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We have chosen the guideline recommendations of: 3, 7, 8, 10, and 11.

In terms of priority: the PMP will be of most importance

Our system goals will be to obtain a baseline for where we are within these categories. With that initial data, we will need to PDSA on how to improve and set a specific goal on improvements in each of those domains.


Residents are leading education and QI on improving PMP checking. This will be reassessed in 11/2020.