Quality Improvement Principles Research Articles

ԲԱՐՁՐԱԳՈՒՅՆ ԿՐԹՈՒԹՅԱՆ ՈՐԱԿԻ ԱՊԱՀՈՎՄԱՆ ՄՈԴԵԼՆԵՐԻ ԳՈՐԾԱՐԿՄԱՆ ՍԿԶԲՈՒՆՔՆԵՐՆ ՈՒ ԱՌԱՆՁՆԱՀԱՏԿՈՒԹՅՈՒՆՆԵՐԸ / THE PRINCIPLES AND PECULIARITIES OF IMPLEMENTATION OF HIGHER EDUCATION QUALITY ASSURANCE MODELS

The article examines the principles and peculiarities of the implementation of American and European models of quality assurance in higher education. As a result, similarities and differences were identified between the studied models and quality assurance processes in the Republic of Armenia. According to the results of this research, the main similarities among the models are in identifying and meeting the needs and requirements of stakeholders, the vision of managers, their managerial abilities and skills, the application of the principle of continuous quality improvement in various processes, strengthening and developing cooperation and encouraging employees. The differences among the studied models are mainly related to the peculiarities of the field of higher education quality assurance in a given country, some principles and approaches to the implementation of the models. Unlike the studied models, in Armenia special attention is paid to the units of measurement of the results of the processes - key performance indicators (KPI) or quality assurance indicators (QPI) in the context of quality assurance, since the performance of entities depends on them.

Quality Improvement Training Framework Adoption at Katutura Hospital in Windhoek Namibia

In Namibia, most health care facilities have not been yielding good results in response to patients’ health care needs. Health care systems are becoming more complex with paradoxical challenges resulting into inefficiencies due to ever increasing science and knowledge in medicine, which makes it difficult to internalise and understand, as well as to implement certain procedures. The study explored and found that research indicates that total quality management (TQM) and continual quality improvement (CQI) principles can be applied to strengthen a health system to improve its quality. This could be particularly useful in Namibia where people demand basic services and the health service users raise their issues with the Ministry of Health and Social Services (MoHSS). It becomes essential to ascertain the extent to which health care facilities have responded to this call. Against this background, it is important to analyze the responses to QI and QA and how it could be used to develop a framework for quality health care delivery at the health care facilities in Namibia. The main focus of this paper is to identify quality improvement aspects at Katutura Hospital and to develop a quality improvement training framework to empower and equip health professionals with the right knowledge, skills, aptitudes, and behaviours to apply the methods and techniques with the purpose of improving customer service.

Improved Utilization Amongst Adult Sickle Cell Disease Patients: A Multi-Disciplinary Medical Home Approach

Background Worldwide, Sickle Cell Disease (SCD) is the most common monogenetic disorder. SCD is costly to the American health care system: $460,151 per patient for the 100,000 affected US patients. Biological and behavioral health comorbidities with limited hospital resources contributed to a cost increase in SCD readmissions at the Virginia Commonwealth University Health System (VCUHS) from 2012-2016, after a long history of decline. With increasing census, in FY16 the 30-day SCD readmission rate was 33.7%, up from 22.5% in FY14. The average SCD length of stay was 6.7 days, compared with an expected length of 4.2 days. The number of ED visits for SCD patients in FY17 was projected to be double that of FY14. The percent of ED returns in 3 days was projected to be triple that of FY14. Method The VCU Adult SCD Medical Home (ASCMH) was funded and launched to address this issue, based on the success of a pilot that showed cost savings of $333,000 for 5 patients in 12 months. The SCD ASCMH officially began January 1,2018 with a two-year pilot funding period. The ASCMH was structured and designed using quality improvement (QI) principles and consisted of multidisciplinary teams to coordinate inpatient care, emergency care, and ambulatory care respectively. Evaluation compared utilization during CY 2017 (pre-intervention) versus CY 2019 (2 years post intervention). For all patients we compared the average 30-day readmission rate, the average length of stay (ALOS), the average 3-Day ED return rate, the number of ED discharges, the numbers of inpatient days, inpatient discharges, and outpatient visits, the number of patients who used the ED, and total VCU charges. Results Among 541 (2017) and 592 (2019) SCD adults, including 40.6% males and 59.4% females, comparing pre-intervention to intervention, average utilization and VCU charges were either numerically or statistically significantly reduced. Mean 30-day readmission rates were reduced (31.60% vs 20.40%) ALOS was reduced (5.6 days vs 4.3 days), inpatient days were reduced (5313 days vs 3340 days), and total charges were significantly reduced ($15,664,895 vs $13,939,842). Conclusion At VCU, a multi-disciplinary ASCMH that featured intensive case management (CM) reduced annual utilization and cost savings for adult SCD patients. CM program elements that were most effective should be studied in the future and next steps should include a randomized controlled trial that can demonstrate evidence of their efficacy in strengthening and improving utilization Table Disclosures Smith: Emmaeus Pharmaceuticals, Inc.: Consultancy; GlycoMimetics, Inc.: Consultancy; Novartis, Inc.: Consultancy, Other: Investigator, Research Funding; Shire, Inc.: Other: Investigator, Research Funding; Imara: Research Funding; Novo Nordisk: Consultancy; Ironwood: Consultancy; Pfizer: Consultancy; Incyte: Other: Investigator; Health Resources and Services Administration: Other: Investigator, Research Funding; NHLBI: Research Funding; Patient-Centered Outcomes Research Institute: Other: Investigator, Research Funding; Global Blood Therapeutics, Inc.: Consultancy, Research Funding; Shire: Research Funding.

