Maintenance of Certification (MOC) Portfolio Program Active Projects
The Children’s Health℠ Maintenance of Certification (MOC) Portfolio Program maintains a list of projects available for participation credit. For additional information about a project, please contact the MOC Portfolio Program.
Participate in a MOC-Approved Project
Step 1: Select a project and reach out to project lead.
Step 2: Complete participation criteria.
Step 3: Submit a Participation Form (pdf) to the project lead for signature. Then, submit signed Participation form to
MOCProgram@childrens.comStep 4: MOC Program will submit the participation form directly to ABMS. Credit will be issued within 30 days.
Active Projects
Behavioral Health Integration and Guidance: Improve Pediatric Behavioral Health Screening
Project Leader: Sabrina Browne & Vijeta Salunkhe
Board: Pediatrics & Family Medicine
Project Summary: Behavioral health disorders in pediatric patients epitomize a substantial challenge across the nation's health care system. The number of children and adolescents requiring mental and behavioral health care continues to rise, while the behavioral health workforce faces an ongoing shortage. Traditionally, pediatric patients experiencing behavioral health concerns are either not identified early enough or are referred directly to psychiatry (for non-acute needs) or the emergency department (for acute crises). This reactive model of care does not effectively meet the growing behavioral health needs of children and adolescents. Recognizing that many lower acuity behavioral health conditions can and should be managed within the primary care setting, this project focuses on equipping primary care clinicians with the knowledge and tools to confidently screen, diagnose, and treat these conditions. Specifically, the Behavioral Health Integration and Guidance (BHIG): Improve Pediatric Behavioral Health Screening project aims to close current gaps in clinical practice. By improving the consistency of behavioral health screenings, we will promote early identification, comprehensive management, and appropriate reimbursement for services provided. Through workflow optimization, physician education, and peer to peer consultation, this initiative seeks to ensure that pediatric patients receive timely, integrated behavioral health care within their medical home.
Beta-Lactam Allergy Delabeling in the Inpatient Setting
Project Leader: Jenny Bohorquez
Board: Pediatrics
Project Summary: While penicillin allergy is reported in >10% of the general population, studies have shown that >90% of these are in fact tolerant to penicillins. Unnecessary avoidance of penicillins leads to longer hospital stays, increased exposure to suboptimal antibiotics, and increased risk of antimicrobial resistance. Beta-lactam oral provocation testing has been found to be safe, but currently in our facility there is no coordinated effort to identify patients at low risk for true penicillin allergy and conduct oral provocation testing where appropriate. Our goal is to increase beta-lactam allergy delabeling to 15% of patients admitted to the PHM service who are reported to have a penicillin allergy.
Enhancing Physician Follow-up with Out-of-network Referral Sites
Project Leader: Katherine Renee French & Tetyana Nesterenko
Board: Pediatrics
Project Summary: As part of a broader goal to strengthen community relations and improve regional referrals, closed-loop communication between referral providers outside the University of Texas Southwestern (UTSW) referral network and providers at the Children’s Medical Center Dallas Neonatal Intensive Care Unit (CMC-Dallas NICU) has been prioritized. The baseline average rate of completed call backs from CMC-Dallas NICU providers to referral providers after out of UTSW network patient transfers is 52%, which represents an opportunity for improvement. Interventions include the creation of a standardized electronic medical record documentation process, routine reminders from the outreach communication coordinator, and a star reward program to incentivize individual provider compliance. Bi-weekly monitoring was conducted using statistical problem control (SPC) methodology. The outcome measure studied was completed call backs and the process measure included completed call backs within the time frame of a shift. A provider survey was created as a balancing measure to better understand the barriers to this process.
