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Quality Portfolio Sample

Quality Portfolio Sample

July 20XX

XXXXX Y ZZZZZ, MD

1. FACULTY NARRATIVE

I have been involved in quality improvement projects since I joined the faculty of XXXX in 2001.  My primary activities have been in the Department of Medicine focusing in 3 major domains:  peer review, quality of care metrics, and resident education.  In peer review, I am the Medical Coordinator of the Medical Peer Review Committee, a multi-disciplinary committee in the Department, which reviews all deaths on the Medical Service for quality of care.  My work in the area of quality of care metrics involves publicly reported measures in the management of community-acquired pneumonia:  I am the Physician Director of the Inpatient Pneumococcal Vaccination Program and co-chair of the Influenza Vaccination Working Group.  Regarding resident education, I have been involved directly in a Patient Safety Rotation, an elective in Quality Improvement, and lecture on the quality of care metrics in pneumonia with an emphasis on practice-based learning.

I fundamentally believe improving the quality of care requires a comprehensive, data-driven multidisciplinary approach.  Many of my successes can be attributed to making sure that from the beginning we have all of the stakeholders “at the table” and all of them are given a voice. I have also harnessed the value of small incremental change to overcome inherent resistance to change and create successful, lasting improvements over time.  In our vaccination programs, our success came through a series of miniscule changes in the process in everything from documentation to how the vaccines are stored on the floor.  The current process now works smoothly and efficiently but we never would have achieved this without all of those small system changes. 

In the future I hope to continue to have quality improvement play an important role in my career.  I hope to take on further leadership roles in the Department of Medicine and I look forward to the ongoing mentoring and teaching of both housestaff and other junior faculty.
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2. QI LEADERSHIP

Major Administrative Responsibilities
2004 –  Physician Director, Inpatient Pneumococcal Vaccination Program
   Chair committee and lead multi-disciplinary team to improve      inpatient vaccination rates
2004 –  Medical Director, 12 MMMMM, Medical / Obstetric & Orthopedic Surgical Floor
  Work collaboratively with nurses, pharmacists and physicians from  multiple disciplines to maximize teamwork, communication, and quality  of patient care.
2005 –  Core Faculty, Patient Safety Committee
  Direct committee performing individual case reviews in the  Department of Medicine and overseeing policy and system changes which  derive from the reviews.
2006 –   Associate Director, Quality Improvement, Department of Medicine
   See above in my QI Narrative

  
3. QI PROJECT ACTIVITY

Project Title:  Inpatient Influenza Immunization Initiative
Project Timeframe: October 07 – March 08
Time Commitment: 4 hours per month
Project Description / Goals: Increase screening and immunization to >90% for all medical inpatients aged 50 and over for Oct 07 to Mar 08 comprising on average 2000 eligible encounters per month.
Role/Contributions: Co-chair, (co-chaired with inpatient senior nurse administrator)
Intervention and/or Team Members: Hospital Medicine, Nursing, Pharmacy, Information Technology
Project Outcomes/results: to date, screening and immunization rates achieved 89% through Feb 08 with an average of 2000 eligible encounters per month.
Dissemination: poster presentation at XXXX Quality Improvement Forum (see below)
Time Commitment: 4 hours per month

Project Title:  Using Provider Order Entry to Improve Inpatient Pneumococcal Vaccination Screening and Immunization Rates
Project Timeframe: July 2005 – ongoing
Time Commitment: 6 hours per month
Project Description / Goals: Longitudinal effort started in 2005 to increase screening and immunization rates to >90% for medical inpatients age over 65 with a discharge diagnosis of pneumonia.
Role/Contributions: Director
Intervention and/or Team members: Hospital medicine
Project outcomes/results: since inception, have achieved at least >70% screening / immunization rates to date with an average of 20 eligible encounters per month.
Dissemination:  Abstract poster presentation at Society of Hospital Medicine national meeting (2007)

