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QI Projects

The goal of the quality improvement initiative at the McGovern Medical School is to apply the concepts and tools of quality improvement science to everyday clinical care to advance medical science and community health at UTHealth and our affiliates Memorial Hermann Hospital and Harris Health. UTHealth faculty and staff participate in a wide range of QI activities including projects that are:

  • Aimed at improving local systems of care, or improving the performance of institutional practice;
  • Designed to bring about immediate improvements in health care delivery;
  • Designed to verify that promising methods of care introduced into clinical practice result in improved outcomes
  • Intended to compare a program/process/system to an established set of standards such as standard of care, recommended practice guidelines, or other benchmarks.

The Committee for Protection of Human Subjects (CPHS) is responsible for oversight of human subjects research. Not all quality improvement projects meet the definition of human subjects research. According to federal guidance issued by the Office of Human Subjects Protection, “the intent to publish is an insufficient criterion for determining whether a quality improvement activity involves research.”

Under the leadership of Dr. Bela Patel, Vice Dean for Healthcare Quality, McGovern Medical School, Dr. Charles Miller, Associate Vice President, Clinical Research and Health Care Quality and in partnership with the Committee for Protection of Human Subjects, we are delighted to launch a new program to register quality improvement projects. This will not only help us keep track of all the projects that are conducted at the institution, but will help to streamline the review and approval of QI projects. 

When a QI project is registered, IRB staff will review it to ensure that the activity does not meet the definition of human subjects research. Once this determination is made, a formal ‘not human subjects research’ letter will be issued and the project template and outcome letter will be shared with the department quality leader. 

Structured, well-designed QI projects that are based on accepted improvement science and methodology may be eligible for points of MOC credit or for CME credit. Successfully completed QI projects may be included in a Quality Improvement Portfolio as part of a promotion and tenure package for faculty members involved in Quality Improvement. Only registered projects with a status or completion report may be included in the QI Portfolio.

For questions, comments and suggestions, please contact us by email. You can access the registration form below: 



  1. QI Project Charter Template (please submit a detailed charter based on SQUIRE 2.0 guidelines) 
  2. UTHealth Quality Plan 2018-2020
  3. QI Activities Registration and Review Procedure
  4. QI Project Review Flowchart
  5. List of Departmental Quality Leaders 


CPHS HELPLINE   713-500-7943
iRIS HELPLINE    713-500-7960
UTHealth’s Compliance Hotline (1-888-472-9868)

IRB OFFICE HOURS Thursdays from 1 to 4pm, via the Teams Room at this link

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Committee for the Protection of Human Subjects
7000 Fannin St, Suite 1840
Houston, Texas 77030

Phone 713-500-7943
Fax     713-500-7951

IRIS Support 713-500-7960

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