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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 Area Health Education Centers (AHEC) projects. These AHECs are 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 ProjectDescriptionPhysician Lead and Project Manager
Preventing Patient HarmPreventing 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
Megan Miller,
Preventing Patient Harm Project Manager
Opioid StewardshipThe 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
Constanza Bacon,
Program Manager
Enhanced Recovery After Surgery (ERAS) - Adult and PediatricsThe 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.
Lyla Hance,
Patient Safety Quality Improvement (PSQI) Program Manager
Improving Transitions of Care and Preventing ReadmissionsReducing 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
Ayana Simon,
Quality and Organizational Excellence Leader, UNC HCS
Clean In, Clean Out: Hand Hygiene at UNCHospital 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.
Emily Sickbert-Bennett,
PhD, MS, CIC| Director
Hospital Epidemiology and Occupational Health Services
UNC Hospitals
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
Crystal Hoffman,
HealthCare System Program Manager, Improvement Collaboratives
Practice Quality, Innovation and Population Health Services
Improving the Implementation of Lung Cancer Screening GuidelinesThis 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 SepsisPrompt 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
April Glick,
Quality and Organizational Excellence Analyst,
UNC Hospitals
Antibiotic Stewardship in the Pediatric ED: Standardizing UTI Testing and TreatmentUrinary 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
Elizabeth Walters,
Doctor of Nursing Practice Student, School of Nursing, UNC-Chapel Hill
Cystic Fibrosis Transition: Graduating from Pediatric to Adult CareWith >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).
Jen Goralski,
MD, Assistant Professor, Pulmonary/Critical Care Medicine/Pediatric Pulmonology
Clinical Pathway for the Outpatient Education of Pediatric Patients with Newly Diagnosed Type 1 Diabetes MellitusType 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
Elizabeth Sandberg,
MD, Fellow,
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 ActivitiesThe 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 and Andrea Corona

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
Antipsychotics (SGA).
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

Acute Dialysis
Lauren Kearns
Maggie Cannon, Quality Leader, UNC Hospitals

Respiratory Therapy
Lauren Kearns
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
Dawn Morriston

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 ReadReach 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 EnhancementThe 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 ConexionesThis 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 ProjectCurrently, 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 Spencer Dorn
Chlamydia Screening in AdolescentsChlamydia 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 HIVAdherence 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 DelayThe 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 CareAccording 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 StandardizationThis 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.Mike Craig, MD

Emily Kertcher, Quality/Organizational Excellence Leader
UNC Medical Center Daily Safety HuddlesSafety 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.
Tom Ivester, MD

Bret Shultz, Research Program Manager

COVID-Related Quality Improvement ProjectsDue to the pandemic, many Physicians and Physician Assistants have made changes in workflows, census management, screening processes, communications, clinical processes, patient education, virtual patient visit options, etc. These improvement activities/interventions are included under a general COVID-related QI project. If you participated in COVID-related improvements, you are eligible to complete an Attestation to earn credit.Please contact
Monecia Thomas, MOC Project Manager
Mortality, Morbidity and Improvement ConferencesThere are silos related to Quality Improvement and the departments-specific Mortality, Morbidity, and Improvement Conferences. UNC determined that it was best to centralize these efforts and ensure that there was communication and collaboration across departments. This will allow the MM&I leaders to escalate issues to hospital leadership for appropriate resource allocation and removal of barriers more efficiently. All School of Medicine affiliated MM&I Conferences will use a centralized reporting tool to document case discussion, improvement opportunities, and action items, ultimately driving improvements in patient care and safety. Lauren Schiff, MD

Kelsey Accordino, Program Manager
Ambulatory Quality CouncilThe Ambulatory Quality Council will oversee the quality work completed across all 160+ outpatient clinics at the medical center. The Council will not only support individual quality projects in the clinics, but it will also drive system-wide efforts to alleviate quality gaps.Tommy Koonce, MD, MPH
Reducing Over-utilized Diagnostics and Therapeutics in BronchiolitisBronchiolitis is the most common cause of hospitalization among infants <12 months of age, but its non-specific symptoms (wheezing, lower respiratory findings on exam) often prompt providers to perform a more extensive evaluation. The AAP guidelines on bronchiolitis discourage routine chest radiographs and viral testing, yet these practices remain common in the community. This project aims to reduce chest radiographs from 35% to 15%.M. Alex Ahearn, MD

Emilee Lewis, MD
Under Pressure: Reducing Inpatient Pediatric Pressure InjuriesThe NC Children's hospital has made it a hospital wide goal to decrease patient harm events. One of the most frequently reported patient harm events is pressure injuries. UNC has created a Purple Belt Project to enact change around medical device causing injuries and pressure causing skin injuries. Melissa Smith, MD

