Approved NC MOC Projects
Each approved NC MOC Project is integrated into the work physicians do every day in their office or in their clinical practice in an effort to improve the process of care and produce better patient outcomes.
If you have successfully completed all of the Participation Requirements for a project listed below, please complete the NC MOC Attestation Form. The form will be sent to the Project Leaders for approval.
Click here for the Mountain Area Health Education Center (MAHEC) projects. MAHEC is a Participating Organization which means they help their affiliated physicians earn MOC practice improvement credit for participating in initiatives approved by the NC MOC Advisory Board and the American Board of Medical Specialties.
|Approved QI Project||Description||Physician Lead and Project Manager|
|Preventing Patient Harm||Preventing Patient Harm is a program aimed at reducing hospital-acquired infections and patient safety indicators. Although much work has been done to prevent patient harm over the past decade, this work is gathering even more momentum, with tremendous efforts underway across the entire medical center.||Tom Ivester and
Preventing Patient Harm Project Manager
|Opioid Stewardship||The aim is to develop a system to standardize the education of prescribers and patients regarding the implications of unused medications and facilitate appropriate drug disposal. We hope to produce Standard Opiate Prescribing Schedules (SOPS) to guide responsible prescribing by our providers and minimizing unused pills in homes, while not limiting patients’ access to the medication when it is needed.||Brooke Chidgey, Peggy McNaull and
Patient Safety Quality Improvement (PSQI) Program Manager
|Enhanced Recovery After Surgery (ERAS) - Adult and Pediatrics||The Enhanced Recovery After Surgery (ERAS) pathways’ goal is to maintain physiologic function and to facilitate early post-operative recovery. The pathway serves to ultimately improve the quality of care delivered, improve patient experiences and accelerate recovery (via improvement in the use of pain medication, decreased costs, decreased length of stay and decreased readmissions).||For a full list of physician leads for each ERAS project, click on the Enhanced Recovery After Surgery (ERAS) link in the first column of this table.
Patient Safety Quality Improvement (PSQI) Program Manager
|Improving Transitions of Care and Preventing Readmissions||Reducing readmissions is an ongoing organizational goal and strategic priority for UNC Medical Center. |
Key elements of readmission prevention are: risk stratification & patient identification; comprehensive assessment by care manager; medication management; self-care training; timely, accurate discharge summary; post-hospitalization phone call; structured, patient-coordinated appointment with follow-up provider within 7 days; and ongoing care management.
The project’s goal is for the transitional care model to be standard practice for all high and moderate risk adult medicine and surgery inpatients admitted to UNC Hospitals.
|David Hemsey and
Quality and Organizational Excellence Leader, UNC HCS
|Clean In, Clean Out: Hand Hygiene at UNC||Hospital Acquired Infections remain a priority of prevention in healthcare delivery especially in higher risk times of care such as during admission to an inpatient unit. Appropriate hand hygiene practices have been shown to decrease healthcare acquired infections and mortality as well as shorten length of stay in inpatient settings and decrease healthcare costs.|
The program’s goal is that the UNC Hospitals inpatient care areas will have achieved a specific mean regarding hand hygiene compliance as detected on audits completed at the individual unit level.
PhD, MS, CIC| Director
Hospital Epidemiology and Occupational Health Services
|Primary Care Improvement Collaborative (PCIC)||UNC Health Care provides comprehensive primary care to a large population of North Carolinians through a variety of locations, both academic and community-based. |
Primary care practice representatives from across the UNC Health Care System have joined together as a
Primary Care Improvement Collaborative (PCIC) to facilitate shared learning and accountability.
