Quality Improvement Commons^™

Reducing Surgical Site Infection After Colorectal Surgery: A Multidisciplinary Review Of Process Improvement, Robin Daemmrich, Quentin Dipasquale, Deborah Klepac, Nick Mathers, Travis Holloway

Central & West Texas and San Antonio GME Research Day 2026

No abstract provided.

Redesigning Outpatient Chemotherapy Scheduling: A Management Approach To Site-Integrated Operations, Dominick J. Morrone

MUSC Theses and Dissertations

Outpatient infusion centers face persistent scheduling complexity driven by variable treatment durations, coordination between clinics, pharmacy lead times, and constrained staffing. This doctoral project develops and reviews a comprehensive framework for infusion scheduling transformation that integrates workforce role redesign, site‑level communication pathways, and data‑informed workqueue governance. Using a multi‑phase case at a large cancer center as an anchor, the framework specifies responsibilities across central schedulers, on‑site teams, medical coordinators, and nursing; details communication and escalation design (secure messaging and in‑basket use); and outlines training and proficiency tiers. The project synthesizes evidence from scheduling science and time-driven activity-based costing principles to …

Glucometer Cleanliness On A Neuro-Medical Intensive Care Unit, Abbey Camire

Operations Transformation

Glucometers on the Neuro-Medical ICU are being docked with visible reddish/brown residue, indicating they are not properly cleaned beforehand. This poses a risk of transmitting pathogens, endangering patient and staff safety, and violates hospital policy and regulatory standards. Proper disinfection of mobile medical equipment is essential for infection control and hospital accreditation.

New Patient Onboarding, Jennifer Fournier, Sarah Flagg, Alletta Roberts Dzik, Lyndsay Stevens, Shannon Smith, Karen Waterhouse

Operations Transformation

Currently there are barriers to establish a new patient with a primary care. The workflow for patients who self-refer currently requires 10 steps and is performed by 7 care team members.

• 4 PSR at the front desk complete paper intake forms that are then manually entered into a spreadsheet by 3 other care team members.

The step in the workflow, to obtain the release of information for patient records to be requested and submit the form, is inconsistently followed internally and externally and results in very long process time of 40+ days. This step is frequently overlooked due to the …

Sbirt Workflow, Dory Hart Emery, Tory Gamage, Sara Watts, Carol Mcclure, Anne Barker, Liz Berry, Liz Anderson

Operations Transformation

SBIRT stands for Screening – Identify patients with unhealthy substance use. Brief Intervention – A collaborative conversation that raises a person’s awareness of substance use and its consequences and encourages behavioral changes. Referral to Treatment – Actively link patients to resources when needed. It is a substance use screening tool that we ask patients 18 yrs. old and older to fill out once a year when having their CPE or AWV. SBRIT has been recognized as an integral part of primary care. It is an approach that delivers prevention, detection, and early intervention for individuals at risk of substance use …

Pbpa Creating Pathways To Ensure Patients Are Using Their Inhaled Medications Effectively, Suzan Michelle Collins, Heather Blake, Chandler Blodgett, Sue Vermette, Martine Eon

Operations Transformation

Problem: Patients do not consistently know how to prepare, use and/or clean their inhalers effectively.

Impact: When patients do not consistently know how to prepare, use and/or clean their inhalers effectively they are in fact, not receiving the benefit from their prescribed medication.

They experience poor patient outcomes and overall poor patient experience.

• Increased calls to provider offices for unresolved, worsening symptoms and/or complications. (Thrush, hoarseness, cardiac symptoms etc.)
• Increased same day office visits.
• Patient crowding in Urgent Care and/or Emergency Department.
• Hospital Admissions.
• Increase in emotional and financial stress from missing school and/or work.
• Increase in referrals to specialists …

Mainehealth Medical Group Report Inventory, Holly Ward, Robin Lozinski, Stephanie Lepine, Shawn Mcglaughlin White, Tracey Shaw, Sheila Adell

Operations Transformation

Variation of Epic Quality Reports being used across MHMG following the merge of Coastal, Mountain and Southern region quality departments resulting in inconsistent workflows and processes. This can lead to inconsistent care and outcomes of Quality Data we report.

