Project Registry

Big Aim
Clinical Area
Clinical Setting
MeSH Keyword

Utilization of the HEART Score and a Multidisciplinary Chest Pain Algorithm in the Adult ED: Safely Decreasing Admissions and Resources

QPI: Brandon, Allen, (

The goal of this CQI/IRB-approved project is to provide a tool that helps risk stratify patients with chest pain concerning for ACS to a low risk cohort that can be safely discharged OR a group that will need further testing or admission.

"ED Provider in Triage Decreases Walkouts, Improves Door-to-Provider Times, and Increases Hospital Revenue: A Value-Based Intervention"

QPI: Brandon, Allen, (

A well-known intervention to decrease LWBS is a Provider in Triage (PIT) model to perform Medical Screening Exams (MSE) and identify emergencies while improving utilization of resources.

Pressure Ulcer Algorithm Project

QPI: (

The purpose of this project is to develop a reliable tool for the nurses to utilize in accurately identifying and staging pressure ulcers.

Implementation of a Withdrawal Assessment Score in Pediatric ICUÕs

QPI: (

"To improve communication and management of withdrawal in pediatric critical care patients, a search for a validated withdrawal assessment tool was conducted, and the WAT-1 was selected."

Addressing Hospital Readmissions: Impact of Weekly Review

QPI: (

The aim of this study was to examine the readmission rate to a family medicine residency program inpatient service following the implementation of a once per week session that reviewed patients who were readmitted during the prior week.

Fast Tracking Pediatric Patients Post-Anesthesia

QPI: (

"The purpose of this pilot was (1) to decrease exposure of severely immunocompromised children to the general population in the PACU, (2) improve OR throughput in times of high PACU census, and (3) improve patient satisfaction."

Success with an Evidence-Based Antimicrobial Protocol in the Trauma ICU

QPI: (

Patients who unnecessarily receive antibiotics are at risk for serious adverse events with no clinical benefit and this practice has contributed to the growing problem of antimicrobial resistance.

Reducing Blood Culture Overuse in the Adult ED: Sustained Success

QPI: (

Avoiding blood cultures in low- risk patients directly decreases treatment costs and contributes to patient safety by minimizing the risk of false positive results. The goal of this project was to sustain the decrease in blood culture ordering for patients at low risk for bacteremia. We hypothesized that incorporating the blood culture ordering algorithm into the Epic EMR would improve sustainability by frequently reminding ED providers to use the algorithm.

Improving an Alert System for Dangerous Laboratory Test Results In the Ambulatory Setting to Reduce Adverse Patient Outcomes

QPI: (

We sought to improve the critical value alert process to advise clinicians of elevated glucose levels earlier so that dangerous adverse outcomes can be avoided in the ambulatory clinical setting.

A Single Center Quality Improvement Initiative to Reduce Free Text Orders and Improve Patient Safety

QPI: (

Due to an increased number of patient safety events related to NCOs we performed a quality improvement project to reduce NCO usage.

After Visit Summary (AVS) Performance Improvement Team

QPI: (

"Create a concise and standardized AVS format that is more meaningful to patients and families. Post information under prioritized headers so that the patient might better understand and comply with intended discharge instructions, possibly contributing to a decreased readmission rate"

Electronic Safety Checklists Reduce Severe Errors and Increase Workflow Efficiency in a Radiation Oncology Department

QPI: (

To review the impact of our electronic safety checklist program on radiation therapy (RT) treatment planning efficiency and in reducing errors in its first year of implementation.

A Proposed Questionnaire to Evaluate Inpatient MICU* Transfers to be Used for Improving Internal Medicine Resident Learning and for Identifying Future Areas of Quality Improvement.

QPI: (

"To propose a questionnaire derived from literature review for the evaluation of inpatient MICU transfers that will improve IM resident education, and identify patient-care system failures."

Want to improve your Mortality Index? Do this!

QPI: (

"The Neuromedicine Interdisciplinary Clinical and Academic Program (NICAP) examined metrics of quality including the Vizient (formally UHC) Morality Index. Two domains, Clinical Documentation Improvement (CDI) and Palliative Care referrals affect this index and were the focus of these improvement efforts."

Implementation of Comfort Positioning as a Standard of Care for Pediatric Patients Undergoing Painful Procedures While on a Pediatric Medical-Surgical Unit

QPI: (

To introduce the concept of comfort positioning to nursing staff To determine efficacy of comfort positioning in children To determine if nursing staff utilized this method to reduce discomfort To evaluate parentsÕ satisfaction regarding use of the technique

Education Prior to Urodynamic Testing Improves Patient Experience

QPI: (

Create an educational video for patients to view before testing appointment. Improve patient preparation prior to urodynamic testing. The video would clarify the indications for the procedure. The video would explain every detail about what happens during the testing. Thoroughly prepare patients to improve testing results and supplement the patient-physician interaction. Show that appropriate education can increase patient satisfaction.

Increasing Nurse Participation in Patient and Family Centered Rounds

QPI: (

"To improve teamwork on the general pediatric floor, a goal was set to increase nurse participation in patient and family centered rounds to ensure more consistent communication from the medical team to the patients."

Retrospectively Determine if Long Acting Antipsychotics Decrease Readmission Rates Over a Two Year Period.

QPI: (

"The purpose of this study is to investigate the effect of LAIs on readmission rates and average length between readmission in patients discharged from an inpatient psychiatric hospital with the diagnosis of Schizophrenia, Schizoaffective disorder and Bipolar I Disorder."

An Assessment of Patient Safety Reporting Before and After Implementation of an Anonymous Electronic Reporting System

QPI: (

"To implement an electronic, standardized patient safety reporting system at the NFSG VA to replace the previous paper based reporting system. To educate physicians on the importance of reporting patient safety concerns in an effort to reduce system errors. Patient safety reporting at the VA will increase by 100% in the first 4 months after introduction of an electronic reporting system and education program given to internal medicine physicians about reporting patient safety concerns at the VA."

Expediting Discharge to Shands Rehab Hospital

QPI: (

Current State: Complexity and regulatory requirements for admission to IRFÕs have a potential to create delays prior to arrival. Desired State: Overcome obstacles to expedite admission to rehab and provide a timely discharge from acute care.

Maximizing the Electronic Health Record to Improve Nutrition in Hospitalized Patients

QPI: (swolfe@UFL.EDU)

Evaluate the effects of a process improvement strategy to improve the administration and documentation of ONS: Reducing variation of care processes by standardizing nutritional order sets in a new Electronic Nutrition Administration Record (ENAR) Linked nutrition tab in the medication administration record Scheduled administration of nutritional supplements Evaluate current process and workflow Improvement in administration of ONS as compared to pre-assessment Increased % of formula not returned to food & nutrition services as compared to pre-assessment Staff satisfaction with process changes

Improving Compliance in Critical Lab Result Documentation by Dual Nurse Verification Methods

QPI: (

The Unit 55 Process Improvement Team set a goal to increase compliance of critical lab result documentation by implementing dual-verification process between two nurses.

A Comprehensive Approach to Elopement Reduction in the Psychiatric Inpatient Environment

QPI: (

Create a safer environment for patients Reduce elopements from our facility Bridge the gap between hospitality and safety

Resident Assessment of Risk at UF Health Shands Psychiatric Hospital

QPI: (

The purpose of this study was to assess the incidence of patient violence towards staff members on the inpatient psychiatry unit at the UF Health Shands Psychiatric Hospital (Vista).

Monitoring the Use of Personal Protective Equipment (PPE) in Isolation Rooms

QPI: (

Prior to Aug. 2015 the compliance rates with PPE usage in isolation precaution rooms at UF Health Shands Hospital was not studied. The purpose of this initiative was to develop a monitoring program using an electronic tool with Òsecret shoppersÓ to determine PPE compliance rates.

Implementation of Near-Infrared Technology (AccuVein AV-400¨) To Facilitate Successful PIV Cannulation

QPI: (

Describe the impact of device use in successful vein cannulation Discuss the effect of device utility on staff satisfaction Identify the benefits of device use on decreasing central resource utilization

A MINI-CASE SERIE OF CLINICAL-PATHOLOGIC DISSOCIATIONS: Importance of the standardized approach for quality assurance in specimen grossing

QPI: (

How can we deal with these clinical/ pathological discrepancies as residents? What role as in-training pathologists do we have in quality control/ quality improvement systems ? How can we apply these systems as pathology residents to improve patient care? Did we improve the outcome for the patients in any of the cases received? Highlight the importance of a Òteam approachÓ when confronted with an unexpected result and the reconciliation of disparities with our clinical colleagues.

Continuous Lidocaine Infusion as Adjunctive Analgesia in Critically Ill Patients: A Case Series

QPI: (

"Systemic lidocaine infusion has been used as an adjunct analgesic agent in patients with various types of pain, including chronic pain associated with terminal illness as well as pain from surgery or neuropathy. Although lidocaine infusion has a promising role in pain management in the intensive care unit (ICU) due to the lack of respiratory depression, the safety and effectiveness of its long-term use in ICU patients have not been well studied"

Eating Disorders: Increasing Appropriate Diagnoses

QPI: (

Early screening and psycho-education can allow those individuals who are in the dark to come forth and talk about their current issues; this will allow for early intervention and thereby reduce mortality.

Reducing Electronic Prescribing Errors and Saving Ambulatory Practice Time Using an Intraprofessional Collaborate Approach

QPI: (

"In order to assess the problem of duplicate refill medication requests, we conducted a multi_faceted process review involving clinical staff, providers, and community pharmacists to understand the process and identify areas for improvement."

"Improving Physician and Nursing Communication on Antepartum, Postpartum, and Gynecology Units (35 and 95)"

QPI: (

Develop a paging system that easily identifies which residents are on call for each service. Develop techniques to improve communication on the units including bundling non-urgent pages and utilizing text paging.

Evaluating the Incidence of Central Line-Related Infections in Patients Receiving Parenteral Nutrition: A Retrospective Analysis

QPI: (

Determine the incidence of line-related infection in patients receiving PN at UF Health Shands Hospital through a retrospective study Identify modifiable and non-modifiable risk factors for development of line-related infections in PN patients Develop and implement clinical educational programs for hospital staff and patient care bundles aimed at reducing CBRSIs in this patient population

Enteral Nutrition Administration Record (ENAR) Prescribing Process Using Computerized Order Entry: A New Paradigm and Opportunities to Improve Outcomes in The Critically Ill.

QPI: (

To create a new Electronic Nutrition Administration Record (ENAR) with a linked nutrition tab within the EHR that will make data easily accessible and will be meaningful to the end user. To promote enhanced patient outcomes by improving adherence to established institutional EN protocols and early caloric goals.

Afternoon discharge huddles to increase early discharges

QPI: (

Daily afternoon multidisciplinary team huddles will increase the discharges orders before 10am by 10% on the Medicine teams by June 2015.

Deploying Just Culture Event Investigations to Drive High Reliability

QPI: (

The Just Culture¨ model was deployed in all levels of patient safety event investigation and analysis in order to unite the college of medicine and the 996 bed hospital on a cultural journey towards high reliability. The end goal: to drive measurable improvements in patient safety.

Using Simulation to Identify Knowledge Gaps and Improve Resident Competency in Emergent/ Critical Care Imaging

QPI: (

"In 2011, the Department of Radiology in the College of Medicine at the University of Florida in Gainesville created an Emergent/Critical Care Imaging Simulation (a component of the Wisdom in Diagnostic Imaging [WIDI] program) to assess resident preparedness to proceed to the next level of training _ to competently and independently cover Radiology consulting for the hospital on the overnight shift in the reading room _ an Entrustable Professional Activity (EPA)."

Use of Health Maintenance Tables to Improve Screening Mammography

QPI: (

Assess the potential use of health maintenance tables to improve rate of screening mammography

Magnetic Resonance Imaging Safety Process Improvement Team

QPI: (

"The identified problem was the current process did not meet American College of Radiology (ACR) Magnetic Resonance Imaging (MRI) zoning, signage, staff competency, safety requirements, and all hospital needed related education. Ferrous metallic objects have been inadvertently allowed as far as Zone 4 creating an unsafe patient environment and damaging machinery. UF Health currently has six magnets at five different locations with no two sites identical in physical design"

"Physician Burnout, Depression, and Suicide Prevention"

QPI: (

"Conduct a study to better assess depression prevalence, risk factors and potential barriers to treatment amongst UF residents Last yearÕs study included a survey using the Center for Epidemiological Studies Depression Scale"

Increasing the Number of Certified Nurses in the PACU

QPI: (

"Our goal was to offer education, mentoring and support to meet unit and hospital goals of 38% certification rate of our nurses."

ABO Verification for Solid Organ Transplant

QPI: (

To ensure OPTN/UNOS ABO Verification policy compliance a process improvement team was formed including members of UF Health Shands Operating Rooms and UF Health Shands Transplant Center to identify measures to improve the ABO verification process in the OR at the time of the transplant.

Improving Documentation of Pain and PRN Reassessment

QPI: (

"A reassessment of the patientÕs response must be documented within one hour of administration of a prn medication for pain or another indication (e.g. nausea, etc.). Historically, a staff nurse reviewed 5 medical records/week to assess compliance in the Pediatric Intensive Care Unit (PICU). Documentation compliance averaged 63% (range 32% - 100%) March 2014 Ð June 2015. Various passive efforts to provide education and reinforcement of documentation requirements did not improve compliance. The hospital received a requirement for improvement (RFI) related to reassessment after The Joint Commission visit July 2015. The PICU then implemented additional, more active, strategies to improve documentation compliance."

Inpatient STEMI Process Improvement Project

QPI: (

The focus of this project is to improve patient outcome and the quality of service delivery by implementing a standardized approach to care management of inpatients who develop STEMI.

Bone mineral density (BMD) and vitamin D status in patients with Inflammatory Bowel Disease (IBD): An approach to quality improvement

QPI: (

The aim of this study was to determine how effectively BMD and vitamin D level were being monitored and treated for quality improvement and compared with AGA guidelines. The secondary aim was to formulate an intervention to help improve bone health assessment/evaluation in IBD clinic.

Standardized reporting of vascular incidental findings on cross-sectional imaging

QPI: (

"Vascular findings are common incidental findings on cross-sectional imaging. Many of these are aneurysms of the abdominal viscera (e.g. abdominal aortic aneurysm, renal artery aneurysm), or penetrating atherosclerotic ulcers for which follow up imaging is indicated. There are also many vascular incidental findings that require no follow up imaging. There is inconsistent reporting of these findings which may lead to uncertainties in management."

Providing Care to Obstetric Patients Who Refuse Transfusion of Blood Products

QPI: (

"To improve provider and patient awareness of the primary and secondary blood products available at UF Health. Primary blood products are universally not accepted by JehovahÕs Witness. However, the acceptance or refusal of secondary blood products are left to the individual personÕs biblical interpretation. Considering the vast options of secondary blood products available at UF Health, it is important to give all patients, especially those who would refuse primary blood products, proper information and education on the options available to them."

Effects of Collaboration between Nurse-Physician Extender among 5 West Trauma patients

QPI: (

To determine the effects of collaboration between physician extenders and nurses among 5 West Trauma patients

Facilitating Patient Safety Reporting by Residents: A Brief Educational Intervention

QPI: (

"Patient Safety Reports (PSRs) are electronically submitted statements filed by members of the allied healthcare team when actual or potential harm has befallen a patient. PSRs constitute a vital data stream to direct quality improvement within UF Health. Despite being a prominent aspect of daily patient care, resident physicians have exhibited low rates of PSR use. The authors contend that brief educational interventions can increase resident knowledge of PSR policies and procedures."

FALL PREVENTION: Fall Risk Analysis in a Psychiatry Inpatient Setting

QPI: (

Current fall risk assessment scales do not account for the differences between general acute care and psychiatric patients

An Improved System of Abnormal Cervical Cytology Follow-up

QPI: (

To create a new and improved system for follow-up of abnormal cervical cytology/pathology that: Provides an enhanced health care experience for our patients Maximizes efficiency for providers Is financially feasible Limits loss to follow-up Decreases rates of progression to cervical cancer

Geolocalization for Improved Patient Care

QPI: (

We organized a pilot starting September 2015 to have 2 hospitalists have all of their patients on one floor. We soon expanded the pilot to 4 hospitalists having all their patents on one floor.

Health Literacy Screening in the Presurgical Center

QPI: (

Knowing a patientÕs Health Literacy is important for patient education. Perioperative care plans can be carried out in a patient-centered manner based on the patientÕs Health Literacy.

Speaking the same language: Providing a Useful Preoperative Medical Consultation Report

QPI: (

"To develop a standardized format across multiple departments (internal medicine, anesthesiology, and surgery) to communicate preoperative recommendations in order to improve the effectiveness of preoperative medical consultation"

Fall Prevention A Multi-Component Fall Prevention Bundle

QPI: (

"The purpose of this project was to evaluate the impact of a standardized, evidence-based, multidisciplinary approach to fall prevention. Additionally, this project aimed to increase the patientÕs awareness of their mobility needs by providing individualized structured signage."

Clinical Validation of R-T Estimation for Coaguchek XS INR Results

QPI: (

"The Anticoagulation Clinic at the University of Florida (UF) Health Cardiovascular Center is staffed by a hematologist, pharmacists and pharmacy students. The census of the clinic is about 210 patients with a wide array of indications for anticoagulation therapy. The clinic uses the CoaguChek XS¨ for most patients for in-clinic monitoring. Traditionally, a venous draw was performed on any CoaguChek XS¨ INR values >4 due to accuracy concerns. This step increases patient cost, wait time and can strain our available resources. Thus, a calculation to correct CoaguChek XS¨ INRÕs above 4 to a predicted venipuncture level was developed and previously reported.1 The equation, 0.621 x CXS INR + 0.639 = venipuncture INR (the R-T Estimation), correlates to a venipuncture INR in their anticoagulation clinic. While the equation was able to provide an estimation of the venipuncture, it was not accurate enough to be called a surrogate for the venipuncture. The purpose of the current study was to provide validation of using the calculation in terms of effect on clinical patient care decisions."

Evaluation of the Appropriateness of Target Specific Oral Anticoagulant Selection and Monitoring in the Outpatient Setting

QPI: (

To determine if patients receiving care at UF Health Internal Medicine are prescribed target specific oral anticoagulants (TSOACs) according to FDA-approved labeling Secondary Objectives are to determine: Percentage of patients receiving appropriate baseline laboratory tests prior to TSOAC initiation Number of patients who had renal function re-assessed after TSOAC initiation Clinical outcomes (bleeding and thrombotic events)

Daily Multidisciplinary Reminder for Urinary Catheter Management in the Burn Center

QPI: (

Two of the UF Health big aims are reducing variance in care and reducing harm. The aim of the project was to reduce the incidence of CAUTI in the Burn Center by decreasing urinary catheter utilization and increasing Burn Center RN and MD compliance with the UCMP. Creating buy in for earlier discontinuation of urinary catheters was especially challenging given the burn/wound populationÕs propensity for massive fluid shifts and insensible losses through open skin and wounds that is hard to quantify without use of indwelling catheters.

Assessment of a Daily Safety/Operations Huddle in a Pharmacy Department

QPI: (

"To enhance its work to foster a culture of safety, the Department of Pharmacy elected to pilot the use of a safety and operations huddle each morning."

Promoting Infant Safe Sleep to Reduce Infant Falls/Drops

QPI: (

Evaluate infant safety within UF Health Shands. To develop an infant safety bundle utilized in the practice environment

Reducing Point of Care Laboratory Errors Utilizing Standard Management Protocols and Training

QPI: (

"In order to reduce errors in POCT testing that contribute to diagnostic errors, increase provider confidence in testing results, and increase staff confidence in conducting POCT tests, we sought to standardize the training, competency assessment, and documentation of POCT testing throughout the UF Health Physician practice."

Safe Surgical Instrument Reprocessing for L&D

QPI: (

"The use of rigid, punctureÐproof sterilization containers is recommended by the Association of Operating Room Nurses (AORN). However, L&D was using Kimguard blue-wrapped trays which can easily suffer microscopic tears when moving the sterile sets rendering them unsterile. Since there is a proposal to convert from a wrapped sterilization system to a rigid container system cost analysis is required. Also a policy and process is developed."

Improving RN:MD Communication to Enhance Teamwork and Patient Safety

QPI: (

"In 2015, the result of nurse perceptions of working well together with physicians from the National Database of Nursing Quality Indicator (NDNQI), was below the benchmark at 3.77 on the Mother/Baby unit 35, GYN Oncology unit 95 at UF Health Shands Hospital. To improve perceptions of nurses and physicians working well together by enhancing RN-MD communication methods as evident by an increase in NDNQI patient safety benchmarks at greater than or equal to 3.9."

The Effect of Vasopressor Use on the Morbidity and Mortality of DNR Patients

QPI: (

"The yellow form employed by the State of Florida for a ÒDo Not Resuscitate OrderÓ (DNRO) states that the undersigned patient wishes cardiopulmonary resuscitation (CPR) to be withheld in the event of the patientÕs cardiac or respiratory arrest. This is further specified in parentheses to include artificial ventilation, cardiac compression, endotracheal intubation and defibrillation. What is not specified on the State of Florida DNRO form is whether or not the use of vasopressors is permitted. There are significant data about the likelihood of patients surviving CPR in the hospital. This information helps direct physician/patient discussions about the risks and benefits of CPR. The use of vasopressors is a key part of the ACLS algorithm for CPR, however, there are no current guidelines for vasopressor therapy in DNR patients. Each physician must arrive at a decision, if indicated, with the patient and their family whether or not to provide cardiopulmonary support with vasopressors."

Labor and Delivery Pushing Through the Certification Goal

QPI: (,)

"ÒSpecialty cer-fica-on and competence of registered nurses are related to pa-ents safety.Ó (AJCC, 2009) ÒNurses who have achieved their specialty cer-fica-on have perceived intrinsic value, empowerment and heighten collabora-on with the health care team.Ó (ASPSN, 2011) ÒSpecialty nurse cer-fica-on provides personal sa-sfac-on and affirma-on of skills, poten-al opportuni-es for advancement, a posi-ve marke-ng tool for ins-tu-ons, and confirma-on to the client that he or she is cared for by highly trained professionals.Ó (ASPSN, 2011) ÒCer-fica-on for nurses in their respec-ve specialty would greatly benefit the consumer, provider, and professional nurse.Ó (ASPSN, 2011)"

Standardization of Needleless Valve Changes for CLABSI Reduction: Shared Successes from Staff-Drive Initiatives

QPI: Linda, Allen, (

Central line-associated bloodstream infection (CLABSI) rates (CLABSI per 1000 device days) on 64MS were increasing over a period of two quarters and underperforming National Database of Nursing Quality Indicators® (NDNQI®) benchmarks (Qtr4 2015: 1.66 vs 1.01; Qtr1 2016: 5.52 vs 1.07). As such, the unit’s newly formed Unit Practice Council (UPC) embraced CLABSI reduction as their first official project under the guidance of their Clinical Leader (CL) and Nurse Specialist (NS) advisors. During the unit’s annual skills fair anecdotal evidence surfaced that needleless connectors were not being changed according to hospital policy and staff responses suggested variability in routine line maintenance practices, specific to use of needleless connectors. Similar findings were discussed at the Nursing Department’s Safety Huddles where several units shared success with standardization of practice around routine needleless connector changes. In response, the CL and NS brought these strategies to the UPC for consideration. The UPC, in collaboration with the CL and NS critiqued current practice and suggested practice changes against the Infusion Nurses Society (INS) recommendations and came to consensus that its first CLABSI reduction initiative would be to standardize practice with regards to changing needleless connectors, replicating the process used with success on 7W.

UF Health Personalized Medicine Program

QPI: Amanda , Elsey, (

There is substantial evidence that nearly all diseases have a heritable (genetic) component, and that both efficacious and adverse responses of many drugs are significantly influenced by genetic variability. Despite the substantial number of important genetic discoveries, there are limited examples of translation to practice. There are numerous examples for pharmacogenetics, that are clinically actionable; and 10% of all drugs contain pharmacogenetic information in their FDA-approved product label. However, despite incorporation of pharmacogenetic information into the FDA labels of a large number of drugs, including boxed warnings in some cases, there is limited uptake of pharmacogenetic testing in the clinical setting. There are numerous potential causes for the limited clinical translation. The UF Health Personalized Medicine Program (PMP) seeks to continue to implement pharmacogenetic testing into UF Health, overcome a majority of these barriers, and facilitate adoption of genomic medicine into clinical practice.

Nature of Medication Errors of Omission Identified Through Solicited Reports by Attending Physicians in an Academic Medical Center

QPI: Eric, Rosenberg, (

This was a cross-sectional study (approved by UF IRB) conducted 2002-2003 to determine nature and frequency of medication errors of omission from the perspective of attending physicians. Physicians were trained how to report errors that resulted in patient harm or errors that had 50% likelihood of resulting in harm. The study investigators reviewed medical charts and interviewed the physician reporters and their patients to obtain information on adverse outcome symptomatology, error etiology, and causality. (J. Investig. Med. January 2004;52(01-s1):155.

Developing a Patient Safety Curriculum for Internal Medicine Residents

QPI: Eric, Rosenberg, (

This was a pilot project conducted from 12/2004 through 1/2005 to: 1) Ascertain Internal Medicine residents' knowledge, attitudes, and skills regarding patient safety; 2) Determine whether case-based seminars and standardized patient scenarios can teach residents to identify, self-report, prevent, and investigate errors; 3) Apply results to develop future patient safety curricula at this institution. 30 Internal Medicine residents completed baseline surveys to determine baseline patient safety knowledge, attitudes and prescription writing skills, then PGY-1 residents received two, 1-hour seminars on systems-based analyses of hazardous practices. These included discussions of ways to prevent prescriber errors and miscommunication during "hand offs" and methods of disclosing errors to patients. PGY-1 residents were then re-surveyed following the seminars. Following completion of the seminars, two teams of PGY-1 and PGY-2 or PGY-3 residents were video-recorded conducting mock team work rounds and disclosing errors to standardized patients. One scenario concerned a patient with poorly controlled diabetes who is hospitalized for treatment of cellulitis; an ordered dose of antibiotics is erroneously not administered and a diabetic medication is erroneously admitted from admission orders. A second scenario concerned a patient with chronic sleep apnea and emphysema hospitalized for treatment of pneumonia; the patient is resuscitated in radiology after a respiratory arrest attributed to oversedation from multiple sedative agents administered for pain. [Funded by a grant from UF COM Chapman Education Center; Seminar materials adapted from those developed by J Gosbee, VA National Center for Patient Safety; C Mottur-Pilson, American College of Physicians; M Cohen, Institute for Safe Medication Practices]. In: J Gen Intern Med. 2005;20(s1):30.

SICU Music Listening

QPI: Angela, Larson, (

This project will allow ICU/IMC patients in the surgical intensive care unit to listen to music during specified time intervals. Chlan (2013) demonstrated that access to patient preferred music for ICU patients was associated with reduction in anxiety and need for sedation when compared to usual care. Therefore, music listening will become the standard of care in the surgical intensive care unit for patients who wish to listen to music during their hospitalization. This CQI project will include surgical intensive care patients on 4E/4W. Patients and or families will be able to specify their music listening preferences, and preferred music listening intervals. Patients will be provided music listening per their request.

Engaging Parents in Pediatric Fall Prevention

QPI: Jeanette, Green, (

Prevention of inpatient pediatric falls is both an important and challenging goal for those hospital units that care for pediatric patients. In reviewing the monthly pediatric fall data in our own hospital, UF Health Shands Childrens Hospital, from July of 2013 to June of 2016 it was noted that 145 pediatric falls occurred. Our hospital uses the Graf-PIF risk assessment tool to determine pediatric patients who are at high risk for falling and for these patients, fall prevention bundle interventions are implemented. Upon review of current literature on pediatric fall risk scales, the findings demonstrate that the fall scales currently available, including the Graf-PIF, do not have the precision and accuracy to adequately identify the patients at risk for falling (Ryan-Wenger, 2012; Ryan-Wenger, 2013; Jamerson, 2014; Kramlich, 2016; & Messmer, 2013). Of the145 pediatric patients who fell, 124 were scored with the Graf PIF fall scale (validated for children 1 to 17 years old). Of those 124 children who fell, only 57 (46%) were scored as high risk for falling (a score of 2 or greater on the Graf-PIF). Of the 145 pediatric patients who fell, 104 (72%) fell in their hospital room. Staff completing the patient safety reports documented as to whether family was present at the time of the patient’s fall for 133 patients and of these 133, family being present at the time of the fall occurred for 87 (65%) of these patients. Current literature supports that they majority of pediatric patients fall in their room with a family member present (Razmus, 2012; Fujita, 2013; Jamerson, 2014). As such, the children’s hospital will be implementing a targeted in-hospital fall risk education intervention for both parents/caregivers and nursing staff.

Respiratory Isolation Practices at the University of Florida

QPI: Michael, Lauzardo, (

Description: Tuberculosis has been declining in incidence in the US for the last 20 years but despite this decline, TB is still relatively common in high risk groups. However, many patients who are low risk for TB can have clinical presentations that mimic TB and will end up being isolated in the hospital for prolonged periods of time increasing the length of stay inappropriately. New guidelines are coming out from CDC that may help reduce length of stay without compromising infection control practices. It is unknown what the outcomes are of patients isolated at UF Health nor is it known what the impact is on length of stay. We propose establishing a baseline study of the characteristics of patients who are put on respiratory isolation and assessing what the risk factors are for prolonged length of stay in isolation and the accuracy of properly identifying patients who should be on isolation.

Patient Transition Improvement Project

QPI: Angela, Larson, (

This project will involve collaboration between the surgical intensive care unit (4W) and two medical/surgical units (5W and 55) on improving patient transitions from the ICU to med/surg units. This project will provide the patients and families with the opportunity to tour the receiving unit and to have an opportunity to speak to an identified designee from the receiving floor. The purpose of this project will be to improve patient satisfaction through the development of a structured transition process from the ICU to MS. The leader of this project will be the unit educator for 4West T.Jennifer Boneta, BSN, RN, CCRN, who is taking part in the Rose Rivers leadership fellowship program. The additional facilitators will assist in helping to take patient's family members on a tour of the receiving unit and also serve as designees to speak with patient and their family.

QI Room vs QI.PR

QPI: Susan, Ford, (

Compare project submission sites for required fields and time process takes.

Patient–centered Care Model: Leveraging the Patient Portal

QPI: Cathy, Zorilo, (

The failure to communicate diagnostic results is a medical error that may have detrimental effects on the quality and quantity of the life of the patient. This physician–centered academic medical center (AMC) lacks a patient-centered care model for associated patient notification of diagnostic findings. An Ishikawa diagram, also known as fishbone or a causal diagram, was constructed. At the mouth of the fish, is the practice problem, that there is a failure to inform patients of diagnostic results that require follow-up. Theses spines depict the identified four causal categories: physician, methods, patient portal, and patient/family. This project targeted two of these smaller spines by beginning with the development of a staff script and procedure to enroll the patient into the patient portal, using an I-pad if the patient does not have a smartphone or tablet with them. The patient demonstrated their understanding of accessing and utilizing the patient portal to locate diagnostic results and to send a secure email communication to their provider, through Teach-back. Inclusion criteria were all patients over 18 years of age with a neurosurgery clinic appointment. Exclusion criteria were any qualifying patient who chose not to participate in the active enrollment of the patient portal and declined proxy to their families. The evaluation processes in the form of P-D-S-A, include assessment of process, outcome and balancing measures occurring at two-week intervals. Process Measures includes Activation Rates, Failure Rates, and Reasons for Failed Activation. The average monthly pre-intervention activation rate for this clinic 30.8%. These were the early adopters, where patients had to self-enroll into the patient portal using a unique 14-digit code. Although the data collection is in progress, the first month post-intervention data is encouraging with an increase of 8.2%.

Increasing Colorectal Screening Rates in Primary Care

QPI: Rica, Jester, (

In line with the NCCRT aim to increase colorectal screening rates to 80% by 2018, the Family Medicine Residency Program at UF hopes to increase screening rates in our own clinic. The core of this QI project will center on increasing knowledge of the different screening modalities available: stool tests, imaging studies, and direct visualization. Residents and faculty will be taught these options in a dedicated didactic session. The effectiveness of this teaching will be assessed with an educational survey administered prior to, immediately after and 1 month after the didactic session. Patients will also be educated on their options with easy-to-read handouts and in depth discussions with their primary care provider. The number of screening tests ordered will be measured before and after the above education is provided.

The Impact of a Structured Fall Prevention Resource Role on Organizational Safety Outcomes

QPI: Marsha, Crane, (

Implement a structured fall prevention resource role with defined role expectations to support organizational fall prevention initiatives

Year Round Masks

QPI: Jaime, Thomas, (

Respiratory viral infections are frequent complications of hematopoietic stem cell transplant. Surgical masks are a simple and inexpensive intervention that may reduce nosocomial spread. In one clinical trial recently published in Clinical and Infectious Diseases (Sung et al. CID 2016: 63) there was a significant reduction in respiratory viral-related infections compared to historical control after instituting a year-round universal mask policy. We propose to institute a similar policy of universal mask protection in the BMT Unit and Clinic on 7th floor of the Cancer Hospital at UF Health. These units serve, not only those recipients of hematopoietic stem cell transplantation but also non-transplant, highly immune-compromised patients being treated and cared for with various hematological malignancies such as leukemia, lymphoma, and myeloma as well as other bone marrow failure disorders (e.g. myelodysplasic syndromes, aplastic anemia, etc. ). The use of masks in this policy will include not only all medical staff involved in care for these high risk patients, but also the patients, their caregivers, and family members who visit them while hospitalized on 7 West or when accompanying them to a clinic visit on 7 East.

Determining affective strategies for improved tacrolimus dosing

QPI: Serlemer, Coleman, (

Historically patients treated with tacrolimus have been subtherapuetic with the tacrolimus dosing. This project will evaluate the effects of changes in workflow to enhance optimal dosage timing. We did not alter the dose timing. Instead, we chose to change the RN workflow to improve accuracy of dose administration. The dayshift RN gives both am and pm dose, while the night RN is responsible for ensuring the prograf trough level is completed at 0600.

Participant Satisfaction Survey of Older Adults Attending a Death over Dinner Event at ElderCare of Alachua County

QPI: Toni, Glover, (

In conjunction with National Health Care Decisions Day, UF Health and ElderCare of Alachua County is sponsoring a Death over Dinner event at the Senior Center on April 5, 2017. Death over Dinner events provide an opportunity to discuss advance care planning and preferences for end-of-life care in a social setting. To learn more about this unique project, visit All Senior Center members will be invited to RSVP for the dinner via an email list maintained by Mr. Anthony Clarizio, Executive Director, UF Health Shands Home Care (the sponsor of the event). Along with UF Health and community leaders, 40 older adults will participate in the dinner event. Following the dinner, we would like to send out a brief survey to those that participated to assess their satisfaction with the event, advance directive completion, communication about advance directive with their healthcare provider, and comfort level in discussing end-of-life care preferences.

Simplifying the NICU Discharge

QPI: Erik, Black, (

Residents perceive the discharge process in the Neonatal Intensive Care Unit as cumbersome and complex, often times small components are missed which may lead to adverse outcomes. Roles are not clearly identified which leads to frustration and confusion on the part of the residents, attendings, nurses and fellows.