Our goal is to improve the health and outcomes of the patients we treat. The collaborative will target measures that balance the needs of our providers, priorities of the organization, and the impact to our patients.
|Lynne Fiscus and
HealthCare System Program Manager, Improvement Collaboratives
Practice Quality, Innovation and Population Health Services
|Improving the Implementation of Lung Cancer Screening Guidelines||This project aims to improve the delivery of appropriate lung cancer screening by: increasing collection of accurate, detailed smoking histories; increasing use of clinical reminders for lung cancer screening; conducting and documenting Shared Decision Making (SDM) for lung cancer screening; and increasing the use of Lung-RADS classification in CT screening scan reports.||Daniel Reuland and
Laura Cubillos Starrett, MPH,
Research Associate/Project Manager, Lineberger Comprehensive Cancer Center, University of North Carolina
|Code Sepsis||Prompt recognition and treatment of sepsis have been identified as a means of improving sepsis survivorship. Many of the interventions aimed at early recognition of sepsis also increase the likelihood of earlier recognition of complications included in the definition of Failure to Rescue. The main indicators of survival from sepsis are timely administration of initial antibiotics and fluids, making recognition a key component of treating patients with sepsis. Code Sepsis aims to implement a standardized pathway for adult and pediatric sepsis patients including recognition, activation, and treatment in UNC Hospitals.||Main contacts: Lydia Chang, Jay Lamba, Gary Burke
Rex: Charul Haugan (Sepsis System-wide Leader)
Hillsborough Hospital Contacts: Katie Davenport, Clare Mock
Quality and Organizational Excellence Analyst,
|Integrating Palliative and Oncology Care||Cancer patients who receive palliative care have better advanced care planning, reduced ICU admissions, and earlier Hospice referral providing a better quality of life for the patient and reduced cost savings for everyone.|
This project will review the census on a daily basis to identify patients with metastatic cancer who could benefit from a Palliative Care consultation. In addition, the project will provide monthly feedback of palliative care metrics and provide training in Palliative Care skills to the Hematology/Oncology fellows, residents, and NP/PA staff.
|Laura C. Hanson,
Professor, Geriatric Medicine
Director, UNC Palliative Care Program
|Antibiotic Stewardship in the Pediatric ED: Standardizing UTI Testing and Treatment||Urinary Tract Infections (UTIs) is one of the most common pediatric infections and effective management requires appropriate diagnostic methods and treatment. Antibiotic resistance is an increasing threat in healthcare, which is principally driven by the misuse of antibiotics. Therefore, it is critical to follow clinical practice guidelines and provide the most appropriate antibiotics, only to patients who truly have a bacterial infection. The Pediatric Antimicrobial Stewardship Program at UNC is tasked with implementing programs that enhance the appropriate use of antibiotics in both inpatient and outpatient areas.||Zach Willis and
Doctor of Nursing Practice Student, School of Nursing, UNC-Chapel Hill
|Cystic Fibrosis Transition: Graduating from Pediatric to Adult Care||With >50% of US CF patients currently 18 or older, CF can no longer be considered a pediatric disease. Yet compared to age-matched peers, young adults who grow up with a chronic health condition achieve milestones later in life or not at all. This may be an unintended consequence of the family-focused care provided in pediatrics that can limit education, independence, and attainment of self-management skills. |
Our aim is to improve the CF transition process by creating a streamlined approach to transition for patients beginning early in adolescence and extending to the handoff to adult clinic (age >=18).
MD, Assistant Professor, Pulmonary/Critical Care Medicine/Pediatric Pulmonology
|Clinical Pathway for the Outpatient Education of Pediatric Patients with Newly Diagnosed Type 1 Diabetes Mellitus||Type 1 Diabetes Mellitus (T1DM) is one of the most common chronic illnesses in childhood. At the time of diagnosis, a significant amount of education is needed to equip children and their parents with the knowledge and skills necessary for managing diabetes. Historically pediatric patients with newly diagnosed T1DM have been hospitalized to receive this education, and prior to discharge, the family was required to demonstrate the ability to check blood sugars, give insulin, and know what to do in the case of hypoglycemia or hyperglycemia. |
Our goal is to develop, implement, and refine an effective and safe outpatient diabetes management pathway
Division of Pediatric Endocrinology, School of Medicine at UNC-Chapel Hill
Reducing Exposure Vancomycin-Related Nephrotoxicity
|Some cases of nephrotoxicity are likely preventable. Recent evidence has demonstrated that the combination of vancomycin and piperacillin-tazobactam confers an increased risk of nephrotoxicity compared to vancomycin plus a different beta-lactam antibiotic. We identified patient populations in whom vancomycin target troughs could be safely lowered, which we predicted would result in a decreased incidence of supratherapeutic troughs and nephrotoxicity.|
We aim to decrease the incidence of vancomycin-related nephrotoxicity in our children’s hospital by 50% by the completion of our project.
