Examples of successful clinical and non-clinical Improvement in Medical Practice projects that have been previously approved ABO for Continuing Certification credit are listed below, some of which have been developed using AAO IRIS® Registry dashboard data. You are encouraged to browse these project plans and use them as templates to design a project relevant to your own practice or clinical interests. Projects developed according to one of the templates below do not need pre-approval from the ABO.
Clinical Project Samples
- Assessing the Degree of Pain Associated with Intravitreal Injections
In this practice, internal guidelines called for patients to be brought into the treatment room for an intravitreal injection within 5-20 minutes following instillation of 2% Lidocaine gel. However, compliance with this guideline was only at 64%. After implementing steps to streamline processes, 94% of patients were treated within these guidelines. In addition, patients’ average pain index score decreased from 1.12 to 0.5 after the project’s interventions.
- Critical Problem Areas in Patient Safety and Education in Age-Related Macular Degeneration
This project sought to define a comprehensive strategy for specific and appropriate patient education measures regarding the prevention of progressive vision loss and new onset of vision loss, along with safety measures to minimize unnecessary vision loss. Among the project’s outcomes was that all but one patient in the study experienced an improvement in visual acuity.
- Improving Amblyopia Compliance in Children
This project examined compliance with patch therapy in pediatric patients. Interventions included enhanced patient education techniques and counseling. By the project's conclusion, patch compliance in 30 patients improved from 81% to 94%. The project helped staff learn what motivates families to patch and inspired the care team to more diligently recommend correction of patient amblyopia.
- Improving Counseling and Compliance for Patients with Use of AREDS in Advanced AMD
The project’s goal was to use data to increase the number of patients with advanced AMD taking AREDS. Initially, about half of patients were not taking AREDS. Following the plan’s interventions, which included a systematic patient outreach plan, 57% of patients who were counseled to take AREDS began to take AREDS within a 90-day follow-up period. The majority of patients who reported not taking AREDS in the 90-day follow-up period agreed to start taking AREDS as soon as possible.
- Improving Dry Eye Management After PRK Surgery
Many patients who have PRK surgery have post-op dry eye symptoms and are recommended to undergo punctal occlusion by plugs. This project will evaluate the effectiveness of this treatment in improving dry eyes after PRK surgery.
- Improving Effectiveness of Treatment of Patients with Diabetic Macular Edema
Diabetes is an increasingly common, systemic disease often complicated by sight-threatening visual loss resulting from diabetic macular edema. Successful treatment can be slow and difficult, involving numerous visits and very expensive drugs. The aim of this project was to leverage resources to achieve improved eye health in patients with diabetic macular edema. Patients in this study experienced a greater rate of decrease in both blood sugar and systolic blood pressure following project implementation.
- Improving Guideline-Concordant Surveillance Imaging in Patients with von Hippel-Lindau Syndrome
Patients with von Hippel-Lindau (VHL) syndrome present to ophthalmologists because of the high prevalence of retinal capillary hemangioma (RCH). In addition to making the diagnosis of VHL, the appropriate management of a patient with newly-diagnosed VHL includes referral for appropriate systemic imaging to rule out other associated malignant and benign tumors. Because many subspecialists are involved in caring for the protean manifestations of this syndrome, care is often fragmented. In addition, primary care physicians are often unaware of the surveillance guidelines for this rare disease. Appropriate surveillance can be life-saving, but is often neglected due to fragmentation of care. This process improvement project led to 100% concordance with published imaging guidelines.
- Improving Rate of Gonioscopy Performed on Glaucoma Patients
About 33% of patients presenting for glaucoma evaluation were receiving goniosopic evaluations. Gonioscopy was falling through the cracks, perhaps because patients were dilated prior to being identified as glaucoma suspects or having POAG. Implementation of a reference chart to ensure that the diagnostic tests were performed resulted in improved quality of care, with 97% of subsequent patients receiving a gonioscopy evaluation.
- *Registry-Based* Increasing Tobacco Use Counseling
This project focused on increasing the rate at which tobacco use counseling was provided to patients (within a mostly Medicare-age population), particularly those with ARMD. In July 2017, just 2.7% of patients received tobacco use counseling. After the implementation of a systematic checklist prompting staff to ask about patient tobacco use, that percentage increased to 94.09% by the end of 2017.
- Reducing Extraneous OCT and VF Testing of Plaquenil Patients
This project aimed to decrease extraneous testing in order to reduce risk to patients and conserve organizational resources. Following interventions, there was a 12.9% reduction in superfluous testing when all "Plaquenil patients" presenting to the clinic were examined. Given that prior to the intervention 100% of all Plaquenil patients were subjected to testing, the project had a significant and positive impact on patient safety as well as patient and healthcare facility time, energy, and money.
