Quality and Performance Improvement Projects

Quality and performance improvement is one of our top priorities at UT Southwestern. One of the ways we improve quality is to conduct quality and performance improvement projects related to specific areas of patient care and clinical operations. The projects utilize established methods of improvement that have been taught at UTSW and are aimed at improving the patient outcomes and experience at UT Southwestern. The following is a sample of projects that have been completed or are underway at UTSW or one of our affiliated institutions as part of our Clinical Safety and Effectiveness Program.

Also, included in the list are quality improvement and patient safety projects associated with the M.D. with Distinction in Quality Improvement and Patient Safety.

Clinical Safety and Effectiveness Projects

Quality and Performance Improvement Projects

Increase Sickle Cell Patient Awareness of the Day Treatment Program – UTSW

  • Kelly Robinson, Pharm.D., M.B.A.; April Netek, M.S., CRC; Tonya Mitchell, M.B.A. 

Keeping Moms Toasty: Are We Doing Enough? – UTSW

  • Brian Gelpi, M.D.; Neeti Sadana, M.D.

Appropriate Telemetry – UTSW

  • Peggy Bartholomew, M.H.S.M., B.S., R.N.; Margaret Dupre, M.S., R.N., CNL; Suzanne Stone, B.S.N., R.N.; Christopher Vanstone, B.S.N., B.A., R.N., CEN

Get With AHA Guidelines – UTSW

  • Kay Jones, R.N.; Rhonda Armour, R.N.

Improving Palliative Care Clinic Efficiency – UTSW

  • Fiza Nazir, M.D.; Darren Nelson, M.D.

Perioperative Glycemic Management – Parkland

  • Mary Adams, RN; Kevin Garnepudi, D.O.; Margaret Macauley, R.N., B.S.N.; Karla Voy-Hatter, R.N., M.P.H., M.H.A., CIC; Nancy Baez, M.B.A.  

Decrease the Number of e-fax Prescribed Medication Restock at Bluitt Flowers – Parkland

  • Herron Mitchell; Karen Roath, M.A., PHR

Improving the Release of Information Customer Experience – UTSW

  • Shawna Ridley, M.B.A., R.H.I.A., CPC, CPC-H; Susan Rossiter, R.H.I.A., CHPS; Barvette Garrett, M.S., PHR

A Multidisciplinary Approach to the Development of an Agitation Protocol – UTSW/Parkland

  • Lynn Roppolo, M.D.; Ella Williams, M.D.; David Morris, Ph.D.; Tiffany Carder, B.S.N., R.N.                     

VitalSign6 - UTSW

  • Charlotte Carito, L.P.C., BC-DMT; Ronny Pipes, L.P.C.-S.; Sara Levinson Eidelman, M.S.L.O.C., M.P.H.; Valeria Cantu, B.A.

Improved Coordination of Radio-Ablative Iodination Therapy  UTSW

  • Audrea Tamez; Adis Umpierre, R.N., B.S.N., M.P.H.; Matt Amen, B.S.

Out of the OR Intubation Checklist for Anesthesia Providers – UTSW

  • Proshad Nemati Efune, M.D.; Guy Efune, M.D.      

Inpatient Hypoglycemia Prevention Project – UTSW

  • Regina Bonnette, R.D., CDE, BCADM; Nancy Drobycki, M.S.N., R.N., CDE; Elizabeth Vattakunnel, Pharm.D., BCPS        

Medication Errors in the Surgical Intensive Care Unit – Parkland

  • Pam Farrington, R.N.; Stacey Barker, B.S.N., R.N.

Managing Hemodynamic Instability in the CVICU – UTSW

  • Joy Lo Chen, M.D.; Swathi Tella, M.D.

