As we look ahead, we will continue to focus our improvement efforts on areas that have the greatest impact on patient safety, experience, and outcomes, strengthening the connection between frontline innovation and our strategic goals.
One Team. One Purpose. Ever Better.
Thank you for the dedication and partnership that make this work possible. Together, we will continue building a culture of learning, improv and excellence in care.
Sincerely,
The PEI Leadership Team
WHAT IS UPP?
The UR Medicine Performance Program (UPP) is an interprofessional, teambased approach to engaging individuals to work collaboratively and promote a culture of continuous improvement in patient safety, patient and family centered care, health equity, and efficient operations. Currently, the program has over 50 teams across inpatient units, service lines and ambulatory clinics.
WHAT IS PEI?
A fellowship program for the UPP team leadership dyad which focuses on developing leadership skills, teambuilding, and quality improvement science.
Adult Units
1-9200: Medicine in Psychiatry Unit &
Wins:
More nursing interest
Level 3 RNs taking ownership of goals and tracking/presenting progress each month
Barriers/Challenges:
Lack of multidisciplinary participation
Inconsistent follow through on action items
Next steps:
Working on interdisciplinary standardization of medication times
Outcomes:
Decrease in readmissions
Decrease in length of stay through UR on the Move
G-9200: SMIPS
Publications/Posters: Dr. Wittink presented priorities tool at a poster presentation
3-1200: Perinatal/GYN
3-1400 & 3-1600: L&D Obstetrics & gynecology, ED
3-3600: Mother Baby
Lessons Learned:
Wins:
Family center c-section project launched for scheduled c-sections then expanded to all cases
Patient and staff feedback has been extremely positive
Poster presentation at 4 Annual Better Teams Better Care Symposium th
Buy in is key! Culture change can be challenging
There is a difference between project start and project maintenance “Forever” projects are best done in pieces
Barriers/Challenges:
Standardizing protocols to ensure equal opportunity for experiences by all patients
Next Steps:
Installing speakers into the OB ORs
Additions to the c-section preference menu
Implementation of service data collection
Integration of preference sheet into EMR
Maternal positioner project with undergraduate Senior Engineering Students
2-1800: ADULT ADMISSION UNIT
Wins:
Onboarded a lot of new staff members
Won a Board Excellence Award
Began to roll out UR On the Move; completed 1 PDSA cycle
Continued work on discharge planning and hand hygiene initiatives
Identified as the fall-back home for Hospital at Home patients
Next Steps:
Continue with UR On the Move roll out
Wins:
Improved sense of communication with hospice team
High satisfaction with implementation of new butterfly icon in eRecord
Outcomes:
In process; using butterfly icon as people are liking it
Data for preintervention now being analyzed
Barriers/Challenges:
Data has been harder to collect/analyze than expected
Time constraints with TJC survey
Hospice EPIC is different than ours which impacts how to use Slicer Dicer
Lessons Learned:
Learned more about the hospice process
Next Steps:
Looking deeper into data to help inform next PDSA cycle
4-1600: Heart & Vascular
Wins:
Began PEI In February 2025
Launched UR On the Move Multidisciplinary team Created friendly competition to achieve project goals
Barriers/Challenges:
Maintaining momentum
Next Steps:
Sustainment of UR On the Move!