Improving Procedural Competency in Pediatric Residents at the University of Florida

QPI: Erik, Black, (

Based on ACGME survey results, there were multiple procedures which graduating residents in our program did not feel comfortable performing without supervision. While there are specific procedures that need to be completed before graduation, there is little guidance on where to get these experiences. In addition, it appears that residents are not logging procedures in a timely fashion, which could delay the program in determining the rotations in which there is a deficiency in procedural experiences. The ACGME has a set amount of procedures that must be completed prior to graduation in order for residents to display competency in performing procedures unsupervised. It is important that as residents graduate and move on to their careers, that they feel competent in procedures they may encounter as pediatricians. Furthermore, if residents face barriers to logging procedures, the program will not know if residents are having difficulty gaining experience in certain rotations.

Intraoperative NSAID use in patients with ESRD

QPI: Geoffrey, Panjeton, (

It is well known that NSAIDs can cause acute renal failure as well as worsen chronic kidney disease (CKD), however the effect of exposure in those with ESRD is not well described. In the perioperative setting, where pain management is of significant concern and with the goal of providing multimodal analgesia therapy, the use of NSAIDs is common. However, there is some data that shows that NSAIDs use in ESRD patients can impair residual renal function. The native kidneys in ESRD patient still play important filtration and endocrine function and life expectancy in ESRD patients is directly correlated to the preservation of residual renal function. Currently, there is no warning system in Epic that prompts providers to reconsider administering NSAIDs to patients with ESRD. The goal of this study is to first, determine a baseline for the incidence of NSAID administration in ESRD patients who are on chronic outpatient dialysis over a 6 month period. Then the next step would be to implement an intervention that would prompt providers to reconsider use of NSAIDs in those patients. The outcome will be assessed based on decrease in NSAID administration after intervention implementation.

BMTU Nurse Fellowship Program: A Strategy to Nurture Nurses Hired on BMTU and Reenergize and Retain Current Staff

QPI: Carylee, Pennington, (

Bone Marrow Transplant (BMT) Nursing requires a specialized body of knowledge that is not taught within traditional nursing programs, hospital or nursing orientation, or hospital medical-surgical classes. In fact, at this institution, there are no trained Oncology Educators or Clinical Nurse Specialists. These deficits have created a situation where the unit-based nurses and leadership must provide all the teaching and knowledge to care for BMT patients. However, aside from the obligatory ten-week orientation and a teaching deprived mentorship program, no formalized education occurs to help new BMT nurses progress on the novice to expert continuum. Currently, the BMT unit is experiencing high turnover of staff (26% within their first year) and hard to fill positions (27.1% vacancy rate with some positions open for over a year). The goals of nurse fellowship programs (NFP) are to improve retention, competency and confidence of new nurses, while increasing quality patient outcomes. We propose that competency, retention rates, certification rates, and employee engagement will increase in BMT unit with the addition of a structured NFP.

Establishing a Multidisciplinary Anticoagulation Clinic in a Residency Program and Improving Residency and Pharmacy Education

QPI: Rica, Jester, (

Little is known about the educational benefits of establishing and maintaining a warfarin clinic within a residency program. Patients established with UF Family Medicine (FM) providers visit the anticoagulation clinic at CHFM Main Street. Patients are first interviewed by pharmacy students who then present the patient to FM residents and collaboratively formulate a treatment plan. The FM resident will then precept this patient with a FM Attending. To assess the education benefits for the FM resident and pharmacy student education, a 10-question survey utilizing a Likert scale will be provided to current residents and students. Different surveys will be developed to cater to the recipient’s training (pharmacy student, current resident, recent graduate). The main outcome for the FM residents will be to assess if they would feel comfortable managing oral anticoagulation in their future practice based on their residency experience. The main outcome for the pharmacy students will be to assess if this clinic experience improved their comfort level with working in a multidisciplinary setting in managing warfarin.

Creating order set for pediatric orthopaedics patients specifically Scoliosis patients

QPI: Ali, Zarezadeh, (

Standardization of postoperative patient care will enhance patient's experience and also increase the speed of recovery. We are trying to apply a postoperative protocol with focus of pain management which enable the orthopedics patient to mobilize sooner after the surgery and will decrease the length of stay. This protocol is already being used in well know children's hospitals nationwide. We modified the protocol base on our practice. In this project, we design order sets and educate our staff to use these orders on our pediatric scoliosis patients and also general pediatric orthopaedics patient population. This protocol has been used in Philadelphia Children’s Hospital in the past few years. It has been shown that it reduces the length of stay. We have been using it for the last year with good results. AVG patient LOS is 3 days. In order to have a standardized protocol amongst all providers for all patients, we designed an epic order set. Order set is currently under review.

Assessing nursing knowledge of pediatric delirium in the Pediatric Intensive Care Units

QPI: Molly, McGetrick, (

Delirium in the Pediatric ICU is a common, yet extremely under-recognized problem. The presence of delirium is independently correlated with increased length of stay in the intensive care unit, days on mechanical ventilation and overall mortality. Additionally, there may be long term psychosocial outcomes in those who experience delirium. With that, there is a large movement within the adult and pediatric critical communities to improve the recognition of delirium and implement screening tools. We will be implementing delirium training in the pediatric intensive care unit (PICU), as well as in the pediatric cardiovascular intensive care unit (PCICU). Prior to receiving training materials, nurses will complete a 20 question pre-test. Materials provided for education will include paper hand-outs, case scenarios, online modules, and videos. Participation will be encouraged to all nursing staff, but participation will be voluntary. At the completion of training, nurses will complete a 20-question post-test to assess for improvement.

Improving VA Primary Care Nurse Education on Veteran Advance Care Planning

QPI: Julie, Alban, (

This Quality Improvement project followed an over-arching Model for Improvement and the purposes of this project are (1) assess advance care planning (ACP) knowledge of primary care nurses working at the Department of Veterans Affairs (VA), and (2) deliver and evaluate the effect of an ACP education workshop on this group of nurses. The objective of this project is to determine if education on ACP improves knowledge among VA primary care nurses. This objective will be tested through the use of a course evaluation. In addition, the number of advance directive (AD) discussions implemented at the two clinic sites will be monitored through an Advance Directive Dashboard. This dashboard includes the number of AD discussions notes entered monthly per clinic site.

Improving Documentation of Adverse Pregnancy Outcomes and Associated Cardiovascular Risk in Women

QPI: Ki, Park, (

Cardiovascular disease remains a significant source of morbidity and mortality in women. In addition to the traditional cardiovascular risk factors recognized in the general population, women can have additional sex-specific risk factors such as adverse pregnancy outcomes (APO). These conditions include pre-eclampsia, gestational diabetes, premature birth, etc. However, many women who have such obstetrics/gynecologic (OBGYN) history do not have these conditions documented in their standard medical record; ie in a primary care setting. This represents a missed opportunity to identify women with a history of APO who could then be more routinely followed and screened for modifiable risk factors such as obesity, hypertension and diabetes amongst other. The electronic medical record currently used at UF/Shands, EPIC, includes a section on obstetrics/gynecologic history. However, currently this section is mostly utilized by obstetric/gynecology specialties. Our project aims to expand the use of this subsection of EPIC through education of nursing staff/providers in a variety of outpatient settings including internal medicine, family medicine and cardiology. Nursing staff and providers in these various clinics will be given a mini-lecture on the importance of screening for these APO and educated on how to obtain an appropriate OBGYN history. We will aim to perform this assessment on every woman of child bearing age on a yearly basis and a one time assessment for women who are post-menopausal.

Continuum of Care – With a focus on Home Health

QPI: Jacqueline, Baron-Lee, (

The aim of this project was to improve home health for patients with proper follow-up or intermediate care by enabling health literacy among patients with info graphics and expanding the checklist that case management and social workers have in order to evaluate patients post care needs.

Assessing the Benefits of the Women in Medicine and Science (WIMS) Mentoring Groups in Promoting and Increasing Academic Productivity

QPI: Julia, Close, (

Competing responsibilities for faculty, both professional and personal, may limit the engagement in extra-curricular faculty development opportunities. While overall felt to be informative, attendance at the University of Florida’s Health Science Center Faculty Women in Medicine and Science (WIMS) Group was limited. A new approach, creating small groups of interested faculty meeting to develop specific career enhancement skills, has been developed. Four groups have been created to focus on scholarly productivity, promotion, difficult conversations and involvement in professional societies. These groups allow the group members to determine a time for meeting based on the availability of the small group. The groups have an assigned mentor with experience in the topic area. Each group will meet on a monthly basis to address the targeted area of faculty development. The aim of this study is to measure faculty engagement through attendance at meetings. Secondary measures will include overall satisfaction, perceived improvement in professional development, and areas for improvement in future cycles.

Implementation of a Relationship-Based Care Model of Nursing Practice on a Medical Surgical Trauma Unit: Impact on Nursing and Patient Satisfaction

QPI: Colleen, Counsell, (

The interaction between the patient and nursing staff has been a key component in patient satisfaction. As patients progress along the care continuum they are dealing with frustration and loss due to unexpected hospitalization for the trauma patient. Our goal is to enhance communication during this very stressful experience. Communication between the patient and caregiver is an important element of providing quality patient care. The relationship-based care model focuses on the nurses’ relationship with patient as the central element of the care they provide. It affirms the values that are the foundation of nursing practice, creating an environment where nurses feel they make a difference. Relationship-based care reflects the patients’ values and engages them as partners as issues and priorities are addressed. Relationship-based care also had been shown to enhance teamwork by focusing on the nurses’ relationship with peers and other staff members, thus improving both nursing and patient satisfaction. Our goal is to enhance the communication with the patient by focusing on relationship-based care on a medical surgical trauma unit. The purpose of the study is to evaluate whether or not the implementation of the relationship-based care in which nursing establish caring relations that focused on the patients know values versus the traditional “task oriented” team nursing model of care, makes a difference to both patient and the nursing staff in terms of their satisfaction. Data in the literature indicate that it may, although the data are few and the models are relatively new and few in number. This model seems to be the new “in vogue” solution for how to improve patient and nurse satisfaction.

Reduce Readmissions from Shands Rehabilitation Hospital

QPI: Hannah, Fulmer, (

Readmissions among patients discharged to rehab facilities often make up the majority of readmission cases, as is the case in neuromedicine at UF Health. Among the neuromedicine patients discharged to Shands Rehabilitation Hospital (SRH) in 2016, 69% of patients were readmitted to Shands Hospital, and 31% of those patients were returned back to SRH. Initial analysis shows that 90% of the time patients are transferred back to the Hospital, the neuromedicine provider who discharged the patient was not contacted. Furthermore, 70% of these returns occurred Monday-Friday, 7AM-5PM, not during after hour periods or weekends. All non-urgent case transfers should include a call to the neuromedicine provider before the transfer process is started, which is not being done for the majority of cases. This project will focus on the rate of communication between SRH staff and neuromedicine providers and will work to develop ways to increase these rate and in turn reduce unnecessary transfers. The transfer center process and SRH procedures are being analyzed to determine which method of improvement will best suit this project's goals. It is most likely that a pre-transfer checklist will be implemented to increase communication rates.

Implementation of a Mock Root Cause Analysis to Provide Simulated Patient Safety Training

QPI: Martina, Murphy, (

The proposed revision to the ACGMECommon Program Requirements includes participation in mock or real interprofessional patient safety activities, such as root cause analysis (RCA). In some medical specialties, RCA may occur in low frequency, thus limiting housestaff exposure. Further, while teaching housestaff patient safety and quality care activities such as RCA has become important, there is little data or information available on optimal educational strategies for these topics. In recent years, the ACGME has placed increasing emphasis on simulation-based training. Simulation has been traditionally explored in procedure-based specialties like surgery as a means to improve skills with technical tasks. However, there is data to suggest that simulation may be an effective method for teaching skills like working in multidisciplinary care teams or physician-patient interaction.Housestaff completing our Hematology/Oncology Fellowship program have experienced inconsistent opportunities to participate in institutional RCAs. Based on this perceived need, we developed a mock RCA to simulate this quality improvement and error analysis experience and in doing so, improve housestaff knowledge of and participation in the RCA process.

Discharge Disposition

QPI: Jacqueline, Baron-Lee, (

During the discharge process neuromedicine providers are faced with approximately 80 options of locations to discharge patients to.These options include but are not limited to skilled nursing facilities, rehabilitation hospitals, long term care hospitals, and returning home with or without home care. It is suspected that due to the ample number of options, providers are utilizing all options which can result in the majority of patients returning home, where they may or may not receive sufficient home care. In 2016 Neurology inpatient discharges saw 49% of patients returning home with no planned readmission, 15% to a rehab facility with no planned readmission, 8% to a skilled nursing facility and 2% to a long term facility with no planned readmission. Inpatient Neurosurgery saw 54% of patients returned home after discharge, 15% to rehab facilities, 2% to long term care and 4% to skilled nursing facilities all without planned readmissions. It needs to be determined if these trends in location are adequately meeting the patient needs or are due to habit and the lengthy list. Ensuring a proper discharge process directly affects hospital readmission rates and patient satisfaction.

Effect of Decreasing Numbers of Blood Cultures on Patient Quality Outcomes

QPI: Kenneth, Rand, (

Between 2014 and 2016, there has been approximately a decrease in the number of blood culture sets sent to the microbiology laboratory, from about 3500 - 3800/month in the first half of 2014 to 2800 - 3000 in 2016. While reducing unnecessary testing is a highly important goal for UFHealth Shands as an institution, such improvements in utilization must not result in patient harm. This process was spearheaded in the Adult ED and these efforts have been particularly successful there, with blood cultures dropping from about 1300 sets/month at its peak in the 1st quarter of 2014 to approximately 780 sets/month in the 4th quarter of 2016. In the case of the entire hospital, the rate of positive cultures has risen as the number of blood culture sets has fallen, and this is what one would expect if clinical judgment resulted in cultures not being sent on patients who would have no growth anyway. However, there were almost 200 more patients with positive blood cultures in 2014 than in 2016, while hospital occupancy increased by 10,000 patient days in this time frame.

Automatic tobacco screening and brief intervention for pediatric primary care

QPI: Ramzi, Salloum, (

Cigarette smoking remains the most preventable cause of death in the US and contributes significantly to the occurrence of chronic conditions. Adolescents are a particularly vulnerable and important group to target for tobacco prevention. Moreover, there has been rapid growth in electronic cigarette use and other non-cigarette tobacco products among adolescents, which may further increase their risk for transitioning to cigarette use and the development of other addictions. Primary care providers (PCPs) play a critical role in tobacco screening and counseling and there is an evidence base demonstrating that PCP brief interventions contribute to overall tobacco prevention. Yet there are significant gaps in screening and management of risk factors associated with tobacco use in primary care. Despite national recommendations, compliance with PCP best practices for tobacco prevention is low. The objective of this project is to promote tobacco prevention in adolescent primary care by automating tobacco screening and brief interventions within the patient portal. Novel features of the decision support interventions include: the use of the patient portal to screen for cigarette smoking, alternative tobacco products use and for susceptibly to tobacco use; and tailoring of health messages based on patient preferences. Our strategy involves deploying brief screening for tobacco use into pediatric primary care workflow in conjunction with (1) clinician and office staff training on best practices using clinical practice facilitators, and (2) clinician-engaged adaptations of the intervention to fit their practice workflow.

Pet Therapy Program

QPI: Jared, Burdgess, (

The UF Health Clinic-based Pet Pilot Program is a proposed initiative within the Neuromedicine Interdisciplinary Clinical and Academic Program (NICAP) which will serve as an extension of the existing inpatient Pet Therapy Volunteer program at UF Health, it aims to: 1. Reduce stress, anxiety, and depression of patients and visitors. 2. Provide support and comfort to patients and visitors. 3. Create a non-stressful and a non-judgmental environment for patients/caregivers. 4. Increase self-confidence and reduce self-consciousness in patients. Pet therapy is a method to help patients recover from and better cope with health problems. It has been scientifically supported that pet therapy has a positive effect such as reducing pain, anxiety, depression, and fatigue in both inpatient and outpatient populations (Marcus, 2012). In addition, it helps to decrease the staff stress levels as a result of interactions with the therapy dog (Engelman, 2013).


QPI: Jared, Burdgess, (

The TeamSTEPPS training program is an evidence-based set of teamwork tools, aimed at optimizing patient outcomes by improving communication and teamwork skills among health care professionals. Huddles will be implemented to: i. Reduce interruptions daily ii. Improve communication among staff involved iii. Reinforce plans and adjust plans as necessary iv. Offer opportunities to have conversations that span boundaries and hierarchies v. Create a space of diverse understanding among both routine and unexpected events. I-Pass will be implemented to: i. Improve verbal handoff (communicating information from team to team or team to individual, mainly between doctors), to improve patient safety. ii. Standardize a sign out mechanism

NICAP: Customer Service is Key

QPI: Maria, Casanueva, (

The UF Health Customer Service is the Key Program is UF Health’s employee recognition program for recognizing outstanding performance and behavior. Nominations can be made by internal staff and patients. All nominated employees receive a gold key and a Customer Service Key (CSK) pin to wear with their ID badges. Individuals nominated multiple times are eligible for gift cards and other recognition. Every quarter, all nominations are reviewed and one extraordinary employee will receive the CEO Award. CEO Award winners receive a gift card, personal recognition from the UF Health Shands CEO and a paid day off.

NICAP: Leadership Luncheon

QPI: Maria, Casanueva, (

The Leadership Sponsored Luncheons are a proposed initiative within the Neuromedicine Interdisciplinary Clinical and Academic Program (NICAP) which will serve a staff satisfaction program. Leadership Sponsored Luncheons are a method that helps staff feel appreciated by the physicians and staff they assist every day. The implementation of this initiative intends to improve the staff experience while aligning with the UF Health Big Aim of Quality: Transform Culture. Interest and need for Leadership Luncheons stems from the NICAP Staff Satisfaction Survey that takes place at the end of each year.

Pediatric critical care ultrasound education quality improvement and assurance

QPI: Michael, Tsifansky, (

Critical care ultrasounds performed by Pediatric Critical Care Medicine fellows in the course of daily work will be critiqued weekly by a local critical care ultrasound expert. Didactic lectures on critical care ultrasound will also be given during the same weekly sessions. The goal of this project is to increase the reliability of the trainees' critical care US technique and reads, and thus improving their proficiency in critical care ultrasound.

Clinical Documentation Improvement

QPI: Abigail, Wolz, (

Implementation of a Clinical Documentation dashboard in the Neurosurgery inpatient unit. Through a Plan, Do, Study, Act cycle, the dashboard measured a variety of clinical metrics including length of stay index, risk of mortality, severity of illness, case mix index, mortality ratio, and number and type of documentation queries submitted to surgeons.

Collaborative learning teams to teach and assess teamwork behaviors and attitudes

QPI: Michelle, Farland, (

The Accreditation Council for Pharmacy Education published updated standards for Doctor of Pharmacy degree programs in 2016. One of the new required elements in the standards is to provide an assessment of individual students ability to work in teams prior to graduation. With the inception of the new curriculum at the University of Florida College of Pharmacy in Fall 2015, an assessment plan has been developed to assess team work behaviors and attitudes. The curriculum incorporates collaborative learning teams that remain consistent in all courses throughout the duration of the academic year. A peer evaluation process has been put into place to permit students to evaluate and receive three formative peer evaluation results with one summative evaluation at the conclusion of the year. Prior published work in establishing an appropriate assessment plan related to team work behaviors and attitudes does not exist in Pharmacy education.

Reducing Unplanned Extubations in the NICU

QPI: Tara, Jendzio, (

Project Objectives 1. Reduce unplanned extubations in the NICU to less than 1 unplanned extubation per 100 patient-intubated days. 2. Investigate potential causative unplanned extubation factors. 3. Implement effective interventions to reducing the rate of unplanned extubations. Implement UE prevention bundle with key drivers: Securement and placement Standardized anatomic reference points and securement methods 2-person technique for high-risk procedures High risk situational awareness Sticky note in chart if history of UE Vent cards noting high-risk procedures Knowledge and engagement of stakeholders Skills fair education Announcement in shift huddle on days since last UE Debrief of UE ACA findings in shift huddle Multidisciplinary care coordination Multidisciplinary ACA for each event (RN, RT, MD/NP) Discussion at NICU MD quality meetings & UPC Adequate comfort and sedation & extubation readiness Active discussion on each shift of extubation readiness Future: Standardized sedation/comfort protocols

Implementation of long-term patient bed and space rotation for CLABSI reduction in the NICU

QPI: Nicole, Hilliard, (

In 2017, the NICU began moving long-term (greater than 20 days) patients into clean bassinets and a clean bed space within 30 days. This will allow EVS to terminally clean the environment more frequently and reduce the build up of dust on bed space surfaces and bassinets. The goal of this project is to see if there is a reduction in risk of a CLABSI of NICU patients that have been transferred into a clean bassinets and bed space within 30 days.

Identification of Individual Patient Characteristics for Susceptibility to CAUTI in the Neuro ICU setting

QPI: Amna, Qureshi, (

Catheter-associated urinary tract infection (CAUTI) is the most common health-care associated infection accounting for > 560,000 nosocomial infections annually (Gould,2016). According to the Center for Disease Control, CAUTIs are also a leading cause of secondary blood stream infection resulting in approximately 13,000 deaths annually. The neurocritical care population is especially at risk for CAUTI development related to cognitive, motor, and sensory deficits. Neuro ICU’s goal was to eliminate CAUTIs, defined as a rate of zero. With Initial efforts (2008-2012), CAUTI rate was reduced from 13.1 to 4.0/1000 catheter days (Titsworth et al, 2012). In February 2016, NeuroICU launched a patient centered quality improvement effort to further reduce CAUTIs and began critically identifying which patients met the clinical definition for CAUTI and the circumstances surrounding their diagnosis.

Hand Hygiene

QPI: Brenda, Fahy, (

Anesthesia providers included will be those who provide verbal consent and agree to the survey and the intervention to evaluate their hand hygiene practice. The information for the survey will not be identified other than the year of the provider and will link their post intervention feedback on whether there is room for improvement and feedback about practice habits with their preliminary data. A gel will be placed on the hands and then with hand washing removed by the participant. The hands that have been washed will then be displayed using blue light technique and the areas that the gel remains will be shown. The areas of the hands that are illuminated will be noted. The data analysis will involve analysis of this data as aggregate data to see if there are particular areas that are missed more frequently and this data compared to over 300 other providers here at UF Shands that have completed these observations. In addition there will be before and after analysis of possible improvement with hand washing and practice habit feedback.

Neuromedicine Interdisciplinary Clinical and Academic Program (NICAP): Changing Culture through Leadership Luncheons

QPI: Marissa, Stone, (

Leadership Sponsored Luncheons are a method that helps staff feel appreciated by the teams they work within and assist every day. Interest and need for Leadership Luncheons stems from the NICAP Culture Improvement Survey which measures Staff Satisfaction and Staff Burnout using standard metrics. Included in the survey are open-ended questions that ask for ways to improve work-culture. These data specifically articulated that staff wanted forums for feeling appreciated and many mentioned the idea of leadership sponsored luncheons. In addition, a transform culture working group is held monthly to perform iterative PDSAs on gaining buy-in related to leadership sponsored luncheons, ways to improve them, and expand them. Through this process, the program has expanded to include both faculty and non faculty leaders.

Increasing Mother's Own Milk (MOM) to NICU Infants

QPI: Shannon, Perry, (

In the NICU at UF Health Gainesville since implementing our donor breast milk program (purchased pasteurized human milk) the mother's own milk usage in the NICU has decreased. Upon review of data it was observed that 74% of mother's of very low birth weight (VLBW) infants initiated lactation and by two weeks post delivery there were only 52% . Data demonstrated that 4% of mothers of VLBW at two weeks post-delivery were meeting the minimum volume requirement to sustain lactation.

Eliminating Barriers to Care: Integrating Specialty Care in the Pediatric Medical Home

QPI: Rebeccah, Mercado, (

Starting three years ago, the UF Health Physicians pediatric practices piloted a new project to bring pediatric subspecialty care into the pediatric medical home. Starting with our first clinical site, a subspecialty practice (pediatric ophthalmology) was incorporated into a pediatric primary care clinic creating a Pediatric Primary-Specialty Care Interface. Due to early success, pediatric dermatology and allergy has been incorporated into additional UF Health Pediatric practices. Patients can be scheduled through the pediatric subspecialty division (traditional model) but also by direct scheduling within the patients primary care clinic.

Medication use evaluation of alteplase for catheter flush in pediatric hematology/oncology/BMT patients

QPI: Tara, Higgins, (

Retrospective review of 3 years of inpatient and pediatric outpatient infusion room pediatric hematology/oncology/BMT patients with central access requiring alteplase catheter flush. Will evaluate number of syringes requested, concentration of alteplase administered, was central access patency successfully restored, was heparin flush trialed prior to alteplase and cost attributed to this therapy.

Safe Sleep for Hospitalized Infants

QPI: Candace, Rouse, (

2016 Recommendations for a Safe Infant Sleeping Environment (Pediatrics,138[5]) endorses several safe sleep initiatives for staff to role model and use in educating parents. As a quality improvement project the units of Mother Baby (35/95), Neonatal Intensive Care (NICU), Pediatric Intensive Care (10-2, 10-4) and the general Pediatric units (44, 45) would like to visually audit the current level of practice and compliance with the AAP guideline on Safe Sleep for Hospitalized Infants. These audits and trends will be collected and reported to the Pediatric Fall Task Force and then to the Pediatric Quality Council. The audits will guide staff education regarding the guideline and practices, as well as parent education.

Hypoglycemia in Newborns

QPI: Candace, Rouse, (

As a quality improvement project the units of L&D and MB (35/95) would like to survey the current level of education regarding the care of Hypoglycemia Newborns. We would like to collect data regarding the hypoglycemic newborn's treatment. The latest literature reports that glucose gel administered according to the newborn's glucose level decreases the need for formula supplementation and or IV Dextrose. Glucose gel is an accepted/researched/EBP method for transient newborn hypoglycemia.

Hypertension in Pregnancy

QPI: Candace, Rouse, (

As a quality improvement project in partnership with the Florida Perinatal Quality Collaborative, the units of L&D, MB (35/95) as well as the Emergency Department, would like to audit the current processes regarding the care and treatment of obstetric patients presenting with critical hypertension at the UF Health Shands Hospital. The results of the data collection will guide interventions to educate the staff and patients regarding Hypertension in Pregnancy as well as to track outcome measures listed below.

Effect of dedicated procedure consultants on cost-effectiveness and hospital length of stay for patients admitted for decompensated liver failure and/or ascites.

QPI: Grant, Lowther, (

The internal medicine department at UF Health recently created a consulting team for performing common bedside procedures on patients admitted to the hospital. Part of the goal was to relieve some of the workload from hospitalists in an effort to improve patient care. The investigators of this study seek to examine the effect of this change on patients admitted for liver failure and/or ascites, a patient population that frequently undergoes a procedure called a paracentesis. This will be accomplished via performing a retrospective cohort chart review. We will pull hospital inpatient encounters/charts for patients admitted to an internal medicine service (resident and hospitalist) under intermediate or floor level care for which the admission diagnosis included “decompensated cirrhosis,” and/or “ascites.” The time frame will be from six months months before the consultant service was functioning (3/1/2015 - 12/31/2015) and from six months after the service was functioning (3/1/2016 - 12/31/2016). This information will be readily available by accessing UF Health billing information with ICD-10 codes for the aforementioned diagnoses.

Mobile phones and asthma management

QPI: David, Fedele, (

In the United States, an estimated 73% of adolescents own or have access to a smartphone and, on an average day, adolescents spend over 2.5 hours using a smartphone. The ubiquitous nature of mobile phones coupled with technological advances in recent years has given rise to a rapid proliferation in mobile health (mHealth) interventions that use mobile devices to target a range of health promotion and disease management foci. A number of mHealth programs (e.g., apps) focused on disease management are freely available on the Google Play or App Store and recent research has demonstrated that these programs can be effective in improving health outcomes in youth. mHealth programs may be a viable alternative to improve patient care in pediatric asthma. To date, however, the Pediatric Pulmonary Division has not systematically inquired about the extent to which adolescent patients and their caregivers are using and/or may be interested in using mHealth programs to facilitate asthma management. We propose to conduct a brief survey to inquire about which, if any, mHealth programs adolescents with asthma are using to manage their asthma and what features they may want in an asthma management mHealth program. This information will allow us to do the following to improve patient care: 1) assess the quality of mHealth programs that our patients are currently using, 2) help us to identify mHealth programs that may be a good fit for what patients are seekings, and 3) potentially inform the development of a future mHealth program that could be used by our patients.

Hypertension Quality Improvement Project at the Mobile Outreach

QPI: Michael, Dangl, (

In this quality improvement project, we intend to use the Plan-Do-Study-Act model for quality improvement to develop and evaluate a multi-pronged intervention to improve hypertension control among the medically underserved population that receives care at the Mobile Outreach Clinic. We plan to incorporate community health worker, pharmacist, and lifestyle education interventions at the clinic.

Road Map to Culture of Patient Safety: Feasibility of Interdisciplinary Mock Root Cause Analysis (RCA)

QPI: Vanishree, Hegde, (

An interdisciplinary mock RCA will be conducted with residents from Internal Medicine and Radiology. A sentinel event case relevant to the practice of internal medicine and radiology will be created. The residents will receive clinical details few days in advance to the scheduled simulation to familiarize themselves with the case. Prior to mock RCA, the process and goals of RCA will be presented. The residents are divided into interdisciplinary teams consisting of 2 Internal Medicine and 2 Radiology residents to discuss the case, develop a process map and formulate a root cause statement. The residents will be provided the opportunity to interview any of the healthcare professional involved in the case upon request. The sessions conclude with each group presenting their root cause statement and recommending action(s) to the mock executive committee. The different approaches to RCA and potential impact and limitations of presented actions will be discussed with the participating residents.

The Impact of Interpersonal Relationships on Patient Satisfaction

QPI: Jeanette, Green, (

Introducing relationship based care in the 5 West trauma population to improve patient satisfaction.

Pain Management for Adult Patients s/p Cardiothoracic Surgery following transfer from the CICU to Unit 54

QPI: Karen, Majorowicz, (

Unit 54 receives patients from CICU s/p cardiothoracic surgical procedures. Medications routinely ordered in CICU for pain management include fentanyl IV to achieve pain goals, hydromorphone IV, scheduled high dose tylenol, and po oxycodone. ON transfer to Unit 54, oxycodone po q 4 hours and tylenol are ordered. The most recent quality data available (from July, 2015 through June, 2016) showed the we had room to improve in the area of pain management. At this time, Unit 54 does not use a consistent process for teaching post-op cardiothoracic surgery (aka TCV) patients about the plan for managing their post-op pain on Unit 54. Under the direction of Nurse Manager Rose Phillips, the 54 pain management PIT team, 54's Unit Practice Council, and Clinical Leader Karen Majorowicz have identified a plan to improve our practice in this area and have come up with the following plan: 1) For 1 month, we will ask all TCV patients transferred to 54 to answer a few questions about their pain management experience on 54. 2) We will next work with the nursing staff to implement discussion and education about pain management with each TCV patient at the time of the patient's transfer from CICU to 54. using short PDSA cycles, we will monitor the implementation process and make adjustments as indicated. At the end of 3 months, we will again ask all TCV patients at the time of discharge to answer the original questions about their pain management on 54. Data will be evaluated to determine if the process improved patient satisfaction with pain management.

Blood Pressure Monitoring - Does the monitor and the method matter?

QPI: Rhonda, Dehoff, (

Blood pressure (BP) is a vital sign that is monitored at almost every clinic visit, universally. However, the technique used to measure BP varies considerably, including which BP monitor is used and what technique is used (attended - meaning a health care provider is present and actually obtains the BP measurement or unattended - meaning a monitor that is programmed to measure BP after the health care provider leaves the room) also varies. The landmark, NIH funded SPRINT trial was published in 2015 and suggested that lower BP goals are better for preventing adverse outcomes, and importantly, the BP measured in the SPRINT trial was using a specific Omron monitor, in an unattended fashion. Beginning in August 2017, in the CV Clinic at Spring Hill, the specific Omron BP monitor that was used in the SPRINT trial was implemented in a single practitioner clinic (Carl Pepine) and the unattended measurement technique has been utilized routinely in the Pepine clinic for all patients since implementation. Also, if patients have multiple visits since the implementation of the new monitor, we will also look at BP variability measured with the new monitor and unattended technique. There are currently new hypertension treatment guidelines under review that will impact how BP monitoring and treatment care is provided in the future. These recommendations may include suggestion of unattended BP monitoring, which is not currently the standard of care at UF Health. This project would evaluate results from implementation of this technique in one CV clinic.

Removing CSF antibody orders from the test menu results in dramatic decrease in order volume

QPI: Stacy, Beal, (

The CMV antibodies-CSF, B. burgdorferi antibodies-CSF, and Toxoplasma gondii antibodies-CSF orders were removed from the test menu. A provider could still order these tests using a miscellaneous order. We collected monthly volumes of test orders before and after the tests were removed from the CPOE.

Apixaban Prescribing Patterns in Inpatients with End-Stage Renal Disease

QPI: Bethany, Shoulders, (

Apixaban is a direct oral anticoagulant approved by the FDA for use in the treated of venous thromboembolism and prevention of stroke in patients with non-valvular atrial fibrillation. The package insert includes recommendations for dose adjustments in renal impairment for non-valvular atrial fibrillation but does not suggest adjustments for the treatment of venous thromboembolism, although the drug is excreted ~25% renally and drug accumulation can be expected in renal impairment. Furthermore, initial studies prior to FDA approval of apixaban excluded patients with serum creatinine greater than 2.5 mg/dL. Pharmacokinetic studies of apixaban in patients on hemodialysis are limited to small cohorts and describe levels following once daily dosing versus the twice daily dosing that is recommended via the package insert. Therefore, more information is needed regarding the safety of apixaban in end-stage renal disease.

Does the Availability of Donor Human Milk Influence the Amount of Mothers’ Own Milk Consumed by Very Low Birth Weight Premature Infants in a Neonatal Intensive Care Unit?

QPI: Shannon, Perry, (

A mother’s own breast milk (MOM) is the gold standard in terms of nutrition for premature very low birth weight (VLBW) (less than 1500 grams) infants because of its innate protection against late-onset sepsis and necrotizing enterocolitis as well as its facilitation of improved neurological development. However, mothers of VLBW infants are often unable to produce sufficient amounts of breast milk to meet their infant’s nutritional needs. As of 2012, a donor breast milk program was implemented in the neonatal intensive care unit (NICU) at UFHealth Children’s Hospital to provide donor breast milk to premature infants when sufficient MOM was unavailable. Donor breast milk is known to be inferior to MOM in terms of nutritional content and protection against infection. This project will determine if the availability of donor breast milk in this NICU affects the amount of MOM available for infant consumption.

