Welcome
As we step into 2025, it’s a moment to pause, reflect, and look forward with gratitude and determination. This past year, the Clinical Standards and Variation Reduction Team continued its steadfast commitment to advancing evidencebased care infused with humankindness. Our shared purpose - to improve patient outcomes, bring evidence based care to the forefront, and care for our care teams - has remained our guiding light, deeply aligned with the mission of CommonSpirit Health.
The successes of this past year are a testament to the dedication, expertise, and collaboration of every person at CommonSpirit Health. From physicians and APPs to nurses, administrators, medical informatics teams, and support staff, the collective efforts of our partner teams have transformed ideas into meaningful action and improved care for our patients. Our collective passion, collaborative spirit, and drive for innovation have made this progress possible. Together, we are creating a culture that values purpose, belonging, and excellence in clinical care.
As we look to 2025, we see a year full of opportunities to grow, innovate, and make an even greater impact. Each opportunity is a chance to learn, adapt, and ensure delivery of evidence based care to our patients and communities.
Thank you for your partnership, your dedication, and your unwavering commitment to excellence. Together, we are enriching the lives of our patients while fostering a purpose-driven environment for our care teams.
With heartfelt gratitude and hope for the year ahead,
Ankita Sagar
MPH, FACP System Vice President Clinical Standards & Variation Reduction Physician Enterprise
Gary
Greensweig, DO, FAAFP System SVP and Chief Physician Executive, Physician Enterprise Interim Chief Quality Officer, CommonSpirit Health
Chief of the Physician Enterprise
MPH, MACP Chief Physician Executive Officer, Senior Executive Vice President
, MD,
Thomas McGinn, MD,
Corey Karlin-Zysman, MD, SFHM, FACP,
Together, we are creating a culture that values purpose, belonging, and excellence in clinical care.
Our Key Collaborators
Acute Care Clinical Service Line
Advanced Practice Leadership Council (APLC)
Ambulatory Care Pharmacy Services
Ambulatory Quality & Patient Experience
Ambulatory Transformation & Innovation
Baylor College of Medicine
Business Intelligence Data Solutions
Clinical Engineering
CommonSpirit Health LGBTQ+ Steering Committee
CommonSpirit Health Office of Diversity, Equity, Inclusion, Belonging, and Community Impact (ODEIB)
CommonSpirit Health Oncology Clinical Institute
CommonSpirit Health Research Institute
Community Health
Communications and Marketing Team
Consumer Engagement
Creighton University School of Medicine
Dignity Health Medical Foundation
Division of Continuing Professional
Development, Baylor College of Medicine
Clinician Resources
Enterprise Business Solutions (EBS)
Health Information Management/Coding/
Provider Documentation Education
Intelligent Automations, Software Development, and Integration Engineering
Lloyd H. Dean Institute for Humankindness & Health Justice
Medical Informatics
Mission Integration
Morehouse School of Medicine
Mission and Ministry Fund (MMF)
National Physician Engagement Council (NPEC)
Office of Advanced Practice
Office of Chief Physician Executive
Physician Enterprise Core Leadership
Physician Enterprise Executive Team (PEET)
Population Health
Regional CMO Leaders
Virginia Mason Franciscan Health
What We Do
Clinical Standards and Variation Reduction (CSVR) focuses on elevating the use of evidence-based medicine across the Physician Enterprise and CommonSpirit Health.
Our goal is to accelerate the standardization of clinical care pathways where there is a notable evolution of evidencebased practice, de-novo transformation in diagnosis and management, or an identified need for response to emerging diseases or clinical evidence.
KEY COMPONENTS:
CLINICAL GUIDELINES:
Simplified, evidence-based clinical guidance based on natural society guidelines and expert collaboration
ELECTRONIC MEDICAL RECORD (EMR) INTEGRATION:
Embedding guidelines into the EMR for seamless practice implementation
KNOWLEDGE AND EXPERTISE:
CME learning opportunities through Grand Rounds and cohort programs
DATA ANALYTICS:
Using data to assess needs, monitor performance, and improve initiatives
Clinical Workgroups
Our clinical workgroups are an integral part of reviewing existing evidence, weighing updates to best practice, and producing succinct guidelines for our clinical teams across CommonSpirit. Clinical workgroups are developed as necessary and with a self-limited life cycle. Participants in clinical workgroups include physicians and advanced practice providers (APPs), as well as a combination of clinical, academic, and divisional leadership (as applicable).