4-3600:
Heart & Vascular
Wins:
Began PEI in February 2025 focusing on UR On the Move Mobility Program
Next Steps:
Graduate from PEI in May 2026
4-2800: Cardiovascular ICU
Next Steps:
PEI Graduation in May 2026
Wins:
Began PEI in February 2025
Improved time to mobility for Impella 5.5 patients by reducing barriers to movement through developing a new policy and embedding mobility into unit culture
Current project focuses on improving workflow to ensure timely therapy for patients
Identified barriers to timely therapy through staff survey
Solicited improvement ideas from team
Clarified team roles and responsibility for increased transparency and understanding
Barriers/Challenges:
Current project is broad; working to define to help identify next steps
Staffing
Time
5-1400:
Created a resource sheet that defines scope of practice for nursing and tech roles for increased knowledge
Collaborating with another unit based team working on improving interdisciplinary communication and collaboration
Strong interdisciplinary presence at monthly UPP meetings
Trauma/General Surgery
Wins:
Re-launched UPP team
Collaboration with trauma team
In the early stages of multiple projects
Working on obtaining baseline data
Barriers/Challenges:
Champion engagement
Time
Next Steps:
Create nursing education
Create patient education
Goal of submitting to 2027 Traumacon
5-3400: Orthopaedics & HMD
Wins:
Implemented a visitor policy for patients & family members
Continued to work on and improve upon UR On the Move
Improved interdisciplinary rounds
Engaged Patient Experience Advocate to assist with Geriatric Fracture Center surveys
Implemented MyChart bedside
Goals for 2026:
Improve multidisciplinary representation on team
Begin new project focused on identifying and focusing on what matters most to patients; this is in collaboration with another unit that has already implemented this work in their area
Barriers: Multidisciplinary attendance and participation at monthly UPP meetings
Lessons Learned: Protected time is important to support frontline staff engagement Interdisciplinary ownership and alignment are critical to sustainability
6-1400: Acute Care Medicine
Current Projects:
Exploring How Social Vulnerability Impacts Delayed Hospital Discharge: A Unit-Based Quality
Improvement Initiative
Identifying Discharge Delays: A Multi-Disciplinary Quality Improvement Initiative
Utilization of the Medically Ready for Discharge Date (MRDD) Function in the Electronic Medical
Record: An Interdisciplinary Quality Improvement Project
Med Rec Made Right: A Quality Improvement Project to Reduce Medication Errors at Discharge
Reducing Excessive Laboratory Testing in Hospitalized Patients: An Interdisciplinary Quality
Improvement Initiative
6-1600: General Medicine
Wins:
Pilot unit for CHF protocol to address readmissions
Launched UR On the move; increased nursing and provider education for mobility
Began project focused on improving multidisciplinary communication to improve discharge efficiency
Lessons Learned:
Utilized new technology for UPP team communication to enhance engagement
Next Steps:
Barriers/Challenges:
Identifying a meeting time that works for everyone
Solidifying communication method that works best for leadership team
Solidifying communication method that works best for the discharge team
Wins:
6-3400: Acute Care Medicine
Launched UR On the Move
with a Halloween theme that included costumes, trick or treating and matching shirts
Next Steps:
Continue to work on hand hygiene
Decreasing rates of C-Diff and CLABSI/CAUTI
Working with the interdisciplinary team to discharge patients to the safest location possible
Continue collaboration with 6-1400 on a project aimed at incorporating a pharmacist into resident team rounds
Lessons Learned:
Having pharmacists included in multidisciplinary rounds has increased discharge efficiency and decreased impact of last minute changes. It also has fostered connection with the whole team to the work that they are doing.
Wins:
Began PEI in February 2025
UR On the Move is doing well with good buyin from the team & seeing patients up and moving better
Increased BMAT documentation
Increased activity entries per day
Barriers:
Limited multidisciplinary participation
Smaller environment due to shared space with another unit
Time management; prioritizing mobility for all patients
Outcomes:
Reduced length of stay:
Lessons Learned: A champion is essential for team engagement Mobility is not one size fits all
7-1400: Medicine; Acute Care for the Elderly
Wins:
Rolled out two new collaborative QI projects; HCP
improvement & CHF SAFE-D discharge project
Leadership dyad presence on the Age-Friendly Taskforce efforts
Successful placement/discharge of multiple long stay ALC patients
Weekly ALC meetings with hospital leadership to troubleshoot discharge barriers for long stay patients
Decrease in Lovenox refusal on the unit
Net improvement in HCAHPS comparing Q1/Q2 vs Q3/Q4
Outcomes:
Early data from our project aimed at increasing the % of patients with a valid HCP on our unit is promising. Baseline data showed that appx 50% of patients discharged from our unit had a valid HCP form in place. After our first 4 PDSA cycles, 80% of patients discharged from our unit have a valid HCP form in place.
