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Multi-Specialty Program Approved Efforts

The efforts listed below have been reviewed and approved by the UR Medicine MOC Program. Some projects apply to Multi-Specialty Program and some to the Pediatrics Specialty Board. Projects noted as active may have attestations submitted for MOC Part IV credit, given the physician meets all requirements of the Meaningful Participation Criteria. All attestations must be signed by the Project Lead(s) and include information regarding the physician’s individual involvement in the QI effort.

Active

Improving Hand-offs and Transitions in Care

Approval Date: February 1, 2015
Institution: Strong Memorial Hospital
Type of Effort: Model for Improvement (PDSA)
Effort Lead: Michael Leonard, MD
Project Status: Ongoing (Oct 2012 - Current)
Brief Description: Through the annual Safe Culture Survey, providers have identified that the quality of our hand-offs during transitions in care can increase the safety risk for our patients. This improvement effort focuses on improving both the reliability and quality of hand-off communication being readily available in the electronic medical record.
Focused on: Hospitalized patients
Open to: Anesthesiology, Emergency Medicine, Internal Medicine, OBGYN, Orthopaedic Surgery, Otolaryngology, Pediatrics, Physical Medicine and Rehabilitation, Plastic Surgery, Psychiatry and Neurology, Surgery, Thoracic Surgery
Measures: Compliance with hand-off process tool in eRecord Positive responses on the Hand-off domain of the Patient Safety Culture Survey
Required: Attendance at Hand-off Team meetings or equivalent, review of baseline data within your specialty, 3 cycles of targeted improvement efforts

Readmission Reductions

Approval Date: February 1, 2015
Institution: Strong Memorial Hospital
Type of Effort: Model for Improvement (PDSA)
Effort Lead: Marc Berliant, MD
Project Status: Ongoing (July 2010 - Current)
Brief Description: Unplanned, preventable readmissions within 30 days of hospital discharge may reflect a failure of the healthcare system to fully address patient needs prior to the initial discharge and/or in the ambulatory care setting. This improvement effort focuses on reducing 30 day readmissions.
Focused on: Hospitalized patients, ambulatory patients hospitalized within past 30 days
Open to: Emergency Medicine, Internal Medicine, OBGYN, Orthopaedic Surgery, Otolaryngology, Pediatrics, Physical Medicine and Rehabilitation, Plastic Surgery, Psychiatry and Neurology, Surgery, Thoracic Surgery
Measures: All cause 30-day readmission rate (HW and/or diagnosis specific)
Required: Attendance at Readmission Integration Team meetings or equivalent, review of baseline data within your specialty, 3 cycles of targeted improvement efforts

Preventing Severe Sepsis/Septic Shock Mortality

Approval Date: June 8, 2015
Institution: UR Medicine
Type of Effort: Model for Improvement (PDSA)
Effort Lead: Mike Apotolakos, MD
Project Status: Ongoing (Jan 2013 - Current)
Brief Description: Death from severe sepsis or septic shock can be prevented in many cases by early detection and treatment. This improvement effort focuses on preventing deaths from sepsis through implementation of best practice protocols.
Focused on: Hospitalized patients, ED patients
Open to: Emergency Medicine, Internal Medicine, Orthopaedic Surgery, Otolaryngology, Pediatrics, Plastic Surgery, Surgery, Thoracic Surgery
Measures: Severe Sepsis/Septic Shock Mortality
Compliance with Sepsis Protocol elements
Required: Attendance at Mortality Integration Team meetings or equivalent, review of baseline data within your specialty, 3 cycles of targeted improvement efforts

Preventing Central-Line Associated Bloodstream Infections

Approval Date: June 8, 2015
Institution: UR Medicine
Type of Effort: Model for Improvement (PDSA)
Effort Lead: Mike Apotolakos, MD
Project Status: Ongoing (Jan 2008 - Current)
Brief Description: Central line-associated bloodstream infections (CLABSI) result in significant mortality and morbidity as well as adding significantly to the cost of care for patients who acquire these infections. This effort focuses on preventing bloodstream infections in our patients who require central venous catheterization.
Focused on: Hospitalized patients
Open to: Emergency Medicine, Internal Medicine, Orthopaedic Surgery, Otolaryngology, Pediatrics, Plastic Surgery, Surgery, Thoracic Surgery
Measures: CLABSI Rate (infs/1000 line days)
Line Utilization Ratio (line days/1000 patient days)
Required: Attendance at CLABSI Prevention meetings or Complications Integration Team meetings or equivalent, review of baseline data within your specialty, 3 cycles of targeted improvement efforts

