Annual Improvement Projects
Fiscal year 2026
Quality, Safety, & Health Equity Domain
Enhancing the culture of safety reporting in the Department of Neurology
Patient Experience Domain
Sustaining performance on Overall Rating
Departmental engagement in Measurement Modernization Initiative
Sustaining Resident Communication Coaching Program
Wellbeing & Engagement Domain
Completing annual Wellbeing plan and end-of-year Wellbeing report
Understanding and improving Belonging among Neurology senior faculty
Financial Strength Domain
Stroke Bundled Payments for Care Improvement Advanced (BCPI-A)
Fiscal year 2025
Quality, Safety, & Health Equity Domain
Creating a culture of Near Miss SAFE reporting
Patient Experience Domain
Sustaining performance on ambulatory Likelihood to Recommend Care Provider
Leader engagement in Measurement Modernization Initiative
Sustaining Resident Communication Coaching Program
Wellbeing & Engagement Domain
Completing annual Wellbeing plan and end-of-year Wellbeing report
Measuring the impact of a department-wide system for faculty vacation inbox coverage
Financial Strength Domain
Increasing access by optimizing utilization of available clinic rooms, as measured by visits per room per day
Patient Flow & Capacity Key Priority Area: Length of Stay
Escalating barriers to discharge to improve length of stay
Patient Flow & Capacity Key Priority Area: 30-Day Readmissions
Reviewing the chart for every 30-day readmission
Fiscal year 2024
Quality, Safety, & Health Equity Domain
Sustaining referrals and enrollments to General Inpatient Hospice program
Patient Experience Domain
Sustaining performance on ambulatory Likelihood to Recommend Care Provider
Sustaining Resident Communication Coaching Program
Wellbeing & Engagement Domain
Completing annual Wellbeing plan and end-of-year Wellbeing report
Developing and implementing a department-wide system for faculty vacation inbox coverage
Financial Strength Domain
Increasing access by optimizing utilization of available clinic rooms, as measured by visits per room per day
Patient Flow & Capacity Key Priority Area
Increasing meaningful participation of physicians in L4 Unit multidisciplinary rounds
Appropriately assigning observation and inpatient status
Identifying opportunities to reduce 30-day readmission rate in collaboration with other clinical departments
Participating in Access Compact 3.0 program
Fiscal year 2023
Project 1: General Inpatient Hospice Pilot
Project 2: Delivering Patient Experience Data to Ambulatory Neurologists
Project 3: Patient Experience Bundle in Ambulatory and Inpatient Neurology
Project 4: Improving Access to Neurology Follow-up Care for Patient Discharged from the Emergency Department
Project 5: Improving Access to Neurology for Obstetric Patients
Fiscal year 2022
Project 1: Reducing physician time spent on inbox management
Project 2: Reducing physician time spent on clinical documentation
Project 3: Model Line Work: improving the pre-encounter experience
Project 4: Designing a new system for sharing patient satisfaction data with faculty
Project 5: Creating a Neurology Health Equity Annual Report
Fiscal year 2021
Project 1: Reducing readmissions to the Stroke service
Project 2: Developing a patient experience dashboard that is meaningful to clinicians
Project 3: Implementing self-service scheduling for in-person and video visits in ambulatory neurology
Project 4: Adherence to tracheostomy/feeding tube clinical pathway for patients with neuromuscular conditions
Project 5: Portfolio of Neurology Improvement Projects
Project 6: Implementation of FastPass in ambulatory neurology
Fiscal year 2020
Project 1: Understanding Vizient Neurology Service Line readmissions
Project 2: Increasing patient access by utilizing patient appointment slots opened by late cancellations
Project 3: Improving patient access through self-service online clinic appointments
Project 4: Improving efficiency of practice in ambulatory neurology
Project 5: Identifying opportunities for improvement in the process of send-out labs for neurology patients
Infrastructure Gap 1: Integration of inclusive leadership training into improvement efforts
Infrastructure Gap 2: Iteration of the Mortality Review process
Fiscal year 2019
Project 1: Exploring the root cause of neurologists’ after hours work on the electronic health record
Project 2: Improving patient knowledge of the indications for their medications at the time of hospital discharge (CELT)
Project 3: Sustaining faculty utilization of the Relevant Clinical Conditions smart phrase at hospital discharge to accurately reflect severity of illness and patient complexity
Infrastructure Gap 1: Creation of real-time hospital mortality review process
Infrastructure Gap 2: Creation of monthly Neuroscience Vizient Scorecard
Fiscal year 2018
Project 1: Implementation of the Cost-Conscious Attending Rounds Checklist on the Neurohospitalist and Stroke services
Project 2: Implementation of the Relevant Clinical Conditions smart phrase at hospital discharge
Project 3: Reducing time from referral to scheduling appointments in General Neurology clinic
Infrastructure Gap: Creation of the Neurology Quality Council