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Quality Improvement

Quality and Patient Safety Program: Department of Medicine

The department of Medicine (DOM) has a robust and expanding Quality Improvement and Patient Safety program that is committed to delivering high-quality, safe, equitable, efficient and patient and family-centered care to our patients and community. The DOM fundamentals are based on Upstate's core values: excellence in effective and timely patient care, efficient and equitable care, and patient and family-centered care. Patient and family-centered care incorporates a significant focus on patient safety. Patient safety is based on the culture of learning, reporting, communication, and just culture.



The DOM Quality Team is comprised of: Chair of Medicine, Clinical Chief for Department of Medicine for University of Community General Hospital, Vice-Chair for Quality Improvement and Patient Safety (Team Leader), Departmental & Divisional Quality Officer, Quality Chief Resident, Quality Lead Fellow, Quality Coordinator, Core and Fellowship Program Directors, Divisional Chief. 

The Vice-Chair for Quality Improvement and Patient Safety leads this program in the DOM (including the core and fellowship programs) and oversees/supervises the quality programs for each division. The Departmental and Quality & Divisional Quality officers collaborate to address quality issues across all department and division/s. 

The Quality Chief Resident mentors and supervises residents for the quality improvement and patient safety programs, under the mentorship of the Program Director and Vice-Chair for Quality. The Quality coordinators assigned to the DOM help in the quality data collection, analysis, and projects. The core and fellowship program directors serve as mentors for their respective trainees and ensure robust participation in the department's quality endeavors. 



The vision for DOM in quality improvement and patient safety is aligned with Upstate’s strategic plan (Quality of care, Upstate Experience, Innovation, and Sustainability).  In addition, develop and transform the culture of patient safety from reactive to active to proactive and engage all faculty, fellows, and resident in continuous quality and process improvement. 


“Doing the right thing, at the right time, in the right way, for the right person, and getting the best possible results.” AHRQ. 


The DOM Quality goals are based on STEEP (safe, timely, effective, equitable, efficient, and patient-centered) principles. The outcome, process, and performance metrics are outlined below: this Diagram on the side




1. Inpatient Mortality(O/E)
2. Sepsis Mortality(O/E)
3. Patient Experience
4. Cardiovascular Quality initiatives
5. Ambulatory Quality initiatives
6. Educational Quality initiatives


  1. Inpatient Mortality: Develop a process to review all mortalities by inpatient admitting services in the DOM, identify learning opportunities, and develop quality initiatives based on trends.
  2. Sepsis Mortality: Continue education and awareness for early recognition of sepsis and appropriate medical care. Monitor the utilization of sepsis order set and procedure notes when sepsis is recognized in patients.
  3. Patient Experience: Collaborate with Patient Experience Champions and Chief Patient Experience Officer to develop a process to share HCAPS, Press Ganey scores, and patient comments with provers within the DOM.
  4. Cardiovascular Quality : Reviewing mortalities in division of cardiology and to deacrease O/E for STEMI and CHF. In addition, continuous systemic improvement for door to balloon time, and cardiac rehabilitation.
  5. Ambulatory Quality Initiatives: Create a ambulatory Quality committee to improve quality of care and patient safety by developing quality, process, and outcome measures.
  6. Educational Quality Initiatives: Education and engagement of trainees to develop a process of faculty development in Quality Improvement and Patient Safety Program (QIPS) by:
    • Completing IHI basic certification course in Quality Improvement and Patient Safety.
    • Attending DOM Quality Meetings, Resident Quality Council, and Morbidity and Mortality Conferences.

