The April 2023 issue of the Hospital Quality Improvement Newsletter featuring the latest insights and resources.
In This Issue:
- The latest news from CMS
- Upcoming educational events
- Expert insights and resources on:
- Behavioral Health and Opioid Stewardship
- Adverse Drug Events
- Antibiotic Stewardship
- Patient and Family Engagement
- Patient Safety
- Hospital-Acquired Infections
- Readmissions/Care Transitions
- Health Equity
- Public Health Emergency Information and Resources
- Best Practices Corder
- Success Story
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Registration Now Open for 2023 CMS Quality Conference
Quality improvement is a foundational component of CMS’ mission, and this year's theme—Building Resilient Communities: Having an Equitable Foundation for Quality Healthcare—will guide conversations and improvements around healthcare quality improvement that spark solutions to address America's health system challenges and incredible opportunities ahead.
Register Here
Quality improvement is a foundational component of CMS’ mission, and this year's theme—Building Resilient Communities: Having an Equitable Foundation for Quality Healthcare—will guide conversations and improvements around healthcare quality improvement that spark solutions to address America's health system challenges and incredible opportunities ahead.
Register Here
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Educational Events
Upcoming Learning and Action Network (LAN) Event
Transitions in Care: Preventing Sepsis Readmissions
Thursday, April 27, 2023, at 1 p.m. ET | 12 p.m. CT
This event will feature proactive transitions in care and hand-off strategies to the next level of care provider to improve patient outcomes and prevent sepsis-related readmissions. The patient’s voice will be highlighted via a sepsis survivor story.
Learning Objectives:
Through this program, participants will:
Past Learning and Action Network (LAN) Event
Acute Pain Alternatives: The Impact of Avoiding Opioids on Hospital Delirium
Recorded on March 21
This presentation focuses on real-world methods for preventing hospital delirium. It features a discussion on alternatives to acute pain management and a hospital project example that will inspire you to take on delirium prevention at your facility.
View the Presentation and Recording
I Want To, I Just Don’t Know How: A Practical Guide for Advancing Health Equity
Recorded on Feb 28
This session highlights best practices and examples for successfully implementing health equity strategies within hospital settings. Rosa Abraha, MPH, Alliant HQIC’s health equity lead, addressed frequently asked questions from hospitals and engage in a discussion with participants.
View the Presentation and Recording
Transitions in Care: Preventing Sepsis Readmissions
Thursday, April 27, 2023, at 1 p.m. ET | 12 p.m. CT
This event will feature proactive transitions in care and hand-off strategies to the next level of care provider to improve patient outcomes and prevent sepsis-related readmissions. The patient’s voice will be highlighted via a sepsis survivor story.
Learning Objectives:
Through this program, participants will:
- Review successful care coordination and partnership strategies across the care continuum to prevent sepsis-related hospital readmissions.
- Explore promising practices for overcoming challenges that affect handoffs to the next level of care.
- Learn how to engage patients and families as partners and integrate their health-related social needs into the discharge planning process to improve patient outcomes.
- Hear about a sepsis survivor story
Past Learning and Action Network (LAN) Event
Acute Pain Alternatives: The Impact of Avoiding Opioids on Hospital Delirium
Recorded on March 21
This presentation focuses on real-world methods for preventing hospital delirium. It features a discussion on alternatives to acute pain management and a hospital project example that will inspire you to take on delirium prevention at your facility.
View the Presentation and Recording
I Want To, I Just Don’t Know How: A Practical Guide for Advancing Health Equity
Recorded on Feb 28
This session highlights best practices and examples for successfully implementing health equity strategies within hospital settings. Rosa Abraha, MPH, Alliant HQIC’s health equity lead, addressed frequently asked questions from hospitals and engage in a discussion with participants.
View the Presentation and Recording
If Yes, Click Below.
Click here if you attended an HQIC LAN event and were able to "use tomorrow" what you heard during the webinar.
Community of Practice (CoP) Call
CMS hosts CoP calls on the second Thursday of each month at 1 p.m. ET | 12 p.m. CT | 11 a.m. MT | 10 a.m. PT. The calls are open to all Alliant HQIC hospitals.
Connecting your Hospital Culture of Safety to Patient Harm Reduction
Thursday, April 13
According to the February 2022 New England Journal of Medicine, improvements in patient safety were quickly and severely reversed during the COVID-19 pandemic, indicating that the health care system lacks a sufficiently resilient safety culture and infrastructure. Hospitals now have an opportunity and an obligation to reevaluate patient safety with an eye toward building a more resilient health care delivery system. Join the discussion on how successful and sustainable patient safety improvement rests heavily on an organizational culture of attitudes, actions, teamwork, and technology centered on reducing the risk of patient harm.
