Quality Improvement

Reducing 30-Day Readmissions for Liver Transplant Patients

The Division of Abdominal Transplant seeks to reduce unplanned readmissions, as current 30-day readmission rates for liver transplant patients rank at the 73rd percentile among academic medical centers. Our FY26 goal is to lower this rate from 34.9% to 33.2% (a 5% relative reduction) by the end of the fiscal year.

1. Enhancing “Overall Rating of MD” Performance

   To build on gains in provider-patient communication, we aim to sustain or improve our FY25 “Overall Rating of MD” scores within a 95% confidence interval. Each division will review granular dashboard data and collaborate with Patient Experience leaders quarterly to identify tailored strategies and faculty development needs.

2. Expanding Participation in Advanced ACES Offerings

   We aim to have at least 25% of established providers engage with advanced ACES learning opportunities that focus on communication, presence, and challenging clinical encounters. FY26 includes new inpatient and clinician-to-clinician communication offerings to support this goal.

LEAP Project: CMS TEAM – Major Bowel (Year 2)

To reduce episode costs and improve care coordination for major bowel surgery patients, clinical teams will continue developing and refining a LEAP pathway. By the end of FY26, we aim to achieve a 5% reduction in calculated episode costs, supported by regular stakeholder engagement, pathway design, and clinician-level performance reviews.

1. Annual Wellness Planning and Attestation

   Faculty are expected to complete and attest to an annual wellness plan and year-end summary, reinforcing our commitment to clinician well-being and sustainable practice.

2. Improving Operating Room Team Communication (Year 2)

   Poor communication in the OR contributes to delays, safety risks, and staff stress. In Year 2 of this initiative, we aim to improve the frequency of optimal team communication among Gen 2/3 OR staff and surgeons by 10% by the end of FY26.

High Quality Discharge – General Surgery Readmissions Initiative

To reduce preventable readmissions, the Department of Surgery launched the High-Quality Discharge initiative, focused on standardizing Epic-embedded discharge instructions. After completing English templates in FY24, the FY25 goal is to expand usage to the top five high-utilization languages, increasing adoption from 0% to 60%. Supported by provider education and workflow integration, this effort contributed to a decrease in General Surgery’s 30-day readmission rate from 10.3% to 9.0% (as of April FY25), surpassing the target of 9.7%.

SurgIQ: Cohort-Based QI Curriculum

Launching in September 2025, SurgIQ is a 6-week, cohort-based quality improvement curriculum grounded in the A3 problem-solving framework. Multidisciplinary teams submit real-world project proposals—vetted by Clinical Affairs—and progress through the program together. The focus is on applying QI principles to daily surgical practice, strengthening a culture of continuous improvement across the department.

As part of our commitment to advancing quality improvement across the institution, the Department of Surgery will provide coaching and support for RITE (Realizing Improvement through Team Empowerment) projects that are prioritized at the organizational level. These initiatives are designed to align teams across Stanford Medicine in addressing high-impact, system-wide challenges. Through dedicated mentorship, structured guidance, and practical tools, we aim to empower faculty and staff to drive meaningful, measurable change that supports both patient outcomes and operational excellence.

As part of our broader Quality Improvement and Clinical Affairs strategy, the Department of Surgery organizes and hosts several recurring forums that foster learning, transparency, and system-wide improvement. These include:

• Weekly Surgery Grand Rounds focused on clinical excellence, innovation, and patient-centered care

• Monthly Department of Surgery M&M Conferences, emphasizing case-based learning and patient safety

• Monthly Surgery Quality Council (SQC), where we review mortality cases, SAFE events, PSIs, and share Clinical Affairs updates

These forums are integral to our culture of continuous improvement and are open platforms for faculty and staff engagement, learning, and collaboration.