043 - Enhancing Faculty Knowledge & Engagement via a Quality, Safety, & Operational Excellence Improvement Program

Publication Number: 43.4605

Amanda Nedved, Children's Mercy Hospitals and Clinics, Lenexa, KS, United States; Julia G. Harris, Children's Mercy Kansas City, Kansas City, MO, United States; Darcy K.. Weidemann, Children's Mercy Hospital, Kansas City, MO, United States; Nicholas Clark, Children's Mercy Hospitals and Clinics, Kansas City, MO, United States; Alyssa Stephany, AIM Coaching & Consulting, Overland Park, KS, United States

Background: Institution had variable faculty knowledge and engagement in quality improvement (QI) efforts, with most participants siloed to projects within their division. We developed a Quality, Safety and Operational Excellence (QSE) Improvement Program to support QI initiatives, train faculty leaders, foster collaboration, and empower teams to make impactful change (Figure 1).

Objective: We aimed to increase favorable responses in a program effectiveness survey from 67.7% to 75% by June 30, 2025.

Design/Methods: We met with stakeholders to understand current QI projects, baseline knowledge, and dedicated effort allocated to QI initiatives. We identified the following drivers: consultation, education, resource support, collaboration, and evaluation (Figure 2). We built a curriculum, centralized resources, and offered QSE coaching. We standardized the evaluation rubric for QSE projects and facilitated monthly QSE forums. We used run charts to track percent of favorable responses on a program effectiveness survey, QSE forum attendance and evaluations, QSE curriculum completion, collaborative projects, and the number and scores of QSE projects submitted to our faculty incentive program.

Results: The QSE Improvement Program began in 2023. We currently have 37 QSE Champions across 8 departments. We have facilitated 14 QSE forums with 29 content experts presenting. Forums have consistently been considered valuable to 100% of respondents. Even though not required, 13.5% of QSE champions have completed the recommended curriculum, and 27% have completed the Institute for Healthcare Improvement’s basic certificate in quality and safety. End of year QSE project submissions increased from 51 to 64 between 2023 to 2024 while average project scores did not change. Although we did not see a change in overall favorable survey responses in 2024 (68.9%), we saw an increase in favorable responses for team participation in QSE efforts (67.4% to 75.7%). The subdomains of value-based care and team member wellbeing had the lowest favorable responses (49% and 60.5%, respectively).

Conclusion(s): Development of our QSE Improvement Program has spurred more engagement in QSE efforts across our institution. We continue to actively monitor for improvements and identify opportunities for the program to evolve to make the biggest impact on improving patient care and processes. Future steps include close collaboration with the Center for Wellbeing and the institution’s population health subsidiary to incorporate team member wellbeing and value-based care into QSE initiatives.

Figure 1
The Quality, Safety and Operational Excellence Improvement Program's mission statement, core values and foundational pillars

Figure 2
Key Driver Diagram of the Quality, Safety, and Operational Excellence Improvement Program

Figure 1
The Quality, Safety and Operational Excellence Improvement Program's mission statement, core values and foundational pillars

Figure 2
Key Driver Diagram of the Quality, Safety, and Operational Excellence Improvement Program