Register Here
Successful Strategies for CLABSI Prevention
Recorded on March 9
Recent studies have shown that during the COVID-19 pandemic, many hospitals experienced a significant increase in their Preventing Central Line-Associated Bloodstream Infection (CLABSI) rates. In this call, Healthcare Association of New York State (HANYS) highlighted two hospitals that successfully reduced CLABSIs and other hospital-acquired infections, reviewing successful strategies such as daily utilization reports and device huddles, the importance of hospital leadership support, and the use of nurse-driven protocols to support a culture of safety.
View the Presentation
CMS hosts CoP calls on the second Thursday of each month at 1 p.m. ET | 12 p.m. CT | 11 a.m. MT | 10 a.m. PT. The calls are open to all Alliant HQIC hospitals.
Connecting your Hospital Culture of Safety to Patient Harm Reduction
Thursday, April 13
According to the February 2022 New England Journal of Medicine, improvements in patient safety were quickly and severely reversed during the COVID-19 pandemic, indicating that the health care system lacks a sufficiently resilient safety culture and infrastructure. Hospitals now have an opportunity and an obligation to reevaluate patient safety with an eye toward building a more resilient health care delivery system. Join the discussion on how successful and sustainable patient safety improvement rests heavily on an organizational culture of attitudes, actions, teamwork, and technology centered on reducing the risk of patient harm.
Register Here
Successful Strategies for CLABSI Prevention
Recorded on March 9
Recent studies have shown that during the COVID-19 pandemic, many hospitals experienced a significant increase in their Preventing Central Line-Associated Bloodstream Infection (CLABSI) rates. In this call, Healthcare Association of New York State (HANYS) highlighted two hospitals that successfully reduced CLABSIs and other hospital-acquired infections, reviewing successful strategies such as daily utilization reports and device huddles, the importance of hospital leadership support, and the use of nurse-driven protocols to support a culture of safety.
View the Presentation
Monthly Office Hours-IP Chat
Office Hours-IP Chats are quarterly networking events to build knowledge, share experience and provide support for hospital infection preventionists. The Office Hours-IP Chats are hosted by Amy Ward, MS, BSN, RN, CIC, FAPIC.The next Office Hours-IP Chats will take place on:
- Wednesday, April 26, from 2-2:30 p.m. ET
- Wednesday, July 26, from 2-2:30 p.m. ET
- Wednesday, October 25, from 2-2:30 p.m. ET
To schedule a one-on-one meeting with Amy, please let your quality advisor know. Questions? Contact Amy Ward at amy.ward@allianthealth.org.
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Expert Insights & Resources
Alliant HQIC Online Portal
Access the Alliant HQIC portal to view your assessments and measurement data, and chat with other HQIC-enrolled hospitals to share best practices, barriers and solutions. Download Portal Instructions to Get Started
Access the Alliant HQIC portal to view your assessments and measurement data, and chat with other HQIC-enrolled hospitals to share best practices, barriers and solutions. Download Portal Instructions to Get Started
Behavioral Health & Opioid Stewardship
Patient and Health Care Professional Perspectives on Stigma in Integrated Behavioral Health: Barriers and Recommendations
Stigma related to mental health is well documented and a major barrier to using mental and physical health care. A study published by the Annals of Family Medicine assessed the opinions of patients and health care professionals about mental illness stigma as a barrier to engagement with integrated behavioral health (IBH). It gained insight into strategies to reduce stigma, encourage discussion of mental health and increase uptake of IBH care. Read the Study
Toolkit for Prevention and Treatment of Substance Use Disorders in Rural Communities
Looking for tools to help rural facilities working to prevent and treat substance use disorders? The seven modules in this toolkit provide evidence-based examples, promising models, program best practices, and resources your organization can use to implement substance use disorder prevention and treatment programs. Download Toolkit
FDA Approves First Over-the-Counter Naloxone Nasal Spray
As reported in the Alliant HQIC newsletter last month, an FDA advisory committee provided the recommendation to green light over-the-counter Naloxone nasal spray. On March 29, the FDA provided final approval to make the opioid reversal agent available directly to consumers. Naloxone has been a key tool in the battle against the opioid overdose epidemic. Read More
Adverse Drug Events
Maximizing Student Potential: Lessons for Pharmacy Programs From the Patient Safety Movement
Higher education institutions (HEIs), including pharmacy programs, are experiencing growing pressure from the public and policymakers to develop student-centered learning experiences that meet societal needs. While HEIs may have in-house initiatives to meet such challenges, there are also opportunities for cross-domain learning and the application of useful concepts from other sectors. Read the Article