Looking to Improve Your Practice? Consider the Science of Quality Improvement to Get Started.

Quality improvement in health care is the responsibility of everyone (eg, patients, families, health providers, and administrative staff) to work toward delivering high-quality patient care, advancing professional knowledge and skills, and creating effective and efficient processes of care. Those involved in athletic health care, similar to other health care professionals, should strive to create patient care experiences that are safe, timely, effective, efficient, equitable, and patient centered. Exploring the differences between quality improvement and research will help define the focus of improvement sciences on the health of systems, which is to identify quality gaps and evaluate processes of care, as opposed to filling knowledge gaps. Furthermore, considering the principles of quality improvement will set the foundation for quality initiatives in health care to focus on patients, value teams, emphasize systems and processes of care, appreciate variability, and require data. With a greater understanding of the principles of the quality improvement sciences, athletic trainers will be better positioned to create a culture of quality improvement and to take the initiative in leading improvement efforts so that local systems support the delivery of high-quality patient care.

Dental caries management: A practical approach for your practice.

Chronic disease management models in primary care have demonstrated significant benefits to the patient experience and patient health outcomes. In trying to prepare for the future, with or without COVID-19 implications, dental providers and clinics are facing opportunities to add value, consider alternative payment models, and to incorporate risk stratification and population health management along with medical systems. However, as alternative payment models emerge in dentistry, stand-alone dental clinics may face unique challenges in trying to prepare for the future while still providing patient care in the fee for service environment. This article focuses on a 6-months pilot project of how implementing a comprehensive caries disease management care model, evaluating caries risk, and implementing risk stratification strategies can prepare dental offices for future payment models and inclusion in the greater health system. There are two overall goals for this pilot. First, applying a caries disease management protocol to every patient visit, regardless of reimbursement. Second, applying quality improvement (QI) principles to change how a dental office approaches care delivery. The Institute of Medicine defines quality in healthcare as a direct correlation between the level of improved health services and the desired health outcomes of individuals and populations.

Investigation on fiber fracture mechanism of c/sic composites by rotary ultrasonic milling

With wide application of continuous carbon fiber reinforced silicon carbide matrix (C/SiC) composites, machining damages have been paid more and more attention. Due to prominent anisotropy and heterogeneity, fiber damages affect the service performance of C/SiC parts directly. Surface quality is closely related to fiber fracture mechanism. This paper emphatically analyzed fiber removal process of rotary ultrasonic milling (RUM) of C/SiC composites. A calculation method for fiber fracture stress based on ultrasonic vibration was presented. High-frequency, low-amplitude oscillation varied fiber cutting angle and increased fiber shear stress through deflecting friction form the axial section to radial section of fiber. It promoted shear fracture mode to dominant removal mechanism greatly. The proportion of fiber cutting angle under shear fracture mode was enlarged by 30%. Then both RUM and conventional milling (CM) C/SiC tests were carried out. The principle of surface quality improvement during rotating ultrasonic milling was presented. Experimental results showed that fiber cutting angle affected C/SiC surface morphology directly. Surface of RUM had better machining quality with less delamination, fiber-matrix debonding length and fiber pulling-out damage. Its surface roughness Sa values were reduced by 26.8% and 40.6% during fiber forward cutting and backward cutting, respectively. It proved the rationality and effectiveness of rotary ultrasonic milling C/SiC composites.

