Quality Improvement Commons^™

Evaluating Referral Coordination And Scheduling In Primary Care: A Qualitative Study Of Workflow Gaps, Aprupa Alahari, Philycia Foote, S. Vincent Grasso

Rowan-Virtua Research Day

Background

Healthcare referral workflows remain fragmented despite widespread adoption of electronic health records. Primary care to specialty referrals frequently rely on fax, phone calls, manual scheduling, and disconnected communication systems, creating delays, incomplete referrals, and administrative burden.1,2 Prior literature has identified a lack of referral tracking, referral leakage, and lack of closed-loop communication as major barriers to coordinated care. Altogether, efforts are required to keep cases from falling into the “referral black hole” that plagues health systems.2-4

Hypothesis

We hypothesized that:

1. there is substantial patient burden

2. there is substantial operational fragmentation

3. current referral systems contain limited visibility or verification

Methods …

The Obstacles Of Performing A Retrospective Chart Review, Emily Reilly, Robert Hudrick D.O.

Rowan-Virtua Research Day

Introduction: This research project "Comparing timing of care for skin cancer patients with limited English proficiency who require interpretation during medical visits to patients with English proficiency" was accepted under the CREATE Grant. The hypothesis was that patients who require medical interpretation during their visits would show a longer period of time between noticing a skin lesion to definitive diagnosis. Previous research has shown improved health care outcomes, but has mixed results on patient satisfaction and health care experience. This poster aims to detail the limitations faced during the execution of a retrospective chart review from the perspective of a …

Reframing The Ed–Hospitalist Admission As A Clinical Handoff: The Ed To Hospital Admission As A Cross-System Handoff In A Complex Adaptive Clinical Environment. The Case For Systems Approaches To Enhance Safe And Effective Transitions Across A True System Interface, James Espinosa, Alan Lucerna, Henry Schuitema

Rowan-Virtua Research Day

Background

Transitions from the Emergency Department (ED) to hospital medicine represent a high-stakes clinical handoff across systems. While often experienced as challenging, these interactions are better understood as occurring between services operating under different cognitive loads, operational priorities, and time horizons. Reframing the ED–hospitalist admission as a structured handoff aligns this process with broader patient safety efforts.

Objective

To characterize the ED–hospitalist admission as a cross-system clinical handoff and to identify practical strategies that enhance safety, clarity, and alignment during this transition.

Methods

Conceptual analysis informed by clinical experience, systems theory, and teaching observations. Key domains of potential misalignment were …

Reducing Pharmacy Callbacks And Improving Workflow Efficiency In The Emergency Department: A Quality Improvement Initiative, Philip .. Carhart, Hannah Culleny, Alexis Schuitema, James Espinosa, Robin Lahr, Sergey Medlenov, Gabriel Meister, Alan Lucerna

Rowan-Virtua Research Day

A simple educational intervention combined with structured provider feedback reduced ED pharmacy callbacks by 86%. While individual call duration remained unchanged, the reduction translated into nearly eight hours of provider time saved annually. This study highlights the impact of targeted quality improvement efforts on: • Workflow efficiency • Interprofessional communication • Patient care reliability. Small systems interventions can produce disproportionate operational benefits.

Detecting Early Operational Turbulence In The Emergency Department Using Fourier And Wavelet Analysis: A Conceptual Framework For Signal-Informed Anticipation And Prediction In The Ed Complex Adaptive System, James Espinosa, David Ho, Alan Lucerna

Rowan-Virtua Research Day

Background:

We theorize that Emergency Departments (EDs) function as complex adaptive systems characterized by nonlinear interactions, oscillatory demand patterns, and abrupt phase transitions from stable flow to turbulent states. Traditional dashboards rely on threshold metrics that detect instability after degradation becomes visible. Many ED data streams are significantly retrospective as well as compression-averaged into temporal systems such as days, months, quarters or even years. Signal processing methods—particularly Fourier and wavelet analysis—offer the  framework for detecting latent oscillatory shifts preceding overt operational change from laminar to transitional to turbulent flow states. This could lead to better methods of adaptation.