Antibiotic Stewardship
Early Recognition and Response to Increases in Surgical Site Infections Using Optimized Statistical Process Control Charts
Traditional approaches for surgical site infection (SSI) surveillance have deficiencies that delay the detection of SSI outbreaks and other clinically important increases in SSI rates. A study published by PubMed Central investigated whether the use of optimized statistical process control (SPC) methods and feedback for SSI surveillance would decrease rates of SSI in a network of US community hospitals. Read the Study
Patient and Family Engagement
Declarations on Patient and Family Engagement
According to an article in the American Journal of Critical Care, ICU patients and families have long been expected to be involved in their own clinical care. The shift toward more engagement with patients and their families means that they are increasingly asked to participate in the design and implementation of research studies, quality improvement projects, and organizational or health system reforms. Read the Article
Patient and Family Advisory Councils Blueprint: A Start-Up Map and Strategy Guide
Patient and Family Advisory councils (PFACs) are an excellent way to help health care institutions and providers understand the perspective of patients and families while also helping caregivers identify the needs of their patient population and bring patient and clinician views closer together. As COVID-19 divided and devastated communities, many organizations worked with their PFACs to inform outreach, reduce barriers caused by COVID-19 and drive lasting improvements. To capture learnings and help the field build and sustain high-performing PFACs, the AHA gathered a group of patient and family engagement leaders to share their insights. Download Resource
Patient Safety
Hand Hygiene Compendium Update Published
“Strategies to prevent healthcare-associated infections through hand hygiene: 2022 update” was published in Infection Control and Hospital Epidemiology (ICHE). This expert guidance document highlights practical recommendations for hand hygiene implementation to prevent infections. Learn More
Ensuring Safe Transitions from Hospitals to Skilled Nursing Facilities
Transitions from the hospital to skilled nursing facilities remain a patient safety challenge. Using the Alliant HQIC Inter-Facility Infection Control Transfer Form is a best practice recommendation so receiving facilities are aware of current and historical infectious disease diagnoses or current signs and symptoms, antibiotic use, vaccination status, and the presence of indwelling medical devices. Download HQIC Inter-Facility Infection Control Transfer Form
Patient and Health Care Professional Perspectives on Stigma in Integrated Behavioral Health: Barriers and Recommendations
Stigma related to mental health is well documented and a major barrier to using mental and physical health care. A study published by the Annals of Family Medicine assessed the opinions of patients and health care professionals about mental illness stigma as a barrier to engagement with integrated behavioral health (IBH). It gained insight into strategies to reduce stigma, encourage discussion of mental health and increase uptake of IBH care. Read the Study
Toolkit for Prevention and Treatment of Substance Use Disorders in Rural Communities
Looking for tools to help rural facilities working to prevent and treat substance use disorders? The seven modules in this toolkit provide evidence-based examples, promising models, program best practices, and resources your organization can use to implement substance use disorder prevention and treatment programs. Download Toolkit
FDA Approves First Over-the-Counter Naloxone Nasal Spray
As reported in the Alliant HQIC newsletter last month, an FDA advisory committee provided the recommendation to green light over-the-counter Naloxone nasal spray. On March 29, the FDA provided final approval to make the opioid reversal agent available directly to consumers. Naloxone has been a key tool in the battle against the opioid overdose epidemic. Read More
Adverse Drug Events
Maximizing Student Potential: Lessons for Pharmacy Programs From the Patient Safety Movement
Higher education institutions (HEIs), including pharmacy programs, are experiencing growing pressure from the public and policymakers to develop student-centered learning experiences that meet societal needs. While HEIs may have in-house initiatives to meet such challenges, there are also opportunities for cross-domain learning and the application of useful concepts from other sectors. Read the Article
Antibiotic Stewardship
Early Recognition and Response to Increases in Surgical Site Infections Using Optimized Statistical Process Control Charts
Traditional approaches for surgical site infection (SSI) surveillance have deficiencies that delay the detection of SSI outbreaks and other clinically important increases in SSI rates. A study published by PubMed Central investigated whether the use of optimized statistical process control (SPC) methods and feedback for SSI surveillance would decrease rates of SSI in a network of US community hospitals. Read the Study
