Great Neck, New York–based Northwell Health is taking a dynamic, data-driven approach to improving population health through the creation of its Ambulatory Quality Improvement Collaborative (AQIC). AQIC is a change management framework focused, for now, on hypertension and depression screening, and has delivered clarity, consistency and measurable improvements systemwide.
Northwell Health is New York State’s largest health care provider and private employer. It operates 28 hospitals, more than 1,000 outpatient facilities and over 16,000 affiliated physicians in New York and Connecticut. Northwell Health is part of the AMA Health System Member Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
"The AQIC framework is critical to our success," said Nancy Beran, MD, an internist as well as vice president and chief quality officer for ambulatory at Northwell Health. "It has enabled us to target specific patient populations within our large organization and launch these new initiatives.”
Physicians, nonphysician providers, operations, regional leadership and tech specialists worked together to design, test, implement and sustain this far-reaching initiative, which relies on wide-ranging collaboration between disciplines. Each stakeholder creates their own workstream that incorporates disease management, data analytics and ongoing innovation to ensure that the new, strategically driven improvements are delivered across a variety of care settings.
From high readings to elevated results
Northwell first used the AQIC model to revamp blood pressure measurement. They developed a systemwide treatment algorithm, standardized workflows for clinical teams and created educational materials for patients and physicians.
“We started off by targeting primary care, cardiology, medicine subspecialties and people who routinely manage blood pressure,” including internal medicine and nephrology, Dr. Beran explained. When staff who measure blood pressure but do not manage it detect elevated readings, they refer patients back to primary care. From there, steps are taken to address the patient’s blood pressure.
The approach delivered positive results in a relatively short time. Hypertension control in adult primary care and cardiology settings rose from 69.1% to 78% in less than two years, and, Dr. Beran added, “we are currently trending higher than that and hope to get above 80%.”
Just as crucially, the data not only tracks overall outcomes but analyzes performance by market, service line, and patient demographics.
“Now, we’re able to look at it through subcohorts, including race, ethnicity, language, and see when one needs more resources,” she said.
The AQIC framework allows teams to work smarter. For instance, remote monitoring of patients with white coat hypertension allows data to be gathered and analyzed daily. That information is delivered in real time, reducing in-office visits and speeding follow-up by registered nurses.
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Creating a digital infrastructure
One of the early challenges Dr. Beran’s team faced in hypertension was standardizing the definition of blood pressure control throughout the system. While the Centers for Medicare & Medicaid Services (CMS) use 140/90 mm Hg as a standard reporting threshold, Northwell’s disease management team chose 130/80 mm Hg as their internal clinical goal. Even though most EHRs default to the 140/90 mm Hg threshold too, it was a strategic move that prioritized evidence-based care over administrative convenience.
Northwell’s work in depression screening required even more operational change because it targeted specialty offices, not just primary care. After a pilot using the Patient Health Questionnaire-2 (PHQ-2) depression screening tool in otolaryngology—a specialty not typically associated with mental health screening—the team was able to evaluate the tool in a controlled environment.
When Northwell scaled and implemented the PHQ-2 depression tool systemwide, screening rates increased from 25.2% to 41.4% in 2024, and 60.6% of eligible patients were screened in the first quarter of 2025, exceeding the team’s original target of 53%.
Solidifying infrastructure ahead of implementation has been key to Northwell’s success. A universal electronic workflow allows screening to be done by medical assistants and embedded into the visit experience. Patients now complete the PHQ-2 when they register electronically, before even seeing their doctor.
“Patients answer two questions, and their answers are entered into discrete data fields," Dr. Beran explained. "For patients who are not positive, the screening is over and done with, with no additional staff time needed.”
Screening is only as effective as the organization’s ability to act on the results. Close collaboration between Northwell’s behavioral health, quality and operations teams include other health professionals embedded into primary care, pediatrics, oncology, and obstetrics offices, and social workers and psychiatry teams working with referring physicians to ensure continuity of care.
Northwell’s behavioral health department also created 18 regional resource guides, expanded co-located behavioral health teams, and established a Behavioral Health Access Center that managed around 1,600 referrals in the last quarter of 2024, and just as many in the first quarter of 2025.
"There's not a field of medicine that depression doesn’t touch," Dr. Beran said. “Twenty percent of our population, especially ages 18 to 25, are experiencing some type of mental health issue, such as depression or anxiety.
“We love the model because it has shown us what it takes to get things done, how many touches it takes to engage and how incentives need to be aligned,” she added.
Embracing competition
To boost engagement and adoption, the team launched a competition across Northwell’s ambulatory practices. They were encouraged to complete staff training and track progress through a performance dashboard that detailed screening rates by site and physician. Every service line’s baseline performance, threshold goals and target benchmarks were color-coded and updated monthly, while leadership was kept apprised of progress, challenges and next steps—all in real time.
This gamified approach created momentum and supported accountability by making quality improvement a visible, team-driven effort. Over 70% of all practices joined the competition within three months.
The centralized data and monthly updates identified offices with high opportunity but low performance, which prompted offers of targeted coaching and support.
"We're actually working on PDSAs, Plan-Do-Study-Act cycles,” Dr. Beran said. “What are the barriers? What do they need to succeed?”
This approach gave Northwell the agility to adjust their approach in a manner that was not punitive but instead focused on improvement and opportunity.
What comes after success
Northwell is now applying the AQIC model to new areas, including diabetes and colorectal cancer screening. Diabetes has posed some unique challenges, especially in how data is captured in the EHR. Much of the necessary information, such as lab results, may be scanned in as images instead of entered as structured data, which makes tracking and measuring outcomes difficult.
“There’s a disconnect between billing data and clinical data,” acknowledged Dr. Beran. “Just because a patient is labeled as having diabetes in a visit summary doesn’t mean their lab results are recorded in a way we can measure.”
To close that gap, the AQIC team is improving data entry practices, refining workflows, and offering education and eConsults to support clinical teams. Throughout this entire process, AQIC’s creators have learned valuable lessons about engagement, adaptability and infrastructure. Dr. Beran emphasized the importance of empowering clinical teams.
"It’s not all on the physicians," she said. "Administering the screenings and entering them into the EMR are responsibilities to be shared across the care team."
Looking ahead, Northwell plans to continue adapting the AQIC model to new clinical priorities, including chronic kidney disease in 2026. But the core principles remain the same with each initiative: define clear goals, standardize workflows, support care teams, leverage data, and ensure access.
"We’re getting better at identifying who needs help and allocating resources accordingly. Not every site needs the same level of intervention, and this model allows us to be strategic," said Dr. Beran.
The team’s enhanced ability to slice data by physician, market and patient subgroups has provided new levels of visibility and insight that have improved performance and accountability.
In a constantly changing environment in which the evolving complexities of ambulatory care demand a rapid and unified response, Northwell’s AQIC model demonstrates how structure, strategy and data can drive a system to embrace flexibility, identify and respond to changing needs, and improve—and sustain—outcomes.
AMA MAP™ Hypertension is an evidence-based quality improvement program that provides a clear path to significant, sustained improvements in BP control. With the AMA MAP program, health care organizations can receive tools and resources, coaching support and process metrics to help increase BP-control rates. The program has demonstrated a 10% increase in BP control in six months with sustained results at one year.