- Reducing Incidence of Post-Intravitreal Injection Corneal Abrasion
This project was designed to reduce the frequency of post-intravitreal injection corneal abrasions. The estimated risk of corneal abrasion in two large studies of intravitreal injections is roughly 0.15% (1 in 750). After making changes in the intravitreal injection procedure (provider/staff/equipment) over three months, the incidence of corneal abrasions after intravitreal injections at the clinic was dramatically reduced from 1 in 50 (2%) to 1 in 200 (0.5%).
- Reducing Rate of Perioperative Incidents Related to Intraoperative Time-Out Procedure
To improve quality outcomes and create a safer medical practice environment for patients, this project addressed perioperative incidents related to gaps in the process of conducting sign-in/time-out for surgical vitreoretinal procedures. Following systematic changes to the sign-in/time-out processes, none of the 126 patients in the follow-up study groups experienced perioperative incidents. The surgical team plans to adopt these new processes as a “lifetime” project.
- Reliability of Neuroimaging Studies
Patients are seen for a variety of neuro-ophthalmic disorders and undergo neuroimaging. These scans are often interpreted by general radiologists without specific neuro-radiologic training. This project reviewed 54 neuroimaging studies by neuroradiologists at an academic medical center to see if any abnormalities were overlooked and/or misinterpreted, and if so, whether it altered the diagnosis and management of the patient. In 12/54 of cases, new or re-interpreted findings emerged which led to a change in diagnosis or patient management in 75% of those instances.
- Unilateral Ptosis Repair
To improve Margin to Reflex 1 (MRD-1) symmetry in unilateral ptosis patients, this project incorporated Hering's Law testing in the preoperative assessment. Pre-intervention analysis of 40 unilateral ptosis patients revealed postoperative MRD-1 asymmetry to be 0.96 mm. Incorporating the Hering's Law test improved postoperative MRD-1 symmetry to an average of 0.48 mm over 40 unilateral ptosis patients, which was a 50% improvement.
- Using QI to Reduce Severe Retinopathy of Prematurity ROP in Infants in a Colorado NICU
At the University of Colorado Memorial Hospital, there was a significant increase in severe ROP (stage 3 or treatment warranted), requiring surgical intervention, in the first half of 2017. Laser surgery for severe ROP increased by 59% from 2015 to 2016 and by 109% from 2016 to the first half of 2017. The goal of the project is to reduce the number of severe ROP cases by increasing nursing and parent education about the modifiable contributing factors to ROP.
- Improving Intraocular Lens Selection Process
To chart the steps and implement a review, specific to the lens selection process and share the key steps, review findings, and the steps formulated to improve this safety process
- Assessing Osteoporosis/Osteopenia Risk for Patients Taking Oral Corticosteroids for Uveitis
In my Uveitis only practice, I am covering over ten counties and interacting with 25 rheumatologists and 100's of PMD's. I would like to develop a stream-lined method to communicate easily and effectively with these physicians at the initiation of oral prednisone. Primarily I would like to delineate patients at risk, based on age, gender, ethnicity and concomitant co-morbidity/medications.
- Improving Documentation for Patients Taking Chloroquine or Hydroxychloroquine
Improve the percentage of patients with chart documentation identifying high risk factors for development of retinal toxicity in patients on Chloroquine or Hydroxychloroquine using the updated Recommendations on Screening for Chloroquine and Hydroxychloroquine Retinopathy.
- Assessing the Degree of Pain Experienced by Patients Undergoing an Intravitreal Injection at the Moment of Needle Insertion
Intravitreal injections evoke a sense of fear and anxiety in patients. Fear of pain associated with the procedure is a primary concern for patients. By assessing the amount of pain experienced and reducing that pain, the fear and anxiety may be reduced as well. This would improve the patient experience overall and potentially improve patient compliance with subsequent injections, which are often required for treatment of retinal disease.
- Tetravisc Versus Lidocaine Pledget for Short-Term and Intermediate Term Pain Control After Intravitreal Injections
Compare and contrast side effects and pain relief during injection of Tetravisc versus lidocaine pledget during the cold months. Patients already receive the injections using a variation of lidocaine pledget versus Tetravisc drops. I hope to document a preference for each according to each patient’s wishes and discover statistically which method seems best to start their treatment.
- POAG Plan of Care Documentation
Intraocular pressure of patients 18 yrs. of age and older with Primary Open Angle Glaucoma will be evaluated to determine whether their baseline IOP was reduced by 15% with intervention. Utilize EMR data to determine whether criteria have been met and develop care plans that will be used during future visits.