Financial, Social and Clinical outcomes in Injection Drug Users administered Intravenous Antimicrobials and provided Drug rehabilitation through the Substance Abuse PICC Program

QPI: Nila, Radhakrishnan, (

Injection Drug Users (IDU’s) are a complex population subset and difficult to manage in the inpatient setting 1. They frequently have infectious complications and these account for as high as 60% of their admissions with infectious endocarditis (IE) accounting for 5 to 15% of these admissions(Levine, Crane et al. 1968, Scheidegger and Zimmerli 1989). The treatment of these infections is complicated by inability to administer Intravenous antibiotics safely through a peripherally inserted central catheter (PICC), in an outpatient setting or in a skilled nursing facility (SNF), due to concerns of intravenous drug abuse (IVDA). Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry and is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors; and without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death(Public Policy statement). In the hospital, addicted patients can be disruptive to the facility and other patients and make increased demands of physicians, nurses’ time with behaviors such as bartering, bargaining, self-harm to receive pain meds, exaggeration of symptoms, and triangulation of the treatment team. They also demonstrate Non-compliance by leaving the unit for several hours, obtaining drugs from visitors or other patients and PICC line tampering. They also have more frequent recurrence rates(Welton, Young et al. 1979, Alagna, Park et al. 2014). There were concerns for PICC tampering in the outpatient setting and for poor adherence to therapy; lack of supervision and potential risk of exposure of vulnerable patients in the SNF setting from visitors of IDU’s these patients historically had completed their course of IV antimicrobials through an extended stay in the hospital. The Infectious disease providers did not recommend patients be discharged on oral antimicrobials since these therapies are considered suboptimal(Al-Omari, Cameron et al. 2014). Infectious disease society of America recommends for most cases of endocarditis at least 4 to 6 weeks of IV therapy (Baddour, Wilson et al. 2015). Since the primary issue of addiction was not addressed, patients had readmissions with repeat infections. Some of these patients required expensive valve replacement surgeries and due to ongoing drug use developed complications of prosthetic valve endocarditis(Alagna, Park et al. 2014). Due to these issues, a Substance Abuse PICC Program (SAPP) was developed at University of Florida Health – Shands Hospital (UFH) in 2013 modeled on the successful program at Virginia Commonwealth University. At VCU, it was estimated that the SAPP saved 2.5 million dollars in a 6 year period to the hospital (Jewell, 2013). The goal of SAPP was to create a program that focuses on the management of the underlying diagnosis of addiction in parallel with the treatment of the active infection caused secondary to the addiction. It was postulated that successful implementation of SAPP would also decrease readmission risks, decrease demand on nursing resources and decrease length of inpatient stay in this high risk population. The program task force is a multi-disciplinary team including social work/case management, legal experts, nursing and physicians from psychiatry/addiction medicine (AM), internal medicine, and infectious disease (ID). A contractual agreement was put in place with Meridian Behavioral Healthcare, Inc for drug rehab and monitoring at the Bridge house.

Workflow Comparison of Two Gel Analyzers

QPI: Joseph, Pelletier, (

Two automated testing systems will be compared for process steps, maintenance tasks, operator/analyzer time span, and cost (testing/maintenance personnel time)

Engaging Residents in Mortality case reviews

QPI: Nila, Radhakrishnan, (

Residents have knowledge of front line quality and patient safety issues. Each department has case reviews to perform and residents can be very helpful in performing case reviews with a structured tool to capture key information. The cases are then discussed with a faculty mentor and systems issues are identified. These systems issues can then be discussed and reviewed at Departmental M&M or QEC meetings. Action items can be created and addressed. Residents find this an educational experience and this can be part of any QI curriculum.

Characterization of N-acetylcysteine (NAC) Use for the Preventions of Contrast-Induced Acute Kidney Injury (CI-AKI)

QPI: Bethany, Shoulders, (

CI-AKI is described frequently in both the inpatient and outpatient settings. Risk factors for this complication include elderly patients and those with chronic kidney disease and diabetes. Guidelines for AKI provided by the Kidney Disease Improving Global Outcomes (KDIGO) group include recommendations for the management of patients at risk for CI-AKI including using the lowest amount possible of contrast media, administering iso- or low-osmolar contrast media, and giving intravenous volume to high risk individuals. The guidelines also recommend oral NAC in conjunction with intravenous crystalloids with a strength of evidence rating of 2D. Studies offer conflicting conclusions regarding the benefit of NAC and therefore, UF Heath Shands Hospital implemented criteria for use to restrict the medication use to the highest risk individuals. Furthermore, the hospital decided to restrict the intravenous route as it is not recommended by the guidelines and is associated with a risk for an anaphylactoid reaction. This study aims to describe the adherence to the institution's restrictions and to evaluate the safety and effectiveness of this medication for this indication.

Standardization of Nursing Care of Pediatric Patients on Phototherapy

QPI: Tara, Jendzio, (

Jaundice is a common problem in neonates that can results in serious complications. The most common treatment for neonatal jaundice is phototherapy. Phototherapy can be a very effective treatment for jaundice when done safely and effectively and this treatment can reduce the duration of hyperbilirubinemia and decrease length of stay. The purpose of this quality improvement project is to evaluate current nursing care in pediatric patients on phototherapy when compared to the current standards of care.

Evaluating a Weight Management Program in a Primary Care Setting

QPI: Denise, Schentrup, (

The aim of this Quality Improvement (QI) project is to evaluate the impact of a comprehensive weight management program at Archer Family Health Care. The setting is a nurse-led integrated primary care and mental health practice in Archer, Florida. Evidence based protocols have been developed for implementation as part of an initiative to improve health in high risk patients. This project will serve to evaluate if a structured weight management program improves clinical outcomes. It will also serve to identify patients with comorbid conditions such as diabetes, hypertension, depression and binge eating disorder.

Streamlining Care of the ELBW (Extremely Low Birth Weight)

QPI: Meredith, Mowitz, (

Caring for ELBW infants is a complicated process which requires high attention to detail. This project seeks to streamline the care of these infants by creating an order set and practice parameter based on current literature and best practices for all clinicians in the NICU at UF Health to follow. Using current literature we will create a practice parameter to guide the management of ELBWs in the first few hours of life. Additionally, to help ensure success in following the parameter, we will create an order set specific to this unique group of patients based on the practice parameter. The practice parameter and order set will address the needs of the ELBW at admission and include things such as nutrition/fluid management, medications, and monitoring procedures. We will collect baseline data to determine the variation in these practices as well as significant morbidities that may be associated with the variation. Then, following implementation of the parameter and order set we will again follow these practices and morbidities to look for change.

An Evaluation of the HEDIS Countdown Call Campaign at Community Care Plan

QPI: Marissa, Stone, (

Community Care Plan uses the Plan Do Study Act (PDSA) cycle to implement and perform its quality improvement initiatives. With one hundred (100) days left in the 2016 calendar year, over thirteen thousand (13,000) enrollees displayed gaps in their HEDIS measures. These gaps were identified across 7 different HEDIS measures: Adult Access to Preventative Care (AAP), Cervical Cancer Screenings(CCS), Breast Cancer Screenings (CBS), Well-Child visit for ages 3 through 6 (W34), Adolescent Well-Care ages 12 through 17 (AWC 12-17), Adolescent Well-Care ages 18 through 20 (AWC 18-20), and Children and Adolescent Access to Primary Care (CAP). To alleviate this gap, CCP implemented the HEDIS Countdown Call Campaign. The HEDIS Countdown Call Campaign was performed to improve quality and health outcomes for its members. The HEDIS Countdown Call Campaign was an after business-hours outreach call campaign that took place from October 26th 2016 through December 17th, 2016. The employees used a AHCA approved script to collect qualitative data. This evaluation will look at the “Study” facet of PDSA by evaluating the data set. The evaluation will look at two sets of deidentified data. The first set, is call campaign data that includes the number of enrollees and if the call made to him or her was “successful” or “not successful”. A “successful” call was a call an enrollee answered and listened to the caller on the line. Subcategories for this data include reasons for an “unsuccessful” and for a “successful” call. The second set of data includes the number of enrollees and if his or her HEDIS gap was closed (Yes or No). The evaluation will focus on two questions. In the short term, were the number of successful calls made reaching or exceeding industry standard by December 2016? In the midterm, by March 2017, were the gaps of all “successful” calls closed?

Assessing Patient Handbook Utilization and Outcomes in Neurosurgery

QPI: Janelle, Alongi, (

This project aims to optimally provide patient education using a patient-centered approach. It focuses on coordinating and integrating care, while communicating expectations, and educating relevant information to facilitate autonomy and self-care in an attempt to alleviate fear and anxiety for patients, family, and friends. We plan to do this by assessing healthcare professionals’ effectiveness of providing patient education by linking patient education to patient outcomes. In January 2016, our department formed a Patient and Family Advisory Council (PFAC) in which a representative sample of current and former patients and caregivers shared their experiences in a focus-group format and consulted on improvement opportunities monthly. All PFAC members shared the needed improvement for patient education. Specifically, the PFAC requested that a consolidated patient educational reference was available to patients and caregivers. From that PFAC, our team created a Neurosurgery Patient Handbook (handbook) that informs patients and caregivers what to expect across their journey of care as a Neurosurgery patient. It includes pre-, intra-, and post-operative sections, as well as medication reconciliation, follow-up care, and notes. Each page has our department’s direct phone number and other institutional details such as maps, related services, and a materials’ pocket holder. The handbook was created by Health Education and Behavior experts with careful attention to written grade-level, reading-ease, and health-literacy. Standard methods and assessment metrics, include Flesch-Kincaid, were utilized. Moreover, the handbook was vetted by seven stakeholder groups, including residents, faculty, nurses, staff, PFAC members, marketing, and legal.

Breath Easy

QPI: Thomas, Pittman, (

QVAR (beclomethasone proprionate) has been shown to be the most effective inhaled medication for control of asthma symptoms, however most patients of UF are on Flovent as this was the only option on the hospital formulary. This project was started to help change from Flovent to QVAR which is now on the hospital formulary

Quality Evaluation and Improvement of Nutrition Management in Critical Care

QPI: Sandra, Citty, (

This project seeks to evaluate the ordering, administration, documentation and evaluation variables related to nutrition in critical care and describe and evaluate the current state of nutrition risk, length of stay and hospital readmission in critical care.

Evaluation of Safety and Efficacy of Albuterol with and without Preservatives

QPI: Lucas, Orth, (

In October 2015, the UF Health P&T Committee voted to approve the addition of BAC-containing albuterol solution to the Formulary with the provision that a three-month analysis of adverse events be performed. A single-center retrospective review of all patients receiving continuous albuterol for nebulization between July 27, 2015 and January 26, 2016 will be conducted. Patients will be divided into two cohorts based upon date of albuterol initiation prior to or after the change to a BAC-containing albuterol product occurred on October 27, 2015. Patients intubated for the full duration of albuterol therapy will be excluded from analysis. Evaluated endpoints will include duration of continuous albuterol nebulization therapy, duration of supplemental oxygen requirement, and documentation of poor patient response by physicians or respiratory therapists within the electronic medical record. Poor response will be defined as need for escalation in oxygen support, escalation in albuterol dose requirements after one hour, addition of alternative therapy, or occurrence adverse drug event. Mean total and weight-based hourly dosage requirements will also be calculated, and presence of confirmed viral or bacterial infection will be evaluated.

Use of Visual Aid to Promote Compliance with Hourly Rounding

QPI: Tiffany, LeGault, (

Compliance with hourly rounding on unit 74 averages between 15-20%. Stephanie Heinis, RN on unit 74 was involved in the Leadership Fellowship and made hourly rounding her fellowship project. Through research, Stephanie found the Visilert device. This device provides a visual aid for staff to remind them the patient has not been rounded on in the last hour. Stephanie contacted the company that manufactures the device and received an auxillary grant to purchase the devices. The project will include education for the staff and patients, product instillation, monitoring of hourly rounding compliance, and staff feedback.

Pharmacist-led monitoring for direct oral anticoagulants (DOACs)

QPI: Eric, Dietrich, (

Pharmacist working at an outpatient clinic (Internal Medicine at Tower Hill) and will be monitoring patients who are receiving direct oral anticoagulants (DOACs), a group of medications used to prevent blood clots. Historically patients were managed with warfarin which required frequent clinic visits but the DOACs do not require routine clinical monitoring. Recently data has suggested patients on DOACs should receive counseling and education 2-4 times per year to ensure the safe use of these medications. The current project will collect clinical data related to the patient visits with the Pharmacist related to DOACs. Data will be used to determine the usefulness of the clinical service to determine if more frequent monitoring is needed, types of monitoring that may be needed, specific questions or areas for improved patient education and counseling to target, or if additional interventions need to be implemented in order to ensure the safe use of these medications.

Perioperative Coordinated Care for Spine Surgery

QPI: Basma, Mohamed, (

This is a CQI project aimed at developing a protocol to standardize the perioperative care of patients undergoing elective spine surgery. There are four phases of care involved in elective spine surgery. This protocol will address aspects of each phase. Phase 1: Preoperative Phase 2: Intraoperative Phase 3: Acute post-operative period Phase 4: Subacute postdischarge period

Quality evaluation of current chest pain algorithm in the emergency department

QPI: Sydney, Banack, (

The quality improvement project seeks to evaluate current practices regarding the algorithm of care in patients whom present to the Emergency Department with chest pain. Evaluation will be reviewed thorough readmission data regarding AMI.

Improving the discharge process on one medicine unit.

QPI: Grace, Mayne, (

Healthcare organizations are experiencing external and internal pressures to cut costs and adopt strategies to improve throughput and reduce length of stay. Reducing delays in patients discharges will improve throughput, decrease length of stay and ultimately costs. The pilot unit is currently not meeting current unit/hospital metrics. Introduction of a 3pm discharge huddle to identify patients for next day discharge and any anticipated barriers to discharge. Discharge huddle uses a multidisciplinary approach to improving the discharge process.

Reduce job stress through the buddy system

QPI: Victoria, Holley, (

The Employee Engagement survey results were reviewed during the January 25th, 2016 RPD council meeting of which I am a member. Work group reviewed departmental results related to fatigue schedules, recognition, and other indicators. Based on the indicator results, I noticed an opportunity for improvement my unit, unit 64 med/surg. With the advisors of the RPD council, Duke Lim and Mary Beasley, I discussed possible approaches including implementing the buddy system. I partnered with a night shift RN to collect charge nurse and staff opinions of the possible implementation. Nurses that had floated to other units that use the buddy system reported feeling more support during dual verification process, tasks that required two RNs such as complicated wound care or blood administration and most of all the ability to take 15 minute as well as 30 minute uninterrupted lunch breaks. This increase in support was directly due to knowing ahead of time who their buddy would be for the shift. The initiative was supported by unit leadership: the nurse manager, the clinical leader and other charge nurses. The buddy system was introduced to staff during morning huddles. At the beginning of each shift the charge nurse assigned buddies and handed out quarter paper sized forms to all nurses that included their buddy’s name and phone number: These forms were passed out every shift for about a month until staff were used to the new process. An email was sent to all staff reminding them of the new process and the benefit it served for them. The also encouraged any feedback. Education was provided by project RN, one on one, with every charge nurse and a roster signed to ensure understanding of the process and allow for feedback or suggestions. During the implementation process, staff that were unable to take a 30 minute uninterrupted lunch break decreased but there was still compliance issues. One barrier that was identified was a lack of consistency of when or if charge nurses assigned buddies. We designated buddies using matching character magnets on the assignment board. RN investigated other units’ successful implementation of the buddy system. Based on findings, a new assignment board would help hardwire the process by buddies being assigned automatically based on their placement on the board. RN coordinated with unit manager to create the new board. The setup of the new board automatically assigns buddies in horizontal rows and includes the corresponding PCA. This simple change has greatly improved compliance and decreased missed breaks even further. pre data Q1 = 2/16-4/16 = 11 implementation period Q2 = 5/16-7/16 = 7 Post data Q3 = 8/16 – 10/16 = 1 Q4 = 11/16 – 01/17 = 1 Q4 = 2/17-4/17 = 3

Steroid administration upon admission for pediatric asthma patients

QPI: Christopher, Campbell, (

Asthma is one of the most common illnesses in childhood affecting up to 8.4% of American children (CDC) with the incidence rising. Patients access the emergency department most often when they are in an acute exacerbation of their asthma. National and international guidelines have been published that provides a treatment algorithm for most patients. One component of that treatment algorithm is the prompt administration of systemic corticosteroids to decrease airway inflammation in moderate to severe exacerbations. At the University of Florida (UF) Health Shands Children’s Hospital, the Pediatric Asthma Center of Excellence (PACE) is a multidisciplinary team devoted to improving asthma care. The team consists of pulmonologists, allergists, respiratory therapists, hospitalists, pediatric intensivists, nurse practitioners, nurse leaders, emergency physicians, clinical pharmacists, a pharmacogenetecist, certified asthma educators and social workers. One of several metrics that is evaluated monthly is the percentage of admissions to the emergency department who receive a steroid within 30 minutes. Historically, based on EPIC reports, this number fluctuates between 30-40%. This number is believed to be higher since this EPIC report only tracks doses administered at our hospital (versus an outside hospital or EMS). This retrospective chart review will review asthma admissions to the pediatric emergency department to assess the true rate of this metric. The purpose of this evaluation is to identify areas for improvement in the medication use process

Therapeutic enoxaparin in neurocritical care patients

QPI: Aimee, Gowler, (

Enoxaparin package insert directs to use actual body weight when calculating therapeutic enoxaparin doses. Enoxaparin has a small volume of distribution and dosing on actual body weight likely leads to supratherapeutic levels in obese patients. This review aims to evaluate enoxaparin dosing and levels from patients in the NeuroICU for guidance on patient parameters that may prompt weight-based dose adjustments.

An Evaluation of the HEDIS Countdown Call Campaign at Community Care Plan

QPI: Marissa, Stone, (

Community Care Plan uses the Plan Do Study Act (PDSA) cycle to implement and perform its quality improvement initiatives. With one hundred (100) days left in the 2016 calendar year, over thirteen thousand (13,000) enrollees displayed gaps in their HEDIS measures. These gaps were identified across 7 different HEDIS measures: Adult Access to Preventative Care (AAP), Cervical Cancer Screenings(CCS), Breast Cancer Screenings (CBS), Well-Child visit for ages 3 through 6 (W34), Adolescent Well-Care ages 12 through 17 (AWC 12-17), Adolescent Well-Care ages 18 through 20 (AWC 18-20), and Children and Adolescent Access to Primary Care (CAP). To alleviate this gap, CCP implemented the HEDIS Countdown Call Campaign. The HEDIS Countdown Call Campaign was performed to improve quality and health outcomes for its members. The HEDIS Countdown Call Campaign was an after business-hours outreach call campaign that took place from October 26th 2016 through December 17th, 2016. The employees used a AHCA approved script to collect qualitative data. This evaluation will look at the “Study” facet of PDSA by evaluating the data set. The HEDIS Countdown Call Campaign data set includes the number of enrollees, the month the call was made (October, November, December), and if the call made to him or her was “successful” or “not successful”. A “successful” call was a call a patient answered and listened to the caller on the line. Subcategories for this data include reasons for the failure of the call. The call campaign data also includes if his or her HEDIS gap was closed (Yes or No) for all calls made. The evaluation will focus on two process and two outcome questions: Process: 1. Were the number of successful calls made reaching or exceeding industry standard by December 2016? 2. Did the month the call was made effect the success of the call? Outcome: 1. By March 2017, were the gaps of all “successful” calls closed? 2. Did the month a successful call was made effect the number of gaps closed?

Review of Transitions of Care Clinic - Internal Medicine Medical Plaza

QPI: Ryan, Nall, (

Last year Internal Medicine at Medical Plaza (IMMP) developed an interprofessional transitions of care (TCM) clinic. Currently the clinic operates every Wednesday afternoon. Our primary goal is to reduce 30 day hospital readmission and ed utilization. Currently, after discharge from UF Health all patients are contacted to make sure they are doing well since discharge, reconcile medications, and arrange clinic follow up. Our primary goal are for patients to follow up with their primary care physician within 2 weeks. If this isn't possible the TCM clinic provides additional access. Prior to the clinic session we meet as an interdisciplinary group from 1-1:30 and discuss the pts we are seeing that day. The team consists of pharmacy, social work, home health, nursing, medical student, resident, and attending. We focus on the issues that might keep patient from being readmitted. Patients are then seen by the physician along with other team members felt to be necessary at that time. Our team would like to perform a chart review to determine the effectiveness of our TCM clinic on reducing hospital readmission. Our plan is to review patients seen by our TCM clinic vs a cohort of IMMP patients discharged from UF Health who were not seen in the TCM clinic. We will collect data in UF CTSI REDCAP. Data to be collected include (a copy of this REDCAP tool can be sent) : 1. Pt demographics 2. Pt chronic health conditions (DM, HTN, CAD, etc) 3. Characterization of Hospital Admission (ie. Icu vs IMC, LOS, etc) 4. Follow-up (days until follow up in clinic, was appointment schedule) 5. Medication issues (how many medications, high risk meds, medication changes) 6. Did patient attend transition clinic? 7. Days until readmission 8. Days until ED visit

Subarachnoid Hemorrhage “Fast Track” Discharge Model: Safety and Feasibility

QPI: Christina, Smith, (

Some nontraumatic subarachnoid hemorrhage patients, especially those with Fisher scores of 3 or less, fared far better clinically than those with higher Fisher grades. These patients typically did not need cerebrospinal fluid (CSF) diversion by means of an external ventricular device (EVD) or a lumbar drain (LD). These patients also did not develop the more serious and potentially devastating complications of the disease. This subset of patients met typical hospital discharge criteria by hospital day 7. We questioned whether we could decrease LOS by one half while safely discharging these patients home, with outpatient neurological monitoring, prior to the typical LOS of 14-21 days for this disease.

Improving lactation practices through self-efficacy

QPI: Dawn, Disalvo, (

The purpose of this project is to improve the percentage of mother’s providing milk for their infant in the NICU. This project hopes to accomplish this through educating staff on an evidence-based practice (EBP) change implementation in the NICU. The EBP includes a lactation support group developed under the self-efficacy theory by Dr. Dennis as well as including a peer-to-peer support. NICU staff will be educated on the evidence and the practice change. The project will provide support to the nurses as they implement the EBP practice change. The NICU already collects data of the percentage of mothers who provide milk for their infant, the percentage of infants receiving donor milk, and percentage of mothers who are making acceptable minimums at 15 days. This data is collected by the NICU for quality improvement processes and benchmarking. This project will continue to collect this data and evaluate the intervention for changes via run charts.

Utilizing the EMR to curb inappropriate inpatient thrombophilia testing

QPI: Grant, Jester, (

Venous thromboembolism (VTE) is a common clinical diagnosis encountered in the hospital and it is imperative to investigate the etiology of the thromboembolic event after initiating appropriate treatment. According to the American Society of Hematology Choosing Wisely Campaign, VTE provoked by a temporary risk factor does not warrant further evaluation for heritable risk factors of thrombophilia. Inappropriate thrombophilia testing is costly and may increase adverse events if anticoagulation treatment is extended based on these results. We aim to identify the prevalence of improper thrombophilia testing in the inpatient setting and institute an EPIC advisory to prevent inappropriate use. The project was previously approved The Sebastian Ferrero Office of Clinical Quality and Patient Safety (Quality Center). Seeking Registration on QIPR as to forgo the need for IRB approval for publication.

Quality of warfarin management at IMMP

QPI: Katherine, Vogel Anderson, (

I would like to determine the quality of my warfarin management by calculating my patients' time in therapeutic INR range. In order to do this, I need to request a list of all IMMP patients who have been prescribed warfarin from 4/1/16 through 4/30/17. This list will also help me identify patients who are no longer on warfarin, or if we have lost any patients to follow up.

Use of Simulation to teach Bone Marrow Biopsies to Hematology/Oncology Fellows

QPI: Martina, Murphy, (

Hematology/Oncology fellows are required to learn how to perform bone marrow biopsies, invasive procedures often required to make the diagnosis of a variety of hematologic conditions. Oftentimes, while fellows have learned about this procedure in a didactic setting, they have not had prior hands on experience. Simulation is an educational strategy that relies on imitation of aspects of patient care through standardized patients. Use of simulation has been shown to better prepare learners as compared to didactic sessions alone without risk to patients and the ACGME has placed great value in its use. We plan to teach first year fellows how to perform bone marrow biopsies and then allow them to practice using an artificially constructed pelvis that mimics human bone. This will allow them to get hands on experience prior to performing this procedure on an actual patient. Second/third year fellows will be offered the opportunity to participate in this simulation session as upperclassmen in an alternative session geared toward troubleshooting common stumbling blocks that may present themselves during the procedure (e.g. difficult anatomic landmarks). In collaboration with a proceduralist in our Department, an artificially constructed pelvis was constructed using cow bone. An interior chamber was created and filled with a gelatinous substance that will mimic actual bone marrow. After learning the steps of the procedure including indications/contraindications, informed consent, and anatomic landmarks, fellows will be given time to practice and refine their technique.

Improving Care for infants with Neonatal Abstinence Syndrome

QPI: Mary, Siebenaler, (

We would like to start a QI initiative working with a multidisciplinary group to provide excellent, high-value care to infants affected by maternal opioid use in utero and decrease unnecessary use of opioids after birth for treatment of neonatal abstinence syndrome (NAS). We are in the planning stage, but hope to assemble a multidisciplinary team of doctors from Pediatric Hospital Medicine, Newborn Nursery, Obstetrics, as well as nurses from similar units and in the community, QI leaders, resident physicians, parents, and community opioid addiction centers. Our specific goals would be to: 1) increase use and education about non-pharmacologic interventions, 2) simplify assessments of infants including use of simplified withdrawal score (rather than the Finnegan scoring system) particularly in infants > 8 days of life, 3) decrease duration and total daily dose of morphine given to infants, 4)Improve communication between hospital staff and families and empower mothers and care-takers of infants. We hope to improve the long-term outcomes of children as well as decrease overall healthcare costs. Our project also will be using similar techniques and measures a those published in a NIH funded QI effort from Yale. See Grossman MR et al. An initiative to improve the quality of care of infants with neonatal abstinence syndrome, Pediatrics, Vol 139, Number 6, June 2017.

Safe Sleep Assessment

QPI: Kendall, Steadmon, (

Sudden Infant Death Syndrome (SIDS) is the leading cause of death amongst one month and one year old children. Approximately 1500 children died of SIDS in 2014. Safe sleep practices as listed below have been proven to decrease the risk of SIDS. In accordance with the AAP guidelines, safe sleep practices include sleeping on the back on a firm surface, breastfeeding the infant, sleeping in the parent’s room but in a separate surface designed for infants for at least the first 6 months of life, keeping loose and soft objects away from the infant’s sleep area, avoiding smoking/alcohol/illicit drug use, and immunizing children. The primary purpose of this project is to improve the quality of safe sleep practices by assessing current sleep practices from parents of the Mother Baby Unit (Units 35 and 95) at Shands Hospital, part of UF Health. A collaborative approach between social workers, medical doctors and the family partner from the Coordinated Intake and Referral program (CI&R) is aiming to assess different measures of safe sleep practices, including safe sleep environment, safe sleep education, sleeping practices (i.e., co-sleeping), smoking and breastfeeding. According to Moon (2016), racial and ethnic disparities impact SIDS and Sudden Unexpected Infant Death (SUID) mortality rate. As a result, researchers will assess racial and ethnic differences in knowledge and practice of safe-sleeping. Additionally, safe sleep implementation and education will be assessed for parents who have children in the Neonatal Intensive Care Unit (NICU), aiming to assess if a difference exists between level of education and implementation of safe-sleep practices. Moreover, recent research findings suggest a vast gap exists between patient knowledge about safe sleep practices and what they’re being taught by health care providers. For instance, Eisenberg and colleagues (2015) found only 54.5% of mothers in the United States were educated on appropriate supine sleeping positioning, 19.9% were coached on safe sleep location, and 11% were instructed on appropriate use of pacifiers. The aim of this study is to assess current safe sleeping educational strategies at UF-Health Shands to improve this approach ensuring each parent is knowledgeable, confident and equipped to prevent and decrease incidents of SUID and SIDS.

Holding the Gain- Sustaining a Successful Triage Asthma Protocol

QPI: Matthew, Higgins, (

Asthma is the most common chronic condition among American children with a prevalence of 8.8% nationally and 9.9% in the state of Florida. $50.1 billion is spent annually towards the direct treatment of asthma, and asthma is a leading cause of school absenteeism with an estimated 13.8 million school days lost annually. Exacerbations of asthma are the number one reason for emergency department (ED) presentation and a leading cause of inpatient admissions nationally accounting for roughly 640,000 ED visits in the 0-15 year-old cohort and 136,669 inpatient admissions in the 0-17 year-old cohort. The ED at Johns Hopkins All Children's Hospital recently implemented new asthma protocols to address the needs of our population and to bring our practice in line with the recommendations. Initial auditing showed the protocol was being used and was effective, but it is unknown if the gains made after the initial implementation and audit have been sustained.

UF Urology Fusion Prostate Biopsy

QPI: Michelle, Van Leer, (

We have recently implemented a new procedure in the urology clinic, prostate fusion biopsy utilizing a Uronav system and MRI. This was put into place in October of 2016. We would like to see how well our patients are doing (complications, etc.) and also see how well we captured cancer based on the MRI fusion process.

Evaluation of Pediatric Hematology/Oncology Fellow and Pediatric Pharmacy Resident Chemotherapy Education

QPI: Tara, Higgins, (

Implementing a new education process which includes giving patient scenarios and having fellows provide diagnosis, which protocol to treat based on and have them write the chemotherapy using old paper order forms. For the pharmacy residents they will be provided scenario, diagnosis and protocol and will have to write the chemotherapy using old paper order forms. The fellows will be provided at least 6 scenarios throughout the year and the pharmacy residents will be provided scenarios weekly during a 4-5 week rotation. A rubric will be used to grade their work. Also a survey for self evaluation of their progress and confidence will be distributed at the beginning and quarterly for pediatric fellows and at the beginning, midpoint and end of the month long rotation for pediatric pharmacy residents.

Phosphate replacement in Pediatric Diabetic Ketoacidosis

QPI: Christopher, Campbell, (

In the setting of a potassium phosphate shortage in late 2012, the UF Health Shand's faced a critical parenteral phosphate shortage. Initially alerts were placed in EPIC to lead prescribers to oral products but in April 2013, the Pharmacy and Therapeutics committee enacted a restriction for all intravenous potassium phosphate products. The product was restricted to: 1) IV phosphate therapy during continuous renal replacement therapy (CRRT), 2) IV phosphate replacement in any patient with a serum phosphorous below 1, and 3) IV phosphate replacement in any patient with a serum phosphorous between 1 and 1.5 when no other oral medications were prescribed. Pediatric patients with diabetic ketoacidosis (DKA) have a profound hypophosphatemia due to intravascular volume depletion. Phosphate has historically been replaced in these patients as a continuous infusion in a two-bag method. During this shortage at UF Health Shand's, continuous phosphate replacement was restricted and patients were treated with enteral phosphate with as needed intravenous phosphate for severe hypophosphatemia. This project aims to see if this restriction resulted in less intravenous phosphate usage with no change in clinically relevant outcomes.

Evaluation of a PCR-based gastrointestinal panel at UF Health Shands Hospital

QPI: Stacy, Beal, (

Diarrheal diseases are a major cause of emergency department visits and hospitalization. Conventional methods for identification of gastrointestinal pathogens are time consuming, expensive, and have limited sensitivity. Patients may not receive antibiotics in a timely manner, may undergo unnecessary diagnostic testing, and incur excessive healthcare costs. We compared patients before and after a new test was implemented.

CT Contrast Reaction Guide Sheet

QPI: Bryan, Swilley, (

The dosages for medications and route of administration can be a source of confusion and medical errors in the acute setting of a contrast reaction. This project will involve making a poster to post at each CT scanner for quick reference when contrast reactions occur. Each poster will have the commonly used medications ,dosages and route of administration (as outlined by the American College of Radiology Contrast Manual) for each common type of reaction encountered.

Decreased Pain in Pediatric Laceration Repair in the Pediatric Emergency Department

QPI: Cristina, Zeretzke-Bien, (

When pediatric patients enter the emergency department with a laceration the situation can be both stressful for the parent and the child. Pain, fear, and unfamiliar environment can lead to high anxiety which can make treatment challenging. When a child's pain or anxiety is addressed appropriately, it can make clinical performance of laceration repair easier for all involved. There are approaches to interact with children that can minimize the anxiety, decrease the pain, and maximize cooperation. A pain memory can be formed as early as 6 months and it is imperative that clinicians decrease pain as best possible to decrease the formation of pain memories for future encounters. There are techniques such as shifting awareness, pharmacologic adjuncts, using desensitization, which show improvement with procedural pain in pediatrics. We would like to implement several techniques to overall decrease the pain in laceration repair. We have proposed that use of different quality interventions will decrease overall pain in pediatric patients who are undergoing laceration repairs in the pediatric emergency department some examples are the use of comfort holds, buffered lidocaine, distraction techniques, pharmaceutical pain control, and other procedural techniques. We will look at pain management during laceration repairs on patients with lacerations less than 10 cm, and on patients who are then discharged after repair. Excluded patients will include Trauma alerts, and admitted patients, and patients who are sedated for the laceration repair. We will review pain scores measured before the procedure, during the procedure, and after the procedure using FACES WONG Score. We will also look at patient satisfaction scores to be decreased after six months of intervention.

Utilizing a pulmonary embolism evaluation algorithm to reduce unnecessary CT scans

QPI: Grant, Jester, (

Patients being evaluated in the Adult Emergency Department (AED) at UF Health present with a wide variety of conditions, many of which may be life-threatening if not treated appropriately. One of the most difficult conditions to diagnose is pulmonary embolism as its signs and symptoms often overlap with other conditions. We will be instituting a clinically validated algorithm for the diagnostic evaluation of suspected Pulmonary Embolism in the AED using the Wells’ Criteria, Pulmonary Embolism Rule-Out Criteria (PERC), and Age-Adjusted D-Dimer to allow for appropriate risk stratification and avoid unnecessary testing with Computerized Tomography (CT) scans(1). Physicians from Internal Medicine, Emergency Medicine, and Hematology have collaborated to institute an evidence-based algorithm to direct the evaluation and work-up of patients with suspected pulmonary embolism. This multi-disciplinary team has implemented the algorithm and created a patient-centered decision aid tool. Recent best practice advice from the American College of Physicians have shown use of the PERC instrument in conjunction with D-dimer testing to be both safe and effective in the exclusion of suspected pulmonary embolism who are deemed to be low risk. The patient’s pretest probability of having pulmonary embolism should be determined by use of the Wells’ Score, a very well validated clinical instrument. Patients deemed low to moderate risk can be further stratified with PERC and age-adjusted D-dimer testing(see figure 1 below). This quality improvement project aims to reduce the rates of unnecessary computerized tomography scans in patients stratified to be low or moderate risk below age-adjusted D-dimer cutoffs for diagnosis of pulmonary embolism. This will ultimately reduce health care and unnecessary adverse effects associated with computed tomography imaging (e.g. radiation exposure and intravenous contrast associated adverse events).

Description of Outpatient Medication Fast Discharge Process

QPI: Anna, Cosnahan, (

This project aims to characterize the FAST process at UF Health Shands Hospital in terms of its use and typical patient population so that it may further be optimized. Currently, social work has been paying for medications through this FAST process for patients at time of discharge due to a variety of reasons, such as patients not being able to obtain insurance, issues with insurance acceptance, and preferred locations not having medications, for example. As a part of this project, I will be characterizing the type of patients that are utilizing this particular method of obtaining critical medications, what medications are being obtained and also looking at the reason for utilization of the FAST process for individual patients. I will also be looking at the process itself by looking at the forms for the FAST process to assess appropriate use. My aim is to use these results to further improve upon the FAST process.

Evaluating the Use of Granulocyte-Colony Stimulating Factor in Solid Organ Transplantation

QPI: Wenhui, Li, (

Filgrastim is a recombinant granulocyte colony-stimulating factor (G-CSF) that stimulates the production, maturation, and activation of neutrophils to increase both their migration and cytotoxicity. Filgrastim has been studied extensively in hematopoietic stem cell transplantation and cancer but there is low level of evidence for its use after solid-organ transplantation (SOT). Currently, there is no guidance of how/when to use G-CSF at our institution in SOT. This project is to summarize the current use of G-CSF in SOT patients at our institution.

