Utilizing Quality Improvement Research Articles

Using quality improvement approaches to increase emergency department provider engagement in research participant enrollment during COVID-19 and opioid overdose public health emergencies.

We utilized quality improvement (QI) approaches to increase emergency department (ED) provider engagement with research participant enrollment during the opioid crisis and coronavirus disease (COVID-19) pandemic. The context of this work is the Evaluating Microdosing in the Emergency Department (EMED) study, a randomized trial offering buprenorphine/naloxone to ED patients through randomization to standard or microdosing induction. Engaging providers is crucial for participant recruitment to our study. Anticipating challenges sustaining long-term engagement after a 63% decline in provider referrals four months into enrollments, we applied Plan-Do-Study-Act (PDSA) cycles to develop and implement an engagement strategy to increase and sustain provider engagement by 50% from baseline within 9months. Our engagement strategy was centered on Coffee Carts rounds: 5-min study-related educational presentations for providers on shift; and a secondary initiative, a Suboxone Champions program, to engage interested providers as study-related peer educators. We used provider referrals to our team as a proxy for study engagement and report the percent change in mean weekly referrals across two PDSA cycles relative to our established referral baseline. A QI approach afforded real-time review of interventions based on research and provider priorities, increasing engagement via mean weekly provider referrals by 14.5% and 49% across two PDSA cycles relative to baseline, respectively. Our Coffee Carts and Suboxone Champions program are efficient, low-barrier, educational initiatives to convey study-related information to providers. This work supported our efforts to maximally engage providers, minimize burden, and provide life-saving buprenorphine/naloxone to patients at risk of fatal overdose.

Addressing social determinants of health through customization: Quality improvement, telemedicine, and care coordination to serve immigrant families.

The purpose of this project was to establish a pathway for electronic medical record (EMR) customization, utilizing quality improvement methodology, to both identify and address adverse social determinants of health (SDOH) among a diverse spina bifida (SB) population. Starting in September 2020, the four fundamental steps were to (1) facilitate an advisory committee to safeguard the standard clinical protocols, (2) characterize barriers to implementation, (3) evaluate workflow to sustain data entry capture, and (4) manage the technology platform for seamless integration. The SB clinic was the first clinic within the enterprise to rollout the use of an adverse SDOH mitigation activity. A Spanish-speaking interpreter was scheduled for all clinics, as many families were limited in English proficiency. The customization of the EMR to support an efficient workflow to address SDOH was feasible in a large and diverse urban medical center. Of the 758 patients served in the clinic, a myelomeningocele diagnosis was present in 86% of individuals. While 52% of participants were female, ethnically 52% of individuals served were Latino. Many of these individuals disclosed being recent immigrants to the United States. Often immigration and asylum related issues were at the forefront of the SDOH issues addressed. Given the occurrence of adverse SDOH among individuals with SB, many of whom are new Latin-American immigrants, meaningful clinical efforts are needed to both identify and address the causes of the observed disparities. EMR customization is feasible and can identify and, through social prescriptions, address SDOH to support the provision of safe, high quality, and equitable care for vulnerable and medically complex populations at home and potentially abroad.

Increasing optimal coagulation factor dosing in the paediatric emergency department: Update to a quality improvement study.

Prompt, appropriate coagulation factor replacement according to injury and bleeding severity in persons with haemophilia is required to prevent acute and long-term complications. Increase proportion of persons with haemophilia A (HA) and B (HB) treated appropriately for an acute injury and bleeding episode at a tertiary children's emergency department (ED) from 65% to 85% and sustain for one year. Secondary aim: increase time interval between patient ED encounters with out-of-range factor dosing. Utilizing quality improvement methodology and plan-do-study-analyze cycles, ED encounters for individuals with HA/HB receiving coagulation factor replacement for injuries were audited for in-range coagulation factor dosing. Goal factor dose defined as 50% correction for minor bleeds and 100% correction for major bleeds. Optimal dosing range defined as 90%-120% of the calculated goal dose to account for vial size variability. Interventions targeted communication via the EMR problem list and optimization of physician education. Our previous publication demonstrated 33.3% of ED encounters with out-of-range factor replacement. Following several interventions, the cumulative rate of encounters with out-of-range dosing decreased to 18%. Overall, there was an increase in the mean percent of encounters receiving optimal factor dosing for both HA/HB compared to baseline (82.2% vs. 71.1%), though this was not a statistically significant difference. Despite implementation of multiple interventions, out-of-range factor dosing continues to occur. Our team plans to reinstate simulation center education for ED staff and continue education efforts of pharmacists and hematology trainees with the goal of further reducing out-of-range dosing in our ED.