Conceptual Framework: …

The Safety Paradox Of Emergency Department Shift Length: Why The Relationship Between Hours Worked And Patient Safety Is More Complex Than It Appears, James A. Espinosa Md, Alan Lucerna

Rowan-Virtua Research Day

Background: Emergency department shift duration has long been debated as a determinant of patient safety. While longer shifts may increase cognitive fatigue, shorter shifts may increase the frequency of patient handoffs, which themselves introduce communication risk. Objective: To conceptualize emergency department shift length as a safety paradox arising from the balance between fatigue and handoff-related communication risks. Conceptual Framework: We propose the Emergency Department Shift Length Safety Paradox model illustrating the nonlinear relationship between shift duration and patient safety. Implications: Optimal shift design may depend on balancing fatigue risk and communication risk within a complex adaptive healthcare system. Conclusion: Emergency …

Reframing Outpatient-To-Ed Transitions As A Patient Safety Interface: Recognizing, Structuring, And Preserving Signal Across Clinical Boundaries Conceptualizing The Call-In To Ed Referral Model As A Handoff Of Care Model, James Espinosa, Alan Lucerna, Henry Schuitema

Rowan-Virtua Research Day

Background

Transitions of care are recognized sources of patient safety risk. Structured handoff processes have improved communication reliability in inpatient and emergency department (ED) settings. However, outpatient-to-ED referrals—despite representing a transfer of care—are not consistently conceptualized or operationalized as formal handoffs.

Objective

To reframe outpatient-to-ED referrals as clinical handoffs occurring across a system boundary, and to propose a conceptual and operational framework to improve safety through recognition, structure, and signal preservation.

Methods

Conceptual analysis informed by clinical experience, systems thinking, and existing literature on handoffs and patient safety. Comparative evaluation of structured (ED→ED, ED→inpatient) versus less-structured (outpatient→ED) transitions.

Results

Outpatient-to-ED …

Designing Patient Update Intervals In The Emergency Department: A Queueing-Theory And Operational Science Model Of Patient Updates And Progress Signaling To Improve Patient Experience, James Espinosa, Alan Lucerna, Henry Schuitema

Rowan-Virtua Research Day

Background Patients in the Emergency Department (ED) frequently experience uncertainty while awaiting diagnostic results, reassessment, and disposition. Even when clinical processes are progressing, prolonged informational silence may create the perception of that those processes are not advancing.

Objective To develop a conceptual and operational mathematical, queuing-theory based  model linking bedside communication, conversational time, and informational silence to patient experience.

Methods A back-of-the-envelope operational model was constructed to estimate the time required for bedside update communication during a typical physician shift. A queueing-theory framework was applied to examine how intervals between informational updates influence perceived waiting burden. Concepts from queueing theory …

Examining Racial And Ethnic Differences In Quality Of Care Between Home And In-Center Hemodialysis, Sukhman Bains

2026 Symposium

Home hemodialysis (HHD) offers improved flexibility and clinical outcomes compared to in-center hemodialysis. However, its use remains limited, particularly among racial and ethnic minority populations disproportionately affected by end-stage renal disease (ESRD). This systematic review analyzed seven retrospective cohort studies (2004–2025) to assess disparities in HHD utilization and outcomes. Minority patients were significantly less likely to initiate HHD, with adjusted odds ratios ranging from 0.45 to 0.70, while no disparities were observed within Canada’s universal healthcare system. Although HHD was associated with lower mortality, this finding is likely influenced by selection bias, as HHD patients tended to be younger and …

Synchronizing Success: Interprofessional Teamwork In Optimizing Throughput Management, Deborah Nimick, Eran Wilkerson

Providence Nursing Research Conference 2023 – Present

No abstract provided.

Evaluating The Impact Of A Nurse-Driven Oxygen Titration & Weaning Guidelines On Length Of Stay And Costs Of Care: Qi, Stephanie Zarate

Providence Nursing Research Conference 2023 – Present

No abstract provided.

