Quality and Patient Safety initiative members attend 2023 Institute for Healthcare Improvement Forum

QPSi members presented on quality improvement projects underway at UF Health

In December, members of the University of Florida College of Medicine’s Quality and Patient Safety initiative traveled to Orlando to attend the Institute for Health Care Improvement’s IHI Forum, an annual four-day international conference bringing together health professionals committed to working to advance patient and workforce safety, improvement capability and artificial intelligence.

Image of Maya Jordan, B.S.N, R.N., B.C. standing in front of the research poster she worked on.
Maya Jordan, B.S.N, R.N.-B.C. standing in front of the research poster she worked on.

One such attendee was Maya Jordan, B.S.N, R.N.-B.C., a UF Health Shands Hospital nurse who presented a poster on efforts to increase hepatitis B vaccination rates before liver transplantation as part of a new unit-based quality improvement program.

Jordan started as a lung transplant and vascular unit nurse with the University of Florida in 2018 and later became a pre-liver transplant coordinator during the COVID-19 pandemic. In 2022, she was selected as the lead nurse for a physician and nurse-led Comprehensive Unit-based Safety Program, or CUSP, team. Jordan’s partnership with the physician leader, Andreas Zori, M.D., a transplant pathologist, assistant professor in the division of gastroenterology, hepatology & nutrition and the director of development and outreach for liver transplantation, facilitated unit engagement in quality improvement.

Originally developed by Johns Hopkins patient safety researchers, CUSP was piloted in 2022 at UF Health. In the program, physician-nurse partnerships are created to lead a unit-based team in improving the culture of patient safety. Through CUSP teams, quality and safety projects within units are identified, creating a formalized way to solve issues, overcome obstacles and form clear lines of communication to achieve goals.

The CUSP team led by Jordan and Zori launched their hepatitis B project when they observed that only about 16% of patients had their corresponding vaccinations before transplant. Their aim was to improve this percentage because the vaccine reduces the risk of post-transplant hepatitis B, which increases the risk for liver cancer, recurrent cirrhosis, graft failure and death. Patients vaccinated for hepatitis B before transplant also gain immunity, making them eligible to accept a wider donor pool, including hepatitis B core positive donors, and potentially leading to a shorter wait time.

Through CUSP, Jordan, Zori and their CUSP team of GI fellows and coordinators laid the groundwork for their quality improvement project, developing their methodology, identifying barriers and beginning the data collection process. They implemented a screening process to identify patients needing the hepatitis B vaccine, offering the first dose to eligible patients on their pharmacy consult during their transplant evaluation.

They also incorporated the use of the Heplisav-B vaccine, a two-dose series that takes only 30 days to complete, compared with the previous Engerix-B vaccine, which is a three-dose series completed over the course of six months. With the Engerix-B vaccine, the team found that most patients were not finishing the series due to noncompliance or by getting a transplant before the six-month timeframe, making this a crucial point that needed to be addressed through the project.

“I’m so grateful for the results we’ve seen through this initiative,” Jordan said. “This quality initiative has allowed us to improve our patients’ safety and chances of transplantation, and that’s something we have all been passionate about.”

Never having been to a conference before, Jordan was excited to attend the IHI Forum to present the poster she and the team had worked on and to meet other presenters.

“It was a great first conference for me to attend, and the other presenters and speakers were very welcoming and supportive of the work,” Jordan said. “It was nice to put the research into words, show our progress, and everybody was very proud of it.”

Leaving the thriving CUSP team that continues to work on the initiative and data collection, Jordan is now exploring a niche in psychiatric nursing, having taken on a new role within UF Health Shands as a psychiatric mental health nurse and pursuing an online master’s degree in nursing leadership and management at the University of Central Florida.

“I’m excited to take on this new population, learn more about this field of nursing and hopefully even start quality improvement initiatives where I am now, too,” she said.

Click on the images below to view all the QPSi’s attendees, research posters and presenters from the IHI Forum:

About the author:

Damarys Santacoloma, M.S.


Damarys Santacoloma, M.S., Communications Manager, Quality and Patient Safety Initiative.

Damarys Santacoloma, M.S., graduated from Florida International University with a B.A. in philosophy and an M.S. in marketing. Before joining the University of Florida’s College of Medicine as the communications manager for the Quality and Patient Safety Initiative, or QPSi, she worked in a variety of fields, including the nonprofit sector, the startup space and in higher education, previously serving as the communications manager for UF Online. Her skills range from email marketing and customer relationship management, or CRM, to digital and print content creation and website maintenance. Now in her current role, Damarys assists in creating a communications strategy for the QPSi with an omnichannel approach in order to increase the initiative’s reputation and brand awareness.