Building Knowledge Based Expertise and Learning Opportunities
The Physician Enterprise Grand Rounds are for all CommonSpirit clinical teams and administrative leaders. Our goal is to deliver important organizational and clinical news, providing expert insight on relevant publications and breaking clinical topics.
Grand Rounds
• Watch Grand Rounds recordings: Physician Enterprise YouTube Playlist
• Earn enduring credit: Baylor College of Medicine Clinician Resource Site
• Suggest topics: Contact us
We offer both continuing medical education (CME) and American Board of Internal Medicine (ABIM) Maintenance of Certification (MOC) credits for attendees.
5-Minute Check-In
In this video series, Thomas McGinn, MD, Chief Physician Executive Officer, shares updates on organizational news, research, and studies relevant to clinical practices.
• Watch 5-Minute Check-In episodes here
The 5-Minute Check-In and Grand Rounds have thousands of views and downloads on the Physician Enterprise YouTube Playlist and Podcast Channels.
Quality Achievements and Accomplishment
Physician Enterprise and Ambulatory Quality teams have accomplished great successes in 2024.
Quality Achievements
DEPRESSION SCREENING & FOLLOW-UP
11% over baseline (July-Sept ‘24) with current performance at 72% (target 76%)
81% (313k) patients screened in the past 365 days (rolling)
270k patients required clinical assessment & a portion required follow up planning
DIABETES TYPE II CONTROL
98% clinics in top quartile
14% out of control - top decile performance
All regions exceeding FY2026 aspirational goal ANNUAL WELLNESS VISITS
Goal of 58.8%, achieving 56.1% through August 2024
Current gap to goal difference is ahead of FY24 HYPERTENSION CONTROL
94% clinics in top quartile
81% in control - highest level since inception
All regions exceeding FY2026 aspirational goal
What we have accomplished
ACCOMPLISHMENTS
• Cancer Screening
• Hepatitis C Screening & Management
• Depression Screening & Management
• Comprehensive Primary Care for LGBTQ+ persons
• Dementia Screening
• PCORI - Pediatric Antimicrobial Stewardship
GRAND ROUNDS SURVEY
RESULTS
• Almost 100,000 total views on YouTube
• 84% of respondents would change the way they care for patients after viewing Grand Rounds
• 90% said the topics were relevant to their practice
BY THE NUMBERS
HEPATITIS C SCREENING & MANAGEMENT
• Guidelines embedded in all Epic & Cerner instances
• 12 primary care site champions trained
• 24,000+ views of Grand Rounds
• The Hepatitis C Learning Collaborative included 25 new learners in January 2025.
COMPREHENSIVE PRIMARY CARE FOR LGBTQ+
• 85 clinicians completed basic training
• In 2023, 8 clinical sites with special designated clinicians in California
• In 2024, 18 clinicians from CA, WA, AZ, and NV joined to earn Special Designation.
WHERE WE ARE GOING
HEPATITIS C SCREENING & MANAGEMENT
• 12 additional primary care site champions to be trained
• Data capture and analysis in-process
COMPREHENSIVE PRIMARY CARE FOR LGBTQ+
• 17 more clinical sites in CA, WA, AZ, NV
RACE-NEUTRAL PULMONARY FUNCTION TESTING
SOCIAL DETERMINANTS OF HEALTH SCREENING IN AMBULATORY SITES (launch 2025)
COGNITIVE SCREENING & DEMENTIA MANAGEMENT (launch 2025)
Our Key Initiatives
2024 ANNUAL REPORT
Cancer Screening
We are partnering with informatics, operations, quality, and medical leadership teams to improve cancer screening, based on both age- and risk-based approaches for breast, colorectal, and lung cancers. Guided by national recommendations, including those from the USPSTF, this initiative leverages Robotic Process Automation (RPA) to support providers in closing care gaps and optimizing clinical efficiency.