Reducing the rate of central line-associated bloodstream infections; a quality improvement project

BackgroundThe burden of central line-associated bloodstream infections is significant and has negative implications for healthcare, increasing morbidity and mortality risks, increasing inpatient hospital stays, and increasing the cost of hospitalization. Efforts to reduce the incidence of central line-associated bloodstream infections have utilized quality improvement projects that implement, measure, and monitor outcomes. However, variations in location, healthcare organization, patient risks, and practice gaps are key to the success of interventions and approaches. This study aims to evaluate interventions of a quality improvement project on the reduction of central line-associated bloodstream infection rates at a university teaching hospital.MethodsThis was a retrospective review of a quality improvement project that was implemented using the Plan-Do-Study-Act quality improvement cycle. Active surveillance of processes and outcomes was performed in the critical care areas; compliance to central line care bundles, and central line-associated bloodstream infections. Interrupted time series was used to analyze trends pre and post-intervention and regression modeling to estimate data segments preceding and succeeding the interventions.ResultsThere were 350 central line insertions, 3912 catheter days, and 20 central line-associated bloodstream infection events during the intervention period. Compliance with central line care bundles was at 94%. There was a trend in the reduction of central line-associated bloodstream infections by 18% that did not reach statistical significance (p = 0.252).ConclusionsImprovement projects to reduce central line-associated bloodstream infections face challenges and complexities associated with implementing interventions in real-world healthcare settings. There is a great need to continuously monitor, evaluate, readjust, and adapt interventions to achieve desired results, sustain improvements in patient outcomes, and investigate reasons for non-adherence as keys to achieving desired outcomes.

Bridging the Gap: Utilizing Quality Improvement Tools to Refine a Pediatric Varicella Exposure Investigation

Bridging the Gap: Utilizing Quality Improvement Tools to Refine a Pediatric Varicella Exposure Investigation

Improving Wait Times for Children with Caregivers with Limited English Proficiency in the Emergency Department.

In our pediatric emergency department (ED), children triaged as low acuity who presented with Spanish-speaking caregivers with limited English proficiency (SSLEP) experienced disparately longer wait times than similarly triaged children with English-proficient caretakers. Although inequities in ED care based on language preference exist, little is known about effective interventions to eliminate the disparity. This quality improvement study aimed to eliminate the disparity in wait times and share effective interventions. A multidisciplinary team incorporating clinicians, professional interpreters, and data analysts utilized quality improvement methodology to introduce early identification of SSLEP children, standardize physician workflow, and optimize the interpreter process. The primary outcome was the length of stay. The secondary outcome was time to the provider. The balancing measures were revisits and non-LEP length of stay and time to the provider. Secondary analyses distinguished between the effect of our QI intervention and secular trends. The mean length of stay for SSLEP children decreased from a mean of 178 to 142 minutes, a 36-minute (20%) decrease. Mean time to provider for SSLEP decreased from 92.8 to 55.5 minutes, a 37-minute improvement (40%). The 72-hour-revisit rates did not increase for SSLEP children throughout the project. We identified feasible interventions to improve wait times for children with SSLEP. Future directions include addressing components of the entire ED visit to decrease the length of stay discrepancies between populations. We hope to extend our findings to benefit all LEP communities.

