: 10.90% Modified EBIDA Margin
For additional details about all of these goals visit here.

GOAL: Why This Is Important

MEASUREMENT

Goal #1: Quality and Safety – Achieve Zero Harm. Decrease the total number of events that cause harm to patients.

Harm events:

CLABSI (Central Line-Associated Bloodstream Infection)
CAUTI (Catheter-Associated Urinary Tract Infection)
Patient falls with injuries
Surgical site infections
C. diff infection (Clostridioides difficile)
HAPI (Hospital-acquired Pressure Injuries

Threshold: 3 of 6 harms achieve/exceed goal

Target: 4 of 6 harms achieve/exceed goal

Outstanding: 5 of 6 harms achieve/exceed goal

Goal #2: Patient Experience – Create an exceptional experience for our patients and their families.

We evaluate the percent of hospital areas (units) and outpatient areas (practices/clinics) that improve performance from FY24 baseline on "How well everyone at UCSF Health worked together to care for you?” by at least:

.1 on mean score on Press Ganey or maintain high performance at or above 95 mean score:

Threshold: 1 of 4 business units must have 60% of units improving or maintaining high performance

Target: 2 of 4 business units must have 60% of units improving or maintaining high performance

Outstanding: 3 of 4 business units must have 60% of units improving or maintaining high performance

Goal # 3: Financial Strength – Our goal is to improve our financial strength.

Modified EBIDA Margin defined as (Operating Earnings before Interest, Depreciation, and Amortization/Operating Revenue) is a good representation of the financial performance of our organization’s core operations.

Threshold: 9.00% Modified EBIDA Margin

Target: 9.95% Modified EBIDA Margin

Outstanding: 10.90% Modified EBIDA Margin

For additional details about all of these goals visit here.

Compliance Reporting: UCSF Health will report compliance with the incentive goals regularly. Data can be found on the True North scorecard. Compliance with each goal will be measured as “goal met” or “goal not met.” Incremental improvements not resulting in the stated goal will not result in incremental payment.

Eligibility: The program will be open to all residents and fellows performing clinical care at UCSF Health West Bay sites for at least 12 weeks (84 days) between July 2024 and June 2025.

Payment: Payment will be based on achievement of goals with tiered payouts, at rates of $300/$400/$500 for Threshold, Target, and Outstanding for a maximum possible incentive payment of $1800 when combined with the payment for any program-specific goals.

Payments will be made in the fall of 2025 through regular payroll procedures.