Introduction also use health devices for data


UC Health Internal Medicine Practice is a small clinic that focuses on providing education, prevention, and assistance to patients and staff. UC identified a need to enhance patient outcomes by utilizing tools already in place to avoid the cost. The clinic continuously gathers medical history data that relates to smoking and exercise habits. Despite a logging process was in place, the problems consisted: staff lack training, patient education, and poor communication in patient/physician relationship. The clinician’s input highlighted a need to also use health devices for data that could be used in managing patient’s outcomes. For these reasons, UC elected a champion and used data from several tools, which included the patient portal, UC tablets, and monitoring system to create a plan to tackle the issue and increase positive outcomes. The patient indicators chosen were patient satisfaction, screening and treatment trends, and smoking and exercise habits. The IHI model for Improvement strategy/PDSA approach was used for easier patient adoption, expert team utilization, and to allow constant changes. Benchmarking was used to compare results with nearby clinics to ensure the success of the goal.

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Goals or Objectives

The goal is to fix certain barriers such as staff training, patient education, and communication between clinicians and patients to enhance patient outcomes. UC created a CQI to implement a better way to communicate with the patient with devices, patient portal and surveys, and system to encourage prevention and counseling to be successful in completing the goal. The Plan-Do-Study-Act approach (IHI Model for Improvement) will be utilized for two reasons: ensure small continuous changes to allow staff to get used to process and accept; capture accurate data without overwhelming the team tackling the process. The comparative benchmarking will be used to ensure the process is on track to be successful. Overall these methods allow the team to retrieve data continuously and focus on small changes.

Data Collection Tools to Meet MU Stages 1-2

The monitoring system will be utilized to monitor the patient treatment journey and any current developments. The system will alert the clinicians to any new developments that are linked to smoking and poor exercise habits by logging BMI and smoking habits. The monitoring system will send reminders of upcoming visits and alert case managers to call the patient to follow-up on health status. The patients will have the opportunity to talk to the case manager about any concerns. The monitoring system reports will be pulled to capture data and allow for adjustments to be done if necessary. Questionnaires will also be uploaded to UC tablets for patients to fill out while sitting in the lobby before the visit. The appointment reminders will provide the patient with a link to connect safely to while on their own devices to fill out before the visit. The patient portals and UC tablets will be utilized to communicate to the patient about important topics such as smoking prevention and exercise tips. The contact information of staff and available times will be loaded in these devices as well. UC will utilize flowsheets to keep track any adjustments or alerts on patient’s conditions or habits. The flowsheets will highlight the BMI, nutrition, and poor exercise habits to use for counseling or treatment regimen changes. Of course, the team leader will continuously monitor the devices and system to ensure data is being captured and entered for more accurate results. The option of calling into the hotline anytime will still be available.


The clinic relies on government funding and grants to keep functioning. Therefore, the clinic meets requirements of prevention, education, and support to patients by tracking results. The statistics are captured through the monitoring system, tablets, and patient portal to report to the government. UC is small and provides counseling, coaching, and treatment programs, and screening to their patients. The tools were included in the new electronic system and budgeted in last year’s cost, which help keep cost down.


Dr. Cooper will be the head of the process, but all members will be required to give input for decision-making or changes. Although this team will be working on the process, the team also will be working their own duties and will delegate to their staff for help on data collection if necessary. The team will meet weekly in Revenue Cycle committee for any changes or just to recap how the process is moving forward. The team will meet quarterly in QI meeting to keep the -clinic up-to-date reports on progress. Lastly, the team will continue to meet annually for any changes or progress. During the annual meeting, the team will be recognized for their achievements in progress.

Champion-Dr. Cooper
Diana Cobos-registered nurse
Leslie Rodriguez-medical assistant
Adrian Flanagan-patient health coordinator
Nick Sanchez-patient access manager
Lee James- IT lead

Communication Plan

The responsibility of data collection will be managed by the person treating the patient or a case manager. Patients will communicate verse patient portals, tablets, and at the point of care to clinicians. UC will put up posters in lobbies and rooms with several highlights. The highlights will include Service available, staff names, contact information, available times, and prevention and counseling points. A hotline will be set-up for patients to call in if any questions or concerns.


All staff involved in entering data will be trained on the monitoring system, patient portal, tablets, flowsheets, patient support, services provided. The training methods will include PowerPoints or through HealthStream program to educate staff. All training will be provided before the process goes into effect and as needed. The patients will also be trained on using the tablets and how-to set-up the patient portals. The patient access manager will help his staff to train the patients coming in to register.


The evaluation of the CQI plan must be monitored weekly, quarterly, and annually to achieve the goal of enhancing patient outcomes. Because data needs to be accurate UC will be collecting information in small portions to not overwhelm the team. Of course, UC will focus on ensuring data is accurately entered by patients and staff. Once the data is compiled and analyzed, the data will be used to improve treatments and patient and clinician’s communication to each other. The data will be collected by the system, tablets, and external patient devices. The changes will be made small by using the IHI model for improvement/PSDA approach to be more effective.


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