Cardiovascular Disease Prevention in Persons with Hemophilia

Background: Advances in the treatment of hemophilia have resulted in a nearly normal life expectancy for persons with hemophilia (PwH). As a result of this improved life expectancy the aging hemophilia population is now experiencing age-related complications including cardiovascular disease (CVD), which is the leading cause of death in the US general population. Several studies have shown that the CVD risk profile among PwH is less favorable than that in the general population (Fransen van de Putte et al., 2013; Sood et al., 2018). Despite higher rates of hypertension among PwH, rates of treatment are lower than in the general population (Sood et al., 2018). We also know that atherosclerosis develops at the same rate among PwH as in the general population (Biere-Rafi et al., 2012; Zwiers et al., 2012). When CVD occurs in PwH, the management is more complicated due to the requirement for clotting factor concentrates to offset anticoagulant and antiplatelet therapies and prevent serious bleeding complications (Martin & Key, 2016). Recent prospective data indicate that the incidence of cardiovascular endpoints in PwH is lower than would be predicted by the QRISK-2011 score, but the use of novel therapies was not analyzed in that study, and we do not know how widespread use of these therapies will impact the development of CVD among PwH (Van Der Valk et al., 2022). Primary prevention of CVD through risk factor management is essential to prevent cardiovascular complications in the era of novel therapies for hemophilia. Study Design and Methods: This multicenter observational cohort study will utilize quality improvement science informed by frequent data sampling to improve the management of hypertension and dyslipidemia in PwH. Ten large hemophilia treatment centers will contribute 100 PwH each and will be stratified by age such that 25% of the population will be age 18-29, 30-44, 45-59, and 60-89. PwH will be eligible for inclusion if they have hemophilia A or B of any severity, are age 18-89, have been seen in the last 2 years, and do not anticipate relocating in the next 3 years. Men and women with hemophilia will be included. Individual consent will not be required as the dataset will be completely deidentified and the quality improvement interventions will be applied broadly to the hemophilia population at each center. Data will be collected from routine clinical care records. The primary outcome will be the prevalence of diagnosed and undiagnosed hypertension in this cohort. Secondary outcomes will be prevalence of dyslipidemia and rates of treatment for hypertension and dyslipidemia. Exploratory and descriptive statistical analyses will be performed. Deidentified data will be entered into a database via electronic medical record integration. This will allow for collection of 5 years of retrospective data, and subsequent monthly prospective data collection for 3 years. The automated nature of the data collection is novel and will allow for rapid record collection with minimal manual data entry, which can introduce errors and delay analysis. As such, a substantial number of records and timepoints can be collected. Conventional manual data entry of this scale would not be feasible for many independent academic studies. Table 1 contains the most relevant variables that will be collected. Retrospective data will be analyzed to determine the prevalence of hypertension, dyslipidemia, and established CVD. Rates of hypertension and dyslipidemia meeting criteria for diagnosis, but without an official diagnosis will also be determined along with rates of treatment in those who have been diagnosed. Investigators will be trained on the latest guidelines from the American College of Cardiology for the management of hypertension and dyslipidemia as part of this initiative. A survey will be distributed to participating investigators to determine barriers to control of vascular risk factors. This data be used by a steering committee to guide quality improvement efforts at each site. Monthly reports will inform investigators on the progress of their quality improvement initiatives. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Proactive risk mitigation for cardiac arrest prevention in high-risk patients with congenital heart disease

ObjectiveThe prevalence of postoperative cardiac arrest (CA) increases with cardiothoracic surgical case complexity and is associated with a 40% to 50% mortality. Despite having a low overall surgical mortality rate at our center, our postoperative CA rates were higher than expected, with an observed-to-expected ratio of 2.6. Utilizing quality improvement methodology, we evaluated the influence of proactive risk mitigation on postprocedure CA in a high-risk cohort of pediatric cardiac patients. MethodsThis single-center study utilized the Institute for Healthcare Improvement model. We created and implemented our Proactive Mitigation to Decrease Serious Adverse Events program in July 2020, prospectively enrolling preidentified high-risk patients. Enrolled patients underwent scheduled multidisciplinary reviews via virtual platform at 2 periprocedural time points with discussion of patient-specific risks and the subsequent development of proactive risk mitigation plans. Primary outcome measures were derived from the Pediatric Cardiac Critical Care Consortium national registry and included rate of postprocedure CA within 7 days and an institution-specific observed-to-expected ratio for postoperative CA. ResultsOur baseline median number of high-risk cases between postprocedure CAs was 3. Following project initiation, median high-risk cases between events increased to 7. Our observed-to-expected ratio for postoperative CA decreased from 2.56 during the 12 months before Proactive Mitigation to Decrease Serious Adverse Events program implementation to 1.01 during the 12 months after Proactive Mitigation to Decrease Serious Adverse Events program implementation, and hospital length of stay decreased by ∼10 days. ConclusionsImplementation of periprocedure-related proactive risk mitigation strategies in high-risk pediatric cardiac patients led to improvement in postprocedure CA with a 133% increase in high-risk cases between events.

Teaching the tools: Focusing effort and engagement when improving medical education.

Alexander and Shearer discuss how utilising Quality Improvement (QI) tools when planning and prioritising curriculum processes may reduce evaluation fatigue and increase stakeholders' sense of ownership in QI.

Neurology Morbidity and Mortality Conferences and Quality Improvement: Single-Center Experience and National Survey.