|Zach Willis, MD|
Post-Partum Depression Screening
|10-25% of new mothers have post-partum depression. It is a common medical condition that can significantly affect the health and well-being of mothers, infants and family units. Post-partum depression is the most common underdiagnosed obstetric complication. Pediatricians have the greatest opportunity of encountering infants and caregivers.|
Our aim is to implement a post-partum depression screening program, track the number of post-partum depression screenings (at 1, 2, 4, and 6 months well-child visits) in our new mother population, and increase the number of appropriate referrals, while increasing our post-partum depression screening rate from 0% to 75% over a 6-month period.
|Sarah Ryan, MD|
|Faculty Education and Supervision of Medical Student Quality Improvement Activities||The CBLC faculty will be engaged in their own Quality Improvement development as they train and supervise medical students through the implementation of various Quality Improvement projects.|
The aim is to improve the individual Quality Improvement competence and skill level of the Community-Based Longitudinal Care course faculty.
|Karina Whelan, MD|
Improving Provider Adherence to Turner Syndrome Care
|Turner Syndrome is a complex medical condition which requires medical providers to evaluate numerous comorbidities. It can be difficult for both the providers and the patients to keep up to date on the recommended screenings. This project aims to increase the percentage of patients who are up to date on the recommended screening evaluations.||Jennifer Law, MD, MSCR|
Neurodevelopmental Disabilities and the Transition from Pediatric to Adult Health Care
|The transition from pediatric to adult healthcare systems is a complex process requiring cooperation from primary care physicians, pediatric and adult specialists, families, and patients alike. Transitioning can be difficult for youth with any kind of special healthcare need: this seems to be even more complicated for youth with neurodevelopmental disabilities. This project aims to increase the percentage of adolescent patients (ages 12 to 26 years) who receive transition related services (transition planning, resources, etc.) at the Carolina Institute for Developmental Disabilities (CIDD).||Diana Cejas, MD, MPH|
LGBTQuality Improvement: Strengthening Care in Outpatient Pediatrics
|LGBTQ young people have higher rates of obesity, depression and suicidal ideation, substance abuse, eating disorders, unsafe sex, and HIV. |
The pediatrician can be a key figure in promoting a lifetime of health to LGBTQ youth; yet, many key interventions to enhance this unique ability have yet to be implemented in pediatric practice. Leading medical organizations recommend that pediatric practices provide visual and verbal cues of being friendly to LGBTQ populations, confidentially document sexual orientation and gender identity (SO/GI) data, appropriately screen for psychosocial and medical illness in LGBTQ populations, and refer to appropriate resources.
Our aim is to improve patient satisfaction, increase staff knowledge about LGBTQ related issues, increase LGBTQ electronic health record documentation and increase the number of screenings completed in the greater than 13 years old pediatric patient population.
|Emily Vander Schaaf, MD|
Implementation of Antibiotic Time Outs at Hillsborough Hospital
|When patients are admitted to the hospital with a suspected acute infection, they often receive broad-spectrum antibiotics. Often, the initial empiric regimen is not revisited in light of new data, such as diagnostic test results and evolution of the patient’s clinical condition. Patients may then be needlessly exposed to an antibiotic regimen that is more toxic, broader in spectrum, and/or more expensive than a targeted regimen.|
This project aims to increase Antibiotic Time Outs to 80% across all Hillsborough Medical Services and across 2 General Medicine/1 ICU Medical Center Teams.