Efficiency of microvascular free flap reconstructive surgery: An observational study.

We aimed to assess operative workflow and efficiency in microvascular free flaps via a direct observational study based on Lean principles of quality improvement (QI). Observers monitored the workflow of twenty-three free flaps. Pre-operative preparation and surgical duration was recorded with supplemental data provided from our institution's surgical tracking database. Traffic patterns of operating room (OR) staff were documented as "entries" and "exits" from the OR and classified by role and the reason that the entry or exit was required. Patient data was obtained via chart review. The mean surgical time was 9.0h. Approximately 20% of OR time was dedicated to the pre-incision process, averaging 1.6h per case. One third of entries and exits occurred during this period. In total, 180.2 surgical hours were observed during which 6215 "entries" and "exits" occurred. The mean number of entries and exits per case was 270; the most common reasons were supplies and communication. No association was observed between elapsed surgical time or total number of entries and exits with post-operative infection rates. Comprehensive observational workflow studies of free flaps are challenging to execute due to lengthy procedure times. At our high-volume institution, a significant portion of OR time is devoted to the pre-incision period, largely due to inadequate supply availability and pre-operative communication. These findings will serve as a foundation for QI interventions at our institution, while our observational model provides a broadly applicable framework for assessing surgical efficiency.

Picking Up the Pieces: Healthcare Quality in a Post-COVID-19 World.

Picking Up the Pieces: Healthcare Quality in a Post-COVID-19 World.

Using Quality Improvement Principles to Redesign a Cardiothoracic Surgery Fellowship Program Website

Websites are primary sources of information for prospective trainees. However, little is known regarding the information deemed most important to cardiothoracic (CT) surgery interviewees when evaluating a program. The objectives of this study were to (1) report informational content important to CT surgery interviewees on a fellowship website and (2) improve the quality of a specific program's website. Study investigators conducted a survey of interviewees at a traditional 2-year CT surgery fellowship program. Questions were asked to elicit what information interviewees considered important to include in a program website and to identify gaps in the website's content. After administering the survey to 2018 fellowship interviewees, the website was redesigned, and the survey was readministered to 2019 fellowship interviewees. A total of 49 interviewees completed the survey (response rate, 90.7%); 45 (91.8%) of these interviewees had previously visited the program's website. Interviewees reported that the most important information they sought when accessing fellowship websites included faculty profiles (n= 47), rotation schedules (n= 33), current fellows' profiles (n= 29), and past fellows' profiles (n= 26). The website was revamped to include content across each of these domains. After website redesign, there was significant improvement in interviewees reporting that they found the information they sought (mean score, 3.56 to 4.64; P < .001) and that the website was useful (mean score, 3.67 to 4.77; P < .001) compared with the previous year. CT surgery fellowship websites are accessed by the majority of interviewees and are a critical source of program information. Optimizing website design and content on the basis of survey feedback objectively improved the usefulness of the program website to interviewees.

Experiences With Quality Improvement in Training: A National Survey of Urology Residents

To determine the quality improvement (QI) experiences of urology residents in the United States. An Institutional Review Board approved national survey of Urology residents was administered in June 2019. The survey instrument sought to understand QI curricular methods and experiences of urology residents as well as their knowledge of QI fundamentals. Of 465 invited residents, 159 (34%) responded. Respondents represented all 8 AUA sections. The majority of respondents self-identified as white (66%). Females made up 30% of respondents. Less than 1/3 of residents (32%) report use of online modules, whereas nearly 2/3 (63%) report lecture-based didactics. Fifteen percent of residents report no QI curriculum. While nearly 2/3 of residents report receiving training in QI principles (64%), far less report receiving training in how to apply QI methodology (44%). Only 29% of residents report being required to lead a QI project. No differences were seen by training level. Only 3 respondents had heard of the Institute of Medicine's aims for quality improvement. Respondents had better knowledge of process, balancing and outcome measures, but less than half of respondents (49%) were able to correctly identify all 3. Having any QI curriculum is associated with correctly answering knowledge questions (P = .03). From a resident perspective, urology residency programs currently provide QI curricula that are inadequate to ensure residents achieve Accreditation Council for Graduate Medical Education milestones. It is imperative the urology community as a whole address these curricular gaps to ensure graduates are prepared to deliver high-quality, cost-conscious care to their patients once in practice.

