Operational Excellence

Document Type


Publication Date

Fall 9-5-2019


Operational Excellence/Maine Medical Center

MeSH Headings

academic, medical center, inpatients, quality improvement, institute, goal, root cause, nursing informatics, appointment, physician


At a large academic tertiary medical center, an Integrated Medication Assisted Treatment (IMAT) program has been established for those medically stable inpatients with an addiction diagnosis. Over a four month period, this program had experienced a decline in attendance and a quality improvement project was initiated is to better understand the barriers to attendance and institute a process that would reverse the decline.

A goal was established to improve attendance by medically stable patients that have consented to participate to a minimum of 50%.

A root cause analysis outlined numerous causes for low attendance and several countermeasures were established to address these. Among them were the initiation of a KPI to collect patient attendance data and the creation of an IMAT order in EPIC. Since the IMAT order went “live” in EPIC and other countermeasures were started, the goal of 50% has been surpassed.

Next steps include ongoing nurse, physician and care management education, and work with nursing informatics to develop an appointment feature for the IMAT order in EPIC.