RESOURCES
Review Guidlines
• Breast Cancer Screening Guidelines
• Colorectal Cancer Screening Guidelines
• Lung Cancer Screening Guidelines
Source: US Preventative Task Force (USPSTF) and the National Comprehensive Cancer Network (NCCN)
PHYSICIAN ENTERPRISE GRAND ROUNDS
• Breast Cancer: Watch on YouTube | Listen as a Podcast
• Colorectal Cancer: Watch on YouTube | Listen as a Podcast
• Lung Cancer: Watch on YouTube | Listen as a Podcast
ACKNOWLEDGMENTS
Anne Wright, DMSc, MPAS, PA-C, DFAAPA; Cheryl Carswell; Dr. Abdul Waheed; Dr. Ankita Sagar; Dr. Claire Hoppenot; Dr. Colleen O’Kelly Priddy; Dr. Dale Gold; Dr. Dean Field; Dr. Devi Mukkai Krishnamurty; Dr. Gary Greensweig; Dr. James Duncan; Dr. Jessica Croley; Dr. John Chelico; Dr. Julie Nangia; Dr. Kavita Chawla; Dr. Kimberly Bates; Dr. Melissa Gerdes; Dr. Misho Hubka; Dr. Monique Diaz; Dr. Paige Harwell; Dr. Peter Bigler; Dr. Peter Eby; Dr. Peter Emanuel; Dr. Ronald Gagliano; Dr. Sonia Hammad; Dr. Steven Leitch; Dr. Suchitra Pilli; Irene Quartey Papafio; Jessica Stanley, MSN, FNP-BC; Lise Langston, PharmD; Marcia Gruber-Page, MSN, MS, MS, RN; Peeyush Awasthi; Praveen Alladi Papafio; Rachael Bates, RN, MSN, CPHQ; Dr. Thomas Coburn; Traci Kush; Dr. Umar Iqbal; and the Clinical Standards Variation Reduction Steering Committee members.
Early Detection of Cognitive Impairment
CommonSpirit Health is proud to be one of only 10 U.S. health care systems selected to participate in the Early Detection Fellowship Program, sponsored by the Davos Alzheimer’s Collaborative.
Through this fellowship program, we will support seven primary care sites to focus on early cognitive screening. The program allows these sites to pursue early detection in three important ways.
DRIVE INNOVATION in early cognitive screening and care protocols.
ENHANCE PATIENTCENTERED CARE for patients at crucial stages of aging.
PARTNER WITH OTHER CLINICAL TEAMS dedicated to implementation of early cognitive screening.
The Early Detection Fellowship Program is a unique opportunity to lead impactful change in patient care, particularly for aging patients, and to position CommonSpirit Health as a champion in early detection of cognitive impairment.
Special Designation in Comprehensive Primary Care for LGBTQ+ Persons
The program for Special Designation in Comprehensive Primary Care for LGBTQ+ Patients* focuses on improving primary care, including preventive screenings. This year-long program trains a cohort of primary care physicians and APPs in providing comprehensive primary care for patients who identify as members of the LGBTQ+ community.
Further, the designation program closely follows the current work underway across CommonSpirit Health related to the Health Equity Index (HEI)
Program Components
INITIAL LIVE TRAINING
Begins with in-person sessions
ONE-YEAR LONGITUDINAL TRAINING
A comprehensive program spanning 12 months
• Bi-Monthly Case Discussions: Virtual, case-based learning sessions held every other month.
• Informal Coaching: Ongoing support through informal coaching sessions
*This content is accessible within the CommonSpirit network only.
ACKNOWLEDGMENTS
We greatly appreciate the invaluable contribution, expertise, and insights of CommonSpirit Health’s clinical experts.
Resources
PHYSICIAN ENTERPRISE GRAND ROUNDS
Basic Tenets for Clinical Interviews for LGBTQ+ Patients
• Watch on YouTube | Listen as a Podcast
RELATED WORK
Healthcare Equality Index (HEI)
• Learn more about the CommonSpirit Health 2024 Health Equity Index Assessments*
*This content is accessible within the CommonSpirit network only.
Hepatitis C Screening and Management
Established with the goal of curing Hepatitis C in our health system, we created simplified Hepatitis C screening and treatment protocols based on guidelines from USPSTF and the AASLD–IDSA. The initiative includes virtual learning communities and educational materials to build provider knowledge for managing Hepatitis C in primary care. Learn more about the Hepatitis C: A Charge to Cure here.
Resources
PATIENT-FACING EDUCATION
Hepatitis C patient education brochures are available in the four brand identities of CommonSpirit Health via the Print+ National Catalog. Select links for more instructions or contact your Regional Marketing and Communications Leader* for more assistance.