Morbidity and Mortality (M&M) conferences are widespread but vary in goals and methodology. Some focus on clinical enigmas while an increasing number utilize quality improvement (QI) tools to effect systems change. Little is known about the current state of US Neurology M&Ms. We surveyed 56 US academic neurology departments regarding their M&Ms to understand the use of QI tools and assess variability. Additionally, we reviewed the evolution of M&Ms in our department. The survey was completed by 44 (80%) departments; 68% reported quarterly frequency with 61% discussing 1-2 safety events per conference. The number of written guidelines or protocols resulting from M&Ms in 2years varied from 0 (14% of departments), 1-2 (45%), to >5 (5%). Institutional culture regarding quality and safety and conference timing were cited by 71% as important in improving participation. In our own department, the M&M format changed in 2014 based on a sentinel patient event combined with improving safety culture across the hospital: neurology M&Ms transformed into thematic quarterly conferences utilizing QI tools. Attendance increased 3-fold, and in 7years, we have generated 26 guidelines or pathways with corresponding decision-support tools, among other improvement efforts, resulting in specific systems changes. Based on survey results and our experience, suggested M&M "best practices" include the use of just culture, peer review protection, safety event analysis with QI methodology, trainee involvement, and logistical optimization. Structured M&Ms incorporating suggested QI-informed "best practices" can be highly effective in driving system change within neurology.

Eliminating Contamination in Umbilical Cord Blood Culture Sampling for Early-Onset Neonatal Sepsis.

Introduction: Despite the advantages of umbilical cord blood culture (UCBC) use for diagnosis of early onset sepsis (EOS), contamination rates have deterred neonatologists from its widespread use. We aimed to implement UCBC collection in a level III neonatal intensive care unit (NICU) and apply quality improvement (QI) methods to reduce contamination in the diagnosis of early onset sepsis.Methods: Single-center implementation study utilizing quality improvement methodology to achieve 0% contamination rate in UCBC samples using the Plan-Do-Study-Act (PDSA) model for improvement. UCBC was obtained in conjunction with peripheral blood cultures (PBC) in neonates admitted to the NICU due to maternal chorioamnionitis. Maternal and neonatal characteristics between clinical sepsis and asymptomatic groups were compared. Process, outcome, and balancing measures were monitored.Results: Eighty-two UCBC samples were collected in addition to peripheral blood culture from neonates admitted due to maternal chorioamnionitis. Ten (12%) neonates had a diagnosis of clinical sepsis. All PBCs were negative and 5 UCBCs were positive in the study period. After 2 PDSA cycles, there was special cause variation with improvement in the percent of contaminated samples from 7.3 to 0%. There was no change in antibiotic duration among asymptomatic neonates.Conclusions: Implementation of UCBC for the diagnosis of EOS in term infants is feasible and contamination can be minimized with the implementation of a core team of trained providers and a proper sterile technique without increasing antibiotic duration.

A Resident-driven Initiative to Increase Bedside Teaching on Interdisciplinary Rounds.

We developed an organizational structure to complete a long-term resident-led project. Interventions included daily bedside examination teaching on rounds, afternoon examinations, goal communication, topic recording, and a teaching "tip sheet." Using an institutional QI framework, we utilized iterative plan-do-study-act cycles to implement interventions and surveys to assess outcomes, with rounding efficiency as a balancing measure. The survey response rate was 57%. Bedside teaching frequency increased from a mean of 10% to 61%, perceived time at the bedside increased from 37% to 59%, and rounding satisfaction improved from a rating of 6.7/10 to 7.4/10. Efficiency was not impacted. We improved inpatient rounds bedside physical examination teaching and satisfaction without sacrificing efficiency. This project demonstrates the feasibility and success of a resident-driven education initiative to successfully motivate fellow residents and colleagues across disciplines to enact change. The organizational structure may serve as a model for resident-led QI projects across institutions.