Ultrasound Guided Piv Insertion Implementation, Blake Hotchkiss, Beth O'Donnell, Miles Merwin, Billie Jo Senecal, Ronica Smith, Eric Alan, Bryan Tavary, Chelsea Harkins, Taylor Archard, Leslie Geissinger, Lauren Remington

Operations Transformation

Observed high number of unsuccessful peripheral IV insertion attempts. This increases waste (cost and time) and decreases patient satisfaction.

Improving The Utilization Of Lunch Breaks For Nursing Staff, Norma Dawson, Kelsey Robinson, Bridget Miller, Deborah Monck, Beth Kessler

Operations Transformation

The Med-Surg Unit at LincolnHealth has a high number of nursing staff missing lunch breaks, despite encouragement and existing efforts to promote taking breaks. In addition, there are many instances where staff are not accounting for the breaks they have taken on their time sheets.

Key Performance Indicator (Kpi) Development Pathway, Christopher Lloyd, Amy Giles, David Spaulding, Sarah Rines

Operations Transformation

In Q1 FY24 as more team members started to take Operational Excellence classes and subsequently become more engaged in quality improvement it was observed there was much enthusiasm but also some gaps in the understanding of available tools, resources, data collection strategies, and what elevates something to a KPI, etc. There is a need to create a guide that supported gaps, streamlined tracking process, and aligned teams in this new approach.

Addressing Equitable Access In A Safety-Net Hospital System: An Implementation Framework, Hillary Alycon

Dissertations: Doctor of Public Health

Acute care organizations face a significant challenge in effectively implementing health equity programs, particularly in rural areas where guidance is often lacking. Despite abundant literature focusing on health outcomes, there remains a noticeable dearth of published data on implementing health equity initiatives. In response to this gap, I present a comprehensive analysis that utilizes readily available, open-sourced data to address this critical issue.

A thorough assessment of the demographic characteristics of acute care facilities within the catchment regions was conducted based on data from reputable sources such as the US Census Bureau, the American Community Survey, and the County Health …

Patient Throughput In The Emergency Department, Daniel Alanis

MSN Capstone Projects

In response to ongoing overcrowding in emergency departments, it is imperative to explore effective strategies for mitigating the capacity crises. The purpose of this project is to investigate and implement throughput strategies for a large level 1 trauma emergency department in Houston’s Texas Medical Center. The proposal involves launching a process improvement project to identify opportunity potential for two main interventions: 1. Patient classification for split clinical pathways 2. Dedicated liaison role for throughput responsibilities. The review aims to answer the question: In emergency department patients, how does the implementation of a dedicated throughput liaison compared to a split flow …

Quality Improvement In Healthcare: A Practical Guide For Providers, Jeremy Ellis

Transformative Medicine

No abstract provided.

Implementation Of A Drive-Through Covid-19 Mass Vaccination Site: Experiences From Louvax–Broadbent In Louisville, Kentucky, Ruth Carrico, Sarah Beth Hartlage, Valenchia Brown Msn, Aprn, Fnp-C, Sarah M. Bishop, Luanne Didelot, William Hayden, Beverly Williams Coleman, Sarah Tan, Delanor Manson, Kellie Kane, Dawn Balcom, Paul Kern

The University of Louisville Journal of Respiratory Infections

Background: Response to the COVID-19 pandemic has required innovative approaches to vaccination, including methods to rapidly and safely immunize communities. A major challenge to such a response involved access to untapped healthcare worker resources. The Louisville, Kentucky, response involved the use of a large volunteer workforce to supplement local public health employees in planning and implementing a large-scale drive-through vaccination event. The objective of this manuscript was to outline processes involved in training a mass immunization workforce and implementating a large-scale COVID-19 community vaccination.

Approach: Competency-based and standardized training was provided for every volunteer before working their shift. Volunteers worked …

Improvement Cycles In Medical Education: From Quality Improvement To Patient Care And Clinical Research, Julio A. Ramirez

The University of Louisville Journal of Respiratory Infections

No abstract provided.