|Zach Willis, MD, MPH|
Malnutrition in Hospitalized Family Medicine Patients
|North Carolina is third in the nation for senior hunger yet participation in community nutrition resources throughout the counties are underutilized according to the NC Division of Aging and Adult Services. The prevalence of malnutrition at UNC Hospital is between 15% and 25% for all patients and for patients >65 years of age respectively. Hunger and chronic disease are the context of malnutrition, which is an independent predictor of adverse patient outcomes including severity of illness, length of hospital stay, preventable readmissions and hospitalization costs. |
This project aims to implement community based quality improvement interventions around malnutrition and food insecurity in the hospital at discharge that will carry through to the patient’s community and to the patient’s primary care provider.
|Amir Barzin, DO, MS|
Reducing Fall-Related Fractures in Older Adults-Ambulatory and Primary Care
|Fragility fractures result from the confluence of osteoporosis (low bone mineral density) and falling. In the United States, nearly 50% of white women and 20% of white men and black women will suffer a fragility related fracture in his or her lifetime. The annual cost of treating fragility fractures in the United States is estimated to exceed $25 billion by 2025. This project aims to reduce the rate of fall-related fractures in Geriatrics Specialty Clinic (GSC) patients by closing gaps in the management of osteoporosis, and by reducing fall risk via panel management and the development of a Geriatric Bone Health Clinic within the GSC.||Meredith Gilliam, MD, MPH|
Antipsychotic Monitoring Program Improvement - Treatment of the Metabolic Side Effects of Second-Generation
|The project’s goal is to design, test, and implement best practices to monitor for and address metabolic side effects for patients receiving SGAs from providers in the UNC Department of Psychiatry. The UNC inpatient psychiatry units and the outpatient psychiatry clinics are settings in which a large percentage of patients are initiated or maintained on SGAs. Our primary outcome will be the percentage of patients on SGAs that receive metabolic side effect monitoring consistent with guidelines.||Takahiro Soda, MD, PhD|
Optimizing Tarheel Trauma Care: The Golden Hour and Beyond
|As a Level I Adult and Pediatric Trauma Center, UNC Medical Center is the lead trauma resource for 13 counties admitting nearly 2000 trauma patients annually. Survival of severely injured patients greatly depends on the rapid identification and management of life-threatening conditions in the “golden hour of care” after injury. Our aim is to improve patient outcome, staff satisfaction and the patient experience by improving the efficiency, consistency and reliability of trauma resuscitations.||Darhyl Johnson, MD, MPH
Al Bonifacio, RN, UNC Trauma Program Manager
Detecting and Reducing Acute Kidney Injury from Nephrotoxic Medications for Hospitalized Patients
|Acute kidney injury (AKI) from nephrotoxic medications is common in hospitalized patients. Though a high percentage of medication-associated AKI is preventable, AKI rates are not tracked, and there is no standardized methods for screening, monitoring, or hydration to prevent AKI from nephrotoxic medications. One of this project’s aim is to reduce AKI rates from nephrotoxic medications on highest risk services through the development of screening tools and monitoring and hydration pathways.||
Will Stoudemire, Fellow, Pediatric Pulmonology
Quality Assurance and Performance Improvement (QAPI) Program Development, Implementation and Oversight
2. Acute Dialysis
3. Respiratory Therapy
|These projects aim to design, develop and implement a Quality Assurance and Performance Improvement Program for the ECMO, Acute Dialysis and Respiratory Therapy units by creating a governance structure that uses a quality dashboard with multiple metrics aligned with organizational goals that will guide quality improvement efforts. These efforts will be ongoing.||ECMO
Jenny Flythe, MD
Maggie Cannon, Quality Leader, UNC Hospitals
Maggie Cannon, Quality Leader, UNC Hospitals
Maggie Cannon, Quality Leader, UNC Hospitals
Faculty Development Fellowship: Quality Improvement Collaborative
|The Faculty Development Fellowship helps practicing physicians become skilled teachers and leaders while developing quality improvement projects. The Scholarship curriculum provides the support and technical assistance necessary for multiple providers to engage in quality improvement activities during their fellowship year.||Dana Neutze, MD, PhD