Rapid Implementation of Remote Online Patient Portal Activation in a Children's Hospital during the COVID-19 Pandemic

AbstractBackground Patient portal access allows more patient engagement, yet portal usage is not universal. Telemedicine visits became critical when the coronavirus disease 2019 (COVID-19) pandemic limited in-office visits. Given physical distancing requirements and telemedicine platform integrated into the patient portal, our institution needed to rapidly enroll patients and their proxies remotely, including hospitalized patients, to minimize care disruptions.Objectives The study aimed to describe the rapid implementation of remote patient portal activation in a pediatric integrated delivery network during the COVID-19 pandemic. Additionally, to increase the percentage of patients with active portal status upon discharge by 15% (absolute change) across inpatient units within 3 months.Methods A multidisciplinary taskforce utilized quality improvement tools to identify barriers to successful inpatient patient portal activation followed by rapid intervention cycles to effect change. Weekly progress was monitored on a portal activation dashboard.Results We created clinical decision support tools and training within 2 weeks. Active patient portal status upon hospital discharge increased from 44 to 66% within 12 weeks. Online patient portal conversion within 7 days after hospital discharge increased from 6.0 to 24%. Offer rate increased from 73 to 85% across all inpatient units.Conclusion We rapidly and effectively implemented a remote proxy portal activation process in the inpatient setting. Remote activation, training, clinical decision support, multidisciplinary involvement, and emphasis on the portal as integral to ongoing care allowed us to dramatically increase portal conversion. This experience may be informative for pediatric hospitals aiming to increase proxy portal enrollment and adult hospitals with medical decision-making proxies.

A controlled trial of dissemination and implementation of a cardiovascular risk reduction strategy in small primary care practices.

To assess the effect of dissemination and implementation of an intervention consisting of practice facilitation and a risk-stratified, population management dashboard on cardiovascular risk reduction for patients at high risk in small, primary care practices. A total of 219 small primary care practices (≤10 clinicians per site) across North Carolina with primary data collection from electronic health records (EHRs) from the fourth quarter of 2015 through the second quarter of 2018. We performed a stepped-wedge, stratified, cluster randomized trial of a one-year intervention consisting of practice facilitation utilizing quality improvement techniques coupled with a cardiovascular dashboard that included lists of risk-stratified adults, aged 40-79years and their unmet treatment opportunities. The primary outcome was change in 10-Year ASCVD Risk score among all patients with a baseline score ≥10 percent from baseline to 3months postintervention. Data extracts were securely transferred from practices on a nightly basis from their EHR to the research team registry. ASCVD risk scores were assessed on 437556 patients and 146826 had a calculated 10-year risk ≥10 percent. The mean baseline risk was 23.4 percent (SD±12.6 percent). Postintervention, the absolute risk reduction was 6.3 percent (95% CI 6.3, 6.4). Models considering calendar time and stepped-wedge controls revealed most of the improvement (4.0 of 6.3 percent) was attributable to the intervention and not secular trends. In multivariate analysis, male gender, age >65years, low-income (<$40000), and Black race (P<.001 for all variables) were each associated with greater risk reductions. A risk-stratified, population management dashboard combined with practice facilitation led to substantial reductions of 10-year ASCVD risk for patients at high risk. Similar approaches could lead to effective dissemination and implementation of other new evidence, especially in rural and other under-resourced practices. Registration: ClinicalTrials.Gov 15-0479.

Optimizing Interdisciplinary Care of Pediatric Sexual Assault and Abuse in the Emergency Department: A Quality Improvement Approach

The Ann & Robert H. Lurie Children's Hospital of Chicago identified issues with team communication, consistency of services provided, and continuity of care within the sexual abuse and assault program in the emergency department (ED) which necessitated improvement efforts. The aim of this project was to engage an interdisciplinary team to define and delineate roles and streamline clinical workflows from ED presentation to nonacute follow-up. An interdisciplinary team was convened and utilized quality improvement methodology to complete a current state analysis, develop a future state design, and prioritize interventions for improvement. The project team focused on four interventions: (1) establish a team approach with delineated roles and responsibilities; (2) develop and implement consistent workflows to reduce unwarranted variation in care; (3) expand education on the sexual assault nurse examiner (SANE) program more broadly to the care teams in the ED; and (4) implement clinical decision support (CDS) tools to streamline the continuum of sexual assault services provided. Three of the interventions (all but education) were carried out as a comprehensive care guideline for patients presenting to the ED for evaluation. The ED implemented this care guideline in August 2019. The utilization of quality improvement methodology was effective in ensuring an organized, interdisciplinary team response for the evaluation of pediatric and adolescent sexual abuse and assault in the ED. It enabled strong buy-in from team members and ownership of the process with anticipated improvements in patient care and experiences.

Creation of a chemotherapy-induced nausea/vomiting dashboard to improve outcomes for pediatric cancer patients.