Creating A Culture Change Around Stroke: Integrating Process Improvement To Reduce Door-To-Needle Time, Shayna Brewer, Benedict Pereira, Rose Bisellach, Jason Greenspan

Providence Nursing Research Conference 2023 – Present

No abstract provided.

A Qi: Implementing Pawss And Ciwa Adherence Challenge In The Psychiatric Emergency Department, Bailey Poler

Providence Nursing Research Conference 2023 – Present

No abstract provided.

Impact Of Acute Flight Training Stress On Cardiovascular Health, Toni Butler, Noah Robbins, Sophia Vaden, Bryan Hinton

Student Research Symposium (SRS)

Student pilots face a unique set of stressors that are a part of their flight training. These acute stressors can have immediate and long-term impacts on their physiological and psychological well-being. Using near-infrared spectroscopy (NIRS) to measure vascular endothelial function (a marker of cardiovascular health), this investigation will help us understand how the stressors involved in acute flight training affects the cardiovascular health of student pilots. We will test the hypothesis that acute flight training stress obtained from a single bout of flight training reduces cardiovascular function as shown by a reduced post-occlusive reactive hyperemic (PORH) response. Cardiovascular health will …

Developing Nlp-Based Open-Source Tools To Improve Medication Order Interpretation In Ehr Systems, Preslie Breton

Student Scholar Symposium

Interpreting free-text medication orders in Electronic Health Record (EHR) systems is challenging due to variability, increasing the risk of errors and non-compliance with Joint Commission (TJC) standards. This research develops Natural Language Processing (NLP) tools to enhance medication order accuracy, particularly for Duplicate PRN orders. Our open-source, vendor-neutral approach ensures broad applicability across healthcare institutions while maintaining data security.

Using Python and the Natural Language Toolkit (NLTK), we implemented a four-phase methodology. First, the NLP framework was developed on Google Colab for collaborative accessibility. Next, models were trained on 10,000 anonymized synthetic free-text medication orders to detect non-compliant entries. Model …

Developing Nlp-Based Open-Source Tools To Improve Titratable Infusion Order Interpretation In Ehr Systems, Benjamin Brewer, Jay Dorris

Student Scholar Symposium

This study evaluates the feasibility of using natural language processing (NLP) tools to identify errors in titratable infusion orders for Joint Commission readiness. Titratable infusions are adjusted at the bedside by nurses based on predefined parameters, such as monitoring goals, titration rate, conditions for adjustment, and maximum dose. These parameters are often documented as free text within order sets but can be inadvertently removed during the verification process. Some electronic health records (EHRs) may not prominently display this critical information, leading to potential Joint Commission violations. A synthetic dataset was generated using artificial intelligence to simulate one year’s worth of …

Differences In Emergency Department Imaging Modalities For Femur Fractures Based On Insurance And Demographics, Patrick De La Torre Schutz, Bryce M. Bellon, Daniel Salinas, Kelsey Baker, Hamaad Gohar

Research Colloquium

Insurance status and race have been significant predictors of delayed care and reduced imaging utilization in emergency settings, particularly among minority and Medicaid-insured populations (Moser, Shan). The reasoning for the disparities in treatment for these underserved populations is still not well understood. To further analyze these claims, this study examined whether demographic factors such as ethnicity, sex, age, insurance type, and fracture classification were associated with differences in imaging modality among patients with femur fractures. Data from the Texas Department of State Health Services Trauma Registry (2018–2022) was analyzed using logistic regression to determine the odds ratios of receiving CT, …

Decreasing Time To Antibiotics In Febrile Oncology Patients With Central Line In The Pediatric Emergency Department; A Quality Improvement Initiative, Abbigayle Carlson, Leslie Hueschen, Stephanie Clark, Christopher Kaberline, Joel Thompson

Research Days

Background: Oncology patients are at a high risk for sepsis, due to chemotherapy-induced immunosuppression and neutropenia as well as presence of a central venous catheter. Due to the high risk of sepsis, these patients require antibiotics within 60 minutes of Emergency Department (ED) arrival. During our baseline period, Sept 2022-May 2023, we only achieved this 38% of the time at Children’s Mercy ED.