Pediatric Faculty Education and Supervision of Medical Student, Resident and Fellow Quality Improvement Activities
|The Department of Pediatrics has a strong history of education and process improvement and is a leader in the School of Medicine regarding the mentoring of Residents/Fellows. Many physicians have been trained in QI by Intermountain Healthcare and Cincinnati’s Children’s Hospital and have completed TeamSTEPPS and the locally provided Yellow Belt and Blue Belt courses. This program allows faculty to improve trainee learning and assessment which will ultimately result in improved care to patients.||Kathy Bradford, MD|
Newly Inserted and Existing Percutaneous Enteral Access Devices (EADs)
|This project aims to address issues with newly-inserted and existing percutaneous enteral access devices (EADs); i.e. gastric tubes (G, J, and GJ). These issues are related to misplaced re-insertions, tube migration, and variations in care standards with these events. Percutaneous EAD-related issues are not only a risk to patient safety; they can also impact finances, patient satisfaction, and the reputation of our institution. This project will reduce complications and provide a standardized order set for tube placements.||Trista Reid, MD|
Rapid Response Consult Role Re-Branding
|There are multiple pathways existing within the University of North Carolina Medical Center, which impacts escalation of care when a patient's condition deteriorates. One of the pathways is the utilization of the adult rapid response consult (Critical Care Outreach Nurse) role. |
Rapid response nurses are specialty trained critical care nurses. This project aims to improve the percentage of Consults changed to Activated Rapid Response upon arrival of Consult Nurse (Critical Care Outreach Nurse) in the intermediate care units.
|Jennifer Mack and Tiffany Ellis
Advance Care Planning Quality Improvement Project
|Advance Care Planning is important for patients so that treatment preferences can guide medical care that matches patients' values and goals when serious illness occurs. By discussing goals and values with their surrogate decision makers and health care providers, patients can be ensured that they are getting the care they would want. We will improve the percentage of patients aged 65 years of age and older with documented Advance Care Plans consistent with the specific practice site's target.||Katherine Aragon, MD and Kinsey Brady|
Safe Reduction of Primary Cesarean
|Cesarean section (CS) is the most common surgery performed in the United States with one in every three infants delivered via CS. While certain clinical conditions merit delivery via CS, nulliparous women at low risk for surgical delivery experience a higher rate of adverse maternal and neonatal outcomes after CS. This project aims to engage all obstetrical units in North Carolina to improve management of primary labor so that fewer mothers deliver via Cesarean Section.||Angelica Glover and
Michelle Swanson, Senior Quality and Organizational Excellence Leader
|Telemetry Reduction Initiative||Telemetry monitoring is a limited resource that is often overutilized. The Choosing Wisely campaign has identified continuous telemetry monitoring outside of the ICU as a concern. This projects aims to reduce the percentage of telemetry orders that are continuous and reduce the average number of hours on telemetry per patient. The benefits of telemetry reduction include: improved patient comfort/mobility, fewer false positives, decreased labor and equipment costs, improved throughput and avoidance of unnecessary testing.||Clare Mock, MD and
Pamela Entzel, Business Practice Improvement Manager, Carolina Value
|Reach Out and Read||Reach Out and Read, a nationwide organization that promotes early literacy and healthy parent-child relationships, allows pediatric primary care providers books to give to their patients. Babies are admitted to the NICU for many reasons – mild conditions, which warrant a brief stay, or serious conditions, which may require a prolonged hospitalization. Reading aloud in the NICU setting has been associated with enhanced development and decreased parental stress. This project aims to increase the percent of days read to by a parent/caregiver/anyone.||Erin Orth, MD|
|Hospitalist Order Set Enhancement||The System Hospitalist Group polled hospitalist representatives from all entities regarding opportunities to promote evidence-based medicine. Representatives identified order set enhancement as a leading priority. This project aims to review and revise the General Adult Admission order set and all 8 hospitalist-owned diagnosis-specific order sets and create a new General Adult PRN Medication order and new diagnosis-specific order sets (prioritizing the highest-volume DRGs), with the goal of releasing 2 to 3 new or revised orders per quarter.||Clare Mock, MD and