Description of outpatient medication fast discharge process

QPI: Anna, Cosnahan, (

This process aims to characterize the fast process at UF Health Shands Hospital in terms of its use and typical patient population so that it may further be optimized. Currently, social work has been mediating the medication process of the fast discharge for patients due to a variety of reasons, such as patients not being able to obtain insurance, issues with insurance acceptance and preferred locations not having medications, for example. As a part of this project, I will be characterizing the type of patients that are utilizing this particular method of obtaining critical medications, what medications are being obtained, and also looking at the reason for utilization of the fast process for individual patients. I will also be looking at the process itself by looking at the forms utilized to assess appropriate use. My aim is to use these results to further improve upon the fast process.

Dissemination of the Guidelines for Early Peanut Introduction

QPI: Leilanie, Perez-Ramirez, (

In the past, the US practice guidelines recommended the exclusion of allergenic foods from the diet of infants during the first year of life [5]. However, recent data from the Learning Early about Peanut Allergy (LEAP) trial study demonstrated that early introduction of peanut will result in the prevention of peanut allergy for infants with atopy (severe eczema and/or egg allergy)[7]. Despite the recommendations, early peanut introduction guidelines are not always implemented. Preventive measures for peanut allergy are important, since its prevalence has increased over the last decades (now being 2% in the US[9]) and it is the leading cause of food induced anaphylaxis [6, 10]. For this reason, a quality improvement project to disseminate the guidelines for the prevention of peanut allergy in UF primary clinics will be pursued. Data about knowledge and perspective of primary providers about the guidelines for early peanut introduction will be evaluated before and after the intervention.

Improving speed, efficiency, communication, and parent involvement of clinical patient rounds in the Congenital Heart Center

QPI: Kevin, Sullivan, (

Rounds on up to 22 patients with complex congenital cardiac defects can be time-consuming in order to be comprehensive. Patient safety and execution of the patient-specific plans detailed in rounds requires communication and participation from all of the members of a multi-disciplinary team. Failure to procure multidisciplinary input from all care providers and parents results in sub-optimal care and potential errors of omission and commission, as well as patient, parent and staff frustration. Rounds in the CHICU is complicated by the fact that sub-populations of medical, surgical, pre-transplant, immediate post-transplant, and remote transplant recipients with transplant related complications are all present. This is an observational study that seeks in the pre-intervention phase to study and record the participation of charge/resource nurse, bedside nurse, parents (if present), patient (if of age), physicians, extenders, residents, fellows, respiratory therapists, pharmacists, therapists (occupational, speech, and physical), dietician, and social work/case management. Frequency of interruptions and their sources will also be documented. After obtaining 4 months of observational data we will review the areas most in need of improvement and along with nurse leadership will implement corrective changes in our culture and then observe performance changes for four months after a one-month wash-in period. If appropriate, need for additional physical plant or personnel resources will also be considered.

Pharmacogenomics Consultation Service (PGx-CS) Clinic Implementation Data

QPI: Meghan, Arwood, (

The UF Health Personalized Medicine Program (PMP) seeks to continue to implement clinical pharmacogenetic testing into routine clinical practice, though now in the outpatient setting as its own standalone clinical consultation service. To assess the success and impact of this genomic medicine implementation, the PMP plans to track and report implementation metrics and outcomes, including measures of feasibility and clinical utility. The primary therapeutic areas of focus for this implementation will include but are not limited to pain, psychiatry, gastroenterology, and cardiology. Initially, the PMP will pilot this service at the UF Health Internal Medicine at Tower Hill (IMTH) clinic, with the ultimate goal of making the service available to other outpatient clinic sites and eventually all patients within the UF Health system.

Predicting ACGME site visits, match results, and resident attrition using Annual Program Evaluation and ACGME survey results

QPI: Tyler, Loftus, (

This project will assess the capacity of Annual Program Evaluation and ACGME survey results to predict ACGME site visits, match results, and resident attrition for residency and fellowship programs at the University of Florida.

Assessment of Provider Adherence to Best Practices for reaching key populations with HIV prevention and testing services in the Eastern Caribbean

QPI: Kevin, Reeves, (

HIV/AIDS is a significant public health concern in the Caribbean region. The region represents the 2nd highest prevalence rate in the world, behind sub-Saharan Africa. The epidemic is primarily driven by high incidence rates in certain key populations, including men who have sex with men (MSM), female sex workers (FSWs) and transgender. If programs target these key populations with appropriate and timely prevention and testing services, HIV incidence in the region will decrease. This project will assess whether MoHs and CSOs in the Eastern Caribbean are using appropriate strategies to reach these key populations with services. Countries in the Eastern Caribbean region include Antigua and Barbuda, Dominica, Grenada, St. Kitts and Nevis, St. Lucia, and St. Vincent and the Grenadines. These countries currently receive external funding through The Global Fund to Fight HIV/AIDS, TB and Malaria. The project will compare strategies and practices in use and compare to international and regional best practices. Recommendations will be developed to help MoHs and CSOs refocus their outreach efforts on the most effective strategies. The main research question will be, Do CSOs and Ministries of Health in the Eastern Caribbean adhere to and utilize effective and proven strategies to reach and deliver HIV prevention and testing services to key populations?

Assessment of Neonatal Nutrition Status Pre and Post Discharge In NICU Follow-up Clinic

QPI: Katherine, Kisilewicz, (

Assess the overall growth and bone health of neonates pre and post discharge in an effort to decrease postnatal growth failure and improve bone mineralization.

An Evaluation of Cardiac Rehab Education Understandability and Actionability in Open Heart Surgery Patients

QPI: Cori, Nolan, (

Patient education has proven to be an essential part of clinical and patient health outcomes. If patients are not understanding the information they receive while they are still inpatient after surgery, there is a potential risk for decreased patient health outcomes and an increased risk for multiple complications. Therefore, the purpose of this project is to examine the understandability and actionability of educational material of cardiac rehabilitation information presented to patients who have undergone open-heart surgery at Manatee Memorial Hospital. A patient sample size of 20 will be obtained and the PEMAT form will be utilized for evaluation. No personal identifiers will be used. Inclusion criteria includes open heart surgery requiring a sternotomy for coronary artery bypass or valve replacement. Exclusion criteria includes minimally invasive heart surgery and a stay in the cardiac ICU that extends longer than one week.

Inpatient Formulary expansion for Dermatologic medications at Shands

QPI: Eric, Rudnick, (

Compare 20 most commonly Rx'd medications in outpatient setting with available medications on Shands Formulary. Discrepancies will be addressed with the hope of increasing formulary selection for useful and commonly used topical and systemic agents in Dermatology

Umbilical Cord Blood: An Underutilized Commodity

QPI: Megan, Glemza, (

Standard practice upon NICU admission requires up to ~4-5ml of blood directly drawn from majority of infants by peripheral or central sources ie. venipuncture, heel-stick, arterial draw, or centrally from umbilical line placement. This can account for up 10% circulating volume in select extremely low birth weight infants. Minimizing blood draws are critical component to avoiding iatrogenic blood loss, subsequent anemia and painful procedures. The use of fetal blood present in the umbilical cord segment is often discarded, yet can help decrease early phlebotomy losses on admission to NICU if utilized for diagnostic labs such as blood culture, complete blood count with differential, infant metabolic screening, blood type/coombs, and chromosomes, if needed. Umbilical cord blood has been used effectively and supported by literature.

Improving Access to Cancer Clinical Trials by Providing Transportation

QPI: Cheri, Knecht, (

Randomize people enrolled onto UF cancer clinical trials to 1) assisted transportation to achieve study milestones or 2) no transportation assistance

Medical Student Curriculum Revision

QPI: Jessica, Harris, (

The medical student curriculum offered through our department had not been updated in quite some time. Our project aims to update the curriculum for medical students rotating in dermatology, in an effort to improve comprehensiveness of the lectures. Additionally, a final exam will be developed which will provide objective data for improved student evaluations at the end of the curriculum block.

Nurse residency project 2017

QPI: Maureen, Latour, (

Program will present didactic and simulated scenarios focusing on management and delivery of quality patient care and the development of professional role and leadership.Each session will provide the newly licensed nurse information based on CCNE residency program topics: Each session is 4 hours. Program scheduled time: 0800 until 1200 Quality and safety, patient condition, communication and conflict management, professional roles development, management of the changing patient condition and informatics and technology • All attendees to complete the Casey Fink evaluation tool at first session attended and again at the last session. • Four continuing education credits awarded to attendees completing each session. • My Training will have the list of sessions so newly hired nurses may register for all or partial sessions. • Attendance at all sessions are highly encouraged for the newly licensed nurse • A mixed-mode learning environment will be utilized for each session comprising of : o Didactic material o Case scenarios o Scenario simulation o Group discussion August 22: Culture of Safety/Patient centered care September 26: Management of patient care delivery/ management of the changing patient condition October 31: Communication and conflict/Informatics and Technology November 13: Professional development /Performance improvement and evidenced based practice December 12: Ethical decision making/Stress management

Improving documentation of opioid induced constipation at UF Health Cancer Center

QPI: Bilal, Farooqi, (

Constipation is a commonly known side effect of opioid-use. However, it is less commonly known that opioid-induced constipation (OIC) is the most common and persistent side effect from opioid use. OIC affects approximately 10-15% of opioid-treated cancer patients negatively, thereby affecting the quality of life of our patients as well as health care resource utilization and costs. Opioid-induced constipation is a core QOPI measure addressing the need and importance of this issue. In spring 2017, UF Health Cancer Center scored approximately 45.45% in the number of charts assessed that documented constipation. This is significantly below the rate of the academic hospital aggregate which was approximately 55.61%.

Urologic Surgical Collaboration

QPI: Michelle, Van Leer, (

Assess the frequency and types of OR cases that Urology collaborates with other surgical services. We want to look at how this effects the distribution of resources and resident education as well as multi disciplinary collaboration.

Pediatric Cystic Fibrosis Center Patient Satisfaction

QPI: David, Fedele, (

The UF Pediatric Cystic Fibrosis Center will be collecting information on the satisfaction and quality of care that patient and family members at outpatient Center visits. This information is being collected in conjunction with the Center's ongoing quality improvement initiative that has a long-term goal of improving the satisfaction and quality of care for patient and family members through implementing Plan, Do, Study, Act cycles. The short-term of this assessment is to identify areas that the Center can improve upon (e.g., clinic flow, access to additional services). Results of the assessment will be shared with all Center staff.

Establishing a Resident Wellness Curriculum

QPI: Rica, Jester, (

The career of a physician and specifically a medical resident is demanding and at times unforgiving. The toll on resident morale is often profound when balancing life, career, family and patient care. The goal of this project is to design and implement a sustainable resident wellness curriculum, in an effort to increase morale and foster resident resilience. Emphasis on micro-appreciations, chief resident availability, mental health advice and resources will be made to increase overall resident well-being. Residents will complete a MBI questionnaire prior to and after implementation of wellness curriculum in order to measure effectiveness of the new wellness curriculum.

Pharmacist intervention and its impact on prescription fill rates

QPI: Joyanna, Wright, (

In the literature it is estimated that about 30% of prescriptions ordered by physicians are never picked up by the patient. Through the Care One clinic which services many patients who are indigent, identified as low health literacy and recently have been in the ER or hospital, our suspicions is this rate is even higher. Our project would seek to first actually identify all the prescriptions prescribed in a one month period by our physicians, and try to quantify how many of those prescriptions were never picked up. During the fall we will implement increased patient education on new prescriptions authorized by the clinic physicians and in November try to quantify again if our efforts made a difference. We will also be implementing a questionnaire to identify patients at high risk of non-adherence. The pharmacy department is also simultaneously working on updating the charity care formulary which may impact patient costs (as we know cost to be a barrier).

Reducing Redundant Diagnostic Testing for Individuals Transferred in the Emergency Department

QPI: Henry, Young II, (

UF Health is a tertiary care hospital center that receives several transfers from other hospital system daily. Many of these transfers are facilitated through the emergency department. While some transfers are complete, others require repeated diagnostic testing due to failure to send appropriate testing with the patient upon transfer. For many of these individuals diagnostic testing is duplicated. This can cause delays in patient care, increased costs, and potentially increased harm to the patient by excessive exposure to radiation.

Pharmaceutical and Red Bag waste reduction in the Operating room

QPI: Lauren, Berkow, (

This quality improvement project was created with several anesthesia residents to reduce both pharmaceutical waste and improve segregation of red bag and clear bag waste in the operating room. We have collaboration from pharmacy and OR nursing. After a baseline survey to assess attitudes about sustainability and waste reduction, we plan to collect baseline data of the amount of pharmaceutical waste and red bag waste generated, followed by education, signage, and addition of appropriate waste collection bins to improve segregation. After implementation, we will perform a follow up survey and more data collection to hopefully show an impact and reduction both in cost and environmental impact. We have obtained a University Scholars grant to support the pharmaceutical waste portion of this project, and hope to present our data at a future Sustainability meeting as well as publish our results.

The Impact of Structured Bedside Shift Report on Patient Satisfaction

QPI: Marsha, Crane, (

UPC Implementation of structured bedside shift report to improve patient satisfaction: Literature review to identify best practices and existing implementation tools. Staff survey on barriers to successful implementation of bedside shift report. Develop bedside rounding guide (shift sweep and report expectations) Education on structured rounding expectations Role Modeling and Observations in Practice/Check-offs Patient education on bedside rounding-brochure and follow-up with leadership rounding

Key Elements to Capturing Quality Clinical Images to Prevent Wrong Site Surgery

QPI: Ryan, Gillihan, (

Create a document with instructions on how to take quality clinical images of lesions being biopsied in dermatology clinic. The document will illustrate key elements that are beneficial to identifying the lesion when the patient returns for surgery. In turn, this will assist the surgeon in locating lesion of interest with a goal of preventing wrong-site surgeries.

Fluid management for gastroschisis patients

QPI: Keliana, O'Mara, (

Early fluid management goals for gastroschisis patients has evolved over the years. There is a delicate balance between keeping the newborn gastroschisis patient adequately hydrated from GI losses and creating volume overload leading to edematous bowel tissue. The admission weight for gastroschisis patients is often highly variable from following days' patient weights, making it difficult to evaluate the fluid status. Literature suggests that having a standard approach to management can improve outcomes. The objective of this QIPR project is to determine what impact our current management has had on hydration status, electrolyte balance, and urine output.

Impact of an outpatient pharmacy financial assistance formulary at an academic medical center

QPI: Khushboo, Patel, (

This project will consist of developing an updated formulary for patients that are eligible for the financial assistance program (FAP). The current formulary was last reviewed in 2009, and since then there have been many changes in pharmaceutical drugs and the evidence based-practice of medicine. With these changes, it is important to develop a formulary that encompasses a wider population that uses our outpatient pharmacy. The current cost of the financial assistance program is valued at $2.6 million, which includes both patients enrolled in FAP and also patients who qualify for a safe discharge through social work that also use the program..

An Education tool kit for Improving Internal Medicine Housestaff Oncologic Documentation using didactics, personal feedback, and financial awareness

QPI: Arpan, Patel, (

Our question is to evaluate and see if a comprehensive orientation educational workshop improves documentation for the inpatient hematology oncology service. We believe documentation holds a lot of implications with education, billing, financial reimbursement, and communication for patient care. Our study focuses on the improvement of resident clinical documentation for our cancer patients who are admitted to the hospital. Our question is to evaluate and see if a comprehensive orientation educational workshop improves documentation for the inpatient hematology oncology service. We believe documentation holds a lot of implications with education, billing, financial reimbursement, and communication for patient care. Our project will take place on the inpatient hematology/oncology service. The pre-intervention includes a survey about resident comfort and knowledge for documentation for oncologic patients as well as a simulated history and physical where the resident will render their own assessment and plan based on the information provided. The intervention will include a lecture based series for clinical documentation improvement, with a focus on cancer patients. Also at this time we will give the resident their first simulated history and physical with personalized feedback. The post intervention data collection will conclude with a post survey about resident comfort and knowledge of clinical documentation and a second simulated history and physical exam. We will return the second simulated history and physical exam to the resident with feedback. Our metrics include: survey, simulated history and physical, ideal reimbursements from the billing department before and after our intervention.

Building a Culture of Inquiry: Nursing and Clinical Research

QPI: Jeanette, Green, (

Research is an essential factor for advancing nursing and clinical practice to improve patient outcomes. Throughout the last 12 years, several nurses have served as principal investigators through either unit- or department-based research initiatives and research fellowship. However, variation in processes and missed communication opportunities illustrate the importance of optimizing the environment to conduct nursing inquiry. As such, the nurse research council (NRC) members and advisors will distribute surveys, conduct interviews and focus groups to learn the facilitators and barriers to conducting and disseminating nursing research within UF Health Shands-Gainesville. Findings from this project will be combined with the results of the nursing education needs assessment and research study to inform NRC members about new and innovating approaches to advancing nursing science at UF Health.

Improving Contraceptive Counseling in Internal Medicine Primary Care

QPI: Nicole, Dillow, (

Half of all pregnancies in the united states are unintended and adequate contraceptive information, counseling, and prescriptions are essential to helping reduce the major health risks associated with unplanned pregnancies. Recently, there has been a National Campaign that has been implemented to address this very issue. The One Key Question campaign encourages providers to ask reproductive age women the simple question, “Do you want to become pregnant in the next year?” to initiate the conversation about contraception. It has also been well documented that internal medicine primary care often fails to address contraception in routine office visits and annual appointments. This QI project will address if implementation of the One Key Question in UF Internal Medicine Primary Care can help increase the rate of contraceptive counseling and documentation.

Detection of Herpes Simplex Virus via PCR in Cerebrospinal Fluid Samples: Rates of Detection and Impact on Length of Stay and Management

QPI: Maira, Gaffar, (

The detection of herpes simplex virus via PCR (polymerase chain reaction) is an important diagnostic tool for patients with meningitis and/or encephalitis. We plan to analyze data from our institution's LIS (Epic/Beaker) as it pertains to pediatric and adult cerebrospinal fluid specimens that have been tested for HSV via PCR. The results of this project can demonstrate how the HSV PCR can reduce patient harm by decreasing the length of stay and preventing administration of unnecessary antiviral therapy.

Improving surgical outcomes with longitudinal clinical photography

QPI: Kathryn, Potter, (

Residents regularly perform surgical procedures in dermatology and can self assess outcomes immediately post-operatively and at suture removal. However, the most accurate assessment of technical performance needs to performed after complete scar remodeling, typically at 3-6 months. It would be advantageous for the residents to be able to assess the aesthetic performance of their closures at that time point. This project is built to provide them that opportunity. They will assess their surgical performance at the time of surgery (when they are performing the majority of an excision or a reconstruction). Nursing staff will be instructed to obtain photographs of the wound post-operatively, at suture removal, and again at clinical follow up (presuming they are following up in our general dermatology clinic) at 3-6 months. The residents will then perform a final self-assessment, including review of their previous assessment with the intent to identity areas for improvement.

Retrospective Analysis of Outpatient Antibiotic Prescribing in a Student-Run Free Clinic

QPI: Christine, Tabulov, (

Equal Access Clinic Network is a set of clinics that serve the underserved community of Gainesville and antibiotics are frequently prescribed for infections. The most common infections seen in the clinics are sexually transmitted infections, urinary tract infections, skin and soft tissue infections, and respiratory infections. When antibiotics are prescribed at the clinics currently, there is no local antibiogram used and are usually chosen by the most cost-effective option. This project looked at all the anti-infectives (Rx and OTC) prescribed that included antibiotics, antifungals, and antivirals from patient charts that visited Tuesday and Thursday night clinics in 2015 through 2016. The anti-infectives prescribed were compared to national guidelines such as Infectious Disease Society of America and Centers for Disease Control and Prevention. The project was performed to see if there is a need for a potential pharmacy student-run antimicrobial stewardship program at Equal Access Clinic Network.

Increasing the frequency of appropriate use and timing of paracentesis for diagnosis of spontaneous bacterial peritonitis

QPI: Andreas, Zori, (

We will evaluate how often diagnostic paracentsis is performed when a patient is diagnosed with spontaneous bacterial peritonitis in the hospital. We will also evaluate the timing paracentesis relative to administration of antibiotics as this can decrease the diagnostic yield of the aspirate culture. Using this data we will develop educational interventions targeted at ED physicians, hospitalists, and internal medicine residents to improve these measures.

Screening for Adverse Childhood Events in Primary Care

QPI: Rebeccah, Mercado, (

Routine screening for ACEs is recommended by the AAP Brightfutures but for a myriad of reasons is poorly implemented in primary care settings. Having one or more ACEs can lead to increased risk of emotional, developmental and behavioral problems and early referrals to community resources and/or support services may help mitigate these problems. The purpose of this project is to improve routine screening practices within the 4 UF Health outpatient pediatric offices by using an EPIC questionnaire to initially screen patient families and ask them if they would like additional assistance. Since parents and/or an adult caregivers respond to the questionnaire on behalf of the child, it asks the non-abuse ACE items from the 2011-12 National Children's Health Survey.

Impact of the Integration of a Vancomycin Review Process into the Pharmacokinetic (PK) Consultation Process

QPI: Kayihura, Manigaba, (

CMS/TJC requirements for antimicrobial sterwardship practice includes ongoing prospective review of antibiotics' need. To comply with these requirements, in 2017 the anti-infective subcommittee (AIS) proposed a systematic process for reviewing vancomycin at 72 hours of starting therapy while providing pharmacokinetic services. This process was approved by the pharmacy and Therapeutics (P&T) committee in May 2017 with provision that analysis of this process will be conducted at 3 months post implementation and preliminary data will be presented back to P&T. Current Process Step 1. Physician orders PK consult into EMR Step 2. Pharmacist process order (order vancomycin dose, levels and leave a progress note in the EMR) Step 3. Pharmacist continue to dose and monitor vancomycin until order is discontinued by physician New process Step 1. Physician orders PK consult into EMR Step 2. Pharmacist process order (order vancomycin dose, levels and leave a progress note in the EMR) Step 3. Pharmacist assess need to continue vancomycin at 72 hours of starting therapy. If diagnostic and clinical data do not support continuation of vancomycin, the pharmacist will take the following action: a. Contact the prescriber to discuss criteria for vancomycin use b. Suggest discontinuation of therapy, alternate therapy, or Infectious Diseases consult c. Notify the prescriber that Pharmacy will leave final dosing and monitoring recommendations and will sign off as consulting. d. Discontinue the order for the consult per protocol.

Determining the effectiveness of the Hip Fracture Task Force

QPI: Jennifer, Hagen, (

For the last year and a half, members of the orthopedic, hospitalist, geriatrics, anesthesiology, and emergency medicine services as well as representatives of Quality Improvement, physical therapy, case management, and nursing teams have been working to establish a Hip Fracture Task force, centered on improving the care and outcomes of patients at UF Shands. We have developed a clinical pathway that starts in the emergency department and continues into the aftercare of these patients. The pathway involves many facets, including improved pain management, appropriate guidelines for medical management, facilitating timely operative management, and appropriate mobilization with efficient discharge. We meet regularly as a team to assess progress and plan future improvement and have presented our pathway at quality meetings. We now need to asses the efficacy of the pathway by looking specifically at the outcomes of the patients who have been through it and address problems/pitfalls

Retrospective Comparison of Physician-guided Tacrolimus Dosing versus Parabolic Personalized Dosing.

QPI: Michelle, Estevez, (

Tacrolimus is often the backbone of an immunosuppressive cocktail to prevent rejection and maintain graft function in solid organ transplant recipients. Tacrolimus is a narrow therapeutic index drug whose dosing relies on therapeutic drug monitoring to avoid rejection or medication-related toxicities. Standard practice for dose adjustments is highly variable between institutions. There is significant interpatient variability in tacrolimus pharmacokinetics leading to high potential for levels not within goal. Models, such as population pharmacokinetics, physiology-based pharmacokinetics, genetics and estimative forcasting, exist to aid in tacrolimus dosing. However, accuracy is variable especially among complex, dynamic patients. Current UF Shands tacrolimus dosing is provider guided based on patient-specific pharmacokinetics.

Pediatric MyChart Activation

QPI: Denise, McIntyre, (

This project aims to increase activation of MyChart among the UFHealth pediatric population. It promotes the use of MyUFHealth, our UF Health Patient Portal, which allows patients and patient proxies 24/7 access to released test results, the ability to communicate with their clinicians, refill prescriptions, and schedule/view upcoming appointments.

Division of Pediatric Surgery Quality Improvement Project for Improving Quality of Care and Patient Satisfaction in Caring for Patients with Gastrostomy Tubes.

QPI: Rachel, Nettle, (

There are about 20,000 feeding tubes placed annually in children less than 18 years of age in the United States, and the frequency of pediatric feeding tube placement is increasing nationally (Richards, et al). Severe complications after feeding tube placement occur in about 5-17% of patients, but minor issues are frequent and create associated financial and clinical impact (Richards, et al). Incidence of minor complications with gastrostomy tubes such as leaking, skin breakdown, infection, tube dislodgment, granulation tissue and tube occlusion are reported to be as high as 80% in children. These complications lead to increase in ED visits, nurse calls, extra clinic visits and ultimately increased expenses for hospitals. This places a significant burden on health care providers involved in caring for this population of patients, who often have many complex medical issues. There is a great need to standardize care for this complex group of patients, but literature and recommendations on how to do this are scarce. The Division of Pediatric Surgery at UF Health then surveyed health care providers to get a baseline assessment of what routine g-tube care is given, how common minor g-tube issues are handled, and what education related to feeding tubes providers would like. Using survey monkey, a survey was sent to about 150 pediatric health care providers at UF Health who care for pediatric patients with feeding tubes. This included pediatricians, ED physicians, GI specialty providers, NICU providers, surgical residents, cardiology and Neurology providers and bedside nurses. There were 58 total responses, which provided valuable feeding back to help initiate a quality improvement project at our institution. There were many inconsistencies in how providers handle routine g-tube care, but a strong interest for more education related to caring for patients with feeding tubes.

Reduction of no show visits in pediatric dermatology

QPI: ()

The rate of "no shows", or appointment slots where patients fail to attend their scheduled appointment without notice, is historically higher amongst pediatric patients compared to adult patients. In UF pediatric dermatology, the rate historically has been 17-19%. A high patient no-show rate leads to significant lost revenue, as no payment is captured while the provider salary and operating costs remain the same. In the department of dermatology, patients are provided with appointment reminders via text message or voice call 2-3 days before the patient appointment. Patients are given the option to confirm the appointment. However, many may ignore the automated text or voice call and miss the opportunity to confirm or cancel their appointment. In pediatric dermatology, the no show rate is historically higher than general and surgical dermatology. This is likely compounded by many factors, possibly including but not limited to: self-limited dermatologic problems in pediatrics (such as viral exanthems, molluscum contagiosum, and warts, all of which may resolve with no treatment), busy family lives, and lower socioeconomic status/limited resources. We propose to initiate a non-automated, staff-initiated reminder for pediatric dermatology visits 24-48 hours prior to the pediatric dermatology appointment. This personalized call may encourage patients to cancel if they no longer need the appointment, which will allow access to appointments for more patients. The reminder would also remind patients and parents of the appointment time.

Initiation of Mobility Protocol in ICU CVVH/IHD Patients with Resulting Improvements

QPI: Carolyn, Harnish, (

With over 70% of critically ill patient’s developing acute renal insufficiency during hospitalization, the use and choice of appropriate of renal replacement therapy is extremely important by intensive care units. Historically, the choices for renal therapy have been continuous renal replacement therapy or intermittent hemodialysis. With the selection of either of these therapies comes draw backs, such as 1:1 nursing care, extreme hemodynamic changes, and increased costs. Due to the priority and side effects of renal therapies, the surgical/trauma found that this patient population was grossly under mobilized in comparison to the overall patient population. To address this under mobilization, a step-wise mobility model was created to facilitate mobility decision-making in this critically ill and very fragile population. This study seeks to analysis quality improvement with this mobility protocol within the Trauma/Surgical ICU of UFHealth. Methods: Mobility actions at the bedside were compared to the orders made by the physician, in which a ratio of compliance was calculated by the facility and the authors. The unit as a whole and the subset renal therapy population were tracked in the 3 months prior (March- May) to the initiation of the progressive mobility protocol and the 3 months following (September to oNovember). The data was compared between the two time frames.

Creating a Comprehensive Standard Equipment Catalog and Sanitation Guide to Improve Disinfection and Sanitation Practices

QPI: Matthew, Citrin, (

This project aims to create a comprehensive equipment sanitation catalog, which will include type of equipment, specific unit location (if necessary), group responsible for sanitation, and appropriate disinfectant distinction. This catalog will reduce ambiguity and increase provider awareness and knowledge with regards to standard equipment sanitation practices. While this project’s main focus is the sanitation policy of standard hospital equipment, a variety of unit-specific/specialized equipment will also be included because of tendencies of equipment being used on multiple patients and by multiple staff. The project is divided into 2 phases. Phase 1 entails creating a catalog of standard equipment found throughout different units in Shands Hospital. This will be completed by using a specifically created REDCap survey that will be used as a checklist system while undergoing unit walkthroughs. No protected health information, patient identifiers, or clinical practices are being recorded. This REDCap survey is simply a tool to be used to create a database to determine standard equipment found throughout Shands Hospital. Phase 2 entails completing an equipment catalog that will delegate sanitation responsibility to the appropriate parties. This will be completed by discussing equipment sanitation practices with key stakeholders, such as the infection control team, clinical engineering, environmental services, nursing, etc. Once completed, this comprehensive catalog can be used by providers as a quick reference guide for determining which party is responsible for equipment sanitation, which disinfectant is appropriate, and where the equipment should be located. With this catalog in place, provider and hospital staff equipment cleansing ambiguity should be subsided, and thus overall knowledge with regards to equipment cleaning practices will be increased.

Improving compliance of sending discharge summaries from the Cardiac ICU

QPI: Frank, Han, (

After working in the Cardiac ICU for several months, it was noted that the discharge summaries are periodically not being sent to referring physicians, when the patient is referred from an outside institution. This will cause delays in the transition of care back to the cardiologist, miscommunications, or even difficulty conducting the long term followup care. The etiology of the difficulty sending discharge summaries mainly lies in the time needed to print out the document, and manually fax the item within a unit that is somewhat understaffed with multiple competing demands. A method was needed to quickly fax the document while still not placing excessive demands on the cardiac ICU staff. Within the EPIC EMR, the routing function was chosen and the percentage of faxed discharge summaries was counted in the previous one month period compared to the period of August 2017. The method using EPIC's internal functionality presented a significant time savings compared to manually faxing the document. Then, the intervention was daily reminders to route the discharge summaries to the referring cardiologist. Afterwards, the rate of compliance with faxing the discharge summary to the referring physicians was counted, and the subjective ease of which the cardiac ICU providers found it to create the fax was analyzed.

Evaluation of Pharmacist Interventions to Prevent Hypoglycemia

QPI: Stephanie, Molchan, (

Pharmacists at UF Health Shands Hospital were provided with a scoring tool that identified patients at high risk for hypoglycemic events. Pharmacists were asked to review the scoring tool and the patients listed then document their actions in our electronic medical record EPIC. No additional training or guidance was provided; all interventions were left up to the individual pharmacist’s clinical judgement. Interventions could include notifying the primary team of hypoglycemia risk, modifying the patient’s diet, modifying diabetic regimen, modifying non-diabetic drugs with hypoglycemia risks, glucose monitoring change, or pharmacists could document no action necessary. After approximately one year of this scoring tool’s release, no impact on the incidence of hypoglycemia was observed. There are several potential reasons that pharmacist’s response to this scoring tool were unable to impact hypoglycemia event rates. Patients may potentially appear on the scoring tool after a hypoglycemia event has already occurred. Pharmacists may not look at the scoring tool until much later during their shifts, after which the primary team may have already made interventions or hypoglycemia events have already occurred. The purpose of this quality improvement project is to evaluate the timing and appropriateness of pharmacist interventions to prevent hypoglycemia in response to a scoring tool.

Tumor Lysis Syndrome in Targeted Patient Population

QPI: Khushboo, Patel, (

There has been an increase in the number of patients admitted to receive traditionally outpatient chemotherapy due to concern for tumor lysis syndrome (TLS). These chemotherapy regimens are administered in outpatient settings due to not necessitating intensive monitoring, or continuous IV fluids and frequent labs. Due to bulky disease, there are some providers that prefer to have patients admitted for close monitoring and the ability to intervene quickly if TLS occurs. Currently, we do not know the number of patients admitted to our inpatient unit that have required clinical TLS intervention while receiving certain chemotherapy regimens. This project will identify solid tumor oncology patients with small cell lung cancer or germ cell cancer, that received cisplatin/etoposide, carboplatin/etoposide, or bleomycin/etoposide/platinum (BEP) as their chemotherapy regimen. Based on this, we will identify the rate of patients that needed clinical intervention due to development of TLS.

Evaluation of Naloxone Administrations in the Past 12 Months at UF Health Shands Hospital

QPI: Aklil, Hiruy, (

In order to address the opioid crisis and improve patient safety, The Joint Commission (TJC) recently published new standards for pain management in the hospital setting including a requirement for hospitals to monitor the safe use of opioids. TJC recommends strategies such as tracking naloxone use and opioid related adverse events to fulfil this requirement. TJC notes that hospitals who monitored the use of naloxone were able to significantly reduce adverse events related to opioid use and identify areas of improvement for patient safety and quality of care. The UF Health Shands accreditation team in collaboration with the pain committee is responsible for ensuring adequate systems are in place to meet the intent of these newly proposed pain management standards. The intent of this medication use evaluation (MUE) is to characterize non-critically ill hospitalized patients who experienced respiratory depression or over-sedation due to opioid medications, along with their care processes. Data collection would seek to identify patients with preventable adverse drug reactions (pADRs), determine risk factors for the development of adverse outcomes with opioids, and identify areas within the system of care that can be improved to prevent these events in the future. The results of this MUE will be presented to the pain committee to assist the committee in implementing systems strategies to enhance the safe use of opioid medications in the hospital. Reference: Pain Assessment and Management Standards for Hospitals; R3 Report Requirement, Rationale, Reference; The Joint Commission, Issue 11, August 29, 2017

Increasing Professional Organization Involvement & Awareness

QPI: Victoria, Holley, (

Professional organizations have not only been proven to be beneficial to the nurse but are crucial to the advancement of the professional nurse from a novice to an expert. Patricia Benner’s nursing theory, From Novice to Expert describes five levels of nursing skill: novice, advanced beginner, competent, proficient and expert. According to Benner’s model, a nurse moves closer to expertise by learning from the shared experience of others through networking and information sharing that occurs within professional organizations. A nurse also develops a more global view through the networking that occurs in professional organizations and advances from a detached observer to an involved, contributing engaged member of the nursing community (Alligood, 2014). These vital transitions advance one’s expertise in nursing. Mashiach Eizenberg, (2011) states a need for research-based information, exposure to professional journals and organizations and organizational support for evidence-based professional nursing practice. As a member of a professional organization, nurses can come together, in unified efforts, to advocate for legislative changes, funding, rights and for their patient populations (Matthews, 2012). Membership also offers an increased awareness of current issues effecting nursing, scholarships, CE credits, annual conventions, newsletters, certifications and career assistance (Black, 2016), (Frank, 2005). Despite the abundant documented benefits that active membership and involvement in professional organizations offer, studies show that only 6% of nurses belong to the American Nursing Association, ANA (Hood, 2013). One theory to explain why this is, is that most nurses believe professional organizations are for specialty areas (Hood, 2013). However, regardless of the population or setting in which one practices, quality nursing care must include incorporating standards of care from appropriate professional groups (Butcher, Bulechek, Dochterman & Wagner, 2013). Through my study, I intend to increase awareness and involvement in professional organizations of registered nurses in the acute tertiary care setting, and determine if this yields improved patient outcomes and satisfaction, increased autonomy and decreased nurse burnout. A facility wide redcap survey was distributed via email to all current nurses. Results were analyzed to identify nurse populations that had the greatest room for improvement. These populations were targeted and invited to attend professional organization informational meetings. Unit practice council chairpersons and clinical leaders were recruited to increase awareness on their units. More research will be needed to determine if these efforts have successfully resulted in improved patient outcomes and satisfaction, increased autonomy and decreased nurse burnout.