Advancing the Culture of Patient Safety and Quality Improvement.

The American health care system has many great successes, but there continue to be opportunities for improving quality, access, and cost. The fee-for-service health care paradigm is shifting toward value-based care and will require accountability around quality assurance and cost reduction. As a result, many health care entities are rallying health care providers, administrators, regulators, and patients around a national imperative to create a culture of safety and develop systems of care to improve health care quality. However, the culture of patient safety and quality requires rigorous assessment of outcomes, and while numerous data collection and decision support tools are available to assist in quality assessment and performance improvement, the public reporting of this data can be confusing to patients and physicians alike and result in unintended negative consequences. This review explores the aims of health care reform, the national efforts to create a culture of quality and safety, the principles of quality improvement, and how these principles can be applied to patient care and medical practice.

Framework for Pharmacy Services Quality Improvement-A Bridge to Cross the Quality Chasm.

To review the literature on the subject of quality improvement principles and methods applied to pharmacy services and to describe a framework for current and future efforts in pharmacy services quality improvement and effective drug therapy management. The Academy of Managed Care Pharmacy produced the Catalog of Pharmacy Quality Indicators in 1997, followed by the Summary of National Pharmacy Quality Measures in February 1999. In April 2002, AMCP introduced Pharmacy's Framework for Drug Therapy Management in the 21st Century. The Framework documents include a self-assessment tool that details more than 250 specific "components" that describe tasks, behaviors, skills, functions, duties, and responsibilities that contribute to meeting customer expectations for effective drug therapy management. There are many opportunities for quality improvement in clinical, service, and cost outcomes related to drug therapy management. These may include patient safety; incidence of medical errors; adverse drug events; patient adherence to therapy; attainment of target goals of blood pressure, glucose, and lipid levels; risk reduction for adverse cardiac events and osteoporotic-related fractures; patient satisfaction; risk of hospitalization or mortality; and cost of care. Health care practitioners can measure improvements in health care quality in several ways including (a) a better patient outcome at the same cost, (b) the same patient outcome at lower cost, (c) a better patient outcome at lower cost, or (d) a significantly better patient outcome at moderately higher cost. Measurement makes effective management possible. A framework of component factors (e.g., tasks) is necessary to facilitate changes in the key processes and critical factors that will help individual practitioners and health care systems meet customer expectations in regard to drug therapy, thus improving these outcomes. Quality improvement in health care services in the United States will be made in incremental changes that rely on a structure-process-outcome model. The structure is provided by evidence created from controlled randomized trials and other studies of care and system outcomes that are based on the scientific method. The process portion is created by the application of evidence in the form of clinical practice guidelines, clinical practice models, and self-assessment tools such as Pharmacy's Framework for Drug Therapy Management. Incremental changes in structure and process will result in the desirable outcome of meeting customer needs for more effective drug therapy and disease management. Authors Richard N. Fry and Steven G. Avey are employed by the Foundation for Managed Care Pharmacy, a nonprofit charitable trust that serves as the educational and philanthropic arm of the Academy of Managed Care Pharmacy; author Frederic R. Curtiss performed the majority of work associated with this manuscript prior to becoming editor-in-chief of the Journal of Managed Care Pharmacy. This manuscript underwent blinded peer review and was subject to the same standards as every article published in JMCP.

Quality and safety in the time of Coronavirus: design better, learn faster.

The COVID-19 pandemic has required health systems to change much faster than normal. Many staff have experienced training in quality improvement and patient safety methods which can be used to support the design of new systems and to accelerate learning about new and adapted practices. This article sets out the principles of quality improvement and patient safety science, applying them in a selection of approaches, methods and tools which may be useful in crisis situations such as the current pandemic. The article also makes reference to several resources which may be of use to those keen to advance their knowledge.

The use of a novel synthetic resorbable scaffold (TIGR Matrix®) in a clinical quality improvement (CQI) effort for abdominal wall reconstruction (AWR).