• Hepatitis C Screening Brochure Creative: How to Order (Connected SItes)*
• Hepatitis C Screening Brochure Creative: How to Order (Unconnected SItes - Mountain Region)*
*This content is accessible within the CommonSpirit network only.
ACKNOWLEDGMENTS
We greatly appreciate the invaluable contribution, expertise, and insights of CommonSpirit Health’s clinical experts in making this work possible, including: Dr. Alan Sheinbaum; Dr. Blaire Burman; Dr. Chia Wang; Dr. Johnathan Zhang; Dr. Justin Reynolds; Dr. Manasa Velagapudi; Rachael Bates; Dr. Rima El-Herte; Dr. Saira Aijaz Khaderi; and Dr. Thomas McGinn. Additionally, our gratitude to Dr. Alisahah Jackson; Boomie Harvey, DNP, RN-BC; Chris Furler; Delana Henderson; Erin Sharp, PharmD; Dr. Erine Erickson; Greg Light, PharmD; Hannah Byrnes-Enoch; Dr. Jesse Singer; Dr. Joel Ward; John Ralston; Martha Koepke; Marty Koepke; Dr. Nicholas Stine; Nisha Pasupuleti; Reena John; Ryan Crowdis; David Chan; Kelly Porter; Cindy Welch; Laurel Van Tassell; and Vanessa Astros Young for partnering in this work.
Hepatitis C Primary Care Learning Collaboratives
Clinical Standards & Variation Reduction hosts virtual learning collaboratives for physicians and APP champions who are interested in strengthening their knowledge in the management of uncomplicated Hepatitis C in Primary Care.
Case-based approach to treatment, complications
Tips on successful coverage of medications
Interdisciplinary approach to Hep C management
Interested in joining an upcoming Learning Collaborative? Register here.*
*This content is accessible within the CommonSpirit network only.
Medical Management of Osteoporosis
Osteoporosis poses a major health risk in the U.S., affecting approximately 12.3 million adults (USPSTF) over 50 and leading to significant morbidity and mortality, including issues like chronic pain, impaired function, reduced quality of life, and loss of independence. The economic impact is also considerable, with annual costs expected to reach $25.3 billion by 2025 (AJMC).
Review: Osteoporosis Guidelines*
In alignment with USPSTF recommendations, CommonSpirit Health’s Physician Enterprise has adopted evidence-based guidelines from the ACP, AACE, and Endocrine Society for osteoporosis screening and treatment. The Clinical Standards and Variation Reduction team, alongside primary care, rheumatology, endocrinology, and pharmacy experts, have formed a clinical workgroup to streamline these guidelines into a clear clinical standard to help prevent osteoporotic fractures.
AVAILABLE RESOURCES
• Tools for Authorization, Billing, Documentation*
• Patient Facing Materials* (available in four CommonSpirit brand identities)
PHYSICIAN ENTERPRISE GRAND ROUNDS
• Medical Management of Osteoporosis
º Watch on YouTube | Listen as a Podcast
*This content is accessible within the CommonSpirit network only.
ACKNOWLEDGMENTS
We appreciate the invaluable contribution, expertise, and insights of CommonSpirit Health’s clinical experts in making this work possible, including: Dr. Ankita Sagar; Anne Wright, DMSc, MPAS, PA-C, DFAAPA; Dr. Bryan Jiang; Chris Schenk; Dr. David Oates; Dr. Gary Greensweig; Dr. Kavita Chawla; Dr. Mark Heinsohn; Dr. Michelle Difiore; Dr. Prashanth Sekhar; and Rachael Bates RN, MSN, CPHQ.
Transitioning to Updated Pulmonary Function Testing
The American Thoracic Society (ATS) has updated its recommendation on the use of race in the evaluation and interpretation of pulmonary function testing.
The current guidelines recommend the use of race-neutral equations, such as Global Lung Function Initiative (GLI). In alignment with ATS guidelines, CommonSpirt Health is planning to transition the equation to race-neutral GLI equation for pulmonary function testing.
Clinical Standards and Variation Reduction, in partnership with Pulmonary Medicine, Clinical Engineering, Respiratory Therapy, and Primary Care, have formed a clinical workgroup focused on transitioning PFTs to a race neutral calculator across the health system.