Anticoagulant Adverse Drug Reactions in the Setting of Changing Renal Function

QPI: Kristen, Dominick, (

Recent patient safety reports involving antithrombotic therapy have prompted the review of therapeutic dosing of anticoagulants in patients with fluctuating renal function. Anticoagulants, such as enoxaparin, rivaroxaban, apixaban and dabigatran, are eliminated renally, and require dose adjustments in the setting of poor renal function. This project will identify patients on therapeutic anticoagulation that also experienced a fluctuation in renal function. Based on this, we will identify the rate of patients that did not receive a pharmacist-lead clinical intervention, and those that consequently experienced a potentially fatal adverse effect.

UF Health Mobile Outreach Clinic Hypertension Clinic

QPI: Kaylie, Smith, (

We will be managing the hypertension medications of patients at the UF Health Mobile Outreach Clinic. Patients will be seen by a provider with the UF Health Mobile Outreach Clinic and then referred to a pharmacist-managed hypertension clinic upon diagnosis of hypertension. Patients will be followed-up as needed to appropriately manage their blood pressure.

Comparison of Inpatient Sliding Scale Insulin Regimens (Aspart vs. Regular)

QPI: Amy, Sheer, (

A new sliding scale insulin (SSI) order set was put into effect at the North Florida Veterans Hospital in 2016. The new SII order uses Aspart (short-acting insulin). The original SII order set uses Regular insulin (short to medium acting). Currently, both order sets are available for use, with the original (Regular) insulin order set being listed above the newer (Aspart) insulin order set. I hypothesize that the use of insulin Apart SSI order set (vs. Regular SII order set) will result in fewer inpatient hypoglycemic episodes (blood glucose <70mg/DL). If my hypothesis is correct, the Regular SSI order set could be discontinued or made less preferential in the electronic medical system. I will collect retrospective data from when the new SSI order set was first available in the electronic medical system to present. Primary outcome measure will be hypoglycemic episodes measured as any blood glucose of <70 mg/DL. Other measures: age, race, sex, type of diabetes, simultaneous use of other hypoglycemic agents while on SSI, NPO status, and liver cirrhosis. Population: Any patient admitted to the North Florida VA after the initiation of the Aspart SSI order in 2016 set who was placed on any SSI regimen.

Impact of standardized research training program for pharmacist preceptors on quality of pharmacy residency research projects

QPI: Keliana, O'Mara, (

Based on feedback from the pharmacy resident and preceptor groups, there needs to be a more standardized knowledge base amongst the preceptors for the clinical research process as it pertains to residency research projects. We are implementing a core competency program consisting of several 30 minute didactic lectures and a post-lecture competency assessment for every pharmacy resident preceptor. After completion of the standardized training program, preceptors will be receive a certificate and be eligible for serving a primary project advisor for a PGY1 or PGY2 pharmacy resident research project.

Kidney stone patient quality project

QPI: Michelle, Van Leer, (

We would like to improve our pre operative management of patients with complex stone histories and co-morbidities. We need to look back at two years worth of data on specific CPT codes and patients who developed sepsis or SEERS after certain stone removal procedures. From that data we are working with a multidisciplinary team to determine timing of preoperative antibiotics and selection of those antibiotics.

Neurology Readmissions Reduction Quality Improvement Project

QPI: Jean, Saltivan, (

The UF Health Neurology department aims to compile a daily report that will aid in monitoring readmission rates of neurology patients. Currently, neurology patients are being readmitted in the system. However, we would like gather the baseline data and the averages of readmissions on a daily basis. This data will determine the need for future analysis and with the goal of focusing on factors that influence readmissions in an attempt to reduce these rates. A quality improvement in mind is to maximize the utilization of the existing health coach in Community Health and Family Medicine for our neurology patients. To realize this goal, it is important to determine if and what type of Primary Care Provider our neurology patients have, and their respective insurance payer. Patients with Primary Care Providers within UFHealth and non-charity insurance (e.g., Medicare, Medicaid, Private, TriCare, Private Insurers) who were seen by UFHealth Primary Care Providers within three years should be included in the report.

Fall risk associated with steroid use on inpatient oncology units at a large academic medical center

QPI: Khushboo, Patel, (

Glucocorticoids, often referred to as steroids are synthetic, biologically active derivatives of cortisol secreted by the adrenal cortex. They provide several therapeutic benefits including anti-inflammatory, anti-neoplastic, anti-nausea, and immunosuppressing effects. However, steroids are not without adverse effects when used for prolonged periods of times. One of the adverse effects commonly observed is steroid induced myopathy, which usually effects the femoral muscles in the legs. As patients are on steroids for longer periods of time, this can lead to muscle weakness and subsequently lead to falls. Recently, there have been a high number of falls on the oncology units. Steroids are often employed on these for prevent and treatment of nausea, treatment of graft versus host disease, and for the treatment of cancer. Oncology patients are also concomitantly on other medications that can increase a patient’s chance of falling, like opioids and benzodiazepines. We will identify patients that have fallen while admitted to 7W or 8E and review their active medications for use of steroid prior to or during their admission, as well as other medications that could increase a patient’s risk of falling.

Evaluation of Patient Satisfaction through the Development and Assessment of a Patient-Focused Specialty Specific Department Welcome Letter

QPI: Ashley, Anderson, (

The primary aim of this project is to develop a Welcome Letter for the Department of Neurology which is focused on providing first-time patients and their caregivers an informative and comprehensive resource for initial and subsequent visits. This will prove to be a convenient and easy-to-read document written in plain language to be utilized by individuals with a vast range of literacy levels. Information pertinent to the patient’s initial and follow-up appointments will be outlined highlighting areas such as the members of the healthcare team, materials to bring to appointments, and how to contact the clinic during and after business hours. By providing information that is accessible to patients with differing levels of educational attainment, we can reduce variation in the patient experience. This will offer the majority of patients a fulfilling and productive interaction with Department of Neurology clinical, clerical, and administrative staff. The project will be developed using a matched case-control design with pre-and post-tests. New patients during a two-month block from October to December will receive a brief questionnaire to answer based on the current Department Welcome Letter to determine how it contributed to his or her experience. The same questionnaire will be administered during a two-month block from January to March after the new Welcome Letter is distributed to patients. The data collected will be analyzed to evaluate patient satisfaction. Prior to the introduction of the new letter it will be extensively vetted by medical staff, healthcare providers, and patient advocates. The letter will be regularly reviewed and revised using the PDSA (Plan, Do, Study, Act) cycle for Healthcare Improvement.

Improving Fall Prevention for Community-dwelling Older Adults in Rural Primary Care

QPI: Amelie, Middlemas, (

We are conducting a workflow analysis of the three primary care providers during their daily clinic schedule. Factors such as time from arrival to time to exam room, time with provider, and what clinic activities (check in, vital signs) are conducted during a typical visit. Time from check in to end of visit will be recorded for 20 visits. A workflow map will be constructed. The workflow map is a visual representation of the activities that take place from the time a patient checks in to the clinic until the visit is concluded. The workflow analysis and map data will be used to inform how best implement our planned practice improvement strategy (i.e., falls prevention checklist). The practice improvement strategy will be rolled out and a Plan Do Study Act (PDSA) cycle will be used to evaluate if length of visit is affected by using the intervention. Time from check in to end of visit will be recorded for 20 visits after the practice improvement strategy is implemented. The data collected before and after the implementation will be compared, and we will ask for feedback from providers.

Adult congenital heart patients in PCICU: Improving the process and patient satisfaction

QPI: Jeanette, Green, (

Project to improve patient satisfaction

Improvement in the pathology specimens labeling in the GI Lab

QPI: Silvio, de Melo, (

Since we went into an electronic ordering and documentation of the pathology specimens produced in the GI lab, a lot of mislabeling has been occurring. We assigned a GI fellow and a pathology resident to perform a root cause analysis and recommendations to improve the accuracy of the process.

Impact of a Multidisciplinary Shock Team on Outcomes of patients with Cardiogenic Shock

QPI: Islam, Elgendy, (

Cardiogenic shock carries a high risk of short term mortality. Patients with cardiogenic shock often require more than the conventional measures for shock management such as early initiation of mechanical circulatory support devices. However, there has been no standard way to assess the need for such support devices in our critical care units. A new multidisciplinary shock team will become available next month and will be responding to cardiogenic shock consults.

Impact of a CLIA-waived molecular respiratory panel in a pediatric clinic

QPI: Stacy, Beal, (

While molecular based respiratory panels have become common and shown benefits in hospital and emergency department settings they are rarely used for outpatients due to the turn-around time, cost, and other factors. More commonly, rapid antigen tests for influenza and respiratory syncytial virus (RSV) are performed, which suffer from limited sensitivity compared with nucleic acid testing. Therefore, the clinical impact of a rapid, point-of-care (POC) diagnostic test for numerous respiratory pathogens is unknown in this setting.

Resident Feelings and Thoughts relative to addition of overnight attendings and revised call schedule

QPI: Matthew, Jenson, (

Over this past summer, our department has undergone significant changes. This includes the addition of overnight radiology faculty with goals to increase teaching overnight as well as improve the time it takes for radiology studies to get final reports. Our department also completely reworked our resident call schedule at this time. This project will involve sending a survey to the residents within the radiology department to assess the overall mood and feelings relative to those changes.

Improving Screening for Physical Activity in a Student Health Population

QPI: Stephen, Carek, (

Benefits of physical activity have been well documented, including prevention and treatment of cardiovascular disease, cancer and depression, but the high prevalence of physical inactivity remains a major public health concern. Current recommendations suggest that Americans engage in at least 150 minutes of moderate physical activity per week to receive maximal health benefits. Some estimates suggest that only 8% of adult Americans achieved the recommended levels of physical activity. Recommendations for assessment include a physical activity "vital sign" that is incorporated into a patients' routine health screening and kept as a health indicator in their medical record. Currently , at Student Health, no such metric exists to determine the amount of physical activity the population of students at the University of Florida partake in. Such a metric could provide valuable information regarding the current activity level of students and could be monitored over time to provide opportunities for counseling and support for adopting a healthy lifestyle. This project is intended to assess the current rate of screening for physical activity at Student Health and determine an appropriate intervention to improve the rate of screening for exercise and physical activity in this population.

Reducing radiation exposure to cardiac cath/EP lab operators with new facilities and equipment

QPI: John, Brandt, (

Radiation exposure in the cardiac catheterization and EP labs is a major concern for both operators and patients. The amount of radiation exposure to all cath and EP lab staff is tracked monthly by dosimeters worn. With the opening of the new Neuro/Cardiovascular Hospital on the horizon, we believe there is a unique opportunity to measure radiation exposure to a select group of interventional and EP cardiology faculty both before and after the move to the new hospital. We suspect that new equipment including both hardware and software as well as radiation protection equipment will decrease radiation exposure to these operators.

Outcomes of a Pharmacist-Monitored Direct Oral Anticoagulant Service in the Outpatient Setting

QPI: Kaylie, Smith, (

At UF Health Internal Medicine at the Medical Plaza, the pharmacotherapy clinic monitors patients prescribed direct oral anticoagulants (DOACs) to ensure proper dosing, patient adherence, and to assess for signs or symptoms of bleeding or thromboembolism. The intervals at which these patients are followed-up is based on the European Heart Rhythm Association guidelines. In these guidelines, follow-up is based on renal function, health status, and age (1). A previous retrospective evaluation was conducted to determine if patients at two UF Health Internal Medicine clinics were correctly prescribed DOACs (2). As the next step, this prospective quality improvement project is designed to assess outcomes of patients enrolled in the pharmacist-managed direct oral anticoagulant service. References: 1. Heidbuchel H, Verhamme P, Alings M, et al. Updated European Heart Rhythm Association practical guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace. 2015;17: 1467-1507. 2. Rieser K, Rosenberg E, Vogel Anderson K. Evaluation of the Appropriateness of Direct Oral Anticoagulant Selection and Monitoring in the Outpatient Setting. Journal of Pharmacy Technology. 2017;33(3):108-113.

Cognitive Functioning and Colonoscopy Preparation in Older Adults

QPI: Franchesca, Arias, (

Colonoscopy screenings are commonly used to detect, diagnose, and treat a number of bowel disorders. As preventive measures, colonoscopy screeners can be life-saving for older adults, as they are at increased risk for colorectal cancer. Prior to the procedure, patients are required to implement strict dietary changes (e.g., gradually restricting their consumption of solids) and take potent laxatives. Optimal preparation is instrumental to the procedure's success, and marginal compliance may result in inadequtealy cleansed colon and poor detection of existing colon abnormalities. Evidence suggests that individualized patient education improves compliance, and promotes adherence to pre-procedural recommendations. Less is known about the association between pre-procedural cognitive abilities and compliance with colonoscopy preparation recommendations. This is concerning as attention, learning, and memory are known to decline with aging, and older adults are more likely to develop neurodegenerative disorders.

Does reason and frequency of door openings in the operating room change throughout the day?

QPI: Crystal, Almond, (

Surgical site infections (SSI) are among the most common healthcare associated infections (HAI) in the United States and in one HAI prevalence survey, more than 21% of infections were attributed to SSIs. The negative effect of door openings on airflow and temperature in the operating room has been well established. I plan to observe the frequency of door openings in the Neuro operating rooms at UF Health Shands Hospital in an effort to assess and later, breakdown the reasons behind door openings. We have reason to believe that behaviors regarding preparedness or fatigue in the OR change as the day progresses. These changes in behavior may have an influence on the risk of a surgery or procedure resulting in surgical site infections. Our aim in this study is to determine if the number of door openings in a neuro OR is greater toward the end of a day or week. To our knowledge, no study has ever observed the effect time of day has on door openings in U.S. operating rooms. If significant differences in OR behaviors are observed as the day progresses, addressing these problems can help to reduce risk of SSIs in this acute academic hospital setting. Neuro surgeries and procedures will be directly analyzed for the frequency of door openings and the reason for the door opening. Time of day will be categorized by Morning, Noon, and Afternoon and then analyzed with 'Morning' as a reference for the other two categories.

Implementation of a nursing driven sleep protocol in the Neuro ICU: A quality improvement project

QPI: Tiffany, Scalf, (

There has been a large volume of research regarding sleep quality for patients receiving ICU level care which has indicated that improved sleep practices and implementation of nursing driven sleep protocols in these settings have resulted in improved patient/caregiver satisfaction and clinical outcomes. Traditionally, patients in the neurologic ICU have been excluded from these studies due to the need for hourly neurologic examinations. This project aims to gauge nursing perceptions regarding patient sleep, use these perceptions to develop a protocol, and ultimately implement a nursing driven sleep protocol using standard rapid cycling quality improvement methods and multi-stakeholder groups in the UF Neuro ICU.

The impact of intentional hourly rounding on patient satisfaction with nursing care.

QPI: Joanne, McNeil, (

The patients will be rounded on every hour to proactively address their pain, toileting needs, position, and the placement of their belongings, call light, and room equipment/ furniture for safety. Patients will be rounded on by staff hourly to ensure needs are met within a timely manner.

Improving risk stratification in the preoperative setting

QPI: Juan, Gallegos, (

We will collect data on appropriate risk documentation that applies to new surgical patients in cardiac patients. We currently utilize STS risk scores and EuroscoreII to evaluate patient risk. Appropriate documentation has been lacking and our goal is to reinforce the importance of complete documentation, variable that may be problematic in documentation and to improve the documentation process.

Evaluation of Latent TB Infection Screening in Outpatient Primary Care Clinics and Development of Possible Interventions

QPI: Joanne, Li, (

The U.S. Preventive Services Task Force's most recent recommendations for TB has included latent TB infection (LTBI) screening for populations at increased risk for TB disease, both in the private and public setting. Traditionally, public health clinics—namely health departments—have handled LTBI screening. However, for TB elimination in the United States, there must be a massive scale-up of LTBI testing and treatment in populations at risk for TB disease; more than 80% of TB disease cases are due to reactivation of latent TB infection. For this reason, the U.S. Preventive Services Task Force (USPSTF) has most recently recommended that primary care clinics perform LTBI screening and treatment in populations at increased risk for TB disease. Our project, which stems from the CDC-funded TB Epidemiologic Studies Consortium, aims to assess the current practices related to LTBI testing and treatment at UF outpatient primary care clinics, and the extent to which these practices comply with the USPSTF’s recommendations. We are interested in measuring extent to which a key population—foreign-born persons from countries with medium to high TB incidence rates—participates in LTBI services (screening, testing, medical evaluation, recommendation for treatment, and treatment completion). Based on this data, we will then invite the clinics to participate in discussions about barriers and facilitators to scaling up LTBI screening and treatment. Lastly, we will work with the key personnel at each clinic to identify feasible interventions that address these barriers and enhance the facilitators.

Labor and delivery Consent Video

QPI: Kristin, Briscoe, (

Patients often come to labor and delivery with expectations on what their labor will be like. Unfortunately, a lot of patients are not familiar with the intricacies of labor and delivery from pitocin to fetal monitoring to operative vaginal deliveries. This in part needs to be addressed in the clinical setting prior to labor; however, some of this process needs to be performed in the hospital prior to admission. Much time is needed in order to truly educate a patient; however, residents often have limited time to do a thorough consent. We propose the creation of a standard video to be shown on admission to L&D which would serve as an educational and a consent video.

Using Patient Check-in Forms to Increase Clinic Efficiency and Patient Satisfaction

QPI: Jesalyn, Merritt, (

A dermatology clinic check-in form is being created for patient's to fill out while waiting to be seen by the physician. The form will include patient identification, reason for clinic visit, medication changes, allergies, a brief review of systems and pertinent dermatologic personal and family history.

ECHO prior to Cardiac Catheterization Initiative

QPI: Ramez, Smairat, (

Echocardiography (ECHO) is an essential component in the management of Acute Coronary Syndrome (ACS). It aids in the diagnosis of ACS, and allows for further risk stratification, which can help guide management and determine prognosis. ECHO is able to demonstrate important objective data that is paramount in guiding therapy strategies, such as left ventricular systolic dysfunction, the presence of diastolic dysfunction, wall motion abnormalities and valvular heart disease (VHD). Our center, like many nation-wide, receives large numbers of patients presenting with acute chest pain syndromes daily. Many of these patients are diagnosed with ACS and referred for cardiac catheterization. The challenge occurs in allocating precious limited catheterization resources and how to triage these patients properly. In our institution, many low and intermediate risk ACS patients are taken for cardiac catheterization before imaging data is obtained that may impact management.

Increasing HEDIS WCC Adherence - Impact of Days Hospitalized

QPI: Erik, Black, (

A key HEDIS measure for Ped-i-Care is the total number of children that received six or more well-child visits with a PCP during their first 15 months of life (WCC15). Anecdotal data provides evidence that a sub-set of the Ped-i-Care membership spends significant time in the hospital during the first 15 months of life. This time in the hospital may inadvertently impact adherence rates, as the HEDIS WCC criteria does not adjust for in-patient stays. We would like to engage in review of Ped-i-Care data to better understand the number of children who experience in-patient stays, the length of stay and how this may impact the data we report to the state of Florida.

Adoption of QVAR on pediatrics clinical services

QPI: Erik, Black, (

Beclomethasone dipropionate HFA (QVAR) is an emergent alternative to fluticasone propionate HFA (flovent) for the treatment of asthma. Research provides evidence of comparative effectiveness and safety. QVAR was recently added to the UFHealth formulary and is now able to be prescribed by providers. The purpose of this project is to track the adoption of QVAR in pediatric patients admitted for asthma after May 1, 2017.

Quantifying the Value a Pharmacist provides to the Inflammatory Bowel Disease Clinic

QPI: Angie, Bowen, (

The Inflammatory Bowel Disease (IBD) Clinic at UF Health is part of the Division of Gastroenterology, Hepatology & Nutrition at the University of Florida College of Medicine. The team, headed by Dr. Sarah Glover, specializes in treating patients with Inflammatory Bowel Diseases. Advanced technology and highly educated staff members enable the team to take on the most complex cases. The diverse team composed of triage nurses, a pharmacist, dietitian, and multiple GI specialists offer a unique approach to serving patients with world-class treatment. The recent addition of the pharmacist, namely, Tim Edminister, has improved efficiency within the clinic due to the importance of medication for people suffering from inflammatory bowel diseases. Our project focuses on quantifying the value that a pharmacist can add to a clinic like IBD and provide data on that specified value. This project is the third project a Senior Design Group in the Industrial and Systems Engineering (ISE) Department has worked with the IBD Clinic. Our project will also work with the Center for Movement Disorders and Neurorestoration within the Department of Neurology in the College of Medicine to assess the potential of adding a pharmacist to their staff/process. Patients that visit the Center for Movement Disorders and Neurorestoration have a similar treatment regime to the patients in the IBD Clinic and our project sponsor suggested to use that clinic as a baseline comparison throughout our project. The neurology team specializes with diseases that affect the nervous system, which is comprised of the brain, spinal cord, the peripheral nervous system.

Improving Mental Health Access and Provider Awareness in a Mobile Clinic: Implications of the Stepped Care Model for Behavioral Health

QPI: Jazmine, Quintana, (

Develop a mental health connectivity protocol following the stepped care model of behavioral health and assess non-licensed and licensed providers ability to utilize this protocol. As well, assess the health care needs of medically underserved communities in Gainesville for mental health needs. This project aims to understand how to have providers delivers the best and least resource intensive options for patients with different mental/social needs.

Evaluation of rabbit antithymocyte globulin use in solid organ transplant recipients at UF Health Shands Hospital

QPI: Sara, Sterling, (

Rabbit antithymocyte globulin (rATG), a purified polyclonal immunoglobulin, is a high cost, high impact medication used at UF Health Shands for both induction therapy and as treatment for acute rejection in solid organ transplant. Current use at UF Health Shands Hospital is not standardized as this medication is available via various order sets and individual orders in the electronic health record. This lack of standardization leads to possible medication errors in the areas of ordering, dispensing, and administration. Without standardization, rATG can lead to significant adverse effects, such as immune-mediated reactions, infusion-associated reactions, hematologic effects, and infection. This project will summarize the current practices in ordering, dispensing, and administration of rATG in solid organ transplant at our institution, with the goal of identifying areas for standardization via a universal order set to minimize errors.

Improving care for acute asthma exacerbation in the Pediatric ED

QPI: Brandy, Johnson, (

Roughly 7.8% of the US population has been diagnosed as having asthma, with 8.4% of that population falling between the ages of 0 and 17 years per the 2015 National Health Interview Survey. Recent reviews of healthcare utilization list acute asthma symptoms, ranging from non-severe to life-threatening, as one of the most common presenting complaints at emergency departments comprising nearly 2 million visits as described by data collected in the annual, nationally representative 2014 National Hospital Ambulatory Medical Care Survey. The state of Florida alone is estimated to carry 8% of the asthma community, challenging local healthcare providers to ensure the most efficient methods of asthma care delivery are in place. While standards of care for treating acute asthma symptoms have been widely mastered across adult and pediatric hospitals alike, there still remains significant variation in the protocols for clinical assessment and intervention delivery. Numerous barriers to expeditious care have been identified across multiple studies as well, including ED overcrowding, young patient age and less severe presenting symptoms. Rowe et al. conducted a Cochrane Database Review which linked improved outcomes, as defined by hospital admission rates, to systemic corticosteroid administration time within 60 minutes of ED arrival. Through efforts to optimize asthma exacerbation treatment, other centers have demonstrated improved medication adminstration times via RN-initiated protocols for both nebulized medications and systemic corticosteroids. Given the significant asthma burden within our state and rates of exacerbation treatment at the UF Health Pediatric Emergency Department, attention is being directed at local care practices with the goal of determining the most appropriate interventions to optimize care for our community. ED course for patients presenting with acute asthma symptoms during the months of October and November 2017 will be closely examined to determine practice patterns related to triage, formal assessment and intervention completion, as well as the rates of discharge versus admission. While each aspect of patient care will be closely examined to optimize time to medication delivery, there will be a specific focus on time to corticosteriod administration as research suggests this intervention to be most contributory in improving outcomes.

Analysis of UF quality data from the Quality Outcomes Databank (IRB 201300564)

QPI: Linda Kephart, Fallon, (

I serve as the coordinator/gatekeeper for the IRB project above. This registry is conducted in more than 100 locations throughout the US. At this point, it behooves us to review the UF data accumulated to determine the quality of care based on patient perceptions of their well-being collected at baseline, 3 months, and 12 months. The Principal Investigator, Dr. Daniel J Hoh, has asked for an excel spreadsheet of the data collected to date. Dr. Hoh does not have access to this data, I would need to download the data requested and do not intend to include most identifiers in the data set. Furthermore, all data downloaded would be retrospective (data collected through November 22, 2017). The only potential identifier would be date of surgery; however, there are approximately 150 patients in the cervical branch of the registry and approximately 245 patients in the lumbar branch of the registry. Data has been collected for more than three years, so it is highly unlikely that any particular person could be identified by date of surgery. Dr. Hoh has stated that he intends to use this data for quality control purposes.

Optimization of lung transplant immunosuppression

QPI: Tara, Veasey, (

The lung transplant program at UF Health Shands has noticed a high incidence of acute cellular rejection and is evaluating potential contributing factors. The immunosuppression medication regimen, both at time of transplant (induction) and after transplant (maintenance), is very important for graft survival. This quality improvement project will review the medical regimens of recent adult lung transplant recipients to ensure appropriate intra-operative administration as well as therapeutic maintenance immunosuppression.

Assay Performance Validation Using De-identified, Discarded Patient Specimens

QPI: Matthew, Feldhammer, ()

This is project with no direct contact with patients. We intend to use expired patient specimens (whole blood, serum, plasma, CSF, urine, feces, etc) which would otherwise be discarded to perform validations for new clinical assays. Furthermore, patients’ charts will be retrospectively reviewed to gather pertinent clinical information (diagnosis) as applicable to the project. Any patient sample used, will be de-identified prior to use in validation studies. This project, in no way, involves direct participation of patients, thus posing no direct risk to the patients themselves.

Accurate Assessment of QT Prolongation among Psychiatrists

QPI: Eric, Downes, (

The goal of our QI project is to educate on accurate assessment of corrected QT intervals, as computer generated QT intervals may be inaccurate. We are hoping to address an over reliance on computer generated calculations of QT intervals. We plan on collaborating with the Cardiology Fellows in setting up an education module for faculties and residents. This will include a pre-test and a post- test to psychiatry faculty and residents involving de-identified EKG from publicly available online libraries. There will also be a 20-30 minute video lecture module presented by Cardiology fellows.

Improving Nurses' Knowledge of Metabolic Syndrome in Patients Receiving Antipsychotic Medication

QPI: Merredith, Oakes, (

Adults with serious mental illness treated with antipsychotic medications are known to be at greater risk for developing or exacerbating risk factors for metabolic syndrome(MetS). The literature reflects that the increase in risk for MetS that patients' taking antipsychotic medications, particularly second generation antipsychotic medications (SGAs) experience, whether they take a single agent or multiple medications, appears to be in addition to, but independent of, mutable risk factors such as eating habits and activity level or any existing non-mutable risk factors that patients may be burdened with, such as gender or genetic factors. Registered nurses, including advanced practice registered nurses, have a duty to provide safe and effective care, which includes monitoring for medication side effects. Medication side effect monitoring for SGAs includes monitoring for MetS. Registered nurses have a responsibility to monitor for and act to prevent or mitigate development of MetS in patients treated with medications such as SGAs which are known to place patients at greater risk for developing MetS. Data reported by the Northeast Florida State (NEFSH) Hospital Quality Improvement department reveals nurse MetS monitoring is inconsistent with current practice standards. Evidence-based education and training will be provided to a convenience sample of consenting nursing staff at NEFSH in addition to workplace prompts to assist nurses with identifying and monitoring MetS. No patients or patient records will be involved in this QI project.

Improvements of Cardiovascular Disease Management for Women Veterans at Malcom Randall VA Medical Center

QPI: Ashley, Dwarka, (

The VA collects health outcome measures on various categories including ischemic heart disease, tobacco cessation, behavioral health, prevention, and diabetes. These outcome measures are separated according to gender to determine if there are any disparities in care and outcome measures in terms of males and females. Upon review, there seems to be a major disparity among women ages 50-64 in regards to cardiovascular disease management. The goal of this project is to look into the protocol and procedures of the VAMC to determine if there are any discrepancies in care, and whether care is being carried out in an effective manner. Ultimately, the goal is to determine whether policy changes or new recommendations are needed to reduce this health outcome disparity to ensure that women are receiving the proper care for cardiovascular disease management. The use of a data set extracted from VA databases with standardized scores was analyzed to find trends regarding gender health disparities. This database included standardized scores and sample sizes from multiple dates for VA medical facilities nationwide. After examining trends, the baseline measure of the gender disparity for cardiovascular disease management was determined. A policy and protocol analysis will be utilized to determine the effectiveness of care. This will be done by reviewing related literature of cardiovascular disease management methods and by consulting stakeholders and physicians in the facility about protocol. After reviewing trends, conclusions will be drawn to consider effectiveness of policy and procedure.

Improving communication between anesthesia providers during the perioperative period.

QPI: ()

This project will attempt to standardize and improve interpersonal and group communications within the anesthesia department as relates to preoperative (including day before surgery planning), intraoperative, and postoperative discussions. This encompasses both communications for educational purposes (sharing of scholarly materials) and also patient care purposes (messages about the status of an ongoing case). Current practice involves an adhoc mixture of email, phone calls, text messages and pagers which is often complicated by inadequate information about urgency (as in pagers) or poor phone reception inside the hospital (as in phone calls and SMS messages). It is hoped that improving this situation will improve patient safety, reduce variance in patient care and reduce delays in care caused by missed communications.

UF Health Cancer Center Distress Screening Program Development, Implementation, and Analyses

QPI: Deidre, Pereira, (

In 2012, the American College of Surgeons (ACoS) Commission on Cancer (CoC) published Cancer Program Standards that required hospital cancer committees to develop and implement a process to integrate and monitor on-site psychosocial distress screening and referral for treatment as standard of care. Basic requirements for this process included: (1) distress must be assessed at least once during a pivotal medical visit, (2) a strong preference for standardized and validated measures with clinical cut-offs, (3) individuals with moderate/severe distress must be referred to appropriate resources for management, (4) assessment, referral, and follow-up must be documented in the medical record, and (5) the policies and procedures must be overseen by the hospital cancer committee’s psychosocial representative. For the University of Florida Health Cancer Center (UFHCC) Dr. Deidre Pereira, Associate Professor in the Department of Clinical and Health Psychology was appointed to oversee this process with Dr. Merry-Jennifer Markham, Associate Professor in the Department of Hematology/Oncology. In 2014, distress screening policies and procedures were developed by Drs. Pereira and Markham. Specifically, it was determined that patients attending visits in Medical Oncology would undergo screening via administration of the Distress Thermometer, problem-area checklist, and Patient Health Questionnaire – 2 by medical assistants at the point of assessment of vitals. Individuals scoring > 7 on the Distress Thermometer and/or > 3 on the PHQ-2 were deemed to have a positive distress screening, requiring a referral to Oncology Social Work with or without other appropriate referrals (e.g., Psycho-Oncology Service in the Psychology Clinic). These procedures were piloted started in October 2015 and then formally and routinely implemented in January 2016. In approximately November 2016, these procedures were also implemented in Radiation Oncology. Drs. Pereira and Markham lead a Distress Screening Clinical Quality Improvement Team comprised of the following individuals: Jennifer Adams, LCSW, Oncology Social Work Brigette Coleman, MSW, Oncology Social Work Debra Hutchinson, RN, BSN, OCN Victoria Pearson, LCSW, Oncology Social Work Michele Scavone-Stone, M.ED, Oncology

Interpreting Motivational Interviewing Use During Telephonic Medication Reviews After Implementing Training Sessions

QPI: Mariyem, Naboulsi, (

Objectives: To evaluate implementation of an improved training model for pharmacists and technicians on motivational interviewing (MI) at the University of Florida, College of Pharmacy, Center for Quality Medication Management. Background: MI is a patient-centered counseling method that helps resolve patient ambivalence with response to change. According to the Society for the Study of Addiction, there has been more than 80 randomized clinical trials that have been published supporting its efficacy. They also claim that many of these studies which place emphasis on training MI have failed to achieve sustained practice change in MI according to their criteria. CQM currently requires all staff members, upon being hired, complete MI training with an initial video presentation by Bruce Berger, co-author of Motivational interviewing for Health Care Professionals. It is also required that employees participate in a refresher recorded lecture annually on MI. These newly proposed MI training sessions will attempt to speak to the need for enhancing MI training at CQM for pharmacists and clinical associates who may find MI useful when encountering a patient resistant to change. Methods: Participants consist of a subset of CQM staff members including pharmacists and technicians. Training will be held in CQM's designated training room. Training entails six sessions for a duration of three months, with two sessions per month. Each session will be 15 minutes long and held on two consecutive days during that month. The first day will include an introduction to an MI topic and the second day will focus on applying the MI technique reviewed the day before using team-based learning activities. Sessions will include one designated trainer and a group of 5-8 employees. Training will also include work station handouts to function as a guide for using MI if trainees encounter patients that qualify for use of MI techniques during calls. Pharmacists and technicians will be assessed by the number of MI techniques demonstrated using Motivational Interviewing Treatment Integrity Scales (MITI). Trainers will screen recorded calls for MI techniques used by pharmacist and technicians before and after new training is completed. Only recorded calls where patients who present as "ambivalent to change" will be screened for MI techniques as MI is not necessary in all situations. Patient recorded calls will be selected for review by trainers based on patients who appear as "ambivalent to change".

Improving Medical Student Access to Appropriate Psychotherapy

QPI: Daniel, Pietras, (

Depression is more common among medical students than their age-matched cohort due to multiple psychosocial factors and expediting access to care may help facilitate better medical training. We will assess the current state of access to psychotherapy from medical students meeting criteria for major depressive disorder as measured by the Patient Health Questionnaire - 9 item (PHQ-9), along with their perceptions of the effectiveness of care received so far, using a Qualtrics survey. We will also obtain all available data regarding the current waiting time for medical students to be seen for psychotherapy at the Student Wellness Center and the Adult Outpatient Psychiatry Clinic. We will then identify areas of improvement in the current pathway to care and develop an alternate algorithm to reduce the length of wait and apply it for one month. We will assess the difference in wait times before and after implementation and, if significantly different, seek to institute the new algorithm into standard operating procedure.