The Pediatric Low Value Care Collaborative: Reducing Unnecessary Head CT Utilization
Project Leader: Amy Lee
Board: Pediatrics & Radiology
Project Summary: Low value care (LVC) is the delivery of health care services for which the likely benefits to the patient do not outweigh the risks or cost. LVC has been identified as an important problem in pediatric health care, and reducing LVC has become a central area of focus in health care improvement. Currently, the Children's Hospital Association (a collaborative association of ~ 200 children's hospitals that focuses on patient safety, analytics, and quality improvement) utilizes their Pediatric Health Information Systems database to report date on LVC. There are currently ~22 studies or tests that are identified as LVC when used for particular diagnoses.
Our CMC collaborative analyzed our institution's PHIS data and identified low value studies that, if could be reduced, would have high impact across the Emergency Department and inpatient service lines on both the Dallas and Plano campuses. We noted that both campuses had high use of head CT scans in children presenting with minor head trauma, simple febrile seizures, or breakthrough seizures in patients with known epilepsy. As such, our LVC provision was quite high in this area, and our comparative data revealed we are outliers in a negative way. The collaborative aimed to improve this.
Our specific aim was reduction of non-evidence based/low value care head CTs in the above mentioned populations by 5% in 6 months.
Improving Ambulatory Blood Pressure Monitor Use
Project Leader: Brian Snarr
Board: Pediatrics
Project Summary: Ambulatory blood pressure monitoring (ABPM) is the ideal way of determining white coat hypertension in the pediatric clinic, and superior to home blood pressure reporting. ABPMs had not been used in our clinic due to technical misunderstanding, equipment malfunction, and unfamiliarity within the clinical staff. In order to offer highest quality of BP evaluation in our patients, this project was designed to see if we could overcome the roadblocks and improve ABPM access and usage for our cardiology clinic.
A Checklist for Success: Reducing Unplanned Extubations in the PICU
Project Leader: Amy Lee
Board: Pediatrics
Project Summary: The pediatric intensive care unit (PICU) in the Dallas PICU tracks unplanned extubations (UPE) as a quality-of-care measure. In 2023, the unit rate was 0.58, higher than the benchmark value of 0.33. A multidisciplinary group was formed with the aim of reducing UPE. A thorough analysis via fish bone was utilized to determine action items. An area for improvement was noted: identifying patients nearing readiness for extubation and expediting their extubation such that UPE is avoided. After thorough literature search and survey analysis as well as group consensus, a peri-extubation checklist was developed with common criteria that patients must meet in order to be extubated. The goal was to ensure the multidisciplinary group at the bedside had thought of and addressed all components of the patient's care that might prevent timely extubation in a patient whom otherwise was clinically ready.
Clinic Documentation Integrity Query Response Quality Improvement Project
Project Leader: Clifford Chen & Alan Poole
Board: Emergency Medicine, Medical Genetics and Genomics, Otolaryngology, Pediatrics, Preventive Medicine, Surgery, Urology
Project Summary: Clinical documentation integrity (CDI) is an essential part in providing care to the patient in the hospital. It is the process to ensure that documentation accurately reflects the patient’s clinical status and care that was delivered while in the hospital. CDI Queries are sent from the CDI team to providers to elicit clarifications for vague or unclear documentation. Delays in the responses of the query from providers can affect delay proper coding of the encounter and underrepresents the severity of illness of the patient. The goal of the project is to improve the response time of CDI queries from medical staff. We plan to use PDSA with implementation of education, physician advisor program, and CDI clinical definitions. By 12 months, our goal is to reduce the response time to CDI queries from baseline 90 hours to 72 hours AND decrease the percentage of queries with responds after 96 hours or closed unanswered from baseline 39% to 20%.
Improving RSV Prophylaxis Counseling and Delivery
Project Leader: Preeti Sharma
Board: Pediatrics
Project Summary: With the widespread availability of nirsevimab for the RSV season starting in 2024 to 2025, our clinic proposed to screen eligible infants for RSV protection by documenting if it has been given or if maternal vaccination in the third trimester was used for RSV protection. By understanding if infants have been given RSV protection in either maternal antibodies or direct use of nirsevimab we aimed to provide information to families and encourage use of nirsevimab to protect eligible infants. This is particularly relevant, as infants seen in the pulmonology clinic can be higher risk, and RSV prophylaxis is particularly beneficial for this population.