Significant Accomplishments

  1. Creation of multi-disciplinary quality teams for Medical ICU, and Hematology and Oncology.
  2. Development of Palliative Quality Dashboard to review and analyze data to identify opportunities for improvement.
  3. Collaboration with resuscitation and SWAT team to improve quality of care and service to our vulnerable patient population.
  4. Collaboration with IMT and EPIC team to identify with opportunities for improvement and improve the system.
  5. Development of RN-MD platform to meet weekly to improve communication and understand each other’s perceptive to improve quality of care to our patients.
  6. Development of infection control rounds to reduce CAUTI and CLABSI.
  7. Development of patient experience rounds.
  8. Creation of platform for each division in DOM to present quality initiatives and report.
  9. Creation of Quality Management policy for DOM.
  10. Collaboration with advance practice practioners and clinical documentation to improve clinical care and documentation.
  11. Development of quality audits for admitting residents to improve critical thinking and mitigate diagnostic errors.
  12. Sepsis Rounds at DT and CGH campus to share the new quality initiatives, data and metrics. Monthly Quality  Rounds & Sepsis Rounds at DT and CGH campus to share the new quality initiatives, data and metrics. Also get feedback from the Also get feedback from the team for concerns in the quality of care and service.
  13. Development of Quikstarter, a platform for residents to present their quality projects.
  14. Development of micro-credentialing in Quality
  15. Creation of the great catch award program.
  16. Creation of pulmonary embolism response team (PERT).
  17. Monthly quality highlights through emails to DOM to share the top three quality trends in the DOM
  18. Creation of awards to provide positive enforcement, for example, Sepsis Champion, The Best Mortality and Morbidity Presentation award. 
  19. Implementation of Sepsis campaign for education and awareness of sepsis, and to reduce observed and expected mortality.
  20. Creation and collaboration of interdisciplinary teams with emergency department and trauma, to share cases that improve quality of care and service to our patients.
  21. Creation of departmental multidisciplinary quality and patient safety conferences: Quality Updates.
  22. Creation of physician code team leader for the hospital code/rapid response team.
  23. Creation of physician sign-out tool that is embedded in the hospital EMR.
  24. Creation of admission, process note, and discharge note templates for internal medicine residents that optimize accurate documentation.
  25. Creation of multidisciplinary rounds with case management, physical therapy, nutrition, nursing, and physicians to facilitate patient-centered care and hospital throughput. 
  26. Creation and implementation for hospital discharge workflow process to ensure patient safety, improve accuracy of medication reconciliation, and ensure a safe transition to outpatient care. 

Quality and Patient Safety Publications

  • Gambhir HS, Dhamoon Amit, Goodrich Samantha, Kaul Viren. Impact of Structured and
    Scheduled Family Meetings on Satisfaction in Patients Admitted to Hospitalist Service.
    Journal of Patient Experience. March 2021. DOI: 10.1177/23743735211002748.
  • Sean Byrnes, Rao Suman, Banerjee Sanchari, Paularaj Shweta, Shah Siddharth, Raj
    Vijay, Singh Avneet. Clinical utility of transesophageal echocardiograms in the workup
    of acute ischemic stroke. The American Society of Echocardiography. June 2021
  • Paularaj Shweta, Raj Vijay, Ohja Niranjan, Sean Byrnes, Prashant Kumar Ashok,
    Singh Avneet. Impact of a Quality Initiative to Reduce Inappropriate Ordering of
    Transthoracic Echocardiography in a University Hospital. The American Society of
    Echocardiography. June 2021.
  • Billal Mohmand, Naqvi Abeeha, Durland Justin, Sruti Akula, Raj Vijay, Shah
    Siddharth, Singh Avneet. Can It Wait? Transthoracic Echocardiograms Prior to
    Discharge. The American Society of Echocardiography. June 2021
  • Kudaravalli P, Doobay R, Carvounis C, Toomey C, Dhamoon A. Initiatives to reduce the inappropriate use of proton pump inhibitors in an outpatient primary care clinic. Ann Pharm Fr. 2020 May 30:S0003-4509(20)30069-9. doi: 10.1016/j.pharma.2020.05.002.

Morbidity and Mortality Conference

  • Biweekly conference at the Department of Medicine’s Power Rounds
  • Presented by team of two PGY‐2 residents
  • Systems‐based conference model with focus on dual goals of clinical education as well as addressing patient safety issues and reducing preventable errors

Resident Quality Council

  • Monthly, informal meeting involving residents, faculty and other services including nursing, pharmacy.
  • Review of interesting cases from a quality perspective, raising of important quality and system issues to be addressed
  • Opportunity to present results or progress of ongoing and completed quality projects
  • Opportunity for residents to partner with students and other disciplines/services for QI projects and scholarship

QI Curriculum –Workshop series




  • Novel, “flipped”, longitudinal curriculum initiated this academic year
  • Based on the Institute for Healthcare Improvement(IHI) Open School’s Basic Certificate in Quality and Patient Safety
  • Focus on active learning and trainee‐engagement
  • Monthly workshop during ambulatory week
  • Small‐group exercises to help anchor quality improvement and patient safety concepts to day‐to‐day clinical work


 Distinction in Quality and Safety Program

  • Certificate awarded to recognize resident involvement in quality and patient safety as evidenced by participation in quality projects within the department of medicine, the review and presentation of morbidity and mortality events and regular participation in the resident quality council. 

Quality Updates Meeting

  • Monthly inter‐disciplinary department‐wide meeting
  • Review of data/quality metrics for the department of Medicine
  • Discussion of initiatives for improvement
  • Regular updates from other teams – Clinical Documentation Improvement(CDI), Patient Experience (PX), Infection Control, Resuscitation, CHF Nurse Coordinators
  • Opportunity for resident/faculty education