The use of hernia mesh is a common practice in abdominal wall reconstruction (AWR) operations. The high cost of biologic mesh has raised questions about the value of its use in AWR. Resorbable synthetic mesh may have the potential benefits of biologic mesh, minimizing the need for removal when infected, at a lower cost. A hernia program has implemented the principles of clinical quality improvement (CQI) to improve patient outcomes. One process improvement attempt was implemented using a newly available resorbable synthetic scaffold. Long-term follow-up was obtained as a part of the CQI process. A total of 91 patients undergoing AWR were included between 8/11 and 9/15 (49months). There were 58 female (64%) and 33 male (36%) patients. The average age was 57.2years (28-80). The average BMI was 34.0 (17.6-53.4). There were 52 patients (57%) with recurrent hernias. Mean hernia defect size was 306.6cm2 (24-720) and mean mesh size was 471.7cm2 (112-600). Outcomes included a mean length of stay of 7.5days (0-49), a recurrence rate of 12% (11/91) and a wound complication rate of 27% (25/91). The recurrence rate decreased to 4.5% (3/66) after several improvements, including adopting a transversus abdominus release (TAR) approach, were implemented. There were no mesh-related complications and no mesh removal (partial or total) was required. The mean follow-up length was 42.4months (0-102). In this group of patients, an attempt at process improvement was implemented using a resorbable synthetic scaffold for AWR. With no mesh-related complications and no mesh removals required, there was an improvement in value due to the decrease in mesh cost and improved outcomes over time. Long-term follow-up demonstrated the durability of the repair.

Development and application of ‘systems thinking’ principles for quality improvement

Introduction‘Systems thinking’ is often recommended in healthcare to support quality and safety activities but a shared understanding of this concept and purposeful guidance on its application are limited. Healthcare systems...

Testicular Pain Pathway in Children: Investigating Where Missed Torsion Occurs Most Often.

Acute scrotal pain in children is a common presenting complaint in hospital, and it is imperative that cases of testicular torsion are identified and managed promptly. We aim to identify the most influential points in the pathway in determining whether patients are managed in the appropriate time frame, so these areas can be targeted to improve salvage rates. Using quality improvement principles, the pediatric scrotal pain pathway was mapped out, commencing with initial symptom onset and ending with definitive surgical management. We retrospectively reviewed data on all patients between 0 and 18 years of age attending the emergency department at Whipps Cross University Hospital with acute scrotal pain between October 2010 and October 2013. Over the 3-year period, 238 patients 18 years or younger presented to casualty with scrotal pain. Of the patients assessed initially by an emergency department physician, 52.8% (n = 67) were discharged without referral. To our knowledge, none of these patients presented later with a missed torsion. Torsion was diagnosed in 23.2% of the patients operated on (n = 22), of which 5 required orchidectomy, comprising 2.1% of all patients presenting with scrotal pain. In this group, 4 were due to late presentation by the patient. We demonstrate the value of different stages of the pathway, as more than half of patients seen in A&E were correctly discharged without referral. In the context of our study, late presentation to hospital appears to be the most significant factor leading to orchidectomy. To target this issue, awareness among both children and parents must be improved.

A Conceptual Model for Effective Quality Management of Online and Blended Learning

Institutions considering online and blended learning (OBL) face the challenge of strategically adopting OBL to develop, implement, monitor, assess and improve the quality of programmes and courses. The principles of continuous quality improvement (CQI) allow this challenge to be addressed. Effective CQI management implies that quality assurance and quality improvement follow and inform each other as part of a continuous cycle. Scholars report however, that quality management of OBL usually focuses on assurance. The purpose of this paper is to provide a state of the art approach for effective CQI management which allows practitioners to achieve coherence between quality assurance and improvement of OBL. In this conceptual paper we link and integrate work across fields to address the challenge of achieving coherence between quality assurance and improvement. We discuss research in the context of CQI that uncovers features of OBL that prevent practitioners from achieving coherence. The conceptual model for effective CQI of OBL integrates data based decision‑making. The conceptual model provides a foundation for research on the effectiveness of this CQI management approach in the context of OBL. The quality management approach supports practitioners during the entire CQI‑cycle to foster dialogue and consultation between all stakeholders in the institution in order to strategically develop assess and improve the quality of OBL programmes and courses. The originality of the model lies in making explicit data‑based decision making as a driver for effective CQI management in the context of OBL.

Lessons Learned From Introducing Staff to Quality Improvement Through Systematic Training at the Boston Public Health Commission.