Amber Kirkley, Clinical Nurse IV, Children’s and Women’s Hospital
Building High-Performance Team Dynamics for Rapid ResponsesThe goal of this project is to enhance rapid response team performance for all patients undergoing adult rapid response activation at UNC Hospital with demonstrated reduction in repeat rapid responses per patient, length of stay, and mortality as well as improved provider satisfaction with rapid response events.Evan Raff, MD and Lauren Raff, MD
Preventing, Recognizing and Managing Delirium in Critically Ill ChildrenThe goal of this project is to increase the percentage of PICU patients who are screened for pediatric delirium. Despite the prevalence of delirium and the known association with morbidity and mortality, no standard exists for treating this condition at UNC. Significant advances have been made in the past few years in the epidemiology, recognition, associated risk factors, and concerning outcomes for patients with delirium. Interventions to mitigate harm to our
patients by minimizing modifiable risk factors for delirium are advocated.
Stephanie Schwartz, MD and Tracie Walker, MD
Improving COPD Symptom Management for Patients with HIVChronic obstructive pulmonary disease (COPD) has been identified as a significant pulmonary comorbidity in people living with HIV infection, as there is overlap in risk factors for both disease processes including tobacco use and lower socioeconomic status. This project is designed to increase referral of patients from UNC Health's HIV clinic to the HIV-COPD clinic, facilitate accurate diagnosis and proper treatment, and offer ongoing care management for patients experiencing barriers to adherence.Subhashini Sellers, MD MSCR
Improving Radiologic Communication and Follow-up: Results Tracking ToolThere are multiple sources of missed opportunities for care after a radiologic study identifies non-emergent but important radiologic findings. Reliable follow-up is essential to increase the chance for detection of disease at an early stage, reduce the potential for negative patient outcomes, and mitigate risk for the physician and medical system. This project aims to increase use of an Epic-specific tool ("Results Tracking Tool") designed to facilitate timely communication of these incidental findings to the ordering provider (and primary care provider).Benjamin Mervak, MD, CIIP
IP Care for IV or Opioid Drug Use-Associated InfectionsHistorically, patients with endocarditis have been at high risk for prolonged hospital stays and frequent readmissions. This has resulted in unnecessarily long LOS and suboptimal outcomes for the patients. This project focuses on aligning efforts across internal medicine, infectious disease, addiction care, surgery and social work to better coordinate all the elements needed to support the successful treatment of endocarditis patients.Clare Mock, MD CPPS, Asher Schranz, MD MPH and Elizabeth (Babette) Stern, MD
Improving Glucose Management in the Inpatient SettingHyperglycemia can increase risk for infection, readmission, and increased length of stay. Hypoglycemia can lead to altered mental status, coma, MI, stroke, and ultimately death. The risks associated with both of these conditions are severe; therefore, this project places an emphasis on prevention and the importance of specific glucose targets in the inpatient setting.Morgan Jones, MD
PreOp and OR Inpatient preparationEfficient preparation for the inpatients coming to the Operating Room Holding Area is vital for the timely flow of patient throughput in the Perioperative process. This project aims to reduce patient wait time related to transportation and operational inefficiencies.Janet Chadwick
Quality Improvement Program (QIP) for Family Medicine ResidentsAll 3rd year Family Medicine Residents are required to participate in the Quality Improvement Program (QIP). A clinical metric is identified by the clinic leadership and the residents (along with faculty and a QI coach) work towards developing practice-wide strategies to better manage the care of patients.Ashley Rietz, MD
UNC Medical Center ED-to-Hospice TransitionsThere is a need for patients to have a conversation about the goals of care and options for hospice prior to Admission via the Emergency Department. This project allows patients to be routed to the appropriate level of care at the right time and avoid unnecessary inpatient stays in the hospital. Jared Lowe, MD
Clinical Leadership in Quality and Safety (CLQS)The Clinician Leadership in Quality and Safety Program equips students with skills that they can directly apply in clinical settings as future clinicians. The students are paired with a Mentor who works with them through the development, implementation, sustainability, and spreading of a QI project. By the end of the program, students will possess the knowledge and skills to implement a quality improvement project.Casey Olm-Shipman, MD and Monecia Thomas, MHA
IHQI Improvement Scholars Program The Improvement Scholars Program is a structured, experiential learning program. Participants learn clinical improvement leadership by proposing, designing, and leading a project with guidance and support from experienced clinical improvement leaders. Scholars receive training, mentorship, and guidance from IHQI Faculty Coaches as well as half-time support of an IHQI project manager for 12 months. Darren DeWalt and
May-Britt Sten
Clinical Team Quality Improvement Champions The aim of this project is to address several quality metrics related to the social determinants of health, diabetes, hypertension, and colorectal cancer screenings. Groups of clinicians, Licensed Clinical Social Workers, and Medical Assistants will work together to impact the screening rates and improve the health care for those with hypertension and uncontrolled diabetes. Dana Neutze, MD
Improving Documentation in Child Medical Evaluations The North Carolina Child Medical Evaluation currently has a continuous quality improvement review process for reviewing medical reports to ensure accuracy. Missing report items can impact the medical provider’s ability to reach a complete understanding of the maltreatment concerns. This project aims to improve the required documentation.Molly Berkoff, MD, MPH and Jessica Guice-Albritton, MSW
Implementing Enhanced Well Child Visits to Improve Kindergarten Readiness This project aims to increase the percentage of children (under age 6) receiving the Kindergarten Readiness Promotion Bundle during well-child checks. The Bundle encourages physicians to connect children to community services.Kori Flower, MD, MS, MPH
IMPACT HPV Vaccination Financial Incentive Intervention with Primary Care Clinics in North Carolina This is a state-wide grant-funded project based at UNC. The project aims to improve HPV vaccination rates using Announcement Approach Training (AAT) and a clinic-level financial incentive with monthly clinic performance updates.Michelle Hernandez, MD, Katy Brignole and Justin Trogdon
Monitoring DXA and Vitamin D Levels of Patients Receiving Bisphosphonate InfusionsPediatric patients with fragile bones need Biphosphonate Infusions. At one time, Care practices were not standardized and patients were not receiving the recommended routine screenings (DXA [bone density] scans and Vitamin D Level checks). This project focuses on an Infusion Therapy Plan and Bone Health Clinic Appointments.Jennifer Law
Making Trauma Less Traumatic: Implementing Inpatient Pediatrics Screening of Acute Stress SymptomsThis project aims to increase psychological screening consults for admitted pediatric trauma patients using quality improvement methodology with iterative interventions.Jennifer Fuchs, MD
Quality Improvement/Patient Safety LeaderIf you hold a position related to Quality Improvement/Patient Safety, you can earn MOC Part IV credit (Physicians) or PI-CME credit (for PAs). For example, Chief Quality or Safety Officer, Vice-Chair for Quality, Quality and Safety Committee Chair, Advisor/Mentor/Preceptor to Learners conducting Quality and Safety Work, or Member of a UNC Health QI Oversight CommitteeMonecia Thomas
Quality Improvement PosterAny physician or PA who meaningfully participated in improvement work that was/is represented on a poster is eligible for credit through the Portfolio Program.Monecia Thomas
Decreasing Moderate to Severe Malnutrition in Pediatric OncologyPediatric oncology patients can be at nutritional risk for suffering from moderate to severe malnutrition, which can lead to increased hospital length of stay and complications. Up to 25% of patients with malignancy have malnutritionJohn Hipps, MD
UNC-Medical Center Daily Safety Huddles - Part 2Safety 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.
Tom Ivester, MD