Preventing Catheter-Associated Urinary Tract Infections

Approval Date: June 8, 2015
Institution: UR Medicine
Type of Effort: Model for Improvement (PDSA)
Effort Lead: Paritosh Prasad, MD
Project Status: Ongoing (Jan 2015 - Current)
Brief Description: Catheter-associated urinary tract infections have been associated with increased morbidity, mortality, healthcare costs, and length of stay. The effort focuses preventing CAUTI among our hospitalized patients.
Focused on: Hospitalized patients
Open to: Emergency Medicine, Internal Medicine, Orthopaedic Surgery, Otolaryngology, Pediatrics, Plastic Surgery, Surgery, Thoracic Surgery
Measures: CAUTI Rate (infs/1000 catheter days
Catheter Utilization Ratio (catheter days/1000 patient days)
Required: Attendance at CAUTI Prevention meetings or Complications Integration Team meetings or equivalent, review of baseline data within your specialty, 3 cycles of targeted improvement efforts

Preventing Healthcare-Associate C. Difficile Infections

Approval Date: June 8, 2015
Institution: UR Medicine
Type of Effort: Model for Improvement (PDSA)
Effort Lead: Ghinwa Dumyati, MD
Project Status: Ongoing (Jan 2011 – Current)
Brief Description: Clostridium difficile (CDI) is a significant cause of infectious disease mortality and morbidity. While CDI can be acquired in the community without healthcare facility exposure, most cases occur when patients are hospitalized or in skilled nursing facilities and/or have undergone treatment with antibiotics. This effort focuses on preventing healthcare associated C. Difficile infections.
Focused on: Hospitalized patients and patients in Skilled Nursing Facilities
Open to: Emergency Medicine, Family Medicine, Internal Medicine, Orthopaedic Surgery, Otolaryngology, Pediatrics, Plastic Surgery, Preventive Medicine, Surgery, Thoracic Surgery
Measures: CDI Rate (Cases of CDI per 10,000 patient days
Required: Attendance at C. Difficile Prevention meetings or equivalent, review of baseline data within your specialty, 3 cycles of targeted improvement efforts

Preventing Surgical Site Infections

Approval Date: June 15, 2015
Institution: UR Medicine
Type of Effort: Model for Improvement (PDSA)
Effort Lead: Catherine Humphrey, MD
Project Status: Ongoing (Jan 2014 – Current)
Brief Description: Surgical site infections can cause significant morbidity and result increased lengths of stay and/or readmissions. This effort focuses on adopting and implementing specialty specific best practices to prevent surgical site infections.
Focused on: Patients Undergoing Surgical Procedures (Hospital or ASC)
Open to: Anesthesiology, OBGYN, Orthopaedic Surgery, Otolaryngology, Plastic Surgery, Surgery, Thoracic Surgery
Measures: NSQIP SSI odds ratio (for relevant procedures) SSI Prevention Bundle Compliance
Required: Attendance at SSI Prevention Bundle Task Force meetings and/or Department QI meetings or equivalent, review of baseline data within your specialty, 3 cycles of targeted improvement efforts

Reducing Length of Stay (LOS) for Medicine Inpatients

Approval Date: June 25, 2015
Institution: UR Medicine
Type of Effort: Model for Improvement (PDSA)
Effort Lead: Val Lang, MD; Paul Levy, MD; Marc Berliant, MD
Project Status: Ongoing (Jan 2015 - Current)
Brief Description: High census results in patients not being in the appropriate setting for their care for example inpatients boarding in the ED. Reducing LOS, while ensuring no negative impact on readmission rates, would have the same impact as adding additional beds ensuring that admitted patients can be efficiently assigned and moved to their bed.
Focused on: Hospitalized patients on the adult Medicine Service
Open to: Internal Medicine
Measures: GMLOS by DRG, 30 day readmission rate (# of patients readmitted/# of patients eligible discharged)
Required: Attendance at Medicine LOS meetings or equivalent, review of baseline data, 3 cycles of targeted improvement efforts

Pediatric Readmission Reductions

 

Approval Date: May 19, 2016
Institution: UR Medicine
Type of Effort: Model for Improvement (PDSA)
Effort Lead: Lauren Solan, MD, MEd
Project Status: Ongoing (May 2016 - Current)
Brief Description: Unplanned, preventable hospital readmissions and return visits to the emergency room are a broad problem in healthcare, including pediatrics. These readmissions may reflect a failure of the healthcare system to provide appropriate support and resources to patients prior to discharge and/or a lack of necessary supports in the outpatient care setting.  This improvement effort focuses on reducing unplanned 7 day returns to the ED and potentially preventable 7 and 30 day readmissions.
Focused on: Patients 18 years and younger.
Open to: Pediatrics
Measures:

Unplanned returns to the ED within 7 days of discharge
Unplanned readmissions within 7 days of discharge
Unplanned readmissions within 30 days of discharge

Required: Attendance at planning meetings or equivalent, review of baseline data, 3 cycles of targeted improvement efforts

 

Preventing Avoidable Adverse Drug Events​

Approval Date: December 28, 2017
Institution: UR Medicine
Type of Effort: Model for Improvement (PDSA)
Effort Lead: Timothy P. Stevens, MD. MPH
Project Status: Ongoing (December 2017 – Current)
Brief Description: Studies have shown that adverse events related to medication errors occur frequently in hospitalized patients and are three times more common in pediatric patients than in adults.  The goal of this QI project is reduce the rates of reported adverse drug events that do not cause patient harm by at least 20% and, for pediatric patients, to ensure that the rate of reported ADE events that cause patient harm is lower the Solutions for Patient Safety (SPS) Network benchmark.
Focused on: Hospitalized patients
Open to: Pediatrics, Anesthesiology, Emergency Medicine, Internal Medicine, Family Medicine, Neurology, Orthopaedic Surgery, Psychiatry, Otolaryngology, Plastic Surgery, Surgery, Thoracic Surgery
Measures:

Reported ADE that do not cause harm to the patient

Reported ADE that do cause harm to the patient

Rates calculated using patient days in the denominator.

Required: Attendance at planning meetings or equivalent, review of baseline data, 3 cycles of targeted improvement efforts

Closed

Using Technology to Improve Care for Individuals with Parkinson Disease

Approval Date: September 11, 2015
Institution: UR Medicine
Type of Effort: Model for Improvement (PDSA)
Effort Lead: Ray Dorsey, MD, MBA
Project Status: Closed
Brief Description: Many patients with Parkinson disease have limited access to care.  The focus of this effort is to increase access to care from Parkinson disease specialists and to offer patients excellent care, convenience, and comfort.
Focused on: Outpatients with Parkinson Disease
Measures:

Feasibility of virtual visit approach – # of patients completing virtual visit as scheduled/total number# of patients scheduled
Satisfaction with virtual visit care: # of patients satisfied or very satisfied/ total # of patients surveyed

Patient Counseling Against Drowsy Driving

Approval Date: September 11, 2015
Institution: UR Medicine
Type of Effort: Model for Improvement (PDSA)
Effort Lead:  Heidi V. Connolly, MD, D, ABSM
Project Status: Closed
Brief Description: Teens with complaints of daytime sleepiness are often not aware of the dangers of drowsy driving. It is important to counsel those who are eligible to drive on not doing so while drowsy. This effort is focused on ensuring the counseling is completed and documented.
Focused on: Pediatric Sleep Clinic Patients > 16 years old who are eligible to drive
Measures:

Documentation of counseling against drowsy driving: # of patients in the denominator with drowsy driving counseling documented in the medical record/total number of patients >16, eligible to drive with complaints of daytime sleepiness

Quality in Scoring Overnight Sleep Studies

Approval Date: September 18, 2015
Institution: UR Medicine
Type of Effort: Model for Improvement (PDSA)
Effort Lead:  Heidi V. Connolly, MD, D, ABSM
Project Status: Closed
Brief Description: The scoring of pediatric polysomnographies (sleep studies) directly affects the interpretation and clinical care of children seen in the division of pediatric sleep medicine.  If studies are scored inaccurately then accurate diagnoses cannot be made, nor can appropriate treatments be implemented. The focus of this effort is on improving the accuracy of the scoring by technicians.
Focused on: Pediatric Sleep Clinic Patients
Measures:

Percent of technicians with 85% or greater accuracy rates: # of technicians with an accuracy score of 85% or higher/total number of technicians

Breastfeeding Friends

Approval Date: July 6, 2015
Institution: UR Medicine
Type of Effort: Model for Improvement (PDSA)
Effort Lead: Casey B. Rosen-Carole, MD, MPH
Project Status: Ongoing (Jan 2015 - Current)
Brief Description: The breastfeeding QI project was initiated in response to low breastfeeding rates of patients, the quick drop off in breastfeeding identified in the first month of life among our patients, and the perceived lack of education, training, resources and referral locations for our patients and staff.
Focused on: Infants and mothers
Open to: Pediatrics
Measures: Breastfeeding rates: patients breastfeed at 2 week visit/total eligible patients; patients breastfeed at 2 month visit/total eligible patients
CLC Breastfeeding Consults: average number of visits per month
Required: Attendance at planning meetings or equivalent, review of baseline data, 3 cycles of targeted improvement efforts