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  • R1 QI Worksheet

    Page 1 of 17

    First QI Project

    This assignment will be submitted at two points in time:

    I. Fourth Friday of Block 3

    a) Clinic Approval of Project

    b) QI Worksheet: Assemble Your QI Team and Plan Phase

    II. Fourth Friday of Block 5

    a) QI Worksheet: Do, Study, Act Phases, Reflection, and Lessons Learned

    Each task should be submitted to the DFM resident research training coordinator:

  • R1 QI Worksheet

    Page 2 of 17

    First QI Project: QI Worksheet

    • How to use this worksheet: Type your responses into the correct fields – they will

    expand as you type.

    • Write in complete sentences and provide as much detail as possible.

    • When you create attachments, create an appendix at the end of this document and

    reference your attachments in your answers.

    Submit your QI Worksheet on or before the dates listed above.

    Assemble Your QI Team

    Name of Clinic: Pencil Town Clinic

    Date: September 5th, 20XX

    Role – MOA, Nurse,

    MD, EMR specialist,

    Clinic Manager, etc.

    Responsibilities Name

    Residents The residents will facilitate the QI

    project by engaging the clinic,

    collect data, analyze it, and help

    come up with interventions.

    1. Yong S. Hanger 2. Aileen H. Bergman 3. Nafeesa Daliyah Malouf 4. Zi Ku

    Nurses The nurses will escort patients to the examination rooms and take their weight measurements. They will also help design the interventions.

    1. Thierry Rocheleau

    2. Sadie Douglas

    3. Stanley McIntyre

    MOAs The MOAs will perform vital administrative duties in the clinic such as greet patients when they arrive and queue them up for their appointments. The MOAs will also provide another source of perspective on clinic flow vis-à- vis our QI project. They will also help design the interventions.

    1. Dennis S. Lam 2. Veda Salcedo Lemus

  • R1 QI Worksheet

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    Physicians The physicians will see the

    patients who move from the

    waiting room to the examination

    rooms. They will also help design

    the interventions.

    1. Dr. Lucas Oliveira Barros 2. Dr. Ruth V. Bates 3. Dr. Bonnie R. Coggins 4. Dr. John G. Hansen 5. Dr. Gary B. Johnson

    Clinic Manager

    Ensure that our QI project

    adheres to clinic policy and

    procedures and approves project.

    Iselda Soliz Valenzuela

    EMR Specialist Verify that project is doable from

    an EMR perspective

    Goodwill Boffin

  • R1 QI Worksheet

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    Clinic Approval of QI Project

    To ensure this project is relevant to your clinic and meets its needs, we require clinic approval for all

    resident QI projects.

    Instructions: Please select your clinic type in the boxes below, answer the questions, and sign to approve the

    residents’ QI project. If your project requires the usage of or modifications to your clinic’s EMR, have the EMR

    Specialist/DFM Informatics lead sign-off on your project to indicate the feasibility and timeliness of your use or

    requested modification. For example, you may wish to collect a certain type of data, but your EMR cannot search

    for it or you may wish to make a change to the EMR that is technically feasible, but not practical given time

    constraints, etc.

    If you work at one of the three core clinics (CTC, SFMTC, or SHC) and intend to use the EMR as part of your QI

    project, you must get approval from Scott Jalbert, the DFM’s Informatics team lead, in addition to the clinic dyads.

    Community Clinics or Rural Sites – since there are various types of clinic leadership, this form can be

    signed by an individual who oversees and manages clinic affairs.

    Clinic Name or Rural Setting: Pencil Town Clinic

    Approval Signature:

    September 4th, 20XX

    Sign Here Date

    Core Teaching Site (check one):

    CTC ☐ SHC ☐ SFMTC ☐

    C lin

    ic D

    ya d

    Clinic Manager


    ____________________ _____________________

    Sign Here Date

    Site Medical Lead

    _____________________ _____________________

    Sign Here Date

    EMR Specialist/Informatics

    team lead – if needed

    September 4th, 20XX

    Sign Here Date

  • R1 QI Worksheet

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    Plan Phase

    Topic: CHF Patients’ weights taken at each visit

    1) Describe your clinic: Where is your clinic located? How busy is your clinic? What types of

    patients frequent your clinic? What makes your clinic unique? Paint a picture of your clinic; by

    doing this, your project will be informed by its context.

    Pencil Town Clinic is a busy family medicine clinic located in the southern district of Stationary

    City. For close to a decade, the clinic has provided health care to a wide variety of patient who

    present with all kinds of complaints, from the common cold to managing chronic pain. The clinic

    has 5 full-time physicians, 3 nurses, 2 MOAs, and 4 residents who work at the clinic 2.5 days a

    week. The clinic also has a part-time EMR specialist who visits the clinic once a week to deal with

    technical issues and help the staff work more efficiently.

    2) Problem/Opportunity statement – What is wrong? What did your practice audit show? Why

    bother improving this?

    Recently, one of the preceptors was going through her EMR and realized that patients with CHF

    were not having their weight measurements taken on a regular basis. We need to have up-to-

    date weights on record, so we can track CHF patients’ health – their lives may depend on it.

    3) What are the root causes of your practice gap (Use at least one QI tool: e.g., Process map, Cause

    and Effect Diagram/Fishbone, 5 Why’s – see the Resident QI Handbook for guidance -

    4) Why is this topic important to your clinic?

    This topic is important to our clinic because we need to know when patients’ weights fluctuate.

    Dramatic changes in patients’ weights may indicate retained fluid.

    5) Who will benefit from this project?

    The patients will benefit from having informed family doctors and the clinic staff will benefit

    from having a more complete EMR and picture of patients’ health.

  • R1 QI Worksheet

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    6) How did your QI team arrive at this topic?

    We held a meeting to discuss potential QI project ideas and one of the physicians mentioned

    that one of his patients with CHF died recently and, upon inspection of her EMR, realized that

    the patient didn’t have any weight measurements on file, among other things. The physician

    suggested that we could use this topic as our resident QI project and the nurses and MOAs


    7) Aim statement – What are you trying to accomplish? Your aim statement should be clear, time-

    specific, location-specific, express what you are trying to improve, and by how much. Use the IHI

    format for aim statements demonstrated in the Resident QI Handbook and focus on a process

    measure (See Resident QI Handbook).

    “By November 10th, 20XX, 95% of patients with CHF who visit Pencil Town

    Clinic will have their weights measured and documented in the EMR.”

  • R1 QI Worksheet

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    ARECCI Results

    Instructions: go to and click on “ARECCI Ethics Screening Tool.” Answer all of the

    screening tool’s questions and send the results to using the link at the conclusion of

    the screening tool.

    8) According to ARECCI, you are doing what type of project? Check one – if you get anything other

    than “QI Project,” contact

    QI Project  Research Project ⃝ Program Evaluation ⃝

    9) What is your ARECCI score?


    10) If your ARECCI score is greater than 5, what explanation can you give for your elevated score?

    Not applicable

    Baseline Measure – How will we know that a change leads to an improvement?

    QI Measure1 Breakdown – provide an answer to each of these:

    11) Outcome Measure (this is the “big picture” goal of your project if you were to continue your

    project beyond the required one PDSA cycle):

    Outcome Measure: To decrease the number of hospital admissions by patients with CHF.

    1 Check out Resident QI Handbook for information on the various QI measures:

  • R1 QI Worksheet

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    12) Process Measure (Focus on this measure for your R1 PDSA Cycle):

    Process Measure: For our QI project, our process measure will be the number of times patients

    with CHF have their weight taken versus not taken. We will find this number by reviewing a

    month’s worth of patient presentations to see how many patients