Department Quality and Safety

Announcing the FY18 Children's Quality Goals

Children's Services continues to emphasize safe and high-quality patient care as the focus of our clinical care mission. To this end, The Children's Improvement Council was formed in January of this year and has already been hard at work. This Council approved three pediatric-focused improvement goals for FY18. Active, formal improvement work will begin in July to address these goals:

Enhance Medication Safety-Improve the Discharge Medication Process

Implement a Standard Discharge Process

Reduce Anesthesia Time for Children in the OR

Morbidity and Mortality Conference

M&M Conference Dates for FY19

  • August 31st, 2018
  • September 27th, 2018
  • October 25th, 2018
  • November 29th, 2018
  • January 25th, 2019
  • February 22nd, 2019
  • March 29th, 2019
  • April 26th, 2019
  • May 31st, 2019

UNC Department of Pediatrics Morbidity and Mortality Process (PDF)

UNC Department of Pediatrics Morbidity and Mortality Hierarchy of Actions (PDF)


  1. ED Pediatric Asthma Initiative
  2. Inpatient Discharge Time Initiative
  3. ED Pediatric Sepsis Improvement Initiative
  4. ED Pediatric Stewardship in Improving Bronchiolitis
  5. Newborn Nursery Antibiotic Stewardship Initiative
  6. ED Urinary Tract Infection (UTI) Initiative
  7. Discharge Medication Process Initiative
  8. Direct Admit Initiative
  9. Standard Discharge Process Initiative


Template: Improvement Initiative Reporting Template


A Quality-Improvement Initiative to Reduce NICU Transfers for Neonates at Risk for Hypoglycemia (2018) reports on an improvement intervention that decreased the rate of at-risk infant transfer to the NICU for hypoglycemia

Improving Timeliness of ß-Agonist and Corticosteroid Administration in Patients With Acute Wheezing (2017) reports on an improvement initiative that achieved significant improvements in the timeliness of asthma medication administration in the Children’s Emergency Department.

A Multidisciplinary Children's Airway Center: Impact on the Care of Patients with Tracheostomy (2016) describes multiple improvements made through a multidisciplinary approach to management of tracheostomy patients.

Improving HIV Post-Exposure Prophylaxis Rates After Pediatric Acute Sexual Assault (2017) reports results of an initiative to increase the emergency department rate of HIV post-exposure prophylaxis following a sexual assault.

Lessons learned from measuring Return on Investment in Public Health Quality Improvement Initiatives (2016) examines the efficacy of using economic impact and return on investment analyses in the context of public health settings, and the importance of using these analyses to measure QI projects' financial impact.

Advancing Quality Improvement in Public Health Departments through a Statewide Training Program (2016) describes the impact of an 8-month experiential learning course in which staff members from 37 North Carolina Health Departments learned how to use QI methodology to apply to projects within the health department.

A Multidisciplinary Children's Airway Center: Impact on the Care of Patients with Tracheostom(2016) examines the impact of using a multidisciplinary forum to treat tracheostomy patients, especially in the reduction of median hospital days and reduced tracheostomy complications.

Quality Improvement in Pediatric Heart Failure (2016) describes the challenges in performing quality and process improvement in pediatric cardiology, and emphasizes the need for advocacy, organizational infrastructure, international committees, and a pediatric database in order to more effectively institute quality improvement practices in pediatric heart failure.

Translating Clinical Guidelines into Practice: Challenges and Opportunities in a Dynamic Health Care Environment (2015) discusses how clinical practice guidelines have the potential to improve population health, are currently underutilized. Although there are barriers to implementation, it is possible to integrate these evidence-based recommendations into daily clinical practice.

Decreasing Time to Antibiotics in Febrile Patients with Central Lines in the Emergency Department (2015) demonstrates an improvement project that delivered antibiotics to 90% of patients within 60 minutes and reduced process variation.

Quality Improvement in North Carolina's Public Health Departments (2013) details the QI work that has been used in public health departments across the state over the past decade. A case study on the Macon County Health Department elaborates on a specific QI/lean process, while focusing on the quality of patient care.


Department of Pediatrics External Collaboratives


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