Projects and Programs

At UNC Medical Center, we aim to provide patient-centered, effective, timely, efficient, equitable, and safe care to all patients. Provided below are descriptions of key activities and initiatives focused on improving quality and patient safety. To read more about our leadership and coordination, please see UNC Medical Center Approach to Quality Improvement.


Annual Quality Expo

The Annual Quality Expo highlights performance improvement activities across the institution and allows departments to share success stories. Clinical as well as administrative projects demonstrate how organizational goals are driven by departmental success. Often these projects consist of an interdisciplinary team that is driven by front line staff. Many of these success stories have been shared as best practice across the organization. More than 100 posters were displayed at each of the last two Expos.

Clean In, Clean Out (Hand Hygiene)

Hand hygiene is of paramount importance to the health and safety of our patients. When health care employees properly wash their hands, we can reduce infections and save lives. UNC Hospitals Clean In, Clean Out program asks all employees to clean in and clean out every time they enter and exit a patient room. This goal applies to both clinical and non-clinical colleagues because we all can help keep our patients safe by practicing proper hand hygiene.

Learn more about Clean In, Clean Out.

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    Commitment to Caring Teams/Partnering with Patients and Families

    Several multidisciplinary teams represented by leadership, inpatient, ambulatory, nursing, medical staff, quality and other areas review opportunities and priorities as they relate to the pillars of our foundation: people (staff and patients), service, quality, finance, innovation, and growth.

    The Partnering with Patients and Families committee is an example of how we incorporate patient-centered and family-centered care. Collaboration between patients, families, and caregivers is essential to improving patient safety, reducing medical errors, promoting adherence to treatment, less frequent office and ED visits and increasing satisfaction. These partnerships involve patients and their families in shared decision making for care decisions as well as quality improvement projects, advisory boards, and committees.

    Lean Six Sigma Improvement Teams

    Lean Six Sigma (LSS) is set of complementary methodologies to improve how we lead, teach and care. While Lean focuses on speed, elimination of waste, standardization, and flexibility/responsiveness, Six Sigma seeks to verify root causes of current performance and to examine and eliminate variation. Both seek to continually improve the quality of care we deliver to our patients. In a phrase, “Get rid of what you don’t need and improve what’s left!” The goal of the LSS deployment at UNC Health Care is to train all employees as Yellow Belts – those who can assist with improvement projects. All employees with interest and aptitude are encouraged to pursue further training to become Purple Belts (who focus on Lean projects), Green Belts (who focus on Six Sigma projects) and Blue Belts (manager-level and above who sponsor projects).

    Employees can access the internal Lean Six Sigma at UNC Health Care website.

    Meaningful Use

    The HITECH Act and the Affordable Care Act, two critical federal legislations, have several provisions that focus on improving quality and safety through information technology. Meaningful Use requires eligible hospitals and professionals to demonstrate that they are using a certified EHR technology in ways that meet specified utilization and quality measures. UNC Hospitals has recently successfully attested to Meaningful Use stage 1 and is working on Stage 2 attestation.Read more information about Meaningful Use at UNC Health Care.

    National Patient Safety Goals

    UNC Health Care strives to provide outstanding care in all areas highlighted by The Joint Commission. The National Patient Safety Goals aim to improve patient safety by addressing ways to solve problem areas.

    Outpatient Care Services Operations Improvement

    OCS Operations Improvement (OCS OI) combines the Model for Improvement Methodology with Lean concepts and tools to support smooth operational flow in UNC’s outpatient clinics and service areas, both from an access and clinic/service flow perspective. Prior to working with a clinic or service area, we conduct a baseline data analysis to identify potential opportunities for improvement. During this time, we also meet with clinic/service leadership to determine project goals and areas of focus.

    After improvements have been implemented, OCS OI Quality Analysts conduct periodic check-ins with their clinics/services to ensure that all changes that were made are sustained as well as check for any new opportunities for improvement that may have arisen since implementation. Sustainability is also supported by continuous data monitoring by the OCS OI team, as well as ongoing virtual communication with clinic/service leadership.

    Project TICKER (Teamwork to Improve Cardiac Kids' End Results)

    The aim of Project TICKER (Teamwork to Improve Cardiac Kids' End Results) is to implement a patient-centered and family-centered safe practice infrastructure incorporating teamwork training and integrated clinical pathways for pediatric congenital heart disease patients at N.C. Children’s Hospital. The project involves a partnership among the service units, ancillary support team, medical teams and pediatric congenital heart disease patients and their families. Read more information about Project TICKER.

    Rapid Response Teams

    • Adult
    • Pediatric

    These teams support a patient's primary inpatient physician and nurse by bringing additional consultative expertise (ICU physician, ICU nurse, and respiratory therapist) to the bedside when, in the view of a physician, nurse, or family member, the patient’s condition is acutely changed.

    STEMI Teams (Heart Attack)

    We have a multi-disciplinary team that successfully improved patient care by increasing how frequently we meet Door-to-Device time targets for STEMI (heart attack) patients from 60% to >90%. Comprised of emergency room, Cath Lab, Cardiology, ICU and PI champions, as well as members of EMS teams within our community, this team has implemented: early activation of the cardiac cath lab by paramedics and emergency room physicians, reduced emergency room times, improved documentation, and concurrent and monthly review of all cases, including root cause analysis of cases that do not meet standard timing elements. Due in part to the work of this team, UNC has received a Mission: Lifeline award from the American Heart Association for the past 4 years, including a Mission: Lifeline Gold Plus award this year. Read more about our Chest Pain Center.

    TeamSTEPPS (Teamwork Training)

    TeamSTEPPS™ is a teamwork system designed to improve quality, safety, and efficiency of health care. The Department of Defense Patient Safety Program developed this program in collaboration with the Agency for Healthcare Research and Quality. Read about TeamSTEPPS™ activities on the UNC Institute for Healthcare Quality Improvement website or visit the Department of Defense and AHRQ TeamSTEPPS™ page. If you are interested in seeing TeamSTEPPS™ in action at UNC Health Care, view videos of some of the tools.

    School of Medicine

    The Division of General Medicine Initiatives

    • In order to achieve our goal of improving the health status of North Carolinians, the University of North Carolina at Chapel Hill Division of General Internal Medicine and Clinical Epidemiology is dedicated to promoting an environment supportive of continuous quality improvement. We aim to improve patient care by identifying barriers to patient satisfaction and quality patient care. We utilize continuous quality improvement methods to approach an issue in a systematic way and we encourage faculty, residents, students and staff to lead and participate in the projects. We dedicate time and resources for clinic staff to work as teams on various clinic quality improvement topics twice a month.
    • Department of Pediatrics


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