Skip to main content

Quality Improvement

QI Graphic


The Department of Pediatrics and the Division of Cardiology recognize the importance of quality improvement in healthcare. With a common vision, our team is inspired and energized by the idea of improving outcomes for our patients while supporting our providers through the Quality Improvement process.

Annual QI Theme: “Provide Me with the Right Care”

In order to service the Heart Center, it’s patients, providers and supporters the QI committee has developed an annual theme. This year’s theme, “Provide me with the right care” highlights the desire to focus our efforts on delivering exceptional care to our patients and mimics the Heart Center’s Vision “To discover, teach and deliver exceptional cardiac care that enhances the lives of patients and families.”

Team Members:

Our multidisciplinary QI team is made up of members representing major divisions within our Heart Center.  It supports the importance of perspective in developing quality care and ensures the unique expertise and understanding that each team member brings to the table.

Judson Moore, MD ­ Quality Director

Jennifer Marrietta, RN ­ Quality Co-Director

Emilee Glenn, NP ­ QI Consultant, Project Manager

Chelsea Buckalew, RN ­ QI Consultant, Project Manager

Melissa Winder, NP  QI consultant, Project Manager

Aaron Eckhauser, MD ­ CT Surgery

David Bailly, DO ­ CICU

Kevin Hummel, MD ­ CICU

Megan Wichser, RN ­ CICU shared leader

Adam Ware, MD ­ Cardiology

Ashlee Gardner, RN ­ CCU shared leader

Chuck Pribble, MD ­ Anesthesiology

Bethany Marullo, Heart Center Administrative Director

Tina Wadhwa, MS ­ Senior Data Manager

Current Projects:

Through deliberate support of the QI program and development of it’s team, the Heart Center has collaborated on more than 50 QI projects impacting patients, families and caregivers.  Here is a list of our active projects:


Project Name PI Description
CICU CLABSI Reduction Megan Wichser Decreasing CLABSI rate in the CICU
Target Based Care  (PC4 collaborative) David Bailly, Kevin Hummel Better communicating target metrics for key milestones during post-operative recovery
Final CICU Etiology David Bailly Determining final need for ICU care prior to transfer to step-down unit
Final Hospital Need Adam Ware Determining final reason for hospital stay prior to discharge
Sternal Wound Infection Prevention (SWIP) Emilee Glenn, Jeremy Harman Decreasing SSI rate in post-operative CV surgery patients
Hearts to Home (PAC3 collaborative) Adam Ware Decreasing time to discharge after medial readiness
Genetic Counseling Consults in the CICU Briana Sawyer Increase number of eligible genetic counseling consults in CICU and decrease time to consult
Enhanced Recovery After Surgery (ERAS) Rusty Eckhauser, Kevin Hummel Decreasing time to full recovery after surgery
VAD Stroke Protocol Kari Phillips Improving stroke symptom response for patients with VADs
JET Protocol Claire Newlon Standardizing the management of post-operative JET
Efficiency and Accuracy in the Exercise Lab Ben Hammond Improving exercise lab throughput and obtaining more appropriate testing type based on indication
Social Determinants of Health screening Leandra Bitterfield Implement SDOH screening in HF/transplant clinic and make appropriate resource allocation
Implementation of Bystander CPR Training Yuki Asaki Implementing a bystander CPR training program for patients and families at a community pediatrics clinic
Decreasing transport time of high risk CHD deliveries Whitnee Hogan Decreasing the transport time of high risk CHD newborns from the U NICU to PCH.


Completed Projects:

In the world of Quality Improvement, no project is ever completed but instead falls into a category of Quality Control. The following projects have successfully transitioned into Quality Control.

Project Name PI Description
Neonatal Cardiac Surgery Lead Time Reduction Rusty Eckhauser Decreasing time from admission to OR
Moderate Risk Feeding Protocol Claudia Delgado Standardize feeding regimen for patients that are not high risk
Reducing Radiation Exposure Bob Gray Reduce radiation exposure received by CHD patients undergoing cardiac cath
PA/IVS Guideline Bob Gray Decrease practice variability in medical and procedural management
Fontan Pacemaker Phil Burch/Tom Pilcher Identifying upcoming Fontan patients who should get permanent pacer leads placed at time of surgery
MBSS Guideline Courtney Jones Establishing a guideline for when modified barium swallow study is needed
Improving Echo Interpretation Sara Hooper Improve accuracy of diagnosing PHTN by NICU providers
Syncope Practice Guideline Collin Cowley Reducing unnecessary diagnostic testing in pediatric syncope
Cardiac Arrest Prevention (CAP) Trudy Hardin-Reynolds / PC4 Determine epidemiology of CAP in patients with CHD and prevention of cardiac arrest
Nasotracheal Intubation Chuck Pribble Intubating neonates nasally for surgery to allow for PO feeding/oral skills sooner
Inequalities in Neurodevelopmental Care Kristi Glotzbach Increase the number of referrals to HCNP
Partners in Developmental Care Lauren Malik Improve developmental care in the CICU and CCU evidenced by documentation of 5 process measures
School-Age Patient Referral to HCNP / CNOC Kristi Glotzbach Recognize and document high-risk ND status and referral for formal ND evaluation
Chylothorax (multiple) Melissa Winder Decreasing time for fat-free diet, establishing testing protocol
Standardized Discharge Furosemide (PAC3 collaborative) Adam Ware Standardizing and reducing the use of post-operative furosemide after hospital discharge