The Physician Enterprise offered interactive sessions to improve knowledge and support this transition: a Grand Rounds and a Deep Dive Workshop with the goal of improving knowledge and awareness of the interpretation and application of a race-neutral GLI equation on clinical decision-making and overall impact on patient outcomes.
ACKNOWLEDGMENTS
PHYSICIAN
ENTERPRISE GRAND ROUNDS
Watch on YouTube
Listen as a Podcast
We appreciate the invaluable contribution, expertise, and insights of CommonSpirit Health’s clinical experts in making this work possible, including: Ankita Sagar, MD; Christopher Kirby; Courtney Nanney; Gary Greensweig, DO; Jeff Sippel, MD; Kelvin Polk; Nirav Bhakta, MD; Rachael Bates, MSN, RN; Rajat Walia; Rob Hoffman; Sarika Savajiyani; Thomas R. Vendegna, MD; Robert Wiebe, MD, CMO; Suchitra Pilli, MD; Venketraman Sahasranaman; and Zachary Taich.
Screening for Social Determinants of Health (SDOH) in Ambulatory Care
The Centers for Medicare & Medicaid Services (CMS) has mandated that hospitals screen for Social Drivers of Health (SDOH), make referrals to appropriate resources, and report outcomes.
Recently, CMS has released their similar requirement for hospital outpatient departments (HODs) starting in 2026. CMS is widely anticipated to expand this screening requirement to all ambulatory practice sites beyond HODs.
This reflects a growing recognition of the critical role social determinants — such as housing, transportation, and food insecurity— play in patient health outcomes and the broader goal of improving the health status of our communities. Furthermore, it signals a shift toward system-wide accountability for addressing health-related social needs (HRSN) across all care settings.
As a proactive measure, the Physician Enterprise is preparing ambulatory care practices to meet future requirements by piloting standardized screening tools, workflows, and management strategies. These efforts align with anticipated regulatory standards and offer an opportunity to improve patient care, optimize resource utilization, and reduce disparities in health outcomes.
ACKNOWLEDGMENTS
We appreciate the invaluable contribution, expertise, and ongoing partnership of CommonSpirit Health’s teams including Ambulatory Quality; Clinical Standards & Variation Reduction; Community Health; Medical Informatics; Lloyd H. Dean Institute for Humankindness & Health Justice; Office of Advanced Practice; Health Information Management; Coding; Provider Documentation Education; Physician Enterprise; Transformation & Innovation; and Population Health.
WHAT YOU CAN DO
Our Request: As physicians and APPs, we appreciate your attention to staying informed, promoting engagement, and sharing the resources.
Resource: Know Do Share
Stay Informed: Familiarize yourself with the Accountable Health Communities’ screening tool and CMS requirements
Attend: Physician Enterprise Grand Rounds | March 21, 2025 (add to your calendar)
Engage: Sites interested in pursuing SDOH screening and management can participate in Learning Collaboratives (dates forthcoming; registration here).
This is an opportunity to strengthen our impact on patient care and health equity while proactively being prepared for future CMS requirements. Your engagement in these initiatives will ensure we are prepared for 2025 and beyond.
Wellbeing & Professional Fulfillment
In spring 2023, the Physician Enterprise was awarded the Mission & Ministry Grant for focused work on Physician and APP Well-Being and Professional Fulfillment.
Peer Support
Creating Community and Belonging through Commensality
Optimizing Clinical Care Delivery
The work focuses on clinical voice, listening, social purpose, recognition, evidence-based care, and shared decision making as drivers of well-being and professional fulfillment. This section provides a brief overview of the programs and opportunities for involvement.
PE Wellbeing and Professional Fulfillment
What we have accomplished
ACCOMPLISHMENTS
• Building Community & Commensality
• Peer Support Program
• Optimizing the Delivery of Care
• First Annual Wellbeing Symposium
• Recognition - Vision Awards
WHERE WE ARE GOING
Scaling well-being programs:
• Building community & Commensality
• Peer Support Program
• Optimizing the Delivery of Care
• Well-being symposium
Recognition - Vision Awards
Peer Support
CHAIRPERSONS: Jyostna Ranga, MD, FAPA, DFAACAP and Heather Chambers, DNP, FNP-C, APRN
Peer supporters are physicians and advanced practice providers (APPs) who provide emotional assistance in times of distress to fellow physicians and APPs. By creating a safe, empathetic, and non-judgmental space for sharing experiences, peer supporters can employ and share effective coping strategies, while helping peers navigate to additional resources. More information can be found here
Sign Up to Be a Peer Supporter
Commensality
CHAIRPERSONS: Danielle Vandergriff, DNP, FNP-C and David Ketelaar, MD
Commensality, or the act of sharing a meal, fosters positive social interactions by
Contracting/Entity Legend
Trained Peer Supporters (136) Commensality Programs (14 groups)
Optimizing Clinical Care Delivery Teams (19) Well-Being Symposium Attendee (89)
bringing together a group of physicians and APPs to discuss a theme or topic while breaking bread. Supported by considerable research, commensality events build a stronger sense of community, connection and camaraderie among peers. It is shown to directly improve the sense of disconnection and burnout among physicians and APPs.