Non-Clinical Project Samples
- Avoiding Preventable Errors in Outpatient Intravitreal Injections
To avoid errors in outpatient intravitreal injections, this plan introduced three interventions: 1) performance and documentation of a time-out; 2) site marking of eye to be injected; and 3) identification of injection errors or near misses. The study captured 8 near misses in 509 cases (1.6%) and resulted in no medical errors (such as wrong eye, wrong drug, etc.)
- *Registry-Based* Closing the Referral Loop & Optic Nerve Head Evaluation
Communication with referring physicians remains an important and the comprehensive care of the ophthalmology patient. In order to foster a team based approach, an initiative is undertaken to improve the reporting of examination findings between the specialist and the referring physician. Optic nerve head evaluation is integral to eye care and for glaucoma patients in particular. Consistent documentation of optic nerve characteristics is essential for future clinical decision making therefore efforts at improving the frequency of optic nerve documentation is an important initiative.
- Improving Approaches to Preventing Wrong Site Surgeries
Through this project, an application for a pictorial description of the surgical site was created and implemented at surgery center. The post-project data revealed a 20% decrease in risk factors for wrong site errors such as incomplete laterality, incomplete booking forms, incomplete procedure description, and site marks that were removed during prep or cover by surgical draping.
- Improving Compliance with Diabetic Patients
The no-show rate among high-risk diabetic patients in one group practice was 3-12% higher than the national average. By making what the project author described as “small changes,” including calling patients the day before scheduled visits, the practice was able to reduce the no-show rate among patients with diabetes by 18%.
- Improving Compliance with Follow-up Appointments for Patients Treated with Glaucoma Medications
Development of a Glaucoma Medication Refill Checklist protocol that will be completed for each refill request received for glaucoma medication. The patient's record is reviewed, and the checklist will be used to confirm accuracy of medication requested, and to document if the patient has been maintaining appropriate follow up. If it is determined that the patient is not maintaining appropriate follow up, patient will be contacted by office staff to schedule appropriate follow up, explain the importance of follow up, and inform the patient that limited refills will be authorized to maintain ongoing treatment until the follow up appointment.
- Improving Doctor-Parent Communication for High-Risk ROP Patients
In addition to receiving printed educational materials, just 13% of NICU parents were routinely receiving phone calls to discuss the status of their child’s ROP. To improve parent education, the team developed a plan to better educate parents about the need for close follow-up. By adding a phone call to a newly created checklist for ROP patients, the practice successfully reached 93% of parents to discuss care questions and schedule follow-up visits.
- Improving Long-Term Follow-up of NICU Graduates
In this hospital setting, fewer than 3 out of 4 families were bringing their children to their scheduled ROP screenings. The goal of this project was to implement interventions to improve attendance, such as instituting reminder calls and texts, inquiring about transportation issues, and providing educational materials. Following the implementation of these interventions, attendance rose to 76.5%.
- Improving No-Show Rates in Patients with Diabetic Eye Disease
In patients with diabetic eye disease, the no-show rate for appointments was 26% in this group practice. After implementing a dual call-back system, where both the ophthalmology practice and the patient’s primary call practice provided appointment reminder phone calls, the no-show rate dropped to 18%.
- Improving Surgery Timeout Performance
Incorrect treatment in refractive surgery is a devastating but preventable treatment error. To develop a refractive surgery checklist that will be used consistently and accurately to decrease this error and increase patient satisfaction and reduce treatment errors to as close to zero as possible. By working with optometrists, laser and surgical technicians, tol develop a written surgical checklist protocol that will improve accurate treatment rates and improve patient safety.
- In-Office Procedure Checklist Protocol
Implementing a checklist protocol akin to airline pilots helps surgeons avoid unnecessary errors. In this project, a new system checklist was applied to in-office laser procedures. Following the introduction of the checklist, time-out use for these procedures rose to 100%. Utilizing a standardized checklist system increased the practice’s efficiencies, decreased patient wait times, and enhanced the ability to provide high quality patient care.
- Improvement in Data Collection and Organization in Patients with Glaucoma, Glaucoma Suspect, and Ocular Hypertension
Patients diagnosed in our practice (2 MDs, 1 OD) with glaucoma, glaucoma suspect, or ocular hypertension undergo a variety of standard tests and data collection.
- Improvement in Rates of Entry of Biopsy Results into the EMR
The purpose of this project is to determine the rate of entry of biopsy results into the EMR system. Currently, the results are received from the pathologist as an electronic fax and are supposed to be flagged from an administrator to the ordering physician for review. The physician is then supposed to review the results and then type the results into the patient's electronic chart. If an administrator does not flag the physician, the results may go unreviewed which could be detrimental to patient care.