Published Projects:

Glenn, E. T., Harman, J. R., Marietta, J., Lake, J., Bailly, D. K., Ou, Z., Griffiths, E. R., & Ware, A. L. (2023). Impact of a Surgical Wound Infection Prevention Bundle in Pediatric Cardiothoracic Surgery. The Annals of thoracic surgery115(1), 126–134.

Moza, R., Winder, M., Adamson, G. T., Ou, Z., Presson, A. P., Vijayarajah, S., Goldstein, S. A., & Bailly, D. K. (2023). Prediction Model with External Validation for Early Detection of Postoperative Pediatric Chylothorax. Pediatric cardiology44(6), 1367–1372.

Winder, M., & Bailly, D. (2023). Pediatric chylothorax: where we've been and where we're going. Journal of thoracic disease15(4), 1526–1529.

Winder, M. M., Ware, A., Husain, A., Griffiths, E., Swink, J. M., Ou, Z., & Eckhauser, A. (2023). Interdigitating Technique for Repair of Aortic Arch Obstruction to Reduce Reintervention Rates. The Annals of thoracic surgery, S0003-4975(23)00678-1. Advance online publication.

Marietta, J., Glotzbach, K. L., Jones, C. E., Ou, Z., Profsky, T. K., Clegg, D., Winder, M. M., & Pribble, C. G. (2022). Assessing the Impact of Nasotracheal Intubation on Postoperative Neonates With Congenital Heart Disease: A Quality Improvement Project at a Single Heart Center. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies23(7), e338–e346.

Lion, R. P., Winder, M. M., Amirnovin, R., Fogg, K., Bertrandt, R., Bhaskar, P., Kasmai, C., Holmes, K. W., Moza, R., Vichayavilas, P., Gordon, E. E., Trauth, A., Horsley, M., Frank, D. U., Stock, A., Adamson, G., Lyman, A., Raymond, T., Diaz, I., DeMarco, A., … PC4 Chylothorax Work Group (2022). Development of consensus recommendations for the management of post-operative chylothorax in paediatric CHD. Cardiology in the young32(8), 1202–1209.

Ware, A. L., Reiter, L., Winder, M., Kelly, D., Marietta, J., Ohsiek, S., Ou, Z., Presson, A., & Bailly, D. K. (2022). The final hospital need in children discharged from a cardiology acute care unit: a single-centre survey study. Cardiology in the young, 1–8. Advance online publication.

Winder, M. M., Marietta, J., Kerr, L. M., Puchalski, M. D., Zhang, C., Ware, A. L., & Cowley, C. G. (2021). Reducing Unnecessary Diagnostic Testing in Pediatric Syncope: A Quality Improvement Initiative. Pediatric cardiology42(4), 942–950.

Kevin Hummel & White B, Algaze C, Marrone T, Sinnott J, Wawrzynski S, Winder M, Bailly D (2021). Standardization without protocolization: Implementing transparent bedside benchmarks to reduce variation in postoperative care. NEJM Catalyst. Published, 05/2021

Glotzbach, K. L., Ward, J. J., Marietta, J., Eckhauser, A. W., Winter, S., Puchalski, M. D., & Miller, T. A. (2020). The Benefits and Bias in Neurodevelopmental Evaluation for Children with Congenital Heart Disease. Pediatric cardiology41(2), 327–333.

Winder, M. M., Ou, Z., Presson, A. P., Witte, M. K., Ware, A. L., Marietta, J., Ward, J. J., & Bailly, D. K. (2020). The final reason paediatric Cardiac ICU patients require care prior to discharge to the floor: a single-centre survey. Cardiology in the young30(8), 1109–1117.



Institute for Healthcare Improvement: The Institute for Healthcare Improvement has over 30yrs experience in the science of improvement. Their website has several resources and published white papers describing the framework of Quality Improvement.

IHI QI Essentials Toolkit: The IHI Essentials Toolkit includes a description of QI tools as well as templates for tools so you can get started.

Dr. Mike Evans: An Illustrated Look at Quality Improvement in Healthcare: This is an excellent video that introduces the concepts of quality improvement in an easy to watch animated whiteboard video.

QI Concept Document: Use this document to help you organize your quality improvement idea. Click the link below. 

Contact Information:

Phone: (801)662-5402