Improve Inpatient ED to Inpatient Throughput – UTSW

  • Michael Baldovsky, D.O.; Sherri Hughes, R.N., B.S.N.; Geneva Burnap, R.N., M.B.A., NEA-BC            

Decreasing Routine Lab Tests in the Neonatal Intensive Care Unit – UTSW

  • Juliann Sheehan, M.D.; Nandeesh Rangaswamy, M.D.; Katherine Stumpf, M.D.

Implementation of the Central Line Checklist in the Electronic Health Record – Parkland

  • Jill Sommerhauser, R.N., B.S.N., MAT; Gail Ausbrooks, B.S., R.N.; Joji Mathew, R.N., M.S.N.

Reduce Readmissions of Late Preterm and Full-Term Babies due to Excessive Weight Loss, Jaundice, or Feeding Issues – Parkland

  • Alma Rivera, R.N., B.S.N.; Marisa Aguilar, R.N.; Mavis Amoako, R.N.

Hospital-Acquired Clostridium Difficile Infections - UTSW

  • Ray Hwong, M.D.                                  

DSRIP Category 3 Chronic Condition and Preventive Care Improvement for Diabetic Care - UTSW

  • Valene Torres, CMPE; Jamie Marsh-Wheeler, M.B.A.; Julie E. Urias, CHW; Lilit Mushegyan

Reducing Code Blues Outside of the Intensive Care Units - UTSW

  • Theresa (Tracy) Heineman, B.S.N., R.N., CCRN; Shannon Chalk, B.S.N., R.N., CCRN-CMC; John Christopher Davis, M.S.N., R.N., CCRN

Increasing the Success of Projected 11 a.m. Discharges - UTSW

  • Raquel Martin, B.S.N., R.N., OCN; Susie Molina, M.T. (ASCP)SH, M.B.A./M.H.A.

Breast Cancer Screening/Mammogram Improvement - UTSW

  • Adriana Vega, B.A.; Sarah Bears, LVN, Martha Beshers-Wolfe, CHW; Maya Casanova, CHW

Depression Screening - UTSW

  • Hiland Nguyen, M.S.I.T.; Veronica Martinez

Performance Improvement with Pneumonia Vaccine in North Dallas Shared Ministries - UTSW

  • Monica Bears, LVN

Population Management - UTSW

  • Christy Cawthon; Annette Mace, LVN

How to Reduce the Clinical Trial Start-Up Time at UT Southwestern Medical Center - UTSW

  • Parvin Mohazabnia, M.D.; Sheikh Vikarunnessa, M.B.B.S.

Increasing Administration Rates of the Discharge Risk Assessment (DRA) - UTSW

  • Barry Gabrielson, M.S.; Shubhada Godbole, Ph.D.

Reducing Patient Wait Time from Referral to Appointment - UTSW

  • Catherine Wallace, B.S.R.T(T)., CMPE; Robyn Farrell, ACHE; Tannell Davis Wells

Optimizing Antibiotic Treatment Duration for Community Acquired Pneumonia - VA

  • James Cutrell, M.D.; Kazeen Abdullah, M.D.

Improving Compliance of Foley Catheter Maintenance Bundle - Parkland

  • Calvin White, M.P.H., CIC; LaTarsha Doze, R.S.; Shannon Simmons, M.P.H.

Reducing Coagulase Negative Staphylococcus Aureus (CoNS) Blood Culture Contamination in the Neonatal Intensive Care Unit - UTSW

  • Preethi Srinivasakumar, M.D., F.A.A.P.; Health Miller Weydig, M.D.

Diabetic Eye Exams - UTSW

  • Perce’ Tate, Community Health Worker Instructor; Maria A. Baxter, R.N.        

Improving Ambulatory Nurses’ Response Time to Patient Telephone Encounters - UTSW

  • Rose Dewald, R.N., B.S.N., CMPE; Alisha Orton, M.S., R.N., CMPE; Nancy Sharp, M.B.A., B.S.N., R.N.