Project Title: Discharge Summary Taskforce
Project Timeframe: December 2007 – present
Time Commitment 2 hours per month
Project Description/Goals: The taskforce goal is to improve the quality of discharge summaries dictated by Internal Medicine residents while on inpatient rotations.  To improve the quality, we educate residents (teaching conferences) on the regulatory requirements and evidence-based “best practices” for discharge summaries.   We distribute pocket cards to the residents to use as a guide when dictating discharge summaries.
Role/contributions: Taskforce member.  I conducted literature review, designed educational modules and helped create the pocket card reference.
Intervention and/or Team members: Physicians in the Division of Hospital Medicine and the Geriatrics Division
Project outcomes/results: The formal educational initiative has not yet begun.  We will distribute a one-page survey of conference participants for their immediate feedback.  We will compare discharge summaries after the educational programs to discharge summaries from a year earlier, screening for essential elements and best practices.
Dissemination: none planned currently

Project Title:  Incorporating quality metrics in morning interdisciplinary board rounds
Project Timeframe:  July 2007 – present
Time Commitment:  2 hours per month
Project Description/Goals: Implement a standardized, brief assessment of quality metrics such as foley catheter use, telemetry, and dvt prophylaxis for each medical inpatient during routine morning rounds
Role/Contributions:  Precepted internal medicine resident; developed standardized tool with resident, helped implement in rounds
Team Members: Resident Housestaff, Nurse Manager, Case Manager, Resource Nurse
Project outcome/results: Improved efficiency of board rounds, decreased total time spent in rounds with improved team member satisfaction and work flow.  

4. QI EDUCATION ACTIVITY

Direct Teaching

Teaching Activity/Class: Community-acquired pneumonia (CAP) Core Measures Noon Conference
Year (month):  July 2005 – present
Time Commitment: 20 hours per year
Activity/Class Description/Goals: I lecture on CAP Core Measures and principles of quality improvement to the Internal Medicine residents and medical students every other month (1 hour each).  I teach the residents and students basic quality improvement principles, the evidence-base for the Core Measures, and provide them feedback on their performance by showing them their data on the individual measures.
Number of learners: 240/year (Internal Medicine residents and medical students)
Evaluation of Teaching Activity: None available

Teaching Activity / Class: XXXX Elective in Quality Improvement
Year (month): July 2005 - present
Time Commitment: 45 hours per year
Activity / Class description / Goals: Lecture residents in root cause analysis and quality improvement; precept individual resident prepared cases including root cause analysis and corrective action plan 
Number of Learners: 8-12 residents per year
Evaluation of Teaching Activity: see educators portfolio for evaluation scores compared to historical averages

5. QI RESEARCH / SCHOLARSHIP

Abstracts
1. Using computerized provider order entry to improve pneumococcal vaccination screening and immunization rates. Society of Hospital Medicine, Annual Meeting, Washington, DC, 2006

2.  Developing a high performance team training framework for internal medicine, the ABC’s of teamwork. Society of Hospital Medicine, Annual Meeting, Washington, DC, 2006

3. Creating patient safety modules for house officers and faculty. Society of Hospital Medicine, Annual Meeting, Washington, DC, 2006

4. A model for quality improvement and patient safety programs in Academic Departments of Medicine, Institute for Healthcare Improvement, Annual Meeting, Orlando, FL, December 2007

Invited Presentations
National
2005 Creating a patient safety curriculum for residents, Workshop leader, Society of Hospital Medicine, Annual Meeting, Chicago, IL

Regional and Local

2001 The Hospitalist Movement at XXXX, Lecturer, XXXX Medical Grand Rounds, 100 attendees

2005 Patient Safety Core Curriculum – ABC’s of Teamwork, Lecturer, WWWWW Hospital, 12 medical residents and faculty, 11 hours per year
 
2006 Teaching Patient Safety, Lecturer at Faculty Development Workshop, WWWWW Hospital, 35 interdisciplinary faculty members, 4hours per year

2007 Patient Safety and Quality Improvement at XXXX, Lecturer, XXXX Resident Core Conference, 80 medical students and residents, 5 hours per year

6.   QI AWARDS / HONORS / RECOGNITION

None.