Cast Discharge Instructions

QPI: Edward, Haupt, (hauptet@ortho.ufl.du)

Improving discharge instructions from the emergency department after patient's received casting.

Unit Based Delirium Assessment Compliance and Effectiveness

QPI: Lauren, Ochoa, (

Utilizing pre-data showing poor compliance and effective use of the CAM ICU assessment (validated tool for identification of delirium in the ICU), the unit practice council will perform a survey of nurses in 4W to identify barriers to appropriate use of the tool. Following the survey, a focused education campaign will be done. We will track compliance to CAM-ICU assessment and track improvement and sustainability over 3-6 months post-education to see if the education was successful.

Reducing Inappropriate Telemetry Use in the non-ICU Setting

QPI: Erik, Schneibel, (

Telemetry in the non-ICU setting is commonly inappropriately used based on current major society guidelines. At UF Health, our institutional data suggests that nearly 50% of non-ICU telemetry is used for inappropriate indications. Inappropriate telemetry use can lead to inappropriate consultation, testing, resource utilization, and patient satisfaction. As such, we have tasked our group with reducing telemetry use. We plan to reduce telemetry use by focusing on medicine teaching services with various educational and systematic interventions. Educationally, we plan to participate in internal medicine teaching conferences to reduce inappropriate use. From a systems standpoint, we plan on eliminating an "automatically clicked" telemetry button in the EPIC internal medicine order set to reduce inadvertent automatic telemetry ordering. We intend to collect data pre and post intervention to assess telemetry usage. Secondary outcomes pre and post intervention include cardiology consultation, sepsis documentation in chart, and length of stay.

Pharmacist Delivered Chronic Pain Management

QPI: Robert, Leverence, (

Opioid abuse is a common addiction with a high mortality rate. According to the CDC over ninety one Americans die every day from an opioid overdose. Unique to this addiction is its intimate association with medical prescribing - opioids still are and will likely always be an important component to pain management. Physicians and pharmacists are uniquely positioned to address the problem where it starts – in the physician’s office. Today a battery of validated tools exist to aid the physician in preventing and detecting opioid abuse. National pain organizations and the CDC recommend physicians use these tools yet they uncommonly do as the tools are tedious and time consuming to administer, especially since the patient is often being seen for a condition other than pain. We performed an IDR search to evaluate opioid prescribing in the UF Medical Oncology Clinic. From 9/2/2016 – 8/31/2017, 4,445 unique patients were prescribed an opioid and 879 were prescribed a long-acting opioid. Only 241 patients were prescribed a long-acting opioid along with gabapentin, pregabalin, or duloxetine, despite society recommendations to do so. We recruited a clinical pharmacist certified in chronic pain management to co-manage these non-malignant, chronic pain patients. Upon referral from an Oncology Faculty, the pharmacist meets with the patient and routinely checks the state controlled substance registry, administers a functional status questionnaire, an addiction scale, and a urine drug screen. She also administers a pain contract, makes recommendations for alternative analgesics, and follows the patient prospectively.


QPI: Jeanette, Green, (

Recipe (protocol): education plan (protocol, checklist, steps process...) checklist for foley indications

CT-assisted assessment for left atrial appendage thrombus in patients presenting to the Emergency Department with new-onset atrial fibrillation

QPI: Torben, Becker, (

Patient who present to the ED with chief complaint related to new-onset atrial fibrillation/flutter will undergo a CT scan of the chest to rule-out a left atrial appendage thrombus if they present during approved hours (CT exam will be read between 7am and 5pm Monday to Friday, and once at 8am on Saturday and Sunday). If no clot is present, the new algorithm created for the ED recommends to perform cardioversion to attempt rhythm control. If successful, patients will be discharged with close cardiology follow-up. If unsuccessful, they will be admitted as per usual practice.

Cardiac Arrest Database

QPI: Sarah, Gul, (

Cardiac arrest is the cessation of cardiac mechanical activity resulting in the absence of circulating blood flow. Cardiac arrest stops blood from flowing to vital organs, depriving them of oxygen, and, if left untreated, results in death. Cardiac arrest causes global ischemia with consequences at the cellular level that adversely affect organ function after resuscitation. The main consequences involve direct cellular damage and edema formation. Edema is particularly harmful in the brain, which has minimal room to expand, and often results in increased intracranial pressure and corresponding decreased cerebral perfusion post-resuscitation. A significant proportion of successfully resuscitated patients have short-term or long-term cerebral dysfunction manifested by altered alertness (from mild confusion to coma), seizures, or both. Survival to hospital discharge, particularly neurologically intact survival, is a more meaningful outcome than simply return of spontaneous circulation. Only about 10% of all cardiac arrest survivors have good CNS function at hospital discharge. Postresuscitative care, including circulatory support, access to cardiac catheterization, and targeted temperature management (avoidance of hyperthermia) are factors that can influence outcome post-cardiac arrest. We intend to prospectively collect variables to understand factors that influence outcome of post-cardiac arrest patients and if there are improvements that can me implemented to increase the percentage of patients that are discharged with favourable outcomes.

Environmental Assessment of Operating Room (OR) Surfaces to Evaluate Efficacy of Night Shift Terminal Disinfection and Case Turnover Disinfection in an Acute Care Hospital: A Pre/Post-Implementation Study.

QPI: Ricardo, Martinez Garcia, (

Surgical Site Infections (SSI) are a major burden within hospitals and can cause high morbidity and mortality for patients resulting in infection. Additionally, costs to treat an individual patient for a hospital acquired infection resulting from a surgery/procedure can cost thousands of dollars in lost reimbursement for the hospital, as Medicare/Insurance Companies have no responsibility in covering the costs since the hospital acquired infection was a direct result of the surgery/procedure that was performed. More importantly SSIs are devastating for the patient causing unnecessary suffering, long term morbidity, even death, which prompts the organization to find ways to prevent and control these infections. Many studies have assessed the risk factors for acquiring SSI, ranging from age, sex, race, socioeconomic status, as well as the presence of co-morbidities including diabetes, hypertension, obesity, malnutrition, co-infection/colonization, among others. It is of equal interest to understand the risk factors within the hospital that may increase a patient’s risk for acquiring an infection while at the facility, specifically during a surgical procedure. Some researchers have suggested factors such as behavior of healthcare providers; use of prophylactic antibiotic prior to surgery; ventilation in the operating room; and number of people within the operating room during a certain period. However, lack of research exists regarding the efficacy of disinfection of the surgical suite as well as the indirect effect of environmental surface contamination on patient outcome. For this reason, the following study looks to assess the efficacy of night shift terminal disinfection and case turnover disinfection in the OR at an acute hospital through environmental and microbiological methods. Furthermore, this study aims to understand how evidence based educational programs can improve technical skills in cleaning staff and increase the efficacy of disinfecting procedures in the OR. We believe that frequently assessing environmental surfaces in the OR will identify weaknesses in disinfection protocols and provide opportunities for improvement by introducing evidence based educational programs for cleaning staff. Although it is still unclear if this will influence patient outcome, improvement of disinfecting protocols will most likely lead to cleaner OR surfaces and reduce the patient’s risk for being exposed to potential pathogens. The pre-implementation portion of this study aims to assess disinfection on eight different operating room surfaces. The eight points/surfaces for testing will be consistent for each room tested. Particularly, this part of the study will serve to understand the efficacy of the current methods and protocol used for between case turnover disinfection and effectiveness of night time terminal disinfection. The Association for Operating Room Nurses (AORN) oversees the provision of guidelines for operating room disinfection. In regard to definitions, turnover is the periodbetween one case and another, when patient service technicians disinfect and prepare the operating room for the next case. Terminal disinfection is conducted on every operating room environment and equipment nightly from Monday through Friday and when a room is used on the weekend. In theory, turnover disinfection is completed in a hurry as operating room time costs money. Additionally, there is a push from management to complete as many cases as possible each day as surgery provides large revenue for the hospital. Therefore, the staff is pushed to produce a thirty minute turnover, which means one patient rolls out of the operating room suite and the next patient rolls into the operating room suite within thirty minutes. This means the patient services technician is in a hurry to complete the cleaning quickly. Finally, night time terminal disinfection becomes important so that the operating room suite receives a thorough disinfection once per day each night shift. For this reason, looking at adequate disinfection is important in the prevention of SSI. This study will serve to inform management, in order to modify and improve protocols and educational programs for staff. Finally, the post-implementation of the study will utilize the same methods used in the pre-implementation portion to re-assess surface disinfection on operating room surfaces and evaluate the efficacy of the proposed intervention.

Perioperative Spine Management - Pre-operative Phase

QPI: Hannah, Fulmer, (

This project is aimed at developing a protocol to standardize the perioperative care to patients undergoing elective spine surgery in the prone position. There are four phases of care involved in elective spine surgery; preoperative, Intraoperative, Acute post-operative period ad subacute postoperative period. The pre-operative phase of the project involves the creation of a pre-habilitation consult protocol, data collection and review as the first step of this larger project.

“Implementation and outcomes of a comprehensive combined opioid protocol in elective total joint arthroplasty”

QPI: Justin, Deen, (

Beginning in January of 2016, a comprehensive combined protocol will be developed in an effort to minimize opioid narcotic usage among patients undergoing primary and revision hip and knee arthroplasty procedures. In addition to a multi-modal medication regimen and peripheral nerve blocks, patients will be interviewed and stratified into one of four pathways (Chronic Use, Standard, and Narcotic Naïve, Opioid-Free) based on pre-operative opioid use and patient risk factors for non-therapeutic opioid use. Each category is associated with a specific formulation and quantity of narcotics prescribed. In addition, patients who have a history of chronic continuous opioid narcotic use will be required to develop a post-operative prescription plan with their prescribing pain management physician.

The Educational Experience of a Simulated Root Cause Analysis (RCA) geared towards Hematology Oncology fellows

QPI: Arpan, Patel, (

Our project focuses on a mock root cause analysis (RCA) program geared towards hematology oncology house staff. This program goes through the steps needed to familiarize and participate in a RCA more effectively. Quality improvement (QI) and patient safety education is increasingly becoming part of residency and fellowship programs and is imperative for the awareness of physicians in practice and in training. A specific aspect of QI includes the review of near misses or unseen patient outcomes in order improve system based practices via the root cause analysis method (RCA). We aspired to develop a formal quality improvement simulated RCA curriculum for house staff in hematology oncology training to provide the tools needed to effectively participate in a live RCA and to increase system based awareness and catchment for possible areas for improvement. Methods: This quality improvement curriculum includes a simulated RCA case that tests the ability to review a patient care timeline and progression to a fishbone diagram to point out areas of possible improvement in a live group activity participation conference. Results: This curriculum has been implemented for 14 hematology oncology fellows with improvement shown on assessment regarding a RCA. Discussion: This RCA simulation provides adequate basic tools for learners regarding the basics of a RCA and helps raise awareness for system awareness in hopes to catch more near-misses. While this curriculum was created for hematology oncology fellows, the basic involvement in this simulation can be broadly applied to all interested learners.

Interdisciplinary Team Conference in Pediatric ICU

QPI: Robert, Smith, (

Goal set to have a multidisciplinary team conference weekly regarding pediatric ICU patients to improve interdisciplinary team communication and to facilitate discharge planning and needs.

Determining if adequate cancer screenings are being performed in patients with advanced renal disease.

QPI: Shaun, Hoenstine, (

Standard health care maintenance incorporates age related cancer screenings for secondary prevention. Specific screening recommendations for the general population are well outlined in numerous literature and vary slightly. For the purpose of this study, guidelines from the USPSTF were selected. The focus of this research, will be to determine if adequate health care maintenance screenings are being performed on those patients Advanced renal disease. Advanced renal disease will be defined as those patients with a stable glomerular filtration rate of less than 15ml/min which reflects a very severely reduced kidney function. This particular population has a greater incidence of malignancy which is especially true when examining viral mediated cancers. This includes hepatitis B&C infection which is seen with liver cancer and Human Papiloma Virus which is associated with cervical and oral cancer. Additionally, the highest incidence of cancers are seen in those less than the age of 35 years old. These examples are offered to point out the need for adequate cancer screenings in Advanced renal disease patients on an individualized basis when taking into account life expectancy and risk factors. During this research block I intend to retrospectively chart review those patients with advanced renal disease as defined above and determine if adequate cancer screenings have been implemented over the past 6 months. As this will be a quality improvement project, after data is collected I will work with informatics to create a standardized template that can be employed within the clinic to allow for clinicians to adequately screen patients and ensure that appropriate guidelines are implemented.   

Delay in FDA approved chemotherapy

QPI: Dustin, Begosh-Mayne, (

Medication, including chemotherapy for cancer treatment for an FDA indicated disease, should be approved by insurance companies within 24 hours prescribing the medication. Delays up to 30 days have been observed in clinic. It is the aim of project to identify delays and to implement a protocol to reduce delays in prescribing medications. Patient data will be collected from oncology clinic at medical plaza. Patient data will be retrospectively and prospectively collected to accurately detail the time from clinic visit to obtainment of insurance approval. Included in the data collected will be time from signed prescription to insurance approval and time from insurance approval to delivery of medication.

Outpatient Follow Up List

QPI: Maharsh, Patel, (

To create a list on Epic that is shared with all the orthopaedic residents to add any patients that require outpatient follow up so that appointments are scheduled and patients are not lost to follow-up. Individuals will go through the list every Wednesday or Thursday to check and make sure the patients on the outpatient follow up list have an appointment scheduled for their follow up. Once this has been scheduled, they can be taken off the list.

Getting Point of Care Testing equipment on patient floors

QPI: William, Thomas, (

We are looking to provide a manner of testing a point of care lab value (e.g. Creatinine) on the patient floors in order to prevent delays in treatment for patients with signs and symptoms of a time sensitive diagnosis (e.g. Stroke). Our project stems from a personal experience in which patient on the Orthopedic Surgery floor was "Stroke alerted" due to physical exam findings that were concerning. There was a significant delay in obtaining a CT of the patient's head with contrast due to push-back from the CT technologists regarding the lack of a creatinine on the patient's file. Ultimately, a member of the Orthopedic team personally went to the ED and obtained this POC machine in order to proceed with this scan.

Blood pressure monitoring in patients with aortic arch obstructive lesions

QPI: Ryan, Boggs, (

There are many patients born with concern for an aortic arch obstructive lesion such as a hypoplastic aortic arch or coarctation of the aorta. However, until their ductus arteriosus has closed, the ability to diagnose these patients a coarctation of the aorta or a hypoplastic aortic arch that requires intervention is limited. To determine the need for intervention, the difference between their upper and lower extremity blood pressures is monitored as they are taken off prostaglandin infusions or soon after birth before starting a prostaglandin infusion. - We are planning to evaluate our compliance with this standard of care by performing a retrospective chart review of blood pressure monitoring for patients with concern for aortic arch obstructive lesions in both the NICU and the PCICU. - Based on the results of the retrospective chart review, an intervention will be made with the goal of improving our compliance with the standard of care for monitoring upper and lower extremity blood pressures in this patient population. Possible interventions include placing a card on an infant's crib noting the need for upper and lower extremity blood pressure monitoring, educating NICU fellows and NPs regarding the need to place the correct vital signs order in Epic, creating a smart-phrase for cardiology consult recommendations regarding blood pressure monitoring to be consistent, and a long term intervention could include creating an admission order-set for these infants in the NICU. - We will then prospectively review charts to evaluate any change in our blood pressure monitoring.

Improving ventilator management in the ED

QPI: Torben, Becker, (

Often, after an intubation in the ED, the tidal volume will be set to 500 mL which is too much for the vast majority of patients. We have known for many years that large tidal volumes cause lung injury, and that outcomes of lung injury patients (ARDS) are better with tidal volumes around 6 ml/kg IBW. While traditionally tidal volumes of 8 ml/kg IBW have been thought to be “lung protective”, the literature supports that there is in fact no “safe” tidal volume threshold and that initiating lung protective ventilation with tidal volumes of 6 ml/kg IBW improve the outcomes of our patients, including in the ED, and likely confers a significant mortality benefit.. Therefore, we have worked with a multidisciplinary team involving the ED, Respiratory Care leadership and the MICU to derive a uniform approach to this issue and to provide education on the importance of appropriate tidal volumes.. With few exceptions, all patients should be started on a tidal volume of 6 ml/kg IBW.

Improving documentation in Epic for Pediatric Hematology-Oncology Patients

QPI: Biljana, Horn, (

Keeping good medical records is important for providing good care and for facilitating communication among different care providers. Medical care is provided by medical teams rather than individuals and it is important that information is kept in a systematic way so that any member of any team can easily and quickly find accurate and relevant information. If used as designed, Epic system has made it easier to maintain uniform medical records as it has pre-defined fields for medical history, social history, medications, etc. Epic system supports problem-based (as opposed to system based) documentation; however, in order to be accurate, chart requires maintenance. Inactive problems can be easily moved to medical or surgical history, while a few active problems require updates. Once components of the chart are updated (history, medications, problem overviews) a new note can be generated by assembling the above components. If problem overviews are maintained, detailed information about active problems can be easily identified. The goal of this project is to improve documentation in Epic by filling properly components of medical records including past medical history, family and social history and documenting history of active problems in the problem overview section.

The Effect on Staff Morale and Parental Perceptions of Overall Experience After Modifying Outpatient Clinic Decor.

QPI: John, Pinson, (

Our project is a before and after assessment of how parental and staff perceptions may change after giving our outpatient clinic a make over with new paint and artwork painted by our resident group. Pediatric staff members will be educated as far as when to give surveys, collect them, and where to store the information once obtained. Informed consent procedure will take place in the waiting room before the patient's appointment. Surveys will be offered to all parents of patients that are scheduled for an appointment during the "pre-intervention" time and the "post-intervention" time. Staff will be offered surveys to complete on their own time. The survey is anonymous with the only demographic information obtained being race, sex, age of parent, and relation to patient. Demographic information of staff will include age, sex, race, and position. The survey is 9 questions long and includes questions to screen for individuals who do not like art at all and/or may be biased because the care they received was unsatisfactory. Similarly, the staff member questionnaire inquires about one's like/dislike for art and assess current stress level when taking this survey. These should account for confounding variables. The survey generally determines if participants like what they see, which areas of the clinic are appropriate or lacking, and if the color change and added decorations affect the overall experience/staff morale. Staff responses will be collected over time and parent responses will be collected at the end of their child's visit. Results will be stored in Dr. Wilkinson's office. After we collected a good pre-intervention group, we will then start painting the rooms and adding the artwork. No surveys will be performed at this time. Once all interventions are completed, we will resume giving out new post-intervention surveys. As it may be difficult to have all the exact same parents follow up, we will not be pairing the parental pre-and post groups.

Cardiac Arrest Database

QPI: Sarah, Gul, (

Cardiac arrest is the cessation of cardiac mechanical activity resulting in the absence of circulating blood flow. Cardiac arrest stops blood from flowing to vital organs, depriving them of oxygen, and, if left untreated, results in death. Cardiac arrest causes global ischemia with consequences at the cellular level that adversely affect organ function after resuscitation. The main consequences involve direct cellular damage and edema formation. Edema is particularly harmful in the brain, which has minimal room to expand, and often results in increased intracranial pressure and corresponding decreased cerebral perfusion post-resuscitation. A significant proportion of successfully resuscitated patients have short-term or long-term cerebral dysfunction manifested by altered alertness (from mild confusion to coma), seizures, or both. Survival to hospital discharge, particularly neurologically intact survival, is a more meaningful outcome than simply return of spontaneous circulation. Only about 10% of all cardiac arrest survivors have good CNS function at hospital discharge. Post-resuscitative care, including circulatory support, access to cardiac catheterization, and targeted temperature management (avoidance of hyperthermia) are factors that can influence outcome post-cardiac arrest. We intend to prospectively collect variables to understand factors that influence outcome of post-cardiac arrest patients and if there are improvements that can be implemented to increase the percentage of patients that are discharged with favourable outcomes. Measuring these variables will allow us to monitor the quality of care related to cardiac arrest patients at Shands, and will help us identify area of weaknesses. This will allow us to create targeted quality improvement interventions, which at that time will be submitted as separate QI project, or if indicated IRB research application.

Early Electrocardiogram Intervention in Adult Emergency Department Patients Experiencing Acute Coronary Syndrome

QPI: Stephanie, Drummond, (

The objective of this DNP project is to implement a department procedure requiring adult patients presenting with symptoms of ACS to have a 12-lead ECG completed within 10 minutes of arrival to the ED in accordance with the current recommendations by the AHA. Intervention will be education of staff on current guidelines and ACS recognition. The ED already records time of arrival, initial complaint and time of ECG completion. The de-identified data from the electronic charting system will be the only data collected for this project. The plan is to look at the aggregate data of the ECGs performed on patients presenting with ACS 30 days before and 30 days after the intervention is put into place. The purpose of this project is to enact a procedure that will require current practice recommendations in the treatment of patients with ACS symptoms for all staff that are not currently doing so.

Code button in the main OR

QPI: ()

Currently, in case of a code in the OR, the OR nurse circulator has to press a button which lights up a light in the OR front desk. No sounds are produced by the button. Somebody needs to be physically present at the front desk to be able to see the light going off on the wall, to then call the OR where the light originated from and ask what is going on. The nurse circulator has to answer the phone and communicate to the front desk that there is a code situation, and that all available anesthesia providers have to go to that OR. The front desk person at that point has to contact the AIC (Anesthesiologist in Charge), and request to send any available personnel to the OR where the code is. This quality improvement project is necessary, in order to improve the "code button system", as the current system requires too many people to communicate to each other before help can be sent to the OR in need.

Proposal of intravenous ketamine use as an analgesic adjunct to GA in neurosurgical patients undergoing spine surgery and hence decrease the opioid use for intra operative and post-operative pain

QPI: Venkata, Damalanka, (

Pain is defined as “unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”. Effective management of acute pain is a very important aspect of the optimal care of all patients undergoing surgery. Several recent surveys have shown that still a big amount of patients (around 70%) experience discomfort and moderate to severe pain after surgical procedures. The surgical stress results in increase in secretion of catabolically-acting hormones such as catecholamines, cortisol, ACTH, ADH, glucagon, and aldosterone, and a concomitant decrease in the secretion of the anabolically-acting hormones such as insulin and testosterone. These endocrine changes in turn cause a number of metabolic effects that ultimately result in a catabolic state. Therefore post-operative pain, unless effectively managed, can directly or indirectly cause impairment of the function of various organ systems (modern concepts of acute and chronic Pain management). The opioid epidemic has captured the attention of all the leading medical organizations in the country. Alternatives to opioids or techniques that markedly reduce opioids are highly desirable. Ketamine, an N-methyl-D-aspartate receptor antagonist, has emerged as such a drug because of its potent analgesia and lack of respiratory depression. Ketamine infusions can improve postoperative pain and decrease opioid consumption with the greatest benefit occurring during the most painful surgeries. (Ketamine a versatile tool in perioperative period and beyond) Ketamine, an anesthetic first developed in 1970, is one drug that has gained renewed interest as a part of the multimodal approach towards acute pain treatment. Intravenous ketamine, when added as an adjunct to general anesthesia, reduced postoperative pain and opioid requirements in a variety of settings, from outpatient surgery to major abdominal procedures (Ketamine for perioperative pain management). Ketamine can function as analgesic by blocking the NMDA receptors involved in nociceptive and inflammatory pain response. It is a potent antihyperalgesic agent. It can counteract opioid induced hyperalgesia and prevent the development of opioid tolerance. Ketamine has also been used to treat depression, CRPS, cancer pain, alcohol addiction, heroin addiction, asthma exacerbations, wheezing, and pain during propofol injection. Although it was first used purely as an anesthetic, ketamine is making a certain resurgence in the management of postoperative pain (Acute and perioperative pain section). IV Ketamine reduces opioid consumption by 40%. At one center, Division of Regional anesthesia and acute Interventional perioperative pain, low dose continuous IV infusion of Ketamine has been included as a standard of care for the management of post-operative pain in opioid tolerant patients since 2010 and noticed 40% reduction in opioid use(Acute and perioperative pain section). Meta-analyses of various clinical trials with IV Ketamine has shown the intra-operative boluses ranging from 0.15mg/kg to 1mg/kg and intra operative infusions ranging from0.12mg/kg/hr to 1.2mg/kg/hr to be effective in reducing opioid for intra operative and post-operative pain(Acute and perioperative pain). Ketamine has mind altering effects. Quiet, relaxed surroundings contribute to a reduced incidence of these side effects and when ketamine is administered alone, the prophylactic use of a sedative agent such as 3.75–7.5mg oral midazolam has generally decreased their incidence and severity. No severe physical symptoms have been reported with the use of low-dose ketamine; however, studies have reported benign effects of lightheadedness, headache, nausea, diplopia, drowsiness, and dizziness. These effects, unlike the psychotomimetic effects, tend to be dose-dependent. They are also limited to time of administration and a short time thereafter. Case series demonstrate a temporal link between ketamine abuse and urological symptoms, urinary tract damage, and renal impairment, with some but not all symptoms improving upon cessation of ketamine. Hepatotoxicity has been reported at anesthetic doses (≥1mg/kg) and patients receiving low-dose continuous infusion. Trials using single doses of ketamine <1mg/kg report no changes in liver function tests.

Multidisciplinary CLABSI Reduction Initiative: UF Health's Path Toward Achieving Zero Infections

QPI: John, Delano, (

Central-line associated bloodstream infections (also known as CLABSIs) are serious, life-threatening infections in which organisms enter the bloodstream due to poor insertion technique or improper maintenance of central venous catheters. These purely preventable infections have been associated with increased healthcare costs, length of stay and mortality. The National Healthcare Safety Network (NHSN) reports that in 2015, 26,029 CLABSI events occurred across the 3,550 participating acute care hospitals. Based upon this data, NHSN conducted a re-baseline in which all-future standardized infection ratios (SIR), a summary measure used to track HAIs at a national, state, or local level over time, would be based upon going forward. In 2016 UF Health Shands hospital saw an increase in their CLABSI rate and as a result a ~25% increase in their SIR (from 0.897 to 1.109). As a result, a multidisciplinary team composed of nursing leaders, infection preventionists and infectious disease physicians regrouped in October 2016 in response to the increasing CLABSI rates. The goal of this CLABSI Committee was to develop interventions targeted at preventing these events from occurring and monitor outcomes. Interventions included the development and implementation of: 1) An electronic drilldown tool to track and trend contributing factors when a CLABSI occurs to create future interventions 2) A CLABSI Bundle for standardization of insertion and care of central venous catheters 3) Kamishibai Cards (K-Cards) for monitoring compliance with bundle 4) A patient education brochure for CLABSI prevention and 5) Targeted interventions in select patient populations at high risk of CLABSIs as identified from the CLABSI drilldown trend data

Patient Handout Overhaul in Pediatric Dermatology Clinic

QPI: ()

Several of the handouts currently present in Pediatric Dermatology clinic are outdated and irrelevant. Many were brought to UF via a previous physician and some refer to information from that physician's previous institution. The purpose of this QI project is to evaluate, critically appraise, and re-write all of the handouts available in pediatric dermatology clinic. In addition, we will have commonly used handouts available in patient rooms, rather than interrupting work-flow to obtain handouts. We hope that having relevant handouts readily available will increase use of handouts, in order to provide necessary education to our patients. We will also implement eczema action plans.

Implementing Albumin Criteria for Use: Impact on Patient Outcomes and Financial Implications

QPI: Stephen, Lemon, (

At UF Health Shands Hospital, we undertook a complete review of our albumin use with a specific focus on our adult critically ill patients and transplant recipients. This review was initiated due to the high and increasing annual medication spend for this therapy at our institution. A group of clinical experts representing all the key stakeholders for this therapy were assembled and included surgery, anesthesia, pulmonary, nephrology, transplant, burn, internal medicine, and pharmacy. After reviewing our current practice and the available evidence, criteria for use were developed and approved by our Pharmacy & Therapeutics Committee.

Adding cardiac screening question to paper chart

QPI: Kathy , Noffsinger, (

This is a student Doctor of Nursing Practice Project. The student is a clinician at Sarkis Practice. Her project is to add a screening question about past cardiac history on the intake paperwork for all patients in the practice.

Urgent ICU to OR Handoff Improvement

QPI: Christopher, Schwan, (

The urgent transfers from the ICU are some of the sickest patients that arrive to the OR; the handoffs from the ICU staff to the OR staff are some of the least organized and hurried transfers that occur. 80% of serious medical errors involve miscommunication during handoffs between medical providers; we see this ICU transfer process as a way to improve patient safety and improve safe transfer to timely, life-saving surgery.

Increasing Compliance to the Safe Sleep Policy among Nursing Staff in the NICU

QPI: Holly, Bogdahn, (

In 2016, the American Academy of Pediatrics updated and published their recommendations regarding safe sleep positioning for eligible infants. These updates now include a safe sleep environment, in addition to the safe sleep positioning of the infants. The challenge with implementing this universal protocol in the Neonatal Intensive Care Unit is that certain patients have developmental needs that are not congruent with AAP’s recommendations. Therefore, one of our aims is to educate staff on the qualifications that make a patient Safe Sleep eligible. In the NICU, staff should exhibit risk-reduction modeling for the parents of eligible infants because research has shown that parents model behavior exhibited by the medical team. If parents adopt proper Safe Sleep protocol post-discharge, then the risk of SIDS among this population will decline. With this quality improvement project, we hope to increase nursing staff compliance to the Safe Sleep policy in the NICU. To achieve this, we are collecting pre-intervention baseline data on Safe Sleep compliance of the nursing staff via audits that measure percent compliance based on Safe Sleep protocol elements. We will also distribute a staff survey to determine staff knowledge and beliefs about Safe Sleep protocol. The audit and survey results will serve as a guideline to develop targeted education and interventions. These interventions will include staff education and crib cards promoting Safe Sleep for eligible infants. We then plan to assess the effectiveness of these interventions by continuing the audits and analyzing the degree to which percent compliance changed.

Decreasing Variation of Care through use of Length Boards in ELBW Infants

QPI: Tara, Jendzio, (

Neonatal length is a primary indicator of neonatal nutrition and forms the basis for important future treatment decisions. There are a variety of methods used to assess the length of infants. However, the use of length boards to measure infant's length is a more accurate measurement of length and therefore is a more reliable indicator of neonatal nutrition. This project was designed to assess the variablity in lengths and variability from normal growth curve Z scores before implementation of the length board and after implementation.

Developing a process for tracking laboratory related errors in Veterinary medicine

QPI: Linda, Allen, (

Used PDSA methodology. 1) Researched and identified common laboratory errors and then utilized to classify our laboratory errors (Planning phase) 2) Worked with Quality Officer to design and implement a reporting process in IDinc to capture laboratory errors. (Do phase) 3) Educated staff on how to report laboratory errors. (Do phase) 4) Created procedures for staff to standardize common processes and remove variation in practices (Do phase) 5) Met goal of “go-live” on October 3rd, 2017 6) Evaluated the data collected and made modifications to the system. (Study/Act Phase) a. Added new “additional questions” b. Created a new category to manage staff training deficits 7) Utilized IDInc to enhance the laboratories Internal Audit process and track follow-up/assess trends quarterly.

A social media strategy for reducing pediatric visits for asthma by five percent

QPI: Carylee, Pennington, (

As part of the 2017-2018 Advanced Leadership Fellowship, we have the opportunity to implement a community health improvement project. Our team has chosen to focus on reducing pediatric ED visits for asthma with a reduction goal of 5% over the next fiscal year. Initially, we will develop a public-facing Facebook page that will eventually be maintained by the UF Health Pediatric Asthma Center of Excellence (PACE) Committee. The page will include instructional videos with UF Health asthma experts, daily tips from PACE committee members, and instructional/educational fliers.

Standardized Medication Order Writing

QPI: Gareth, Buckley, (

To standardize the writing of medication orders for inpatient in the UF Veterinary Hospitals to avoid confusion when technicians are administering treatments. The project aimed to educate clinicians, technicians and veterinary students to write orders as a total milligram dose followed by route of administration and frequency rather than variations including "mg/kg" or "1/2 tablet " etc.

Improving Patient Asthma Education through Hands-on Training

QPI: Jeffrey, Lee, (

Patients at the medical plaza clinic do not typically bring aerochambers or inhalers to their appointments. As a result, patient education regarding the use of their inhalers/aerochambers is limited as we are not able to give patients disposable aerochambers or disposable mouth pieces leading to limited teaching of their medications. As limited by such constraints, pharmacy typically teaches patients through a doll rather than having the patient/parent actually place their inhalers/aerochambers to their face and practice technique. This project seeks to enhance the patient education experience and thus improve inhaler technique by reminding patients via telephone one to two days beforehand to bring their inhalers/aerochambers to their appointments. Through the pharmacy student or administrative staff, for the first two weeks, we will not contact families (Asthma return patients only) to remind them about bringing asthma inhaler/aerochamber and tally what % of patients bring their devices. The pharmacy will teach the patients on their technique with either the doll or hands on depending if the family brings their device or not. Then for the following 2 weeks, we will telephone families one to two days beforehand to remind them to bring their asthma inhaler/aerochamber and tally what % of these patients bring their devices. Those who bring their devices will be taught hands on and those who do not will be taught via the doll. We will then compare the numbers to see if our reminders were effective in increasing hands on teaching vs doll teaching. We will use a brief survey for those who did receive phone reminders and who did bring their inhaler inquiring whether 1) whether calling beforehand helped remind them to bring them their inhaler, 2) whether they had been taught with the doll before 3) If they felt hands on teaching was more beneficial than doll teaching and 4) If hands on teaching helped improve their inhaler technique.

“There’s no place like home”: outcomes after implementation of a patient-centered approach to post-operative disposition following joint replacement surgery.

QPI: Justin, Deen, (

With rising healthcare costs and the creation of a prospective payment system for patients undergoing total joint replacement surgery, many institutions have begun to critically evaluate the entire episode of a patient’s care. One of the largest drivers of total cost is the post-acute phase of care (i.e. after hospital discharge). This is highly dependent on the patient’s disposition, with higher costs historically associated with discharges to skilling nursing (SNF) and inpatient rehabilitation (IRF) facilities. Concurrently, advances in surgical technique, post-operative pain management, and emphasis on rapid recovery have made it possible for patients to safely be discharged to home. In addition to the exponential cost associated with post-acute care facilities, recent literature has overwhelmingly shown that outcomes are also affected by disposition. Specifically, discharges to SNF/IRF have been linked to longer hospitalizations, higher complication rates, and higher hospital readmission rates. As a division, we felt that this represented an opportunity to improve our own discharge practices in order to improve value and the overall experience for patients undergoing total joint arthroplasty.

UFHealth Shands Children’s Hospital reduction in incidence of hospital acquired hyponatremia quality improvement initiative

QPI: Charlene, Leonard, (

Over the past year, at least 77 inpatient pediatric patients without an admitting diagnosis of hyponatremia were diagnosed with hyponatremia during their admission. This is likely a significant undercount as it was reliant upon ICD 10 code entry, and likely only reflects those that were symptomatic, triggering problem-list coding. One of these children died, and at least one required a prolonged PICU stay to correct hospital acquired hyponatremia which was due to inappropriate IV fluid selection. This project will begin with phase 1 (review of ordersets used in inpatient peds areas for hypotonic IV fluids, educational component of providers) followed by phase 2 if needed (implementation of a "hard stop" in EPIC requiring provider to answer safety questions prior to ordering hypotonic fluids on pediatric patients, phone call from TPN pharmacist prompting ordering provider to review tonicity of TPN ordered). A steering committee consisting of stake holders from various areas of the children's hospital will be put into place prior to beginning this project and will meet monthly for one year.

