5 High-Impact Performance Improvement Projects Safety and Quality Leaders Can Tackle After Outsourcing Abstraction

Today’s safety and quality leaders know their resources are limited. Competing demands stretch teams thin, making it difficult to launch, measure, and sustain each performance improvement project. But by choosing to outsource data abstraction services, hospitals can redirect valuable staff time toward initiatives that directly improve patient outcomes and revenue flow.

What Is Data Abstraction in Healthcare?

Data abstraction in healthcare converts raw clinical documentation into actionable benchmarks that help hospitals meet compliance standards and identify performance gaps. Hospitals rely on abstraction to comply with CMS and The Joint Commission, as well as to gain insights into quality measures.

Yet abstraction is labor-intensive and can constrain quality teams’ capacity for improvement work. This makes data abstraction outsourcing an attractive option, enabling safety and quality teams to reclaim staff time for frontline improvements.

Why Safety and Quality Leaders Choose to Outsource Data Abstraction Services

By shifting data abstraction to specialized partners, hospitals redirect the time and focus of their most knowledgeable abstractors toward higher-value improvement work. This shift allows safety and quality leaders to realize several key benefits:

• Operations: Greater capacity to lead and sustain high-impact performance improvement projects across service lines.
• Safety: Expanded bandwidth to design and monitor measurable risk-reduction programs.
• Staff: Opportunity to apply their data expertise to identifying trends, validating improvement opportunities, and supporting frontline education instead of manual reporting.
• Patients: Faster progress toward safety and outcomes goals through more focused, data-informed initiatives.

Outsourcing enables teams to move beyond repetitive reporting tasks and invest their expertise where it drives the greatest organizational impact—improving care delivery, compliance readiness, and patient experience outcomes.

Why These 5 Performance Improvement Project Examples Matter

Hospitals have countless opportunities for improvement, from stroke care coordination to medication safety initiatives. However, the five projects outlined here represent some of the highest-impact areas that often appear across organizations of all sizes. They are:

• Closely tied to regulatory requirements and reimbursement risk.
• Supported by strong clinical evidence and proven improvement models.
• Aligned with common hospital safety goals that patients, staff, and leadership all care about.

Safety and quality leaders can pursue many other meaningful initiatives, but these five provide a strategic starting point once time and capacity are freed through data abstraction outsourcing.

5 High-Value Performance Improvement Projects in Healthcare

Performance Improvement Project Example 1: Sepsis Bundle Compliance and Mortality Reduction

Sepsis leads to 1.7 million U.S. hospitalizations each year, with 350,000 resulting in death or hospice discharge. It remains one of the leading drivers of hospital mortality. CMS mandates compliance with the SEP-1 bundle, which focuses on early screening, treatment, and continuous performance monitoring.

Evidence shows that hospitals with strong sepsis programs have lower mortality rates. A Chest Journal study found that adherence to SEP-1 bundle elements significantly reduced patient mortality. Another ICU-focused study confirmed that SEP-1 compliance improved survival rates for hospital-acquired sepsis.

Safety and quality leaders can act by integrating sepsis training into onboarding and annual education, conducting frequent audits of SEP-1 compliance, and educating patients and families about sepsis warning signs before discharge. These steps directly benefit staff by giving them clear, evidence-based protocols and the confidence to intervene quickly. Patients experience safer care and improved survival, while organizations strengthen compliance with CMS requirements and reduce the risk of costly penalties.

Many leaders begin by reviewing their SEP-1 compliance dashboard with their sepsis response team to identify immediate gaps.

Performance Improvement Project Example 2: Hospital Readmissions Reduction

Hospital readmissions remain a financial and clinical burden, with penalties impacting revenue. By freeing staff through data abstraction outsourcing, safety and quality leaders can strengthen discharge processes and care transitions.

A VA hospital study highlighted that facilities adopting a higher number of transition-of-care processes achieved better readmission rates. Core elements included patient education, medication reconciliation, discharge planning, and post-discharge phone calls.

Leaders can build on this evidence by engaging patients in discharge planning, standardizing medication reconciliation across all units, and expanding community partnerships to support patients after discharge. These improvements make discharge workflows more efficient for staff, provide patients with the support they need to avoid complications, and help the organization reduce costly CMS readmission penalties while protecting margins. A common starting point is piloting a 30-day follow-up phone call program for a high-volume service line, such as cardiology or orthopedics.

Hospitals that leverage complaints and grievances systems often gain added visibility into patient-reported issues with discharge and transitions of care, helping safety and quality leaders identify and correct patterns that contribute to readmissions.

Performance Improvement Project Example 3: Surgical Site Infection Prevention

Up to 3% of surgical patients develop surgical site infections (SSI), according to JAMA, leading to prolonged hospitalizations and complications.

Evidence supports performance improvement strategies like the Enhanced Recovery After Surgery (ERAS) model. At one level II trauma facility, ERAS protocols for colorectal surgery reduced SSI rates from 6% to 2%, as reported in the American Journal of Infection Control.