Aim: By April 30th, 2024, we will increase the percentage of ED febrile oncology patients receiving antibiotics < 60 min of arrival from 36.6% to 80%, stratifying by race and ethnicity, to monitor for inequities.

Methods: Our outcome measures were the percentage of ED febrile oncology patients with antibiotics given < 60 min of arrival and the median time to antibiotic administration. Our process measures were the percentage of standard order-set usage and percentage of patients with critical information notes. Our balance measure was time from arrival to ED triage. We created a process map and fishbone diagram and identified several delays in antibiotics administration. We performed interventions with Plan-Do-Study-Act methodology. First, we implemented standing nursing orders to decrease the time spent waiting for a provider to order antibiotics (June 2024). Next, the outpatient oncology providers created a Critical Information Note, which directed prompt antibiotic administration prior to labs or consultation (August 2024). To engage physicians, we made this a Maintenance of Certification (MOC) project, with monthly review of run charts (Oct 2024). Next, we prioritized timely access of the patients’ central line, with a nursing script to communicate with families the importance of accessing their child’s central line as soon as possible (Oct 2024). We created a Central Line Note, identifying the type of central line and needle size required to access the line (March 2024).

Results: With the implementation of …

Time To Transfer - The Clock Is Ticking: A Quality Improvement Project, Tara Rakiewicz, Liam Heneghan, Brianna Costello, Matthew Tucker, Michael Zimmerman, Tanya Thomas, Jessica Sheridan, Adam Binder

Health Equity and Quality Improvement (HEQI) Summit

Background

• Thomas Jefferson University Hospital Center City (TJUH CC) campus is the predominant referral center for patients with hematologic malignancy in parts of PA, DE, and NJ
• Patients accepted for transfer to TJUH under Medical Oncology, often have longer than anticipated time to transfer (time from transfer acceptance to patient physical arrival)
• Long transfer times delay potentially lifesaving diagnostics and treatment; this can be most concerning for patients with aggressive hematologic malignancies given need for subspecialist management
• Data review from 2023-2024 showed patients with aggressive hematologic malignancy (defined as acute leukemia, chronic myeloid leukemia in blast crisis, diffuse large B …

Are Hospital-Acquired Sepsis Cases Over-Reported Due To How Sepsis Is Coded In Electronic Health Records?, Michael Sakarya, Cooper Roslund, Spencer Foreman, David Gaieski, Md, Shruti Chandra, Md, Wayne Bond Lau

Health Equity and Quality Improvement (HEQI) Summit

Introduction

• Hospital-acquired sepsis (HAS) is a preventable cause of morbidity and mortality for hospitalized patients and is associated with greater cost and resource utilization compared to non-HAS.
• International Statistical Classification of Disease (ICD) coding system is used to identify HAS.
• Patients assigned HAS by ICD coding are presumed to have a nosocomial infection.
• Errors by ICD coding may cause misclassification of HAS cases.
• Unclear whether misclassified HAS have different outcomes than actual HAS

Quantiferon Tb Gold Test Utilization During Inpatient And Emergency Department Encounters At A Multi-Site, Single Academic Institution, Laxman Singanamala, Bs, Laura Walters, Do, Devin M. Weber, Md, Courtney E. Comar, Phd

Health Equity and Quality Improvement (HEQI) Summit

Background

• The QuantiFERON-TB Gold Plus test (QG) is an in vitro Interferon Gamma Release Assay that can be used to assess for prior exposure to Mycobacterium tuberculosis (MTB). The optimal use is in screening for latent disease.
• The United States is a low endemic country for MTB infection with 2.5 cases/100,000-persons in 2022 (CDC). Yet, we noted high utilization of the QG in our institution.
• Our goal was to understand our patient population and the clinical rationale for testing to create an electronic medical record (EMR) order set to optimize appropriate test use, decreasing unnecessary testing for patients and healthcare …

