Residents & Fellows Leading Interprofessional Continuous Improvement Teams (REFLECT)

Reflect program


UCSF Health All-Program Goals

Goals for 2022-2023

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 $1200 combined between the all-program goals and any program-specific goals.

Goal #1: Quality and Safety – Achieve zero harm

Our goal is for UCSF Health to 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
  • HAPI (Hospital-acquired Pressure Injuries)
  • Wrong side/site/person surgery and retained foreign objects

Threshold: Achieve/exceed goal for 3 of the 7 harms

Target: Achieve/exceed goal for 5 of the 7 harms

Outstanding: Achieve/exceed goal for 6 of the 7 harms

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


We evaluate: Percent of hospital areas (units) and outpatient areas (practices/clinics) that improve performance from FY22 baseline on "Everyone worked together to care for you?"

Threshold: Either hospital or outpatient areas achieve at least 55% of units improving or maintaining high performance

Target: Both hospital and outpatient areas achieve at least 55% of units improving or maintaining high performance

Outstanding: Both hospital and outpatient areas achieve at least 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: Achieve 98% of FY23 budgeted Modified EBIDA Margin (11.44%)

Target: Achieve FY23 budgeted Modified EBIDA Margin (11.67%)


Achieve 102% of FY23 budgeted Modified EBIDA Margin (11.90%)

For additional details about all of these goals visit here

Compliance Reporting: UCSF Health will report compliance with the incentive goals on a regular basis. 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 resident and fellows performing clinical care at UCSF Health West Bay sites for at least 12 weeks (84 days) between July 2022 and June 2023.


Payment:  Payment will be based on achievement of goals with tiered payouts, at rates of $200/$300/$400 for Threshold, Target, and Outstanding for a maximum possible incentive payment of $1200 when combined with the payment for any program-specific goals.

Payments will be made in fall of 2023 through regular payroll procedures.