Barriers/Challenges:
Prolonged ED boarding time; less of a patient’s admission spent on the unit
Split unit with both APP & resident team patients
7-3400: Solid Organ Transplant
Wins:
Staff training & empowerment
Mobility champions identified
Mobility spotlight initiatives
Barriers/Challenges:
Intermittent engagement
Competing unit priorities
Outcomes:
Average of 4.6 activity entries per day
Medial length of stay (LOS) goal of 5.7 days met or exceeded 54% of the time
Lessons Learned: Persistence is key when driving culture change
Positive reinforcement is highly motivating for both patients & staff
Friendly competition is a great motivator
7-3600: General Medicine
Wins:
Increased utilization of TCU; overcame barriers to use such as staff & patient resistance and provider knowledge of process for utilizing TCU
Improved patient flow
Multidisciplinary engagement and participation at monthly UPP meeting
Next Steps:
Launch UR On the Move Spring 2026
8-1200: NeuroMedicine ICU
Project: Let’s Face It! Pressure Injury Prevention from the Neck Up
Outcomes/Where We’re at Now:
• Since project rolled out (June 2025), total of 6 more pressure injuries:
1 oral (likely from patient biting own tongue) 1 trach (one-sided, likely from agitation and contracture), None from BiPAP or c-collar
• Have continued one-pagers at the nurses ’ stations and frequent bedside teaching
Wins:
At least in the short term, reduction in these PIs!
Barriers/Challenges: Shaving patients and changing ETT holders and collar pads: requires multiple people and time
Lessons learned: Interdisciplinary communication is key! (respiratory)
Project: CAUTI Reduction 2024-2025
Outcomes/Where We’re at Now:
• In 2025, >50% reduction: 4 CAUTIs!
Wins: CAUTI reduction!
Barriers/Challenges:
· Changing a unit cultural myth takes time!
· Aliquoting takes time and supplies
Lessons learned:
· Never would have figured out the issues if we had just continued bundle compliance audits. Need to talk to staff!
· If there’s data you want, sometimes you have to ask for it (needed the lab to send the aliquot data, and they do track that!)
· Interdisciplinary involvement is key
Emergency
Department G-1600: ED 16 & HMD
Wins:
Utilized an Ever Better Board to achieve several “quick win” improvements
Portable monitors that hold a charge & transmit to central monitor
DPS @ Verticare
Improved scheduling
Cup/Lid/Straw holder near water dispenser in Verticare
Pillows stocked in linen carts AND MORE!
Wins:
Launched an UPP team!
Identified a meeting time that allowed for more consistent participation at monthly UPP meetings
BMAT tool is wrenched into main track board; helps with ensuring regular completion by staff
“Mobility Monday” has increased engagement with UR On the Move
Barriers/Challenges:
Physical space is very small; not possible for all patients to get up to a recliner chair for meals
Time for patients to have PT every day
High rate of staff turnover
Lessons Learned:
BMAT posters were not a helpful tool in ensuring BMAT is updated regularly
ED Observation Unit
Wins:
Identified opportunity for improvement with hand hygiene & proper mask wearing
Created an engaging activity to bring awareness to importance; trivia games & team photos as examples
Have seen improvement in hand hygiene compliance
With respiratory season upon us, we sought out ways to once again bring more awareness to infection prevention.
We sent out some fun stories and news articles to read including “Salmonellosis
Associated with a Thanksgiving Dinner” and “The Effect of Long Public Holidays on Healthcare-associated Infection Rate.”
Lessons Learned:
After hearing concerns regarding an uptick in incidence of escalation of care cases the team tracked and reviewed for a few months and determined there was not a problem to address This is something that is still monitored for awareness
Next Steps:
Continue efforts to improve hand hygiene compliance
Strong West ED
Wins:
Incorporating QA/QI metrics into UPP project work; increased bandwidth and resources to pursue quality improvement work
Achieved and maintained compliance with obtaining vital signs within one hour of discharge; celebrated team’s accomplishment with a pizza party
2025 Vital Signs Compliance Data
SMART AIM:
We will increase compliance with obtaining vital signs within an hour of discharge from 87% in December 2024 to 90% by June 2025
Plan for 2026:
Integrate new leadership into UPP team and identify areas of opportunity to focus on in 2026
WCC-5: Surgical Oncology/Urology
Wins:
Formed and launched an UPP team!