Ensuring Timely Interventional Radiology Biopsy Procedures With Standardized Pre-Procedural Protocol And Guidelines, Joy Zhao, Md, Mohsin Arsiwala, Md, Minki Hong, Md, John Scalise, Md, Limi Jamma, Md, Hanna S. Ellingsen, Md

Health Equity and Quality Improvement (HEQI) Summit

Proposal

• Aim
  • To decrease rate of canceled or delayed IR biopsy procedures by 25% by implementing pre-operative order sets for inpatient IR procedures at Jefferson Center City Hospital in the next 6 months 
• Population of Interest
  • Jefferson Center City teaching team patients requiring IR biopsies
• Intervention
  • Implementing pre-operative order sets that include diet restrictions, anticoagulation guidelines, pre-operative labs, and pre-operative blood pressure and glucose goals 
• Quantifiable Outcome Measurement
  • Comparing rates of canceled and/or delayed IR biopsy procedures in the patient group that use the pre-operative order set compared to those who did not use the order set 
• Data Collection Methods …

Readmission For Picc Line Placement In Spine Surgery, Joseph Schaefer, Md, Joshua Heller, Md, James Harrop, Md

Health Equity and Quality Improvement (HEQI) Summit

Background

• Pseudoarthrosis is failure of adequate bony fusion after a spinal fusion
• Prior literature has implicated occult C. acnes infection in cases of pseudoarthrosis
• Intraoperative cultures are often sent in cases of pseudoarthrosis at Jefferson
• C. acnes cultures often result after discharge requiring readmission

Reducing Antibiotic Duration For Pneumonia And Sinusitis In The Emergency Department: A Quality Improvement Approach, Joshua Saucedo, Leslie Hueschen, Amanda Nedved, Marsha Dannenburg, Patricia Phillips, Jennifer Floyd, Alaina N. Burns, Rana El Feghaly

Research Days

Background: Our aim is to increase the percentage of children discharged home from the ED with a diagnosis of CAP or ABRS treated with an optimal antibiotic duration (3-5 days for CAP, 5-7 days for ABRS) from 13% to 70% by July 25.

Methods: Outcome metric is the percentage of patients receiving recommended antibiotic duration for CAP and ABRS. Process metrics include use of order set, "Quick Discharge” order set, and clinical pathway QR codes. Balancing metric is the number of return visits with the same diagnosis < 14 days. Plan-Do-Study-Act methodology was used. In Aug 23, our ASP disseminated a handbook that emphasized shorter durations. A new multidisciplinary team (infectious diseases, ED, and urgent care physicians, advanced practice providers, nurses, and pharmacy) formed in Dec 23. We utilized cause-and-effect analysis, driver diagram, and prioritization matrix, which helped identify other impactful interventions, including implementation of new internal CAP clinical pathway order set (April 24) and “Quick Discharge” order sets (May 24). Next, we surveyed prescriber comfort (June 24) with shorter duration identifying barriers and providing education, leading to posted evidence for lower duration treatment in practitioner workrooms and developing a new ABRS clinical pathway (Sept 24). Top prescribers providing optimal duration received email acknowledgement (Oct 24) and resident rotators received antibiotic handbook and CAP clinical pathway QR codes (Nov 24). New best treatment practices for ABRS were elucidated and disseminated through clinical pathway and internal article publishing to our hospital and associated clinics (Dec 24).

Results: We saw shifts in the outcome metric’s center line in Sept 23 …

Communication Matters! Exploring Experiences Of Non-English Language Preferred Families In The Neonatal And Pediatric Intensive Care Units, Sana Haq, Erin Cohen, Susan Schmidt, Rochanak Moassabeb, Folasade Kehinde

St. Chris Research Day

No abstract provided.