Reduce Inappropriate Use of Proton Pump Inhibitors (PPIs) for Gastrointestinal Prophylaxis at UTSW Hospitals - UTSW

  • Tracie Eshelbrenner, Pharm.D., BCPS; Bryan Poon, Pharm.D.; ThinhTran, Pharm.D., BCPS

Improve Overall Full-Cycle Recruitment Time by 20% - Parkland

  • Ian Reynolds; Michael Quezada, M.B.A.

Enhancement of Access to Epidural Analgesia through Education - Parkland

  • Jerry W. Green, D.O.; Janice Lankford, CNM; Susan Chew, CNM   

Training for Circumcision Consents - Parkland

  • Theresa Wiley, R.N., CPNP; JoAnn Vinson, R.N., CPNP

The Incidence of Adverse Events Associated With Nitrofurantoin Use by Older Adults – UTSW

  • Edward Stocks, MS2; Karin Claussen, MS2; QI Faculty Mentor: Jason Fish, M.D., M.S.H.S.,
  • Project Sponsor: Craig Rubin, MD

Improving Patient-Staff Communication in the Neonatal Intensive Care Unit – Parkland

  • Jamila Hokanson, MS2, M.B.A., M.H.A.; QI Faculty Mentor: Gary Reed, M.D., M.Sc.,
  • Project Sponsor: Mackenzie Frost, MD

Improving Patient Handoffs from CVOR to the CVICU – UTSW

  • Thomas Lowrey, MS2; QI Faculty Mentor/Project Sponsor: Philip Greilich, M.D.

Improving the Intra-Operative Transfer-of-Care Process – UTSW

  • Jim Sheng, MS2; QI Faculty Mentor/Project Sponsor: Philip Greilich, M.D.

Reducing Central Line Associated Blood Stream Infection by Improving Nurses’ Patient Education Process – Parkland

  • Giang Nguyen, MS2; QI Faculty Mentor: Gary Reed, M.D., M.Sc.,
  • Project Sponsor: Joseph Berger, M.D.

Developing a Robust Model to Assess Institutional Climate and Adverse Event Reporting – UTSW

  • Michael Gonzales MS2; QI Faculty Mentor/Project Sponsor: Philip Greilich, M.D.

Development of a Standardized Review of Key Indicators Associated in Parkland Patient with Surgical Site Infections (SSI) – Parkland

  • Christopher Chan, MS2; QI Faculty Mentor/Project Sponsor: Pranavi Sreeramoju, M.D.

Epidemiological Study of Methicillin-Resistant Staphylococcus aureus Among Patient on the Burn ICU

  • Bayless Drum, MS2; QI Faculty Mentor/Project Sponsor: Pranavi Sreeramoju, M.D.

Impact of a physician Dashboard on Episiotomy Utilization at Clements University Hospital

  • Katherine Xiong, MS2; QI Faculty Mentor/Project Sponsor: Robyn Horsager-Boehrer, M.D.

Improving Emergency Department Discharge through Physician Directed Instructions and a Simple Algorithm Designed for Residents in Training: The R2D2 Disposition Protocol

  • Jesse Hernandez, MS2; QI Faculty Mentor/Project Sponsor: Lynn Roppolo, M.D.

Generation of a Practice Facilitator Training Manual and Data Validation for ICD-Pieces Study

  • Mark Sakai, MS2; QI Faculty Mentor: Gary Reed, M.D., M.Sc.
  • Project Sponsor: Miguel Vazquez, M.D.

Improving Diabetes Care in an Endocrinology Outpatient Clinic

  • Eric Kuo, MS2; Benjamin Weia, MS2; QI Faculty Mentor/Project Sponsor: Chanhaeng Rhee, M.D., M.B.A.

Effect of “SMaRT” Enhanced Recovery Pathway for Elective Colorectal Surgeries on Process and Outcomes in a Large, Urban Academic Health Care System

  • Taylor Roberts, MS2; QI Faculty Mentor/Project Sponsor: Jennifer Rabaglia, M.D.