Began a project aimed at improving patient blood management on the inpatient side
Project Leader accepted into Quality
Track Fellowship
Wins:
Began PEI in February 2025
Launched UR on the Move
Next Steps:
Graduate from PEI in May 2026
Outcomes:
Increase in median activity entries from 3.9 daily to 4.2 daily
Transfusion Medicine
Next Steps:
Continue with blood product stewardship project
Partner with ICU APPs to improve process of ordering & receiving blood product
Improved education & knowledge of the role of the Blood Bank and Transfusion Medicine teams
Outcomes:
WCC-6: Blood/Marrow Transplant
Decreased CLABSI from 19 to 12 ; Falls from 33 to 22
Improvement to Interdisciplinary Rounding
Next steps:
Retention
Decrease CLABSI and Unlabeled Specimen
Increase UR on the Move engagement
Barriers/Challenges:
Still struggling with having the residents meet with discharge nurses to discuss discharges to promote safe and timely discharge
Wins:
Publications/posters:
ONS Conference – two posters presented Brittany Pease & Rhona Henry
Hired and successfully oriented
16 new nurses
Ann Hill Phillips Award – WCC6 Unit Council
Preceptor award – Katherine Craig
Wilmot cancer Institute - Patient Unit
Secretary award Charleen Pearson
WCI Leadership award – Rhona Henry
Quality - Safety Culture survey results were exceptional
Piloted MyChart Bedside
BMT team - bone marrow marchers walked alongside their patients and raised over $4,000 towards the Wilmot Warrior March
WCC-7: Hematology/Oncology & HMD
Wins:
Downward trend in length of stay
Increased average activity entries per day
Increase in falls has not led to increase in falls w/ injury
Barriers/Challenges:
Decrease in mobility documentation likely due to documentation fatigue & staff turnover
Goals for 2026:
Continue with UR On the Move
Increased OT involvement
Educational series for patients & caregivers
Decrease LOS & readmission
Lessons Learned:
Initial patient tracker set unrealistic expectations; modified based on feedback from patients; helped patients feel more accomplished
Pediatrics
3-1200: Newborn Nursery
3-3400: NICU
Wins:
Graduated from PEI in December 2024
Barriers/Challenges:
Attendance & participation in UPP meetings
High volume of improvement projects going on simultaneously
Outcomes:
Improved compliance to executing the four core elements of the perinatal plan for neonates with prenatally diagnosed congenital cardiac disease (baseline of 46% to above 75%)
Next Steps:
Creating one space where all QI work in the NICU is reviewed, reported out on, and potentially cleared before starting Would like to create a unit top 10 list and focus on five projects or less
6 North: Pediatric ICU
Wins:
Joined the Solution for Patient Safety
Delirium Screening and Management
Collaborative
Team has been successful in getting data
Worked with Infection Prevention to identify barriers to hand hygiene; work was disseminated to other GCH units
Very engaged team
Barriers/Challenges:
Have had to build some new data displays to track outcomes
Next Steps:
PDSAs on delirium screening & management
Starting a project focused on better standardization of sedation medication
Outcomes:
Obtained baseline data for delirium screening
Improved hand hygiene compliance
6 South: Pediatric Cardiac Center
Wins:
Created a new tool called DEPTHS to increase safety with endotracheal tubs; tool has been disseminated to other units
CLABSI prevention poster was presented at 2025 Better Teams. Better Care. Symposium
Barriers/Challenges:
Team members have expressed concern for use of RL event reporting
Lessons Learned:
Leadership involvement is key to adapting and adjusting to changes on the unit
Next Steps:
Will continue to focus on unplanned extubations which is in line with GCH QAPI plan
7 North: Pediatric Hematology/Oncology
Wins:
Very engaged interdisciplinary team
Successfully implemented an UPP leadership quartet
Collaborated with multiple other groups throughout the hospital doing work around EOL
End-of-life (EOL) note template finalized
Barriers/Challenges:
Pure size of what this project entails
EOL projects are some of the most meaningful but hardest to measure QI projects
Lessons Learned:
Working in sub-committees with SMEs has helped keep project moving forward
Hybrid meeting has helped maintain strong engagement
Next Steps:
Building EOL order set
Reviewing & making pediatric recommendations to a
Serious Illness/EOL tool/navigator in eRecord
Outcomes:
Plan to measure metrics across multiple project elements:
Workflow & efficiency
Education & competency
Staff support/moral distress/emotional impact
Symptom management/clinical quality
measures (order sets & education)
Family support
Want to create an EOL guide for GCH in PolicyStat as a resource to any unit navigating this care
Wins:
1 year CLABSI free!
