Quality Improvement

Research & Quality Improvement
To learn more:

Marica Martinic, MPH

Director, Education
928.522.9855

Email Marica

Quality Improvement

North Country HealthCare and the Colorado Plateau Center for Health Professions are invested in supporting QI projects conducted by students, residents, or staff that study and refine existing clinical and non-clinical workflows. Our clinical and management teams have identified seven of the highest priority areas for which we would like future QI projects to address. 

  • Well Visits
    • Peds 0-30 months, 3-21
    • Adult 18-64.9
    • Medicare 65+
  • Pediatric Focus Month
    • Immunizations
    • Developmental Screening
  • Diabetes
    • A1c >9 or not tested
    • Statin use in patients with DM
  • Women’s Health
    • Breast Cancer Screening
    • Cervical Cancer/ Chlamydia Screening
    • Depression Screening while pregnant
  • Systems Based Measure
    • Hypertension: Controlling High Blood Pressure
    • Ischemic Vascular Disease: Aspirin Use
    • Statin Use for the Prevention and Treatment of CAD
    • Dental Measures

North Country HealthCare has two types of projects and processes for managing our QI efforts: vetted projects and unvetted projects. Potential projects that we would like to have conducted within each of these target areas have been “vetted”, and they provide students, residents, and staff with a template of meaningful projects for which we would like to see improvement. This does not mean that a proposed project that has not been vetted will not be approved, but we may require the scope of the project to decrease dramatically. North Country remains very selective in the unvetted QI projects that we agree to support, as even a small project can take significant staff time and resources away from the other areas in which we’d like to focus.

Vetted Projects

A QI project is vetted by our Continuous Quality Improvement (CQI) Committee, and this generally means that:

  1. The project topic falls into one of the seven priority areas.
  2. The specific workflow needing improvement has been identified, as well as the scope, outcomes, and timelines.
  3. A person of contact and/or a student preceptor has been identified for the project to assist in further planning and execution of the project.

There is no approval process that vetted QI projects need to undergo. This means that there is no formal application that needs to be reviewed on a management or organizational level. The designated contact for each vetted project serves to help oversee and implement the project, assess its outcomes, and plan for the next iteration of improvement. Consequently, vetted projects are ideal for students and residents who may need or prefer and already-focused project tied to clinical members who can support and assist throughout the process. 

Unvetted Projects

It’s possible that you are a student, resident, or staff member that may already have an idea for a QI project that you’d like to conduct that has not been vetted. Perhaps you’ve noticed workflows in your own daily routine that need improvement, or you’re interested in something entirely different. Even if the project topic falls within one of the priority areas (i.e. addresses diabetes or mammograms), North Country HealthCare requires that all unvetted projects have a very small scope and involvement of no more than one provider and their immediate care team. This allows most resources to be allocated for vetted projects, while still allowing unvetted projects to demonstrate efficacy on a pilot-level scope. These projects can then be iterated on a larger scale if workflow improvement can be demonstrated.

Quality Improvement Workflow

Submission Documents & Forms

All individuals wanting to conduct a QI project (vetted or unvetted) must complete and submit a QI Project Management Form. This document serves as a very high-level understanding of the project objectives, scope, and outcomes, and we use this to track and manage the quantity and types of QI projects that are actively being supported by the organization. 

For those who may not have comprehensive familiarity with QI projects and the PDSA cycle of quality improvement, some reference materials are also attached to help design and plan a project.

Forms to Download

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