Resident & Fellow Leading Continuous Improvement Teams (REFLECT)

Reflect program

UCSF Health All-Program Goals

Goals for 2019-2020   

Goal #1: Quality and Safety – Achieve zero harm

With an overarching goal to Achieve Zero Harm, our goal is for UCSF Health to decrease the total number of events that cause harm to patients and employees from the FY19 harm events baseline (with adjustment for volume growth) by at least 25 events.

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

On the CAHPS and Press Ganey surveys for “MD/Provider Communication” sections, we will achieve excellence either by maintaining or increasing current scores, depending on the current baseline for the unit. Our goal is for either Hospital or Outpatient areas to have at least 59% of units improve or maintain “High Performance.”

Goal # 3: Financial Strength - Lower our costs/Improve Financial Performance

The focus is on operations and controllable revenue and costs. Our goal is to achieve 97% of budget for UCSF Health (West Bay) EBIDA Margin. Simplified, EBIDA is a measure of our operating margin. Achieving our goal will allow UCSF Health to support our research and education priorities and care for all patients, and to continue to invest in overall strategic plans, meet necessary capital financial requirements, and meet debt obligations.

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 between July 2019 and June 2020.

Payment:  For programs that do not have a departmental goal, payment will be based on achievement of three goals, at a rate of $400 each for a maximum possible incentive payment of $1200.

For programs that have an approved additional program-specific incentive goal, payment will also be based on achievement of three goals, but with four opportunities to achieve three goals. Payment will be at a rate of $400 for each of three goals for a maximum possible incentive payment of $1200. Payments will be made in fall of 2020 through regular payroll procedures.