7 South: Pediatric Surgery, Renal & GI
Pediatric Procedural Support
Improved staffing with a positive effect on culture & safety
GI Direct Admissions reboot
Consistent engagement & leadership rounds
Great energy about upcoming projects
Cova Clear trial for central line dressings
Lessons Learned:
Need increased engagement of divisional leaders to tackle operational challenges
Improved staffing increases UPP productivity
Using level III projects with a nurse/provider dyad allows for greater breadth of projects
Despite a focus on handwashing, our numbers continue to be unacceptable; need to try different approaches
Next Steps:
Continuing current projects
Increased accountability
Launching new projects
Barriers/Challenges:
Time constraints with competing demands
Difficult to engage ancillary services in projects
8 North: Complex Care, Neuro & Burn
Wins:
Great success with weekly CLABSI prevention rounds
Poster at 2025 Better Teams Better Care Symposium
Drafted manuscript for submission
Barriers/Challenges:
After 6+ months we had a CLABSI; it was hard but we learned from it
Lessons Learned: Including Infection Prevention in CLABSI rounds has been so helpful
Outcomes:
High Touch Surface compliance is tracked
Next Steps:
Continue with weekly CLABSI rounds
Goal is to achieve 1 year CLABSI free
Wins:
8 South: Adolescent Medicine & Orthopaedics
Presented poster at 2025 BTBC Symposium
Won best poster at the American Association of Medical Informatics meeting Publication coming in Hospital Pediatrics in 2026
Strong interdisciplinary collaboration
Very engaged team
Next Steps:
Pain management education improvements for 8South nursing staff
Establish partnership between Acute Pain Service & Pediatric Orthopaedic Department
Collaborate with the GCH Pain Committee on ongoing and future pain initiatives
Barriers/Challenges:
Defined scope of project has required careful prioritization & alignment of workflows within the unit
Lessons Learned: Meaningful improvement takes time Utilizing quality improvement tools together with project management supports sustainable change
Wins:
GCH Infusion Center
Reduction in blood transfusion times from 4hrs to 2hrs
Additional ambulatory tech staff dedicated to supporting clinical care
Addition of 2 check-in station to improve efficiencies nd
Consistent team meetings
Very collaborative team willing to make change
Increased volume of patients with improved efficiency
With increased efficiencies, we ’ ve also been able to support more patients being seen for PRBC transfusions; keeping patients out of the ED
With increased efficiencies, we ’ ve also been able to support other divisional needs surrounding infusions; keeping patients out of ED and/or Urgent Care centers
Barriers:
Identifying other contributing factors that impact overall visit time
Balancing staffing changes
Lessons Learned:
Change is not instant
Flexibility is key
Holding each other accountable is helpful
Many small changes yield a difference
Next Steps:
Gemba walk with key stakeholders in Blood Bank
Outcomes:
Improved efficiency in the Pediatric Infusion Center visit times
We have tools and resources to better evaluate other workflows and medications
Collaborative efforts with other pediatric divisions to evaluate medication administration processes
We have been able to keep all pediatric Hem/Onc patients in need of a blood transfusion out of the ED since October 2025 because of our improved efficiencies
Wins:
Won a 2025 GRQC Platinum Award
Partnership with American Lung
Associate and NYS Department of Health
Multiple poster presentations
GCH Respiratory
Barriers/Challenges:
Inconsistent asthma guidelines across ED/PICU & general care units
Next Steps:
Roll out updated Asthma Care Guidelines and educate on them
Lesson Learned: Standardization across the children’s hospital IS possible!