Fast track pilot in the ED with Family Medicine and Internal Medicine

QPI: Julie, Richter, (

The Fast Track process was enacted through interdisciplinary agreements with the family medicine (CHFM) and internal medicine services for admitted patients not requiring an IMC or ICU admission. At the time of initiation, this time interval was an average of 3-4 hours. Initiation of this process was based on a publication in Academic Emergency Medicine citing success at a similar academic institution that was measured by improved ED length of stay (LOS) via a decreased time interval from bed order placement to ED exit to the hospital floor.

Use of an Epic-based scoring system to identify at-risk patients in need of anticoagulant dose adjustment due to renal insufficiency

QPI: Benjamin, Staley, (

Therapeutic anticoagulation is frequently used in the treatment of deep vein thrombosis (DVT), pulmonary embolism (PE),acute myocardial infarction, and other thrombotic conditions. Several commonly used anticoagulants are eliminated renally and dose adjustments are required in patients with renal impairment in order to reduce likelihood of serious bleeding events. Hospitalized patients on anticoagulant therapy frequently experience fluctuations in renal function that may require dosage adjustment after initiation. The challenge is identifying these patients quickly so that doses can be changed before adverse effects occur. Declines in renal function in patients on anticoagulants may go unnoticed for a variety of reasons. Additionally, changes in serum creatinine that remain within reference range may be perceived as normal despite a 50% or more increase from baseline. Several Patient Safety Reports (PSR) prompted a Medication Use Evaluation (MUE) to evaluate patients that had declines in renal function while receiving therapeutic enoxaparin. Out of 25 patients that had significant decline in renal function, 11 (44%) did not have their dose appropriately adjusted. Five of these patients experienced a bleeding event. In November, a process to identify patients on therapeutic anticoagulation therapy that experience a decline in renal function was created in Epic. A scoring system was created that “flags” patients by drug and degree of renal function. The output of this score is a customized icon that appears in a patient list column. This column is used by pharmacists to identify patients so that an appropriate dose adjustment can occur quickly when renal function declines.

Interfacing Pharmacy and Laboratory Systems to Reduce the Use of Heparin Products During Heparin Induced Thrombocytopenia Work-Up

QPI: Matthew, Wright, (

Heparin products, including heparin, low-molecular weight heparins, and other pharmaceutical products, are frequently used in the hospital setting for their anticoagulant effects. Most commonly, heparin and low-molecular weight heparins are used as prophylaxis against venous thromboembolic (VTE) events. It has been shown that hospitalized patients are at an increased risk for the development of a VTE events. In 2005, The Joint Commission began monitoring VTE prophylaxis rates within the hospital setting and it is now consider a core measure. The current Joint Commission Core Measure requires all patients age 18 or older to receive VTE prophylaxis or have an exclusion from VTE prophylaxis documented in the medical record. These products are frequently used for VTE treatment as well. Furthermore, a number of products, such as line flushes, contain heparin. One serious complication associated with the use of these products is Heparin Induced Thrombocytopenia (HIT). HIT is a disorder characterized by thrombocytopenia and high risk for thrombosis. It is caused by an antibody that targets a complex of heparin and platelet factor 4 (PF4) on the platelet surface. The incidence of HIT varies by population and risk stratification—the incidence in some cohorts is as high as 5%. A history of HIT is considered a contraindication to the use of heparin, low molecular heparins, and heparin containing products. At UF Health Shands, we utilize 2 methods for the diagnosis of HIT: 1. Heparin Platelet Antibody, which detects circulating antibodies. 2. Serotonin Release Assay, which measures C-serotonin release from activated platelets. The typical diagnostic approach for HIT is to order a heparin platelet antibody. If the test is positive then a serotonin release assay is ordered. During HIT work-up, the receipt of heparin, low-molecular weight heparins, and heparin containing products, should be avoided. Ordering providers may not always be aware of a pending HIT work-up when ordering heparin products for patients. Therefore, a change was made within EPIC, the UF Health Shands electronic medical record, to alert providers when heparin products are ordered for a patient with an ordered or processing heparin platelet antibody lab and/or serotonin release assay.

Health System Implementation of Clinical Practice Guidelines for Neck and Low Back Pain in Outpatient Physical Therapy Settings

QPI: Jason, Beneciuk, (

Spine related musculoskeletal pain is a public health problem and one of the most common reasons for seeking health care services. Physical therapists commonly treat patients with neck or low back pain (LBP) in outpatient settings; however unwarranted variation in clinical practice is widespread potentially resulting in suboptimal patient outcomes. System implementation of clinical practice guidelines (CPGs) for physical therapy management of neck and LBP provides a practical strategy to limit variability for highly prevalent musculoskeletal pain conditions, however requires processes which will promote a shift in clinician attitudes, beliefs, behaviors and organizational culture. Lack of multifaceted, frequent and ongoing implementation strategies have been suggested as key limitations to previous studies that have implemented neck and low back pain CPGs in health care settings. This proposed study will investigate implementation of a process to enhance CPG adherence to limit unwarranted variability in initial treatment decisions with high potential for providing more effective and efficient physical therapy management for patients with neck and LBP in outpatient settings. We will determine if physical therapy clinics that receive neck and LBP CPG training are associated with improved patient outcomes compared to those that have not received training. Neck and LBP specific disability and pain intensity will be assessed at intake, on a weekly basis and at discharge (Specific Aim 1a). Secondary patient outcomes will consist of patient satisfaction scores and direct physical therapy costs (Specific Aim 1b). Statistical analyses will evaluate for temporal effects of training considering the stepped wedge study design. For exploratory purposes we will determine if physical therapist adherence to neck and LBP CPG recommendations are maintained over time following initial implementation. CPG adherence will be assessed using pragmatic methods consisting of: 1) clinician checklists, 2) clinician interviews, 3) quality indicators, and 4) total proportion outcome measure assessments captured (Specific Aim 2).

Nurse Integrated Rounds

QPI: Jodi, Mullen, (

Patient safety reports (PSRs) in the Pediatric Intensive Care Unit (PICU) are routinely evaluated for root causes. Communication failures between medical services, nursing, and ancillary departments most frequently contributed to these events. In an effort to improve communication and hence, patient outcomes, nurse integrated rounds (NIR) were implemented. To improve communication and understanding of the patient’s plan of care among all PICU providers, we implemented nurse integrated rounds, where the bedside nurse “presents” the patient’s clinical status and highlights issues that need to be addressed in the plan of care for the day. The pediatric resident then identifies the strategies to address the patient’s problems in concert with the pediatric critical care fellow and attending. PICU nursing staff completed a pre-survey designed to evaluate their understanding of the patient’s plan of care and their perceptions of the effectiveness of patient rounds and communication with the patient’s care teams. Following the pre-survey, the nursing staff was educated on the use of a rounding sheet and the expectations for the nurse’s presentation during NIR. Six months after the implementation of NIR, nurses completed an abbreviated post-survey regarding the efficiency and effectiveness of NIR and whether the process should continue. Patient safety reports were reviewed for trends related to communication failures. Additionally, the Management Engineering department was consulted to evaluate the PICU daily multidisciplinary rounds process and make suggestions for improvement.

Blood Gas Testing in the OR- North and South Tower

QPI: Abby, Estilong, (

The Operating Room (OR) staff are exiting the room to perform blood gas analyses on a single blood gas Radiometer located in the OR substerile room . Staff leaving the room can affect the case productivity from financial and patient safety perspectives The blood gas analyzer services 4-6 different rooms at a time. The point of care department recommends in the interest of patient safety and reduction of TAT that iL-GEM 5000 Blood Gas Analyzer be placed in each operating room so the staff do not leave the room for testing .

Appropriate use of flow cytometric immunophenotyping for hematolymphoid malignancies: choosing wisely

QPI: Satish, Maharaj, (

Flow cytometric immunophenotyping (FCI) is a valuable tool in the diagnosis and classification of hematolymphoid neoplasms. These include lymphoma, chronic lymphoid leukemias, plasma cell disorders, acute leukemias, mast cell disease, myelodysplastic syndromes and myeloproliferative disorders. Starting in 2001, the World Health Organization (WHO) standardized FCI criteria for each disease. As FCI technology evolved, there emerged a gap between practicing clinicians and laboratory technologists. Specifically, under what clinical circumstances is FCI appropriate? Recognizing this need to communicate diagnostic utility, in 2006, the Bethesda International Consensus defined medical indications for flow cytometric testing (presented in protocol). FCI is not indicated in all patients with leukocytosis or lymphocytosis, and the Bethesda International Consensus also highlighted indications for which FCI is inappropriate. We performed a search of MedLine/PubMed and Google Scholar databases and were unable to find any studies examining the appropriate utilization of FCI in clinical practice. To the best of our knowledge, the use of flow cytometry has never been examined from a high value care or quality improvement viewpoint. In this study, we will use a pre- and post- intervention design. In the initial phase we will investigate whether peripheral FCI is being utilized in clinical scenarios where it is not indicated, as defined by the Bethesda Consensus. If it is indeed found after retrospective review that a significant percentage of FCI testing is inappropriate, then an intervention is warranted. Optimizing the use of FCI has benefits to payers of medical services, clinical and laboratory staff and ultimately the organization (UF Health Jacksonville and the UFCOM-Jacksonville). It also espouses the concept of “high value care” promoted by the American College of Physicians (ACP) for internal medicine physicians.

Heparin-induced thrombocytopenia (HIT) testing at an urban teaching hospital: choosing wisely

QPI: Satish, Maharaj, (

UF Health Jacksonville is a 603-bed urban teaching hospital serving northeast Florida and southeast Georgia. On admission, physicians routinely assess patients for deep venous thrombo-embolism (VTE) risk and medical inpatients are almost universally assigned to receive prophylactic subcutaneous heparin. A percentage of patients (<5 percent) will develop heparin-induced thrombocytopenia (HIT). The American Society of Hematology Choosing Wisely Guidelines 2014 recommend against testing for HIT in individuals at low risk, defined by a 4T score ≤ 3. The incidence, investigation and management of HIT has never been studied at UF Health Jacksonville, but data from other health systems has shown prevalent overtesting, overdiagnosis and overtreatment making HIT a costly problem. From an operational view, HIT assay is a costly test and it is neither necessary nor cost-effective to perform HIT testing indiscriminately. Optimizing the use of HIT testing has benefits to payers of medical services, clinical and laboratory staff and ultimately the organization (UF Health Jacksonville and the UFCOM-Jacksonville). It also espouses the concept of “high value care” promoted by the American College of Physicians (ACP) for internal medicine physicians.

Facilitate Awareness of Early Referral of Life Quest for the Critically Ill Patient in the MICU : A Collaborative Approach

QPI: Harvey, Norton, (

There are more than 117,000 patients on the national organ transplant waiting list. Of those, more than 5,400 are listed at transplant centers in Florida. Shortage of organs has been recognized worldwide as a major limiting factor to organ transplantation and missed and/or delays in referral decrease the opportunity for patient participation in donation possibilities During the years 2015 and 2016 MICU has had an increased in the missed referrals to LifeQuest resulting in a decreased opportunity for organs transplanted. This quality improvement project will focus on evaluate of the current processes on MICU and how this has impacted the referral process to LifeQuest. This will be a collaborative initiative with LifeQuest representatives utilizing the Plan, Do, Study, Act (PDSA) methodology to evaluate educational deficits as well as barriers that may exist the leads to a deficit in the referral process.

Improving Speed, Efficiency, and Communication of Medical Oncology Patients Receiving Infusion Treatments

QPI: Barbara, Pesata, (

The purpose of this quality improvement project is to improve speed and efficiency in the adult infusion center by utilizing enhanced communication methods between nurse and provider. The problem is that there is delays in getting infusion treatment started related to orders not being signed, unclear or incomplete orders, or questions requiring clarification. Implementation interventions include new bold orange communication cards to leave at provider workspace prompting them that action is required, physician and nurse education, and meetings with charge nurses/providers to determine the most important information to be communicated. Electronic interventions include integrating a section on the dashboard reports in EPIC for the physicians to see unsigned orders and utilization of Spok, a secure text messaging system.

Evaluation of Pediatric Nutrition in Acute Care

QPI: Sandra, Citty, (

Evaluation of administration and documentation of oral nutritional supplements in acute care (% ONS given, not given, reason not given, volume administered and documented) Evaluation of length of stay and 30-day hospital readmission rate for pediatric patients in acute care and pediatric patients who have nutrition consult (DSS report generated).

Introduction of a Patient Check-in Form in the Outpatient Dermatology Clinic

QPI: ()

On recent Press-Ganey surveys, several patients noted frustration at having to explain their complaint to several people within one clinic visit (the MA checking them in, the resident, and again to the attending). Some patients expressed concern over long wait times. In addition, we noted that we were sometimes under-billing due to incomplete patient history information. To ameliorate these concerns, we proposed the addition of a patient history check-in form. This would serve three goals: 1) The MA would not be required to ask the patient the chief complaint, instead simply pass on what was written on the check-in form. 2) Patients would be less anxious about prolonged wait times if they were spending some of it filling out the form; it also could increase clinic flow and focus clinic visits by asking patients more specific questions based on information entered on the form. 3) Residents and attendings could use the information on the form to verify additional ROS and past medical, social, and family history. The form will be trialed in 1 clinic, and after 1 month of use, providers and MAs who work in that clinic will be surveyed on it's utility.

Increasing Referrals to Smoking Cessation Resources in Cardiology Patients

QPI: Natalie, Hughes, (

Cigarette smoking is common among cardiac patients. Through Florida AHEC, there is a smoking cessation class available that is free to the community. The class is led by a smoking cessation trained counselor who goes through the seven steps for smoking cessation as well as tips and tricks. There is a referral order available to Epic that can be placed on discharge to refer patients to the smoking cessation program. As of January 10th, 2018, the order can be placed by physicians and nursing and there will be a reminder on discharge for smoking patients, where as prior to that it could only be placed by physicians. This change will hopefully increase the amount of referrals to the smoking cessation program and in turn increase the number of patients who stop smoking.

Vaccination in patients undergoing splenectomy and splenic embolization

QPI: Satish, Maharaj, (

Patients with splenic dysfunction or asplenia are at risk for infection with encapsualated organisms and have an increased risk of sepsis. The CDC 2018 guidelines have provided a vaccination regimen that should be offered to these patients as the standard of care. At UF Health, patients every month undergo splenectomy and splenic embolization but, to the best of our knowledge, there is no institutional protocol for vaccination and the administration of vaccination in these patients is not standardized. Some patients may not receive the recommended doses of timing of vaccines. The CDC recommends specific recommendations on which vaccines should be offered (Meningococcus ACWY, Meningococcus B, Pneumonococcus, Hemophilus Influenzae B) and when they should be given (14 days before or after surgery). This project is a quality improvement project from the departments of Hematology/Oncology and Medicine to improve adherence with national guidelines and standard of care for these patients regarding vaccination. This will be done by clinical audit and implementation of a decision-making tool and order panel in the electronic medical record.

Improving early referrals to supportive care services in newly-diagnosed pediatric oncology patients

QPI: Trisha, Kissoon, (

Children with cancer have multiple psychosocial issues that require a unique approach from a multidisciplinary team. Psychosocial effects can manifest at increased levels of depression, anxiety, and concerns about mortality. Equally important is the recognition that treatment of childhood cancer inevitably occurs in the context of a family. In childhood cancer, the effects are often felt by more individuals, including one or both parents, one or more siblings who are themselves children or adolescents, grandparents, aunts and uncles, teachers, friends, and other individuals who may be directly involved in the care or life experience of the child. As advances in the field of Pediatric Oncology lead to improved survival rates, a focus has shifted to providing comprehensive pediatric cancer care from diagnosis, throughout treatment, and into survivorship. The multidisciplinary Psychosocial Standards of Care Project for Childhood Cancer (PSCPCC), consisting of more than 80 oncology professionals and parent advocates, developed a set of 15 evidence-based standards for psychosocial care that are endorsed by key professional organizations. Among these standards include assessment of psychosocial healthcare needs; monitoring of neuropsychological deficits and school support; screening in long-term survivorship; psychosocial support and interventions; parental mental health; psychoeducation and anticipatory guidance; opportunities for social interaction; sibling support; palliative care/end of life care; and bereavement care. Further, it is widely accepted that many chemotherapeutic agents have chronic side effects such as peripheral neuropathy; propensity for obesity; and increased infection risk, especially from oral infections during episodes of mucositis. Providers within large academic settings often have the resources to provide this comprehensive care to patients but these measures are often overlooked while coordinating the procedures required for formal diagnosis and the initiation of chemotherapy.

An assessment of compliance with fall prevention guidelines on an inpatient psychiatric unit

QPI: Bruce, Bassi, (

Reducing the risk of patient harm resulting from falls is one of the Joint Commission on Accreditation of Healthcare Organization safety goals. To accomplish this in an inpatient setting requires a multifaceted approach consisting of assessment of current compliance to guidelines, and then, implementation specific to shortfalls in the assessment. The Agency for Healthcare Research and Quality (AHRQ) has developed toolkits freely available for institutions to measure current compliance to standard fall prevention strategies. To pave the way for a successful, hospital-specific intervention strategy, we first performed an assessment of patient education, environmental, and equipment safety factors to determine compliance with existing AHRQ guidelines.

Effectiveness of Physician and Pharmacist Collaboration in the Focused Treatment of Obesity and Type 2 Diabetes Mellitus

QPI: Amy, Talana, (

This quality improvement project is designed to improve treatment of both obesity and type 2 diabetes via cohesive collaboration between the primary care physician (PCP) and the clinical pharmacist. Specifically, the project would primarily aim to help decrease body mass index (BMI), weight (kg), and hemoglobin A1c in addition to improving core measures designated by CMS, such as patients having up-to-date urinary microalbumin tests and eye exams. Previous studies have shown that collaboration between PCPs and clinical pharmacists have improved hemoglobin A1c control, however there are no available studies that describe the impact of PCP and pharmacist collaboration in the focused treatment of obesity and diabetes. Further, a multidisciplinary approach has been recommended in national guidelines, including the 2018 ADA Standards of Care in Diabetes and the 2013 AHA/ACC/TOS Guidelines for the Management of Overweight and Obesity in Adults. This collaborative model includes a thorough initial evaluation of the patient, including a review of comorbidities, medications affecting weight, drug-drug interactions, and current diet and exercise. There will also be a discussion on the patient’s goals and financial considerations that would likely impact pharmacotherapy choice. The PCP and pharmacist would jointly decide upon a customized plan for the patient and the patient would receive extensive counseling on their new regimen. Subsequent visits would be focused on adherence, barriers, weight and blood glucose log review, insulin titration if relevant, and modification of therapies if needed. Patients would be expected to follow-up every two to four weeks. The project will be rolled out as a pilot initially, with adjustments made to the protocol if needed. If successful, as determined by a clinically significant decrease in BMI, weight, and hemoglobin A1c, it is hoped that this model could be implemented throughout the internal medicine department.

Decreasing CAUTI Using an External Female Urinary Catheter

QPI: Laura, Roberson, (

Purpose: The aim of this project was to reduce incidence of CAUTI and foley utilization in an 8 bed Burn ICU by trialing an external female urinary catheter. The burn population is a high user of internal urinary catheters due to a systemic vasodilation and third spacing, lack of skin causing fluid losses, multiple operations with great fluid and blood losses all leading to a greater need to closely monitor I/O's. We wanted to see if use of an external female urinary catheter would allow us to lower our uses of internal catheters, decrease CAUTI, and accurately assess intake and output.

Evaluating the Effectiveness of Multidisciplinary Rounds through a Patient-Centered Interprofessional and Collaborative Approach

QPI: (

The primary aim of this project is to introduce multidisciplinary rounds in clinical setting to limit adverse events, improve patient outcomes, and increase patient and employee satisfaction. Within healthcare settings, delivering the best medical care is attributed to the coordination of care. Multidisciplinary rounds aim to maximize patient safety, decrease the length of stay, and increase the quality of outcomes. The enhanced teamwork multidisciplinary rounds provide will increase communication between the different levels of healthcare workers. To evaluate the effectiveness of multidisciplinary rounds, a series of the Institute for Healthcare Improvements methodology of the Plan-Do-Study-Act (PDSA) cycles will be utilized. This prospective project is designed to engage patients and their caregivers in their health by facilitating discussions with their healthcare providers. In beginning the PDSA cycles, signage will be laminated in order to notify patients when their care team will be rounding their unit. Once the initial PDSA cycle has been successfully implemented, services will be expanded to different service lines in order to assist more patients and team members.

Utilizing intranasal mupirocin to reduce incidence of cardiac surgery surgical site infections

QPI: Cristina, Crippen, (

Sternal wound infections are associated with increased morbidity, mortality and decreased long term life expectancy. Infections can raise hospital cost by $62,000 per admission. Despite clinical and economic consequences there are no specific guidelines for prevention or treatment of sternal would infections, however prevention recommendations do exist. Preoperative intranasal mupirocin administration was chosen as for high risk group as part of UF Health's decolonization protocol. As such, the cardiac surgery physicians and/or extenders will prescribe and educate patient on mupirocin use as part of clinic pre-op visit. Mupirocin use will be documented in nursing flowsheet at admission. Compliance reporting will be shared with service on monthly basis.

The “Bleed Less” Initiative: Reducing the Risk of Pocket Hematoma in Patients Undergoing Cardiovascular Implantable Electronic Device Procedures While on Anticoagulation.

QPI: Steve, Noutong Njapo, (

Patients undergoing device procedures are not always given clear instructions on when to resume anticoagulation post-procedure. This has, in some instances, led to the development of a pocket hematoma. The initial aim of the project was to reduce the incidence of pocket hematomas, however, due to the low number of pocket hematomas within the targeted time-frame, we implemented a survey to compare patient satisfaction pre and post intervention.

A1C Reduction in a Family Medicine Outpatient Clinic

QPI: Lauren, Bielick, (

Hemoglobin A1C is an important indicator of diabetes control. Studies have shown that more frequent patient-provider encounters may lead to faster A1C improvement. Additionally, moving from a reactive care delivery system to a proactive care delivery system has been shown to improve patient outcomes. In this project, the electronic health records of patients at UF Family Medicine: Haile Plantation clinic will be used to identify diabetic patients with hemoglobin A1C values that indicate poor diabetes control. A team-based approach will be used to enhance these patients' relationships with clinic providers in order to improve diabetes control.

Development of a Safety Checklist for Small Animal Veterinary Dental Procedures

QPI: Amy, Stone, (

The creation of a patient safety checklist for small animal veterinary dental procedures to decrease the patient time under anesthesia as well as to increase communication about the patient between the anesthesia and dental care teams.

Core Laboratory Automation and Renovation

QPI: Mary, Reeves, (

Renovation of Core Laboratory space to create an efficient work flow design adding an automated line for chemistry and hematology. Improve performance through reduced turn-around-time and standardization of laboratory instruments across the Gainesville campus. • Replaced existing aging instrumentation to fully automate Chemistry and Hematology to include auto-verification. • Replaced existing aging instrumentation at Cancer Center Lab. • Replaced existing Chemistry equipment at Springhill ED lab for standardization of result reporting. • Back-up instrumentation/redundancy to support peak workflow and reduce instrument downtime impact. Testing can continue during downtime. Automation of manual processes: It automates sample login, centrifugation, decapping, aliquot, delivery of samples to connected instruments, recapping, storing in ambient or refrigerated storage modules and sorting to outlets. The system also automatically retrieves and performs rerun or reflex testing as directed by LIS information and instrument status.


QPI: Susan, Ford, (

The Department of Anesthesiology has a multi- disciplinary group that visit post-surgical patients and discussed opportunities for quality improvement with patients, families, and nursing staff. The rounding team members are comprised of the Department Chair, Sr. Faculty , PACU and Pre-OP Residents, Department Quality Officer and unit Managers, nursing staff and administration. The discussions revolved around the Patient Pre-Operative, Intra-Op and Post-Op experience and any changes or recommendation to improve satisfaction. After the patient interview/ discussion the group reviewed patient surroundings for the appropriate use of Incentive Spirometers, sequential compression devices and proper placement of Foley catheters. Patients were asked to rate their overall OR experience, Anesthesia care and if all issues had been addressed in a timely manner . Through this process there were many Improvement Opportunities identified and actions initiated. The missing link was asking " What matters to YOU". In January of 2016 the Department Rounding Group incorporated this question for all patient discussion/ interviews .

Who Will Speak for You?

QPI: Anne, Meiring, (

An AHRQ study reveals: • Less than 50% of the severely/terminally ill patients studied had an Advance Directive (AD) in their medical record • Only 12% of patients with an AD received input from their physician in its development • Between 65 - 76% of MDs whose patients had an AD were not aware that it existed • Having an AD did not increase documentation in the medical chart regarding patient preferences Additional research demonstrates that, though patients are asked about ADs, completion rates are only 5 - 15%.

Metabolic and Bariatric Surgery Reduction in Readmission

QPI: Gwendolyn, Crispell (Hasse), (

The opportunity to decrease bariatric weight loss surgery readmission rate is based on the perception readmissions are preventable, unnecessary and increase healthcare costs. The Centers for Medicare and Medicaid Services (CMS) began tying readmission rates to reimbursement in year 2013. Opportunity for improvement was confirmed by a drill down and an informal microsystems assessment of the university hospital bariatric program. A gap in knowledge and utilization of current resources were identified in the patient’s pre and post operative phase. Implementing an evidence‐based multidisciplinary care pathway knows as Enhanced Recovery After Surgery and providing education to staff and patients for the most common causes of post-operative complications could lead to a decreased readmission rate.

Non physician provider subjective assessment of personal risk associated with making an effort

QPI: Louis, Moy, (

Most of the current literature suggests that having a work culture where the staff feels comfortable reporting their mistakes will lead to improvement in in patient care. However, creating such an environment is not easy. The obstacles to creating such a culture can be institutional or personal. UF Health, through staff education and institutional aims, has worked to create an environment where staff can admit to and report errors made which may impact patient safety or care. The concern, however, is that staff may not perceive this culture.

Heart & Vascular and Neuromedicine Pharmacy Service Satisfaction Survey

QPI: Erin, Wright, (

We plan to survey nursing staff periodically (estimated quarterly) on several aspects of pharmacy service. These include turn around time of medication delivery, responsiveness of staff, competence of staff and technology. Our goal with each survey is to track improvements in service as well as identify anything we could improve upon.

Evaluation of an Intravenous Lipid Emulsion for Critically Ill Adult UF / Health ICU Patients Requiring Parenteral Nutrition

QPI: Goeto, Dantes, (

Lipid Emulsions are widely accepted as an integral component of Parenteral Nutrition (PN) formularies. Until recently, Intralipid, a Soybean based product with a high concentration of a pro-inflammatory mixture, (7:1 omega-6 to omega-3 Polyunsaturated Fatty Acids (PUFA), was the supplemental lipid emulsion prescribed at University of Florida. With increasing evidence suggesting that omega-6 PUFAs are harmful (pro-inflammatory and immunosuppressive), a race to develop a more complex lipid emulsion began. Hence, the emergence of SMOF-Lipid, containing a more favorable balance of lipids: (S)oybean, (M)edium Chain Fatty Acids, (O)live Oil, and (F)ish Oil producing a ratio of 2.5:1 omega-6 to omega-3 PUFAs. Even more intriguing is the fish oil is rich with the omega-3 fatty acids: eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). These two PUFAs are the precursor for Specialized Pro-Resolving Mediators (SPMs) that provide an endogenous inflammatory break through expeditious inflammation resolution without untoward immunosuppression. Furthermore, SMOFLipid has a far superior hepatotoxicity profile than Intralipid, producing significantly less cholestasis. It is postulated, therefore, that this may improve clinical outcomes for adult patients already prone to oxidative insult. There remains a gap of knowledge, however, regarding the clinical efficacy of such formulary specifically for adult ICU patients.

Urologic consult service resource allocation in setting of growing hospital infrastructure

QPI: Kevin, Campbell, (

The infrastructure of the University of Florida is constantly growing, most recently with the addition of the new Heart and Vascular Hospital. As the patient census grows, the allocation of provider resources and availability is anticipated to increase in demand. The Urology Department is a heavily consulted surgical and medical service in the existing North and South towers prior to completion of the new hospital. This quality assessment focuses on distribution of resources in the setting of the growing infrastructure, specifically with the addition of a new consult location, whether a consult required a bedside procedure, OR procedure, and what general category the consult fell under. Consult locations are tracked (East, North, and South tower, ER) to assess change of demand on the consult service with the new hospital. This study directly impacts patient care by demonstrating the need for additional resources (supplies, RN training, etc) in various areas of the hospital including the new tower. The study time period extends from prior to and after completion of new hospital. From this investigation, providers and resources can be redistributed to be available for the growing patient needs in a new hospital.

Improvement in Pain Management of post partum patients

QPI: Dawn, Disalvo, (

This is a continuous quality improvement project focused on staff education and staff accountability for documentation of pain assessment and management. All staff were educated as to the importance of pain management, changes in the expectations in pain management, and proper documentation of pain assessment, reassessment, and management. Staff are notified weekly of their individual compliance level.

Patient Shadowing Program: Identifying Quality Improvement Opportunities to Achieve the Perfect Patient Experience

QPI: Michael, Kramer, (

Research shows continuous review of patient experience across the continuum of care improves patient experience metrics. Our program implements quality improvement initiatives and provides support for two academic departments, several ambulatory settings, medical-surgical units, and intensive care units using a team of undergraduate and graduate students. To better serve the patient population and identify areas of improvement within the health system, our program developed a patient shadowing program based on the Institute of Medicine’s (IoM) STEEP model (safety, timeliness, effectiveness, efficiency, patient-centeredness). The shadowing program assesses patient experiences across the continuum of care using quantitative, qualitative, and time-lapse analysis. Utilizing pre-health students to accompany patients and their caregivers to various care encounters, their observations has led to the recognition of obstacles within our health system that may not have otherwise been evident. Standard quality improvement methodology, namely Plan-Do-Study-Act (P-D-S-A) was used to develop and continuously adapt the materials, data collection, and overall process of the patient shadowing program. This process was developed within our academic departments to deploy in the ambulatory setting initially and then spread to the inpatient settings. The initial pilot program began in the summer of 2017 and included 16 patients throughout their entire care experience within a 3-month period. To date, the program has conducted 25 additional patient shadowing encounters within the first 3 weeks of CY 2018 and continues to collect encounters. The students complete observation forms using a Likert-type scale (quantitative), free response (qualitative), and time-stamped data across every new encounter. This form evaluates the IoM STEEP metrics of: safety, timeliness, effectiveness, efficiency, and patient centeredness. This includes environmental issues and staff and clinician interactions.

Optimizing Process and Outcome Culture Measures to Improve Safety and Quality

QPI: Emily, Harvey, (

Academic literature states culture is the foundation for high-level safety and quality healthcare institutions. Oftentimes staff satisfaction and burnout are not adequately measured in healthcare and lack sufficient response rates for generalizability. Studies show 1) organization transparency, 2) appropriate communication, and 3) sufficient staff appreciation all predict satisfaction among staff. Based on the UF Health Big Aims of Quality, our project aims to Transform our Culture to improve job satisfaction, reduce burnout, and improve perceived culture of safety. Research shows staff satisfaction of healthcare workers improves safety and quality measures, employee performance, and patient satisfaction. Staff satisfaction and burnout were assessed annually for that past three years utilizing the 5-factor structure items for both constructs. This short and efficient measure has been shown to be psychometrically robust and as predictive of satisfaction and burnout as other existing healthcare measures. Our biannual Town Hall was based on published best-practices and includes a pre-survey for staff to nominate topics of discussion, thematic analysis of nominated topics, and an anonymous live-feedback option for participants. In addition to the existing forums for recognizing staff, we also received approval for an electronic Customer Service is Key survey and a monthly grass-roots, voluntary-based leader-sponsored luncheons. Our project created clear assessment and structure for all efforts.

Evaluating Adherence to TeachBack Protocol in Clinical Settings to Improve Health Literacy and Patient Safety

QPI: Crystal, Almond, (

Communication between clinicians and patients needs to be improved in order for patients to be able to fully understand their illness, medication, and pain management regimen. Patients do not always know what to expect with their recovery or diagnoses if their healthcare provider is not properly communicating with them. Our project involves educating and training providers on chunk-and-check methodology and the TeachBack protocol. Interns directly observe providers during clinical encounters to assess TeachBack method adherence. These encounters include a variety of outpatient appointments and inpatient rounding. Providers are evaluated on body language, introduction of the method, and whether TeachBack is provided in the domains of: medication, pain management and expectations, activities after hospitalization, and patient assistance. These scores are collected and given to providers monthly on a scorecard.

Neuromedicine Wayfinding Program: Pilot to the Perfect Patient Experience

QPI: Christa, Ochoa, (

The project’s objective is to help reach the NICAP mission of “Achieving the Perfect Patient Experience” by providing concierge-inspired services and guiding neuromedicine patients and visitors wherever they may need to go throughout UF Health. By strategically placing undergraduate NICAP Wayfinders throughout the health system, the program aims to have a positive influence on outcome measures specific to patient satisfaction. Literature shows that issues with wayfinding are directly linked with patient satisfaction. The Wayfinding Guide Program was developed in response to the neuromedicine Patient and Family Advisory Council (PFAC), where patient and family council members reported needing great assistance in navigating through UF Health. This service runs Monday–Sunday from 8 AM to 8 PM and demonstrates that UF Health offers added support to their patients and visitors. This ultimately benefits the healthcare system. Our key stakeholders in the maintenance of this project include Dr. Jacqueline Baron-Lee, the Director of Quality Improvement, three NICAP graduate quality improvement interns, Leilani Johnson, Juan Pulido, and VJ Fitzpatrick, and 53 undergraduate quality improvement interns.

Neuromedicine MyUFHealth Activation Assistance

QPI: Christa, Ochoa, (

UF Health adopted its own patient portal called MyUFHealth on October 20, 2010, and despite the potential advantages to patients, enrollment into MyUFHealth has been slow to permeate all service-line areas including Neuromedicine, specifically Neurology and Neurosurgery. As of December 2016, enrollment into MyUFHealth was reported to be 32% in Neurosurgery, and 46% in Neurology. Institutionally, the median utilization rates hover around 70%. Research has shown that increased enrollment in patient portals has the potential for better clinical outcomes and patient satisfaction. In a comprehensive study conducted by Kaiser, the investigators determined that the use of secured patient- physician email was significantly associated with improved performance for all HEDIS measures. The proportion of patients whose measures improved ranged from 4 percent to about 11 percent. In view of this, the Neuromedicine Interdisciplinary Clinical &amp; Academic Program (NICAP) leadership created an initiative to increase patient enrollment in MyUFHealth. This initiative consists several layers, which includes trained undergraduates actively promoting the benefits of the portal to eligible patients, encouraging and offering enrollment assistance, educational and promotional materials, as well as push email notifications upon checkout. This particular intervention was implemented because studies have shown that most patients are un-interested in enrolling for the portal due to a lack of information and motivation. Using trained interns as an information resource and agents for providing physical and emotional motivation will allow for onsite enrollment and increased knowledge of the portal and its functionalities.