- Improving Follow-Up Documentation for Patients Seen Urgently/Emergently on Weekend Call
Detect the percent of patients seen for emergent/urgent ophthalmic conditions seen on call in Spokane who do not have follow up documented in the EHR and to intervene to lower this number by 50 percent in an effort to prevent ophthalmic morbidity due to noncompliance with follow up.
- Evaluation of Depression in Patients with Inherited Forms of Vision Loss
Currently, my clinical research-based practice does not formally assess our patients with inherited forms of vision loss for depression, although this is likely present. Depression can be effectively treated, once identified, and untreated depression can affect patient well-being, self-care and other medical outcomes.
- Report of Efforts to Reduce, Recycle, and Repurpose Medical Waste at an ASC
Cataract surgery is a high frequency procedure in the United States. Over 3 million cases are performed yearly. Cases are mostly performed in outpatient settings like Ambulatory Surgery Centers. Cataract surgery is a very "clean" surgery with minimal blood and body fluid contamination. Many of the gowns, drapes, wrappings, extra materials, and plastics containers are untouched and still clean when they are placed in the trash. The amount of medical waste produced by a single surgeon for routine cataract surgery was measured and analyzed at a community multi-specialty ASC.
- Improving the Review and Patient Notification of Ordered Tests
Laboratory and Radiology tests are ordered for patients on a daily basis. It is important that each result is reviewed by the ordering physician, the patient notified, and actions taken based on the test results. We will develop a system in our office for this process.
- Using Tele-Retinal Screening to Improve Hospital Primary Care Referral of Diabetic Patients
Our hospital’s current standard-of-care is to refer all patients with diabetes seen in Primary Care Clinic to Ophthalmology yearly for retinal exams. This mass referral leads to long wait times for appointments to see the ophthalmologists, and appointments being filled with "normal" retinal screenings. By having Primary Care Clinics screen diabetes patients with a retinal camera (and photos being read remotely by an ophthalmologist), those with positive findings only can be referred quicker for full eye exams. That should decrease wait times for appointments (and, consequently, improve no-show rates) and link the patients most likely to need ophthalmologic intervention to the Ophthalmology Department. This will increase quality while reducing cost to the hospital system.
- Sharp Health Companion - Designed to Help Patients Prepare and Recover from Cataract Surgery
In an effort to transform the entire cataract surgery experience, our team introduced the Sharp Health Companion app to aid in pre-surgical preparation and post-surgical recovery. Pre-surgical instructions can oftentimes be a lot to consider and remember. However, if patients don’t follow the instructions, surgeries often end up being cancelled. Our app addresses these issues with reminders for required tasks that are needed before a patient is wheeled into surgery. To make an anxiety-ridden surgery day go smoothly, the app provides reminders that help patients remember things like what to wear, and even gives directions to the surgery via GPS map apps.
- Tracking ICL Outcomes in the United States Army
Numerous surgeons in the US Army are performing ICL surgery however the outcomes are not being tracked. There is a need to track ICL outcomes in the US Army.
- Monocular Precautions in at Risk Patients
We would like to identify as a practice, how we are doing in recommending and prescribing monocular precautions for patients that have low vision in one or both eyes or have lost an eye due to infection, trauma, or tumor. Then we would like to implement new methods of carrying out counseling and prescribing protective lenses to this at-risk population.
- Improve Patient Understanding of Glaucoma with Photos of Optic Nerves Compared to Age Matched Normals
Patients with new a new diagnosis of glaucoma will be shown their optic nerve head photos in comparison to "normal" in order to help the patient understand their disease process and aide in compliance with medications. The goal is twofold, to establish a best practice of disc photos for future comparison as well as to help the patient better understand their own disease.
- Improve the Percentage of Functionally Monocular Patients at the Dean McGee Eye Institute
There are almost 2.5 million eye injuries annually in the US. The AAO Preferred Practice Patterns for Amblyopia recommends that all patients with unilateral visual acuity < 20/50 in the amblyopic eye be prescribed protective eyewear. We have modified that to include > 2 lines of intraocular difference in order to capture non-amblyopic patients who would similarly benefit from protective eyewear. Injury to the better-seeing eye in functionally monocular individuals may produce profound decreases in quality of life, personal health, and economic stability and productivity. Different interventions will be employed in attempt to improve compliance.
- Communication with NICU Parents on Initiation of New Tele-Screening for ROP Program
Newly instituted RetCam photo screening requires a different type of communication with NICU families regarding their infant's diagnosis and treatment program.