Improving Mental Health Processes, Workflows & Responses
Project Leader: Morgan Weyant-Cheeseman & Brian Wagers
Board: Pediatrics & Emergency Medicine
Project Summary: Working with the American Academy of Pediatrics (AAP) Pediatric Acute & Critical Care (PACC) Quality Network this project seeks to implement interventions to improve the care of patients presenting to the hospital with acute mental health complaints. Evidence currently suggests that lab work does not have adequate sensitivity for medical clearance in patients, despite routine lab work being required at many inpatient psychiatric facilities. In order to improve care for patients and reduce any unnecessary harm from blood draws, this project seeks to reduce routine lab work for transfer by implementing an algorithm that guides further evaluation as needed based upon history, physical exam, and vital signs.
Medical Readiness Pulled Flow
Project Leader: Danna Qunibi
Board: Pediatrics
Project Summary: The project aimed to utilize the A3 lean framework and Lean Six. Sigma (LSS) principles to improve the patient discharge process THROUGHOUT THE CHILDRENS HOSPITAL IN DALLAS AND PLANO. CURRENT SERVICES INCLUDE GASTROENTEROLOGY, PULMONARY, HOSPITALIST MEDICINE IN PLANO, NICU, CARDIOLOGY/HEART CENTER with an emphasis on medical readiness. With medical readiness as a trigger for discharge order placement, the result can be an equalization of percentage of discharge orders placed throughout the day (continuous flow rather than batching of discharges after rounds) A series of assessments and interventions driven by the A3 lean framework and LSS principles over a 12-18 month period.
Decreasing Rejection within First Year for Kidney Transplant Patients
Project Leader: Mouin Seikaly
Board: Pediatrics
Project Summary: The kidney transplant team identified a cluster of patients in the Summer of 2023 (N=8)* that had renal allograft rejection. A work group was put together to investigate the root cause(s) and characterize commonality among identified cases. *During this investigation, an additional cluster of patients (n=5) were identified for a new total of 13.
Home Medication Reconciliation Upon Admission
Project Leader: Clifford Chen
Board: Emergency Medicine, Family Medicine, Internal Medicine, Pediatrics
Project Summary: Home Medication reconciliation (HMR) is the process of identifying, entering, and acting on patient home medications. The purpose of HMR is to identify and resolve discrepancies on home medication and those newly ordered medications. As one of the leading causes of medication errors in the hospital, these can lead to adverse drug events in the hospital, patient dissatisfaction for inaccurate records and affect patient outcomes. Joint Commission has listed the medication reconciliation as a National Patient Safety Goals for Hospitals.
Discharge Milestones Readiness
Project Leader: Abiara Agwu
Board: Pediatrics
Project Summary: During this stage of the project, patients with a projected discharge within 12 hours are identified by the attending physician or the resident team by clicking the "Discharge within 12 hours" button found within the Discharge Milestones tab in the EMR (EPIC). Early identification of patient's improve discharge planning and improve discharge efficiency. Additionally, individuals in the PHM division have used this data to better plan for prospective admissions including bed and team assignments.
Improving Access to Neonatal Care Level Four (PRANCER)
Project Leader: Tetyana H. Nesterenko
Board: Pediatrics
Project Summary: Increase the rate of autolaunch neonatal transports dispatched within 30 min of request to > 80% by the end of 2024 and > 90% by the end of 2025
Optimization of Discharge for Med Ready GI Patients
Project Leader: Danna Qunibi
Board: Pediatrics
Project Summary: The project aimed to utilize the A3 lean framework and Lean Six Sigma (LSS) principles to improve the patient discharge process on a gastroenterology (GI) floor with an emphasis on medical readiness. With medical readiness as a trigger for discharge order placement, the result can be an equalization of percentage of discharge orders placed throughout the day (continuous flow rather than batching of discharges after rounds) A series of assessments and interventions driven by the A3 lean framework and LSS principles over a 12-month period.