Two of the most common acute side effects of chemotherapy are nausea and vomiting. Nausea and vomiting impact quality of life, nutritional status, and ability to tolerate further chemotherapy. Parents of pediatric oncology patients rank nausea as one of the most bothersome treatment-related symptoms. Utilizing Quality Improvement methodology, we developed a dashboard interface to facilitate extraction of data from the electronic medical record (EMR), which is presented via a visual display that summarizes the type of chemotherapy and antiemetic medications, use of as needed medications, and number of episodes of emesis. This dashboard interface allows for rapid and efficient identification of patients whose antiemetic regimen is mismatched for the emetogenicity of ordered chemotherapy, thus providing a timely opportunity to modify the antiemetic regimen based on published guidelines before administration of chemotherapy drugs. It also allows measurement of the effectiveness of the antiemetic regimen in terms of the number of break through emesis and the need for as needed medications. A novel CINV dashboard was created, which visually conveys complex information about antiemetics, chemotherapy emetogenicity, as needed medications, and breakthrough vomiting for inpatient pediatric oncology patients.

The Diamond Project: A Quality Improvement Model for Adopting Shared Service Delivery in the Washington Vaccines for Children Program.

Context: Increasing federal requirements with no change in the Centers for Disease Control and Prevention budget creates an unsustainable delivery model between states and their local counterparts for programs like Vaccines for Children (VFC).Project: The Washington State Department of Health collaborated with the Washington Association of Local Public Health Officials to identify how best to improve the quality of the VFC program.Approach: Utilizing Quality improvement and Lean Six Sigma methods, the project team was able to adopt a new shared-service delivery model to improve the quality of the VFC program in Washington State.Discussion: Through utilization of quality improvement methods and Lean methodology Washington State Department of Health identified recommendations to adopt a shared-service delivery and implemented those changes.

A QI Project to Increase QI Knowledge: Utilizing Quality Improvement Methodology to Develop a Longitudinal Curriculum that Increases Resident Knowledge and Application of Skills in QI Science

A QI Project to Increase QI Knowledge: Utilizing Quality Improvement Methodology to Develop a Longitudinal Curriculum that Increases Resident Knowledge and Application of Skills in QI Science

A Front-end Redesign With Implementation of a Novel "Intake" System to Improve Patient Flow in a Pediatric Emergency Department.

Introduction:Children’s Hospital Colorado is an academic, tertiary-care Level 1 Trauma Center with an emergency department (ED) that treats >70,000 patients/year. Patient volumes continue to increase, leading to worsening wait times and left-without-being-seen (LWBS) rates. In 2015, the ED’s median door-to-provider time was 49 minutes [interquartile range (IQR) = 26–90], with a 3.2% LWBS rate. ED leadership, staff, and providers aimed to improve patient flow with specific goals to (1) decrease door-to-provider times to a median of <30 minutes and (2) decrease annual LWBS rate to <1%.Methods:An inter-professional team utilized quality improvement and Lean methodology to study, redesign, and implement significant changes to ED front-end processes. Key process elements included (1) new Flow Nurse/EMT roles, (2) elimination of traditional registration and triage processes, (3) immediate “quick registration” and nurse assessment upon walk-in, (4) direct-bedding of patients, and (5) a novel “Intake” system staffed by a pediatric emergency medicine physician.Results:In the 12 months following full implementation of the new front-end system, the median door-to-provider time decreased 49% to 25 minutes (IQR = 13–50), and the LWBS rate decreased from 3.2% to 1.4% (a 56% relative decrease). Additionally, the percentage of patients seen within 30 minutes of arrival increased, overall ED length-of-stay decreased, patient satisfaction improved, and no worsening of the unexpected 72-hour return rate occurred.Conclusions:Using quality improvement and Lean methodology, an inter-professional team decreased door-to-provider times and LWBS rates in a large pediatric ED by redesigning its front-end processes and implementing a novel pediatric emergency medicine-led Intake system.

Structuring Doctor of Nursing Practice project courses to facilitate success and ensure rigor.

There is currently a lack of consensus on the best format for Doctor of Nursing Practice project deliverables. In this article the project course history, current format, and evaluation methods are described for a Doctor of Nursing Practice program during the transition from a sole post-master's option to one that also admitted post-baccalaureate students. The project course format shifted focus from one in which students independently implemented multiple types of projects under the direction of a chairperson and committee to one in which students carried out projects utilizing quality improvement methods and tools under the mentorship of a project faculty advisor and clinical site representative. The integration of quality improvement models is exemplified through course objectives and assignments. Lessons learned through this transition are provided in the hope that the work may benefit other nursing schools with similar programs.