Safety and quality leaders can replicate these outcomes by aligning surgical teams with ERAS-based practices, auditing compliance with infection prevention measures, and sharing infection rates across departments to foster accountability. These actions reduce variability in practice for staff, which strengthens team efficiency. Patients benefit from fewer complications and faster recoveries, while the organization gains from shorter lengths of stay, lower costs, and improved quality scores.

Some leaders start with a compliance audit of ERAS protocols for one high-volume procedure, such as colorectal or orthopedic surgery. Reporting tools allow hospitals to audit ERAS compliance, trend SSI rates across procedures, and track results to sustain gains from infection prevention protocols.

Performance Improvement Project Example 4: CLABSI Prevention

Central-line associated bloodstream infections (CLABSI) affect more than 40,000 patients annually in the U.S., yet they are often preventable with standardized practices.

Johns Hopkins incorporates a central-line insertion checklist into daily workflows, while AHRQ provides maintenance checklists and communication tools proven to lower CLABSI rates.

Safety and quality leaders can act by implementing insertion and maintenance checklists across all units, reinforcing adherence with regular staff training, and embedding CLABSI prevention metrics into performance dashboards. These steps improve workflow consistency for staff, reduce bloodstream infection risks for patients, and prevent extended hospital stays and financial penalties for the organization. According to AHRQ, each hospital-acquired CLABSI can add approximately $48,000 in excess inpatient costs, making prevention financially and clinically compelling. One option is to run a one-week trial of a central-line insertion checklist in the ICU to test adoption and gather frontline feedback.

Performance Improvement Project Example 5: Inpatient Fall Reduction

Falls remain the most common cause of preventable hospital injury, according to AHRQ. The Fall TIPS Toolkit, developed by Drs. Patricia Dykes and David Bates, offers a proven approach to reduce fall-related harm.

Montefiore Medical Center demonstrated measurable success using this model, reducing fall-with-injury rates by combining leadership support, strong staff engagement, and continuous auditing.

Safety and quality leaders can replicate these strategies by making fall reduction an organizational priority, ensuring frontline staff accountability, and conducting ongoing audits. These efforts engage staff by empowering them to prevent harm proactively, protect patients from injury and loss of independence, and reduce the hospital’s liability exposure while improving safety scores. Leaders often begin by adding fall-prevention metrics to their next safety scorecard review, utilizing falls dashboards in an event reporting application, and piloting the Fall TIPS Toolkit on one unit.

How Safety and Quality Leaders Can Drive Process Improvement Now

Outsourcing data abstraction in healthcare is more than a cost-saving move; it creates the bandwidth for safety and quality leaders to focus on actionable, high-impact initiatives. While hospitals can pursue many different improvement pathways, these five performance improvement project examples stand out as evidence-based, scalable, and actionable. By starting here, leaders can build momentum for broader initiatives that continue to strengthen patient safety and organizational performance over time.

For organizations looking to sustain improvements, ADN solutions such as Data Abstraction Services, Patient Safety Event Reporting, our Complaints & Grievances Application, and Culture of Safety Survey Services provide the infrastructure to turn reclaimed staff capacity into measurable outcomes across safety, compliance, and patient experience.

Frequently Asked Questions

How do I know which performance improvement project to prioritize first?
Leaders should start by reviewing their hospital’s most pressing compliance requirements and patient safety risks. Projects tied to regulatory measures like SEP-1 (sepsis) or hospital readmissions penalties often deliver the fastest return on investment, both financially and clinically. For example, some leaders begin by mapping current SEP-1 bundle performance or analyzing readmission rates for their top two diagnosis-related groups.

How do successful hospitals sustain gains from performance improvement projects?
The most effective organizations build continuous monitoring into their culture. Safety and quality leaders can sustain improvement by creating real-time dashboards for compliance and outcomes metrics, embedding project goals into staff performance evaluations, and conducting quarterly reviews to identify drift and reinforce best practices. For example, hospitals that maintain monthly CLABSI and fall-prevention reviews at unit-level huddles tend to see lasting results.

Can outsourcing data abstraction services impact accreditation or survey readiness?
Yes. Outsourcing partners typically specialize in meeting CMS, The Joint Commission, and state-level requirements. Safety and quality leaders who leverage outsourced data abstraction services can strengthen their hospital’s ability to demonstrate accurate, timely reporting during audits or surveys. Some leaders also use outsourced vendor dashboards during mock surveys to identify gaps before a formal visit.

How does data abstraction outsourcing affect staff engagement?
Freeing staff from repetitive abstraction work allows them to focus on initiatives that directly improve care delivery. This shift often boosts morale, as team members see their efforts tied to meaningful safety and performance outcomes rather than manual reporting tasks. For example, quality staff who once spent hours on spreadsheets may instead lead sepsis education sessions or coordinate ERAS audits for surgical teams.

What are the risks of keeping data abstraction in healthcare in-house?
Managing abstraction internally is labor-intensive and can constrain a quality team’s capacity for improvement work. Hospitals that keep abstraction in-house often report delays in launching new initiatives like fall reduction or infection prevention programs because staff are tied up in reporting tasks.