The widespread adoption of quality improvement (QI) in public health departments holds the promise of transformational change for the American public health system; however, there is a lack of published literature pertaining to organization-level experiences with introductory QI training programs for health department staff. This practice report aims to share the innovative approach, experience, and results of introducing staff to QI principles at the Boston Public Health Commission (BPHC). The BPHC is an accredited health department that introduced more than 80% of its 1100 staff members to QI between January 2015 and December 2018. The commission's QI training program benefited from (1) visible support from senior leaders, (2) well-documented QI training plans, (3) innovative QI training curricula, (4) flexible delivery methods, and (5) a responsive monitoring and evaluation system. To assess the effectiveness of QI training at the BPHC, participant questionnaires from QI training sessions (run between January 2015 and June 2018) and a separate questionnaire on organizational QI culture (administered to the supervisory staff in May 2018) were assessed using the Kirkpatrick model of training evaluation. On the basis of Kirkpatrick's 4 levels of training effectiveness, 91% of participants were satisfied with training content (level 1), 94% of participants found the facilitators effective (level 2), 84% of participants indicated they would apply QI concepts in everyday work (level 3), and 75% of supervisors reported an organization-wide improvement in QI culture (level 4). These results show that the BPHC's QI training program has been resoundingly effective, with positive outcomes across all 4 levels of the Kirkpatrick model. These results reinforce the idea of the BPHC's experience as an exemplar for introductory QI training. Interested health departments should heed the lessons learned from this and other organizational experiences as they attempt to scale up QI competencies among staff members.

A Novel Experiential Quality Improvement Training Program During Residency Improves Quality Improvement Confidence and Knowledge: a Prospective Cohort Study.

The Accreditation Council for Graduate Medical Education (ACGME) mandates resident quality improvement (QI) training to improve patient safety, cost control, and efficiency. Thus, understanding this topic is crucial for early career physicians. This manuscript describes an enhanced, experiential QI curriculum for psychiatry residents and its outcomes. Two cohorts of 12 third-year residents completed the curriculum, which included didactics, external resources, and expert guidance through small group project design, implementation, and analysis/presentation. A survey on resident confidence in QI principles and the quality improvement knowledge assessment tool-revised (QIKAT-R) was used before and after curriculum participation. Data were analyzed using parametric descriptive tests and repeated measures general linear models with Benjamini-Hochberg correction for multiple comparisons. Resident confidence in performing seven of the ten steps of QI and QIKAT-R scores significantly improved for both cohorts (p = .011). Eighty-nine percent of residents felt that the curriculum met their goals. The QI curriculum effectively improved resident QI confidence and knowledge. Residents reported that experiential engagement in the design, implementation, and analysis/presentation of their project was crucial to these achievements. This experiential QI curriculum with resident-generated QI projects addressed ACGME training requirements while integrating QI training directly into the residents' clinical activities, making the QI efforts relevant and meaningful while also achieving ACGME goals.

Realizing the vision for pediatric pharmacy practice advancement through strategic planning and implementation.

In a rapidly changing healthcare landscape, pharmacy leaders must be agile and innovative to ensure that patients receive the highest-quality care. Here we describe the benefits of using a structured approach to pediatric pharmacy practice advancement guided by strategic planning and quality improvement principles. Although there are many profound differences between pediatric and adult pharmacy management practices, many similarities also exist. Small- and large-scale change is most commonly guided by quality improvement methodology at Nationwide Children's Hospital. Using this framework, the pharmacy practice model at Nationwide Children's Hospital was reenvisioned to facilitate best patient outcomes and advance the role of pharmacists in the care of pediatric patients. Through these efforts, the percentage of inpatient hospital services with a pharmacist embedded into the care team increased from 67% to 90%, the number of pharmacists providing direct inpatient care increased from 27 to 50, and the number of ambulatory clinical pharmacists more than tripled, from 3 to 10. Enhanced clinical pharmacy services were developed to provide consistent care on weekends and holidays while striving to reach zero patient harm. Involvement of pharmacists and pharmacy technicians, alignment with the health system's mission, and internal development of pharmacists through focused training programs were vital to successful practice advancement. Significant practice model advancement in a pediatric healthcare system is achieved by using the organization's common language for change, involving frontline staff in creating the vision, and leadership steadfastly committing to realize the vision.