Residents & Fellows Leading Interprofessional Continuous Improvement Teams (REFLECT)

Reflect program

 REFLECT Announcement for FY22-23

UCSF Health All-Program Goals

Goals for 2021-2022

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. 

NEW THIS YEAR: To align with UCSF Health, our goals will be tiered, with different payment levels depending on the level achieved. Rates are $200/$300/$400 for Threshold/Target/Outstanding. This actually increases opportunities for residents and fellows to achieve the financial incentive relative to past years. 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
  • Serious safety events
  • C. diff infection
  • HAPI (Hospital-acquired Pressure Injuries)

Threshold: Achieve/exceed goal for 3 of the 6 harms

Target: Achieve/exceed goal for 5 of the 6 harms

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

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


We evaluate: top box of CAHPS surveys, or top box of NRC Health surveys, or mean score of Press Ganey, for “MD/Provider Communication” survey section

Threshold: Either hospital or outpatient areas achieve at least 59% of units improving or maintaining high performance

Target: Both hospital and outpatient areas achieve at least 59% of units improving or maintaining high performance

Outstanding: Both hospital and outpatient areas achieve at least 64% of units improving or maintaining high performance

Goal # 3: Financial Strength - Our goal is to achieve the FY22 budgeted Modified EBIDA Margin.


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: Maintain FY21 results – Measured by audited Modified EBIDA Margin from FY21

Target: Significantly Improve on FY21 Results – Measured by mid-point of audited Modified EBIDA Margin from FY21 and FY22 budgeted Modified EBIDA Margin

Outstanding: Achieve FY22 budget - Measured by FY22 budgeted Modified EBIDA Margin

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 2020 and June 2021.


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 2022 through regular payroll procedures.