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Quality Improvement Project Intake Form

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What is the specific aim of the quality improvement effort? The Aim Statement should include: (1) a specific and measureable improvement goal, (2) a specific target population, and (3) a specific target date/time period.

EXAMPLE AIM STATEMENT: We will [improve, increase, decrease] the [number, amount, percent] of [the process/outcome] from [baseline measure] to [goal measure] by [date].

* must provide value

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Quality & Safety

Patient Experience

Cost Variation

Academic Pursuits & Research

Yes

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Yes

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Access to care

Asthma

Burnout/clinician wellbeing

Cancer

Cardiovascular

Career Sustainability

Choosing Wisely/High Value Care/ Cost of care

CLABSI

Communication (patient-clinician)

Compliance (regulatory)

Diabetes

Documentation

Efficiency/ timeliness of care

Hand hygiene

Health Literacy

HIV

Hypertension

Immunizations/vaccinations

Length of stay

Medical home

Obesity

Opioid Use

Patient Centered Care

Patient safety/harm reduction

Prescriptions

Preventive care

Procedural Skills

Professionalism

Provider Resilience

Readmissions

Resource stewardship/utilization/ value and/or cost of care

Satisfaction

Sepsis

Surgical site infections

Teamwork/ team-based care

Transitions of care

Other

Continuous Quality Improvement (CQI)

IHI Collaborative Model

LEAN

Model for Improvement (PDSA/PDCA)

Six Sigma (DMAIC)

Total Quality Management (TQM)

Other

Yes

Yes

Yes

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Yes

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Yes

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Yes

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Upload file

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Yes

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Yes

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Yes

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Verify and Attest to their individual participation

Meet with others involved with the QI Effort

Review Performance data not less than 3 times including a baseline, and prior to completion of activity for MOC purposes (post-PDSA 1, Post-PDSA 2)

Develop and or apply tools and interventions to individual/team practice.

Reflect on impact of the initiative on their practice or organizational role.

Yes

Yes

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