Neuromedicine PersPectivE (PPE) Rounds

QPI: Christa, Ochoa, (

Patients within the UF Health Neuromedicine inpatient floors offer a variety of different thoughts on their experiences within the health system. In an effort to support the Neuromedicine Interdisciplinary Clinical & Academic Program’s mission to create the perfect patient experience, the Perfect Patient Experience Rounds initiative was created. In this initiative, specially trained NICAP undergraduate interns round on our patients on the Neuro ICU and MedSurg floors, giving them a very brief survey to gain insight on how our inpatient floors are performing across the domains of tidiness, noisiness, patient discomfort, nurse attentiveness, doctor attentiveness, and how pleasant the staff is overall. This ultimately provides staff with actionable feedback so that we may make our patients’ experiences as pleasant as possible.

Efforts Toward Zero Harm: Implementation of a Supportive Care Team Program in Neuromedicine

QPI: Michael, Kramer, (

Advance Directives assist in achieving Zero Harm by making the goals of care of the patient known to their care team. They, however, are often left out of the treatment plan discussion between doctors and patients as these conversations can be difficult to conduct and often take time. Emphasis instead is typically aimed on the cure of disease and may not focus on goals related to end-of-life goals and decisions. Without a discussion about end-of-life goals, medical intervention may “not only fail to relieve suffering, but become a source of suffering itself” (Cassell, 1982). Thus, the completion of Advance Directives in clinical settings often proves difficult without added supportive team members. Advance Directives provide a plan for future medical care in the event a patient is unable to make their own decisions, they allow the patient to determine a proxy decision-maker, and ultimately they take stress off of the patient, family, and care team. With prior discussion of end of life goals, patients often feel empowered to set their own goals and priorities in the guiding of care. The Supportive Care Team (SCT) includes a group of volunteers through Haven Hospice that was established with the goal of increasing the number of advance directives that UF Health neuromedicine patients have on file. Standard quality improvement methodology was used to develop the SCT Program and included several iterative Plan-Do-Study-Act (PDSA) cycles including implementation of various print materials, processes, and educational aides for key stakeholders. The SCT has been in place for 14 months, with the SCT attending one provider’s clinics in Neurosurgery and Neurology each Wednesday. The volunteers were trained on the purpose of the SCT, the logistics of the program, and how to correctly document their interactions with patients.

ERAS for Gyn Oncology

QPI: Michelle, Larzelere, (

The enhanced recovery after surgery (ERAS) approach was developed as a multimodal and standardized approach to perioperative care, directed at optimizing the patient experience and improving surgical outcomes. Key components of ERAS include comprehensive patient education including patient goals and expectations around surgery, multimodal pain control including nonopioid analgesic agents and regional anesthesia to reduce opioid use, and quick resumption of a normal diet and activity. For women undergoing gynecologic surgery, an ERAS approach has uniformly been found to improve surgical outcomes including decreased length of stay, decreased costs, and patient satisfaction consistent across multiple studies. An ERAS protocol has been formulated and will be implemented and studied in gynecologic oncology patients at UF Health Gainesville.

Increasing Advance Directives documentation utilizing inpatient, ambulatory, and community-based efforts

QPI: Saikrishnapriya, Gunasegaran, (

Advance Directives (AD) are medically-oriented written documents that include healthcare surrogate designation and plans for treatment when patients are unable to speak for themselves. Studies show most people have surrogates and plans in mind, but few communicate these goals to family and clinicians. Without an AD, a medical intervention may not match the goals of care. Clinicians are only able to follow ADs when they are documented in the Electronic Health Record (EHR) if a patient cannot speak for herself or they must identify the patients’ next of kin. ADs provide a plan for scenarios in which a patient cannot make their own decision. They allow a patient to determine a proxy decision-maker, with the goal of taking the stress off of the patient, family, and clinical team. This proves problematic if selected designees and plans for care are not communicated effectively beforehand. To address the gap of limited AD in the EHR our project utilized a multi-pronged approach to 1) improve clinician, patient, and family education in the inpatient and ambulatory settings and 2) conduct community-based efforts to normalize AD completion and its rate of documentation in the EHR. Standard rapid-cycling quality improvement methodology and related evidence-based research were used to develop the educational brochure in the inpatient and ambulatory settings, processes for the SCT in the clinics, and implementation of the Death over Dinner and Before I Die walls in the community.

Neuromedicine Patient Education Video

QPI: Michael, Kramer, (

Literature has shown that optimizing preoperative expectations can lead to improved patient satisfaction as well as shorter length of stays. In order to have consistent and impactful patient education, this quality improvement project will create a video to serve as an educational tool for patients and will walk them through the various settings Neuromedicine patients are exposed to throughout their continuum of care at UF Health. The video will be played in the waiting room of ambulatory clinics and television screens in patient rooms on the Neuro-Med-surgery floor and Neuro-ICU. The video will cover each location as part of the larger walkthrough with a voice over explanation which will stress that any patient could end up in any of these settings at some point. The video will begin in an ambulatory setting (Neuromedicine clinic and 34th St. Clinic) and walk through the potential experiences a patient might have. This video will follow an if-then structure where the patient will see what to expect if they need surgery or if they need to return for clinic visits. The video will follow each pathway through the various potential locations, all the way through to discharge or the sustainability step. The video will be filmed through the point of view of a patient and feature all of the healthcare providers the patient may come into contact with. Ideally, by reviewing education materials such as the expectation video, patients will have more informed expectations which will lead to improved perceptions and better health outcomes.

Utilization of the special limited community permit to facilitate discharge

QPI: Shimaa, Ghonim, (

Historically, an institutional class II pharmacy could not legally dispense multi-dose medications from the inpatient supply. Through the 2014 amendment of Florida Administrative Rule 64B16-28-810, the pharmacy department at University of Florida Health – Shands Hospital obtained a “Special Limited Community Permit” to dispense used multi-dose medications or a 3-day supply of single-use medications from the inpatient supply for use after discharge. The purpose of this review is to describe the utilization of the “Special Limited Community Permit” from March 2016 to February 2018 at University of Florida Health – Shands Hospital. This includes a description of the methodology developed for efficient implementation, a summary of types of medications dispensed, documentation of how often counseling was provided, and a description of barriers encountered.

Nurse-Led Multidisciplinary Rounds Improving Team Communication

QPI: Amelia, Nichols Alava, (

Implementing nurse-led multidisciplinary rounds in the Burn ICU to improve communication between the nurses, doctors, physical therapy, occupational therapy, critical care medicine, pharmacists, and nutritionist.

Diabetes Patient Education in ADTU

QPI: John, Stephen, (

A large proportion of the patient population admitted to ADTU are diabetics and many of them are not familiar with diabetic management strategies including self-injection of insulin.

CLABSI Reduction in the Pediatric Cardiac Intensive Care Unit (PCICU): A review of 2016 through 2017

QPI: Joshua, Campbell, (

This project will compare CLAbsi incidence and introduction of nursing intervention on a timeline from 2016 through 2017 in a retrospective review. In February 2016, the PCICU began the process of random audits of compliance with our central line bundle via the “K Card” process. The bundle was developed using guidelines from the Solutions for Patient Safety network. This process entailed random monthly reviews of 10 patients with central lines. The results are posted in a central location in the unit for all staff to not only recognize areas for improvement, but to also celebrate improvements in bundle compliance. In September 2016, we introduced intravenous TPN tubing changes every 24 hours based on new evidence. In October 2016, the PCICU implemented the use of a manufactured sterile CVL cap changing kit. In November 2016, the process of charge nurses rounding on central lines daily was re-introduced. In December 2016, the PCICU Unit Practice Council (UPC) developed a practice to increase environmental cleanliness and reduction of clutter in patient rooms, also known as the “Sunday Purge”. In February 2017, the PCICU UPC also implemented daily bathing with soap and water before using the CHG bathing cloths. Due to observed variability in the practice of sterile cap changes, education was modified and required for all Children’s Hospital staff in June 2017. In July 2017, an update on the K Card process along with a video was developed and required for all Children’s Hospital staff.

Emergency Department Care Brought to the Lobby to Improve Quality and Safety: A pilot Study

QPI: Julie, Richter, (

The hospital emergency department (ED) is often the portal of entry for patients seeking health care services and is therefore an ideal setting for initiatives to improve efficiency of care delivery and patient satisfaction. Reduction in wait times, enhanced information delivery and ED staff service quality all have a positive influence on patient perception of health care quality and satisfaction. Boarding admitted patients in the Emergency Department (ED) and long ED length of stay (LOS) continues to be a challenge at UF Health. One strategy to shorten the time a patient waits to see a provider is to bring a provider to “screen” for medical emergencies in the lobby or ED waiting room. Multiple publications in the emergency medicine literature support a provider at triage strategy if boarding and excess ED LOS are present at your institution. On February 5, 2018, the ED began to cohort all admitted patients to floor status in a previous care area and moved those resources to the ED lobby.

Pressure Injury Prevention - A Standardized Nursing Process

QPI: Lynn, Westhoff, (

The incidence of facility acquired pressure injury(FA-PU) remains a concern for our patients and the organization quality outcomes. In an effort to reduce 4ESICU FA-PU incidences and rates, a PI Prevention Process was developed. This process was developed from extensive drill down on every FA-PI on 4ESICU. The PI process is an effort to standardize the nursing approach to assessment, documentation, treatment and prevention of FA-PIs.

Improve Efficiency Through Geocentric Team-based Care

QPI: Charles, Crescioni, (

Actively sort like patients (based on Service) and dedicate a geocentric team of caregivers to reduce levels of variation across workflows potentially optimize focused models of care. This will be realized in (at least) the following: o Readmissions (rate) - decrease o LOS Index - decrease o Discharges – increase number of discharges within same number of beds on 74/75 o Patient Satisfaction –increase

An Interdisciplinary ED Super Utilizer Task Force Makes Meaningful Change

QPI: Julie, Richter, (

An interdisciplinary task force was created to assist with emergency department (ED) frequent visitors or super utilizers through the EEPC ED Care Redesign’s direction and became UF Health’s Vizient Performance Improvement Collaborative project. This task force chose our top 25 super utilizers with the UF Health system to assess targeted interventions by leveraging community resources while providing specific patient care coordination plans to providers and staff to view. These best practice alerts (BPA) represent the task force’s recommendations for consistent, evidence-based care to each patient. The initial cohort of 25 patients was reviewed over the year 2017. The scope of the problem within this cohort in 2016 was a total of 818 ED visits and 258 ED admissions with a mean ED length of stay (LOS) of 8.5 hours.

Chasing Zero: Catheter-Associated Urinary Tract Infection (CAUTI) Prevention at UF Health Shands Hospital

QPI: Jaime, Thomas, (

This quality improvement initiative utilized the Plan-Do-Study-Act (PDSA) cycle as its methodology for continuous quality improvement. Review of baseline data, including CAUTI rates, drill down trends and skills observations demonstrated significant variability in CAUTI prevention practices and Urinary Catheter Management Protocol adoption. The primary aim of the quality improvement initiative was to provide oversight in the development of an evidence-based CAUTI prevention bundle to standardize insertion and maintenance practices for adult patients requiring indwelling urinary catheters at UF Health Shands Hospital.

Active Labor Patients direct transfer to L&D by EMS

QPI: Carolyn, Holland, (

The previous process for Alachua County Fire Rescue (ACFR) transport of Labor and Delivery (L & D) OB patients arriving at the North Tower Pediatric Emergency Department involved L & D RNs coming down from the third floor to receive handoff and then transport the patient up to L & D via the elevator. This process was in place to allow emergency transport companies to return to service quickly but could result in delays in expediting patient care in L & D if needed. Initially, the project was just focused on ACFR delivering patients directly to L&D. After initial success, it was spread to other agencies. There has been continued tracking of measures as the process has spread.

Adaptations to facilitate patient safety and throughput in Pediatric Emergency Department during extreme patient surge

QPI: Carolyn, Holland, (

Periods of extremely higher patient volumes that can overwhelm the resources of the PED nursing, facilitators, and physicians, create challenges in multiple areas. Patient expectations of rapid assessment and evaluation by medical staff are note met leading to dissatisfaction. Staff are stretched beyond their typical patient care load can affect patient safety with difficulty in timely reassessments to evaluate for changes in patient conditions and staff fatigue with the continued relentless volume of patient. The flu season has seen unprecedented patient volumes with daily patient visits 20-50 more than normal. Rapid adaptation of patient flow through the pediatric emergency department was a necessary change to enhance throughput while protecting patient safety.

Adult Oncology Patients and the Need to Come to the Emergency Department

QPI: Barbara, Pesata, (

The purpose of this project is to determine what symptoms bring adult oncology patients currently receiving infusion treatments to the emergency department compared to those receiving only radiation treatment up to 30 days after treatment and development of intervention to feasibility prevent the ED visits. The PICOT question is as followed; the population is adult outpatient oncology patients currently receiving infusion treatments excluding bone marrow patients. The intervention is an assessment of why they come to the ED compare to the difference in radiation oncology patients. The outcome is to determine what symptoms were reported by the patients upon arrive to the emergency department.

Point of Care Implementation - HMS Plus

QPI: Abby, Estilong, (

Implement POC Device HMS PLUS at the POC for thoracic-cardiovascular bypass cases. This will assist perfusionists , surgeons and anesthesiologists in providing both a heparin dose response test and heparin assay for individualized heparin and protamine management.

UFH Shands Hospital Point of Care Implementation - Nova Biomedical Glucometer

QPI: Abby, Estilong, (

Conversion of the current Roche Inform II Glucometer in the hospital and its ancillaries to Nova Biomedical Glucometer by March 20, 2018. The POC Team will work with Nursing and OPS sites to replace and train all users.

Use of Paramedics for ED intake of EMS patients.

QPI: Carolyn, Holland, (

The emergency department receives at least sixty (60) patients via EMS each day. Many of these patients arrive simultaneously, and at peak volume times in the department when there are limited care spaces available. Often times, it can be hard to judge, based on EMS report alone, who is the "sickest " patient and needs the first available care space. In recognizing this, we felt the need to add an additional screening process for the patients arriving via ambulance.

Readability of medical information at a large, academic medical center.

QPI: Samuel, Borgert, (

A cross-sectional study at UF Health to assess the readability level of medical information provided to our patients. Consumer medication information (CMI), procedure instructions/informed consent forms, after visit summary (AVS) information, and medication AVS will be reviewed for readability using the Flesch-Kincaid grade level readability formula

IVH Prevention Bundle: The 72 Hour Protocol

QPI: Tara, Jendzio, (

To decrease severe (III or IV) IVH rate to less than 5% December 2018

Noise Reduction in the NICU

QPI: Tara, Jendzio, (

Literature shows that long term exposure to high decibel (dB) levels can have negative effects on infants. The goal of the project would be to reduce current decibel levels by 10% to 50dB. This would be done by increasing awareness of staff and parents, engagement of stakeholders, increased awareness of noise levels and decreased noise from equipment.

Trends in the evaluation and management of hospitalized children with acute hematogenous osteomyelitis

QPI: Matthew, Washam, (

Osteomyelitis is a relatively common invasive bacterial infection in children requiring hospitalization and oftentimes surgical debridement. Most cases of acute osteomyelitis in children are hematogenous (acute hematogenous osteomyelitis, AHO) in origin with Staphylococcus aureus as the most commonly implicated pathogen. Diverse local antibiotic resistance and virulence patterns of S. aureus has made the creation of generalized guidelines challenging. Traditional management of these infections has consisted of prolonged administration of intravenous antibiotics via a peripherally inserted central catheter (PICC) for 4 to 6 weeks, though there is a high degree of variability in management amongst institutions and between clinical providers. Recent data has suggested that earlier transition from intravenous to orally administered antibiotics in uncomplicated cases yields similar outcomes and is associated with fewer adverse events related to PICC use. Anecdotally, there has been a shift in practice locally over the past decade favoring earlier transition to oral antibiotics prior to discharge from the children’s hospital. We have not, however, systematically investigated management of children with AHO over this timeframe in order to identify shifts in practice and adverse events related to care. Additionally, variability in management has not been formally assessed. We propose a quality improvement project focused on identifying 1) changes in AHO management at UF Health Children’s Hospital from 2010 to present, 2) changes in adverse events related to AHO care, and 3) variability in current care. Results of this QI project will be used to formulate guidelines for AHO management, including timing of initiation and choice of empirical antibiotics, imaging modalities, and laboratory markers.

Cystic Fibrosis Patient Profile

QPI: Matthew, Pertzborn, (

Cystic fibrosis is a chronic medical condition involving multiple body systems and requiring a complex treatment regimen for optimal medical management. There is much variation in understanding among the pediatric interns with regard to how to optimally manage cystic fibrosis. Much of the information with regard to the details of the treatment regimen for each cystic fibrosis patient is also difficult to find in the electronic medical record, if available in the electronic medical record at all. For this project we will place an editable table for each cystic fibrosis patient in an easy-to-find place in each electronic medical record patient chart that will contain the key details with regard to a given patient's cystic fibrosis management. It will be the responsibility of all involved providers to keep this chart updated as changes in the patient's treatment regimen occur. The chart should be checked/updated for each patient encounter.

Prospective surveillance study of antimicrobial utilization in hospitalized children

QPI: Matthew, Washam, (

Increasing levels of antimicrobial resistance are a growing threat in the pediatric population. Fewer new antimicrobial drugs to market in the past two decades has limited the medications available to treat these resistant pathogens. Broad-spectrum antibiotics, such as carbapenems, are increasingly utilized due to emergence of multidrug resistant (MDR) bacteria in hospitalized children. Utilization of these agents empirically due to the suspected presence of an infection from an MDR bacteria has also increased. In clinical scenarios where no pathogen is identified, it is often challenging to determine the appropriate antimicrobial choice and duration of therapy required. Optimization of antimicrobial use in the acute care hospital setting through Antimicrobial Stewardship can assist in these scenarios and represents a key component of multifaceted strategies to slow the emergence of antimicrobial resistance Available data in adult patients suggest that nearly 2/3rd of antimicrobials used in the acute care hospital setting are either prophylactic or empirical in indication. There are limited data, however, on how antimicrobials are currently used in hospitalized children to guide interventions to optimize use. Antimicrobial utilization at UF Health Shands Children’s Hospital has not been systematically reviewed previously to determine local use patterns. We propose a quality improvement project focusing on identifying 1) antimicrobial utilization rates at UF Health Shands Children’s Hospital prospectively, 2) clinical indications for antimicrobial utilization, and 3) clinical scenarios in which broad-spectrum antimicrobial agents are used empirically beyond 72 hours. Results of this QI project will be used by the hospital’s Antimicrobial Stewardship Program to formulate guidelines for appropriate antimicrobial utilization across units. Results will also be applied towards a multicenter pediatric healthcare institution quality improvement collaboration, Solutions for Patient Safety.

Gathering Stakeholder Perspectives of the Implementation of Genotype-Guided Pain Management in Patients Undergoing Arthroplasty Surgery

QPI: Leanne, Dumeny, (

Genomic-guided interventions are new to routine medical practice, thus there is an increased need for research regarding the implementation of actionable genomics findings in patient care. To engage in successful implementations, researchers often follow the Consolidated Framework for Implementation Research (CFIR): Intervention Characteristics, Outer Setting, Inner Setting, Intervention Characteristics, and Process. The combination of these ideas forms a common framework or structure in which to develop implementations, many specifically important for genomics implementations. The Personalized Medicine Program in collaboration with the Department of Orthopaedics and Rehabilitation will be implementing a new genotype-guided pain management program in patients undergoing arthroplasty surgery. The program will be piloted this spring to test for the feasibility of this implementation and to evaluate its potential effects clinically. We hope to interview several key stakeholders (i.e orthopedic surgeons, pathology) to understand how the CFIR constructs are designed within this implementation at UF. With this understanding is ability to make decisions on improving the best practices for future pharmacogenomics implementation at UF in the Orthopedics and Rehabilitation Department and other clinical departments. For this quality improvement project, we will be interviewing the stakeholders prior to and after the intervention to evaluate both organizational readiness and barriers to a successful implementation.

Albumin Utilization in Spontaneous Bacterial Peritonitis

QPI: Alex, Ebied, (

Spontaneous bacterial peritonitis (SBP) is the development of a bacterial infection in the abdominal cavity. In addition to antibiotics, albumin has been shown to improve mortality and reduce the incidence of renal failure. An evidence based albumin order set was created for the treatment of SBP. The objective of this QIPR project is to review albumin utilization in SBP and the impact at UF Health Shands Hospital.

Medication optimization in Multidisciplinary Post Myocardial Infarction Clinic

QPI: Farran, Weaver, (

The Heart and Vascular clinic at the UF Health Heart and Vascular Hospital opened a Multi-disciplinary Post-Myocardial Infarction Clinic on December 15, 2017. The clinic’s primary focus is to provide transition of care services to patients who have been discharged from the hospital within 7 days after sustaining a heart attack. The patients are seen by a cardiologist, a pharmacist, an exercise physiologist and are referred to smoking cessation courses if applicable. Our hypothesis is that early follow up after discharge will improve patient outcomes and decrease readmission rates. This study will specifically focus on the patient medication list and the role in which medication optimization can play in improving patient outcomes. Working alongside a cardiologist, the pharmacist reviews both prescription and over the counter medications and assesses for adherence, adverse interactions, duplicates, discrepancies in medication dosing, and errors in self-administration. As patients are identified to have evidence of a medication error, the cardiologist and pharmacist will collaborate to identify the best care plan for the patient and rectify the error. These interventions will be used as our measures and outcomes as outlined below.

Role of tranexamic acid in reducing perioperative blood loss in spine surgery

QPI: Guy, Kositratna, (

Multilevel laminectomy or multilevel spine surgery with instrumentation carries a medium risk of blood loss, which may require allogenic blood transfusion. Previous studies of TXA revealed positive outcomes of bleeding reduction in spine cases. TXA has been commonly used in many institution in and outside the US. At our institution, we still do not have a protocol of TXA used in spine cases. We conduct a study looking at the rate of TXA use amd the dose commonly ordered for spine cases in our hospital. Also, we will create a protocol for TXA and implement it in such operation. Overall, the aim of our project is to get at least 80% compliance by anesthesia providers and aim at reducing blood loss in spine cases. The project will be divided into two phases. Phase I is to look retrospectively for the patients undergoing spine surgeries during the past years. We will focus on the rate and common dose regimen of TXA used in our hospital, and whether or not it reduced perioperative blood loss. Phase II of the project is to create a standard protocol of TXA use and implement it to anesthesia providers responsible for such operation. The goal is to achieve at least 80% compliance from the anesthesia providers in using TXA. We also will compare the perioperative blood loss between prior and after the implementation of the protocol. We hope that this will finally change the routine practice in our hospital.

Improving HPV Immunization Rates in UF Health Clinic

QPI: Catherine, Silva, (

I will assess the effectiveness of current clinic protocol regarding HPV immunizations, identify barriers in the clinic protocol and implement changes to improve immunization rates. The date will be collected by monthly chart review of 11-16 yo patients seen in UF Health clinic. The data collected will include: type of visit, patient’s HPV immunization status, if due for HPV was it offered, if offered did they decline/accept the vaccine, if they accepted was the vaccine in stock and if not did they return for vaccine or go to health department, parental and patient HPV knowledge (via anonymous surveys); if they were starting the series were they scheduled for the second dose and were they registered for the EMR reminder system. No patient identifying data was collected, it was strictly a Quality Improvement project. The project began in June 2017 and will continue for at least 1 year. Thus far after reviewing HPV immunization status it was identified a significant number of patients overdue for HPV were due to missed opportunities because of lack of a reminder system. Data collection and intervention so far has been over a 6 month period. This QI project is still ongoing.

Interactive Iowa Model: EBP, QI, and Research for Nurses

QPI: Jeanette, Green, (

Evidence based nursing practice, Quality Improvement (QI), and research play key roles in the systematic actions that lead to measurable improvement in nursing care services. As such, nurses within a large academic medical center need both a mechanism and resources to support efforts that will lead to evidence based clinical practice, initiation and continuation of QI initiatives, and to develop and conduct scientific inquiry. Integral nurses' success are provision and communication of resource availability and processes for QI and research. Nurse leaders have advocated for a systematic process that would enhance the capture, communication, collaboration, and dissemination of EBP, QI, and research projects. A gap analysis identified deficiencies such as a) lack of awareness of process as measured by education needs assessment, b) inconsistent communication from clinical nurses to nurse leaders about EBP, QI, and research initiatives.

Utility of repeated TSH testing in hospitalized patients with non-thyroidal illness

QPI: Satish, Maharaj, (

A wide variety of symptoms can be associated with thyroid disease. These symptoms are often vague and nonspecific, challenging physicians managing a patient population with multiple comorbidities. When patients are admitted under internal medicine or hospitalist services, they often have testing for thyroid disease with serum thyroid stimulating hormone (TSH) for a variety of nonspecific symptoms. Serum TSH has a sensitivity and specificity of more than 99%. The use of TSH in hospitalized patients with non-thyroidal illness (NTI) remains an area of debate with recommendations ranging from limiting use to those patients with high clinical suspicion to generalized screening. While the question of who should be initially tested is debated, we have noted in practice that there is a group of patients who have repeated admissions and repeated TSH testing. Despite having negative TSH testing recently, many patients go on to have repeated TSH testing on readmission within a 6 month period. We aim to examine the utility of repeated TSH testing in this population. This clinical audit will provide us with the knowledge needed to reduce inappropriate TSH testing at UF Health Jacksonville. We hope to use this information to make testing more cost-efficient and reduce potential harms to patients of overtesting.

Assessment of physician documentation of patient distress prior to the first cycle of chemotherapy

QPI: Arpan, Patel, (

Some experts believe patient distress should be included as a vital sign. Patients who are undergoing cancer care may be under an overwhelming amount of distress prior to starting their chemotherapy treatment. We seek to increase physician awareness about patient distress and to increase the documentation of patient distress in the patient chart. We plan on handing out a fillable review of systems sheet along with NCCN’s established patient distress thermometer. If a patient is found to have a distress score of 5 or higher, this will prompt a social work consult. To study the effectiveness of this tool we plan on educating our hematology oncology fellows about the NCCN patient distress tool. We also will educate them to review the documentation that will be received from patients and to document this in the patient chart. If there is a score of 5 or above, we will prompt a social work consult. Finally we will review the chart of patients who are undergoing their first cycle of chemotherapy to see if physicians are documenting patient distress.

Documentation of anxiety in patients who are receiving chemotherapy

QPI: Arpan, Patel, (

Some experts believe patient distress should be included as a vital sign. Patients who are undergoing cancer care may be under an overwhelming amount of distress prior to starting their chemotherapy treatment. We seek to increase physician awareness about patient distress and to increase the documentation of patient distress in the patient chart. We plan on handing out a fillable review of systems sheet along with NCCN’s established patient distress thermometer. If a patient is found to have a distress score of 5 or higher, this will prompt a social work consult. To study the effectiveness of this tool we plan on educating our hematology oncology fellows about the NCCN patient distress tool. We also will educate them to review the documentation that will be received from patients and to document this in the patient chart. If there is a score of 5 or above, we will prompt a social work consult. Finally we will review the chart of patients who are undergoing their first cycle of chemotherapy to see if physicians are documenting patient distress.

Improving Quality of Patient Handoffs Between Psychiatry Using a Standardized Tool

QPI: Allison, Nussbaum, (

In this quality improvement project, we aim to implement a standardized handoff protocol (both verbal and electronic) for psychiatry residents. We recognized that our psychiatry residents were not utilizing a standardized handoff technique. Standardized handoffs are considered to be standard of patient of care and an ACGME requirement because they have been shown to improve patient safety, continuity of care, a decrease in medical errors and preventable adverse events by improvements in communication and resident work flow. One evidence based standardized handoff protocol is I-PASS. We will measure resident knowledge and current utilization of I-PASS at baseline. Additionally, we will measure resident satisfaction with current handoff protocol. We will then provide residents with an educational handout (training #1) about I-PASS and reassess their knowledge and competence in utilizing I-PASS. We will compare baseline knowledge with knowledge after training number 1. We have created a embedded electronic handoff and a Healthstream training module. For the next training we will provide electronic training through Healthstream on the embedded I-PASS handoff we designed specifically for psychiatry. We will again measure resident knowledge, utilization of I-PASS, and satisfaction with handoff protocol after training #2. We predict that training #1 will improve knowledge, while training #2 will improve knowledge, utilization and satisfaction.

Sleep Hygiene in Unit 52 Psychiatry

QPI: Candace, Rouse, (

Sleep problems are inherent in persons with mental health dx. Literature review notes that this poses the quesion "is the problem a symptom of the illness or does it exacerbate the illness?”. Circadian rhythms are turned around, and many patients will sleep during the day and be awake at night. Medications for sleep can cause dependency, as well as the side effects may increase the fall rate. A non-pharmacologic approach is desired. Staff education is lacking in relation to sleep hygiene, and needs to be addressed. Staff buyin to any interventions will be paramount for success. Interventions that will be utilized per literature review include: 1. Staff and patient education about sleep hygiene 2. Keep patients awake and engaged during the day 3. Relaxation music during evening 4. Herbal tea for sleep 5. Evening snacks without caffeine, sugar 7. Quiet room, quiet music, quiet games 8. Aromatherapy

Evaluation of the Children's Medical Services Managed Care Plan

QPI: ()

The Institute for Child Health Policy was awarded funding and conducts the External Quality Review Organization activities for the Children's Medical Services Managed Care Plan (CMS-P) for the State of Florida. The nature of this work this works constitutes quality assurance for the state. The Children Medical Services Managed Care Plan provides public health care coverage to children with special health care needs (CSHCN) in both Florida’s Medicaid program (Title XIX) and Florida’s State Children’s Health Insurance Program (Title XXI). CMS-P eligibility is based on family income, age, and health status. The purpose of the evaluation activities is to augment current EQRO requirements as well as to conduct optional EQRO activities. The scope of work consists of the following: 1. Oversee the administration, completion, and evaluation of satisfaction surveys for Medicaid CMSN (Title XIX) enrollees by an NCQA-certified vendor; 2. Medical record review of enrollees in Title XIX (Medicaid) to determine compliance with agreed upon standard elements of documentation supporting the provision of appropriate, quality of care; 3. Use review data to determine HEDIS and other non-HEDIS quality of care measures are within compliance for CMSN Title XIX I; 4. Oversee the administration, completion, and evaluation of satisfaction surveys for Medicaid CMSN (Title XIX) enrollees by an NCQA-certified vendor; 5. Administer, complete, and evaluate provider satisfaction survey.

Mentorship Program in 4W

QPI: Lauren, Ochoa, (

I am participating in the nursing leadership fellowship and have decided to develop a mentorship program as my project. I will work on developing a group of mentors among the staff in my unit and establishing meetings for the mentors and activities for the mentors and mentees. Requirements for being a mentor will be attendance at the mento class offered through nursing education and attendance at the quarterly mentor meetings and willingness to participate in mentoring relationships with our new staff. New hires will be informed of the 4W nursing mentor program and expectation that a mentor will be selected during the initial 6 months of hire using the established list of mentors and the mentor profile book as well as their interactions with the staff and personal preference. Mentees without an established mentor by the 6 month probationary eval will be assigned one.

Improving patient's experience at the infusion center for biological in inflammatory bowel disease.

QPI: Silvio, de Melo, (

Coordination with the UF Health Pharmacy Department, Lahn Dang and Abbey Johnston, as well as the infusion centers at UF Health Downtown and UF Health North to alert the ordering physician 30 days before the "therapy plan" for biological agents in inflammatory bowel disease is going to expire as well as assuring that all necessary laboratory evaluations, such as annual tuberculosis screening and hepatitis B infection screening (once) is completed prior to the patient presenting to the infusion center.

Quality Improvement: HMOs

QPI: Michelle, Pagnotta, (

For my final criteria of my Masters in Public Health (MPH), I have a summer internship and a "special project." I will be interning at Palm Beach Accountable Care Organization in West Palm Beach, Florida. They are an accountable care organization that works with both Medicaid, as well as private insurance companies to connect a patient's doctors/physicians so that they can see their previous medical history, prescriptions, test results, etc. and deliver the best coordinated care possible for that specific patient, for the most efficient cost. My specific project will be in quality performance for 3 specific insurance companies: UHC, BSBS, and Cigna. Through analyzing the collected data, I will be finding gaps in the care and missed opportunities. For example, data might show that a high % of those at risk for breast cancer are not getting mammograms; or we might find that we are losing "dropped patients" because doctor's offices aren't scheduling their next appointment before the patient leaves. Based on these data results, I will be contacting patients themselves to close these gaps (ex: try to book a mammogram appointment), as well as educating the doctors on missed opportunities (have reception schedule next appointment in office). Based on these preventative care gaps, I will also be creating initiatives to educate and push patients to minimize those gaps (ex: push for mammograms). After this, I will measure the results again and see if there were any improvements.

Addressing Social Determinants of Health During Clinic Visits

QPI: Lauren, Bielick, (

The UF Mobile Outreach Clinic provides free, mobile healthcare services to medically underserved, low-income areas of Gainesville, Florida. The population of patients frequently seen by the clinic have typically experienced major health disparities which the clinic strives to address. Many of the patients seen belong to minority populations, are homeless, uninsured, rely on public transportation, have adverse life experiences, and many other social factors that affect their life and their access to healthcare. It is becoming increasingly important to integrate these social determinants of health during clinic visits in order to help enhance patient health outcomes. To ensure that patients’ needs are being better met, the MOC is further enriching a health screening process that has a heavy focus on the social factors of a patient’s health. When a patient is seen at the clinic, they will be directed to answer a set of questions regarding SDOH. The patients responses are ultimately coded in a way that helps the volunteers and medical providers see directly what social factor(s) is/are impacting their health. The clinic can then offer the patient fundamental resources and continue to track the progress of their social well-being during future clinic visits to see if the resources provided were helpful. Ultimately, if there is/are an obvious social factor(s) that consistently affects the health of a group of patients, the MOC plans to take policy action on the city and county level in making Gainesville a more inclusive environment.

Anesthesia Pain Clinic Quality Improvement Program (APCQIP)

QPI: Kevin, Lancer, (

At the Malcom Randall VA Medical Center Anesthesia Pain Clinic, we are attempting to apply the best principles of QI and the ethical standards of the Healthcare profession to improve outcomes for Chronic Pain patients being considered as candidates for Spinal Cord Stimulator (SCS ) implantation. The Anesthesia Pain Clinic QI Program (PCQIP) is intended to be completely congruent with the VA goal of “achieving the vision of a learning healthcare system.” Project Description: Purpose: to improve the process of appropriate patient selection for implantable Spinal Cord Stimulators (SCS) in the Veteran population. There is minimal literature on this topic in the Veteran population, and our goals are to improve our care delivery process; identify factors that may affect SCS efficacy, and decrease any inefficiencies in our service delivery process. Scope: We are attempting to evaluate and improve our current practice. Evidence: There is sufficient current evidence to support implementation of this QI activity to engender improved practice efficacy for SCS patients. Clinicians/Staff: All QI activities are conducted by clinicians and staff members who are care providers in the Anesthesia Pain Clinic (APC) and directly responsible for any practice change that may result from the QI process. Methods: Our methods employ standardized validated physiological and psychological measures utilized in Pain, Primary Care, and physical therapy that are simple, non-invasive, and give us the ability to evaluate changes both over time and quantity. Risk: There is no reasonable expectation of causing harm to patients. Only standardized and commonly utilized checkmark (Likert scale) based forms are used. No invasive measures of any type are employed. Sample/Population : Our sample population is the patients normally seen in our clinic. Benefits: At the APC, we hope that the APCQIP will inform our practice in accordance with the best Evidence Based Practices (EBP) of the Healthcare Professions to increase our efficacy in treating our Veterans with Chronic Pain.