Cardiovascular Risk Factors In The Autism Spectrum Disorder Population, Christian C. Iannuzzelli, Andrea L. Iannuzzelli

Rowan-Virtua Research Day

The population of patients with Autism Spectrum Disorder (ASD) have multiple risks and barriers that may make access to proper health care more difficult. After extensive research, some of these barriers may have been identified that pose greater risks to generating proper care for those with ASD. Some of these barriers include medical complexity, more sedentary lifestyles, poor food choices, as well as health comorbities. Some of these health comorbidities include hypertension, metabolic dysfunction, sleep apnea, and inflammation. This study aims to understand what barriers and risks for CVD are present in those with ASD.

Photodynamic Therapy Vs. 5-Fluorouracil For Field-Directed Treatment Of Actinic Keratosis: A Comparative Literature Review, Bhumik Patel

Rowan-Virtua Research Day

BACKGROUND: Actinic keratosis (AK) is a common precancerous skin condition arising from chronic UV exposure and often involves field cancerization, where visible lesions coexist with subclinical damage. Effective field-directed treatments are critical for preventing progression to squamous cell carcinoma.

HYPOTHESIS: Photodynamic Therapy (PDT) may offer superior efficacy, cosmetic outcomes, and patient adherence compared to topical 5-Fluorouracil (5-FU), despite its higher cost and clinical setting requirement.

METHODS: This literature review analyzed peer-reviewed studies from 2015–2025 comparing PDT and 5-FU for field-directed AK treatment. Outcomes assessed included lesion clearance, recurrence, tolerability, adherence, cost, and patient satisfaction.

RESULTS: PDT demonstrated high clearance rates …

Expanded Patient Reach At New Student Run Free Medical Clinic Location, Olivia Krol, Hana Warmflash, Alex Foster

OHSU-PSU School of Public Health Annual Conference

Background: Critical to modern medical education, student run free medical clinics (SRFCs) are present at more than 75% of AAMC member institutions. SRFCs educate students while providing low-barrier, free healthcare to underserved populations. SRFCs provide unique leadership and health systems management opportunities not traditionally emphasized in training, including leading logistical and operational changes.

In this project, we highlight the impact of a student-led operational initiative that transitioned our clinic from the River District Navigation Center (RDNC) to the Resource Center (RC), improving accessibility.

Methods:

Deidentified patient data from medical clinics from January 2024 to February 2025 were analyzed using RStudio …

Shorter Surveys, Better Insights: The Role Of Patient Reported Outcome Surveys In Value-Based Care, Paul Bonilla, Anesu Karen Murambadoro, Victoria Elizondo, Juan Pablo Flanagan

Research Symposium

Background: Patient-reported outcomes (PROs) are essential for tracking patient progress, but lengthy surveys, such as the 40 question Knee Injury and Osteoarthritis Outcome Score (KOOS), create time and cost challenges for private practice. Starting July 2024, the Centers for Medicare and Medicaid (CMS) now require hospitals to collect pre surgery and one year post surgery (9-15 months) HOOS JR and KOOS JR scores for total replacement surgeries, with public reporting set for 2027. Non-reporting carries financial penalties, underscoring the need for streamlined solutions. As value-based care becomes a priority, practical strategies are needed to reduce the burden on providers …

Assessing Patient Satisfaction: The Role Of Net Promoter Scores In Healthcare, Paul Bonilla, Victoria Elizondo, Juan Pablo Flanagan

Research Symposium

Background: The Net Promoter Score (NPS) is a widely used tool for measuring customer satisfaction and loyalty through a simple question: “How likely are you to recommend [company name] to a friend or colleague?” Responses categorize individuals as Promoters (9–10), Passives (7–8), or Detractors (0–6), with the final score calculated by subtracting the percentage of Detractors from Promoters. Introduced in 2003, NPS has become popular across industries for its simplicity, predictive value, and benchmarking capabilities. In healthcare, NPS adoption is increasing as hospitals seek concise, standardized tools to assess patient satisfaction—an essential metric in the shift toward value-based care. …