A commensality group consists of:
• 6 to 10 colleagues sharing a meal
• Regular gatherings over 6 months
• Discussing topics designed to foster sharing and connection
If you are interested in starting a commensality group in your area, you can work with local leadership to secure funding to launch the initiatives through a Ministry Micro-Grant. More information can be found here.
Annual Well-Being Symposium
In fall 2024, Physician Enterprise, in partnership with the National Physician Engagement Council (nPEC) for CommonSpirit Health, held a Well-Being Symposium entitled, “The Power of Connection” in Denver, Colorado.
The symposium curriculum was specifically designed to be part of this continuum of work and to grow and propel these programs forward. In the spirit of One CommonSpirit, the symposium was also an opportunity to find ways for the Physician Enterprise Wellness and Fulfillment Group to partner more closely with the National Physician Engagement Council in the future. Over 90 attendees were nominated by market and regional leadership to experience, learn, and construct plans to grow the Well-Being and Professional Fulfillment programs within their markets.
Optimizing Clinical Care Delivery
CHAIRPERSONS: Marijka Grey, MD, MBA, FACP and Anne Wright, DMSc, MPAS, PA-C, DFAAPA
Optimizing Clinical Care Delivery Committee develops a collaborative structure to offer practical and actionable interventions connecting practices to CommonSpirit Health resources, including standard workflows, coaches, and process improvement experts.
Each intervention option is an evidenced-based, time saving strategy to help the practice run smoother while fostering physician and APP well-being, all while sustaining and promoting high quality patient care. Cycle time for each intervention is between 6-9 months. This project
The Results
PRE-VISIT PLANNING INCREASE
80% of visits that need previsit planning now receive them [from baseline of 0]
CHART NOTE LENGTH REDUCTION
Note length reduced by 15-40% in participants
Time spent charting reduced 4-15%
is anticipated to take at most one hour per week for planning and implementing interventions. This project is CME-accredited.
Intervention options include:
1. Team Based EHR In-Basket Management
2. 90 days + 4 Annual Prescription Medication Renewals
3. Note Bloat
4. Pre-Visit planning
More information can be found here. See here for steps to get started.
SAME-DAY CHART CLOSURE INCREASE
100% reached and sustained [from baseline of 17%]
MEDICATION REFILLS
44% reduction in patients contacting the office for refill requests EHR INBOX MANAGEMENT
35-72% reduction in inappropriate inbox messages
ACKNOWLEDGMENTS
We appreciate the invaluable contribution, expertise, and insights of the Physician Enterprise Well-Being and Professional Fulfillment Leadership in making this work possible, including: Dr. Ankita Sagar; Dr. Barbara Martin; Dr. Gary Greensweig; Haley Uustal; John Kniesche; Dr. Marijka Grey; Dr. Anne Wright; Danielle Vandergriff; Dr. David Ketelaar; Heather Chambers; Dr. Jyostna Ranga; Dr. Chyela Rowe; Dr. Heather Rabin; Lois Lane; Dr. Diane Thompson; Derek Hartman; Heather Miller; Dr. Robert Wiebe; Theresa Jones; Brooke Burgess; and many other who have contributed in meaningful ways.
Our Future
A LOOK AHEAD TO 2025
As we look ahead to 2025, the Clinical Standards and Variation Reduction portfolio will remain focused on innovation and growth, driving progress on key initiatives such as:
• Optimizing Cancer Screening: Leveraging technology and workflows to enhance early detection.
• Implementing Screening for Social Determinants of Health (SDOH): systematically implementing SDOH screening and management across ambulatory care settings.