Wins:
Awarded a $7,000 grant from Vermont Oxford Network to expand from G-tube buddy to NG-tube buddy mentor program
Hired a program manager Publication & presentation
Pediatric Surgery
Barriers/Challenges: Would like to collaborate with feeding tube securement device; unsure of feasibility based on cost of team members time
Outcomes:
Significant reduction in ED visits across all race & ethnicities Plan for 2026:
Expanding the program to Daystar Kids
Lessons Learned:
Mentors love to support families with feeding tubes
Monetary recognition is not as meaningful as a heartfelt thank you and recognition
Wins:
Began PEI in February 2025
Created video on what patients and families can expect when arriving to the Pediatric Surgical Center
Pediatric Surgical Center
Barriers/Challenges:
Change in Medical Director leadership in late 2025
Outcomes:
We track our perceptions of pain management with patient audits; utilizing REDCap for data collection
Next Steps:
Rolling out electronic Ever Better Board
Presenting at the Society of Pediatric Pain Management meeting in March 2026
Staffing scheduled adjusted to better balance workload
Next steps:
Reintroduce Ever Better Board on 4-9200
Pilot of treatment team rounds
Expand unit-level throughput & LOS analysis
Align with a CPEP pilot
Implement daily feedback/debrief model
Barriers:
The relocation of 3-9000 to 49200 suspended improvement work temporarily
Staffing and resource constraints
Data and process gaps
Continued manual staff injury tracking
High-acuity discharge coordination; disrupts unit functioning
Lessons Learned:
Staff-driven feedback with visible leadership response, clear interdisciplinary role expectations, and psychspecific metrics supported iterative improvement despite operational pressures
Resulted in tangible gains, stronger interdisciplinary coordination, sustained BCMA performance, reduced restraint and seclusion, and improved violence data capture.
CPEP
Wins:
First year as a re-engaged UPP team!
Implemented electronic AVS
routing to outpatient providers
Improved patient and staff safety and comfort on the unit
Expanded use of enterprise data to strengthen performance insight, support throughput work & begin early exploration of new dashboards & visualizations
Shared Ever Better Board and QI wins with Department of Psychiatry Quality Steering Committee
Lessons Learned:
Small targeted improvements and strong cross-departmental partnerships can yield meaningful impact
Barriers/Challenges:
Staff engagement
Limited protected time
Prolonged length of stay
Next Steps:
Expand frontline staff participation in formal improvement work
Gemba walks
Continue to explore collaborative pilot opportunities
Outcomes:
Significant reduction in restraint cases: The total number of restraint cases has decreased by over 30% from 880 in 2023 to 604 through November 2025, indicating a positive trend in de-escalation and patient management
Improved restraint duration: There’s a clear shift towards shorter restraint durations, with cases lasting 0-30 minutes increasing from 38% to 50% of the total between 2023 and November 2025
Substantial increase in BCMA scanning rates: Improved from 51.58% in February to 87.72% in October. Highest achieving month was July at 96.10%
Ambulatory
AC-5: Strong Internal Medicine
Wins:
Began PEI in February 2025
Increased multidisciplinary representation at monthly UPP meetings Collaboration with other departments
Began project which focuses on improving time to close urgent clinical advice encounters
Barriers/Challenges:
Staff turnover
Potential for process drift
Incorrect labeling of telephone encounters
Next Steps:
Continue with current project Graduate PEI in May 2026 Review Press Ganey data to identify areas of opportunity as it relates to ease of contact
Barriers/Challenges:
Re-focusing the team
was a challenge that we overcame by implementing the Ever
Better Board
Interdisciplinary communication
AC-6: Pediatrics
Wins:
Development of the car seat clinic
Successfully launched electronic Ever Better Board and solicited several improvement ideas
Protected time is still prioritized for monthly meetings which allows for continued team engagement Spotlight board; highlights great work and accomplishments
Includes everyone who works on AC-6, even ancillary services
Goals for 2026: Dedicated phlebotomy room
Daily overview of rooms
Embedding Certified Lactation Counselors into the clinic
Center for Perioperative Medicine
OB/GYN: Gender Wellness Obstetrics & Gynecology
Projects:
Increasing BCMA compliance
Improved timeliness of care for severe hypertension in pregnant patients
Increasing Time Outs compliance
Increasing nursing engagement
Eastman Dental
Wins:
Established an UPP team with an engaged multidisciplinary team
Identified first project; decreasing no-show rate in Perinatal Dental Clinic
Next steps:
Engagement pre-intervention survey
Launching Journal Club
Barriers/Challenges:
Obtaining right dataset to define problem
Not all no-show reasons are ones that we can control