Heart Failure 30 Day Readmission Reduction
Project Leader: Ryan Butts
Board: Pediatrics
Project Summary: The project utilized evidence-based practices to reduce 30 day readmission rate after acute heart failure admission from 20% to 10%.
Decreasing Critical and Severe Sepsis Mortality in Pediatric Patients
Project Leader: Brian Wagers
Board: Pediatrics
Project Summary: To reduce sepsis mortality at Children’s Health to zero. We improve our processes so much that we eliminate preventable sepsis mortalities for our patients. We want to improve our recognition of sepsis to the point where we do not miss a child who develops sepsis in our system or comes to our emergency department with sepsis. We want to improve our treatment, in accordance with national/international guidelines to provide the appropriate treatment in the time periods specified by these guidelines.
Systematic Screening of Social Determinants of Health
Project Leader: Stormee Williams
Board: Pediatrics
Project Summary: At Children's Health, we screen our patient families for health literacy, social support, food insecurity, transportation and housing. Each of these can influence a patient's access to care and, ultimately, the outcomes of the care they experience. Screening for SDOH is one way we can work to address the unique needs of our patients and reduce healthcare disparities.
Anesthesiology Department Enhanced Recovery After Surgery (ERAS) Project
Project Leader: Katie Liu
Board: Anesthesiology
Project Summary: Improve usage of Anesthesia Enhanced Recovery after Surgery (ERAS) protocols.
Promoting cefazolin use in all Penicillin Allergic Patient
Project Leader: Hadi Sakhai
Board: Anesthesiology, Pediatrics, Surgery
Project Summary: Safer patient care through appropriate use of cefazolin instead of clindamycin in penicillin allergic patients.
Implementing Safe and Targeted Care for Children with Musculoskeletal Infection through Appropriate Work-Up and Treatment
Project Leader: Lawson Copley
Board: Pediatrics, Radiology, Anesthesiology, Emergency Medicine, Surgery
Project Summary: Providing consistent and efficient evidence-based care for children with deep musculoskeletal infection by obtaining appropriate initial work-up to determine correct diagnosis that will guide the decisions for implementing safe and targeted treatment.
Antimicrobial Stewardship Program (ASP)
Project Leader: Jeffrey S Kahn
Board: Pediatrics
Project Summary: The ASP committee serves to develop, lead, implement, and monitor the appropriate use of antimicrobial therapy across all institutions within the system to improve the provision of antimicrobial therapy and maintain the core elements as delineated by regulatory and national guidelines.
Improved Efficiency and Efficacy of Care for Children with Deep Musculoskeletal Infection who are treated by a Multi-Disciplinary Team
Project Leader: Lawson A. B. Copley
Board: Anesthesiology, Emergency Medicine, Orthopaedic Surgery, Pediatrics, Radiology
Project Summary: The Multidisciplinary team applies evidence-based clinical guidelines to improve the care of children with musculoskeletal infections, including length of hospitalization and readmission rates.
Pediatric Hematology/Oncology Central Line Associate Blood Stream Infection Reduction
Project Leader: Victor Aquino
Board: Pediatrics
Project Summary: Local implementation of the CLABSI bundles in the Pediatric Hematology/Oncology unit with the specific goals of reducing the rate of central line infections and increasing reliability of the maintenance bundles.
Implementing Evidence-Based Practice Guidelines for the Management of Bronchiolitis
Project Leader: Vineeta Mittal
Board: Pediatrics
Project Summary: The objective for the next 12 months starting 1/1/2024 is to decrease the need for MV within 72 hours by 10% from 39% to 30%
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