• Transitioning to Race-Neutral Pulmonary Function Testing (PFTs): Standardizing the use of race-neutral equations to improve equity in care.
• Special Designation in Comprehensive Primary Care for LGBTQ+ Persons: Advancing inclusive care for LGBTQ+ populations.
• Hepatitis C Screening & Management: Strengthening programs to improve early detection and treatment.
Our work will further grow to encompass emerging needs, including:
• Cognitive Impairment: Developing guidelines for early identification and management.
• Medical Management of Menopause: Creating evidence-based approaches to improve care for menopausal individuals.
Physician Enterprise Clinical Standards and Variation Reduction
Our Team
Gary Greensweig, DO, FAAFP
System SVP and Chief Physician Executive, Physician Enterprise, Interim Chief Quality Officer, CommonSpirit Health
Dr. Ankita Sagar, MD, MPH, FACP System VP, Clinical Standards & Variation Reduction, Physician Enterprise
Haley Uustal, MPH Well-Being Grant Administration Program Manager, Physician Enterprise
Rachael Bates, RN, MSN, CPHQ System Director, Clinical Standards & Variation Reduction, Physician Enterprise
Abby Lloyd Sabin Executive Coordinator, Physician Enterprise
John Kniesche, MPH System Director, Physician Enterprise Support Services, Physician Enterprise
Physician Enterprise Clinical Standards and Variation Reduction
Steering Committee
The Steering Committee guides the application of evidencebased medicine at the patient level, improving quality of life for patients, families, and communities. Rooted in a clear “WHY,” the committee emphasizes building trust in CommonSpirit Health through initiatives that foster better health outcomes and patient-provider engagement.
KEY RESPONSIBILITIES:
Identify priority areas based on clinical impact
Review and provide feedback on proposed Standards of Care
Champion the adoption of new standards across CommonSpirit Health
Align standards with the Physician Enterprise’s vision and goals
Focusing on high-priority clinical areas, the committee develops CommonSpirit standards of care through expert collaboration, often leveraging partnerships with clinical institutes and regions for seamless adoption.
Andrew French MD, MBA Chief Medical Officer, Mountain Region
Anne Wright, DMSc, MPAS, PA-C, DFAAPA System Director, Advanced Practice Ambulatory Care, Physician Enterprise
Brooke Burgess System Director, Communications, Physician Enterprise
Corey Karlin-Zysman, MD, SFHM, FACP Chief of the Physician Enterprise
Debra Rockman, RN, MBA, CPHRM, CPHQ System VP, Ambulatory Quality
Erine Erickson, MD System VP, Medical Informatics
Ian Vallely Division CIO, Physician Enterprise
Joel Ward, DO, System VP Medical Informatics and Clinical Analytics
John D. Chelico, MD, MA, FACP, FAMIA System Chief Medical Information Officer, Physician Enterprise
Kavita Chawla, MD, MHA, FACP Primary Care Physician, Kirkland Medical Center, Virginia Mason Franciscan Health
Mark Heinsohn, MD Internal Medicine, Chattanooga, TN
Randall Pritza, MD, MMM System Senior Vice President, Midwest Region
Tracy Sklar, MS, MBA System Senior Vice President, Quality
Educational Resources
The Physician Enterprise Resource Library and Grand Rounds continue to support CME, offering tools and recorded sessions to build clinical knowledge.
• For more details or to access additional resources, visit the Physician Enterprise Resource Library *
• Physician Enterprise Grand Rounds: Enduring Credit
• Physician Enterprise Grand Rounds are available for enduring CME credit through the Baylor College of Medicine Clinician Resources page, accessible via CommonSpirit single sign-on. All current and future sessions qualify for credit, with free access for CommonSpirit physicians and APPs. A full list of sessions from the past three years, with credit-eligible ones marked, is available in the link below.
Physician Enterprise Grand Rounds
*This content is accessible within the CommonSpirit network only.
Contact
Us
Physician Enterprise Clinical Standards and Variation Reduction Team
Dr. Ankita Sagar: Ankita.Sagar@CommonSpirit.org
Rachael Bates: Rachael.Bates@commonspirit.org
John Kniesche: John.Kniesche@commonspirit.org
Feedback via PE Resource Library:
Feel free to use the feedback form* to connect with us.
*This content is accessible within the CommonSpirit network only.