Bret Shultz, Research Program Manager

Malnutrition Screening in Patients with Inflammatory Bowel Disease in the Ambulatory Care Setting This project aims to increase the screening for malnutrition in the IBD clinic and create a mechanism for patients who screen positive to see a dietician. Anne Peery, MD
Department of Anesthesiology Team-Based ProjectsThis project focuses on Anesthesiology residents to improve their knowledge and skills to implement a QI project led by Faculty Mentors. Lavinia Kolarczyk, MD

Nathan Woody, Project Manager
Practices Supporting Families with IDD (Intellectual and Developmental Disabilities)Caregivers of children with intellectual and developmental disabilities (IDD) serve as advocates for their child's health and wellbeing. This project will help primary care practices feel comfortable checking in with caregivers about their emotional support needs and assist them in developing and implementing actions plans as needs arise.Dr. Rebecca Baum
Kimberly Schlegel
NC PAL IDD Coordinator. Carolina Institute for Developmental Disabilities.
Improving Pediatric Rapid Response Communication
Improved communication between members of the medical team will aid in the early recognition of clinical deterioration, allowing for earlier intervention and decreased morbidity and mortality for patients.Emilee Lewis, MD
System Sepsis Program Sepsis is the leading cause of death amongst UNC Health's inpatients. Sepsis diagnosis and treatment are complex, and as such, require assistance through improvement projects to make it easier for clinicians to identify sepsis earlier and intervene appropriately. Charul Haugen, MD

Rachel Lyu