Pamela Entzel, Business Practice Improvement Manager, Carolina Value
|Carolina Conexiones||This project aims to increase Spanish-speaking families’ satisfaction with care and visit flow. This aim is guided by the Institute of Medicine’s six domains of quality and our plans to apply the domains of timeliness, efficiency, equity, and patient centeredness to the provision of outpatient care to Spanish-speaking families in the NC Children’s Hospital.||Kori Flower, MD and
Kristina Morris, Volunteer Services Coordinator
|E-Consult Quality Improvement Project||Currently, e-consults are not available and so patients are required to make an appointment with specialists to get their opinion. Many patients/clinicians have questions that can be answered without a formal in-person visit. This project aims to create e-consult availability for every specialty in the department of medicine for all providers in the UNC Health Care System. This will make access to specialist input easier and less costly. This new process may also increase access to specialists for those who need in-person visits. This project will develop a template for e-consults in EPIC, create a schedule for physicians to provide e-consults and collect data on the usefulness of the e-consults.||Spencer Dorn, MD and John Vargas|
|Chlamydia Screening in Adolescents||Chlamydia is a common, under-treated infection in sexually active adolescents and young adults. It can lead to long term serious health consequences such as infertility. Screening and treatment can help prevent complications and prevent spread of disease. This QI project focuses on screening male and female adolescents.||Sarah Ryan, MD
|Improving Viral Load Suppression Among Youth Living with HIV||Adherence to daily antiretroviral medications helps protect individual health and prevents transmission of the virus to others. Youth living with HIV encounter various difficulties in adhering to HIV medications, resulting in more frequent periods of HIV viral load detectability than the overall adult population. Through participation in an innovative, collaborative telehealth program, the UNC ID Clinic has worked to improve HIV viral load suppression among youth ages 18 to 24 under our care.||Christopher Hurt, MD and Emily Duberman, LCSWA|
|Navigating Pathways for Coordinated Care for Children with Autism Spectrum Disorder and Developmental Delay||The health care needs of NC children with ASD/DD and their families continue to present significant challenges, with gaps in screening and identification, coordinated provision of family-engaged developmental monitoring, timely referrals, evidence-based diagnostic and intervention services, and navigation services that are culturally/linguistically appropriate and family-centered. This project seeks to support multiple pediatric practices in improving the process of identification, referral, and follow up of autism screening and developmental delay.||Kori Flower, MD|
|Improving Obesity in Primary Care||According to the Centers for Disease Control and Prevention, nearly 40% of Americans have obesity. A possible effective solution to the issue is a model of a decentralized obesity care nested in primary care practices which greatly improves access. This program involves providers implementing a “physician monitored weight loss program” using FDA approved anti‐-obesity medications in addition to counseling and nutritionist consultation.||Sarah Ro, MD and Shannon Aymes, MD, MPH
|Reducing Low-Value Care Through Syncope Standardization||This project aims to lower the percentage of patients admitted under observation status with a diagnosis of Syncope and zero risk factors. The project included developing a structured protocol and care pathways and an increased use of the outpatient Syncope clinic.||Physician Lead: Mike Craig
Emily Kertcher, Quality/Organizational Excellence Leader
|UNC Medical Center Daily Safety Huddles||Safety huddles are a cornerstone of a highly reliable organization, providing the safest patient care through systems designed to correct and prevent errors. A huddle is a short, stand-up meeting that is typically used once at the start of each workday or shift.|
The goal is to give teams a way to proactively manage safety, while also reviewing key performance indicators (KPIs), standard work, and quality improvement projects.
|Physician Lead: Tom Ivester
Lukasz Mazur, Director of Healthcare Engineering