Patient and Family Engagement
Declarations on Patient and Family Engagement
According to an article in the American Journal of Critical Care, ICU patients and families have long been expected to be involved in their own clinical care. The shift toward more engagement with patients and their families means that they are increasingly asked to participate in the design and implementation of research studies, quality improvement projects, and organizational or health system reforms. Read the Article
Patient and Family Advisory Councils Blueprint: A Start-Up Map and Strategy Guide
Patient and Family Advisory councils (PFACs) are an excellent way to help health care institutions and providers understand the perspective of patients and families while also helping caregivers identify the needs of their patient population and bring patient and clinician views closer together. As COVID-19 divided and devastated communities, many organizations worked with their PFACs to inform outreach, reduce barriers caused by COVID-19 and drive lasting improvements. To capture learnings and help the field build and sustain high-performing PFACs, the AHA gathered a group of patient and family engagement leaders to share their insights. Download Resource
Patient Safety
Hand Hygiene Compendium Update Published
“Strategies to prevent healthcare-associated infections through hand hygiene: 2022 update” was published in Infection Control and Hospital Epidemiology (ICHE). This expert guidance document highlights practical recommendations for hand hygiene implementation to prevent infections. Learn More
Ensuring Safe Transitions from Hospitals to Skilled Nursing Facilities
Transitions from the hospital to skilled nursing facilities remain a patient safety challenge. Using the Alliant HQIC Inter-Facility Infection Control Transfer Form is a best practice recommendation so receiving facilities are aware of current and historical infectious disease diagnoses or current signs and symptoms, antibiotic use, vaccination status, and the presence of indwelling medical devices. Download HQIC Inter-Facility Infection Control Transfer Form
Communication Hand-off Tool
Communication failures are a top root cause of adverse events in hospitalization. Has your team considered I-PASS? I-PASS is an evidence-based standardized hand-off communication tool.
I-PASS stands for:
Hospital-Acquired Infections (HAI)
Identifying and Reporting LabID Events
Need guidance on the MRSA and C. diff Lab ID reporting? Check out this 20-minute presentation by Alliant’s infection prevention technical advisor. Watch Presentation
Study: Overdiagnosis of Clostridium difficile Infection in the Molecular Test Era
Clostridium difficile is a major cause of healthcare-associated infection, but disagreement between diagnostic tests is an ongoing barrier to clinical decision-making and public health reporting. Molecular tests are increasingly used to diagnose C difficile infection (CDI), but many molecular test-positive patients lack toxins that historically defined disease, making it unclear if they need treatment. A study published by the National Center for Biotechnology Information determined the natural history and need to treat patients who are toxin immunoassay negative and polymerase chain reaction (PCR) positive (Tox−/PCR+) for CDI. Read Study
Readmissions/Care Transitions
Joint Commission Journal on Quality and Patient Safety: Assessment of Patient Retention of Inpatient Care Information Post-Hospitalization
Patient understanding of medical care improves readmission rates and patient satisfaction, yet the literature suggests that patients need better retention of care information post-hospitalization. The authors conducted this study to understand how well patients retain care information after hospital discharge and to assess patient perspectives on facilitators of this process. Read More
Health Equity
The Joint Commission National Patient Safety Goal
NPSG.16.01.01 Improving health care equity for the hospital’s patients is a quality and safety priority. This is applicable to the Hospital Accreditation Program effective July 1, 2023. Learn More
R3 Report Issue 38: National Patient Safety Goal to Improve Health Care Equity
Effective July 1, 2023, Standard LD.04.03.08, which addresses health care disparities as a quality and safety priority, will be elevated to a new National Patient Safety Goal (NPSG), Goal 16: Improve health care equity, and moved to NPSG.16.01.01 for ambulatory health care organizations, behavioral health care and human services organizations, critical access hospitals, and hospitals. The NPSG standard and 6 elements of performance (EPs) increase the focus on improving health care equity as a quality and safety priority, but the requirements for accredited organizations are not changing. While some of the original language from Standard LD.04.03.08 and its EPs were revised to focus on improving health care equity rather than reducing health care disparities, the intent behind the standard and associated EPs remains the same. Read More
CMS IQR Reporting
CMS added three measures to their IQR reporting that address Social Determinants of Health (SDOH) beginning in CY23.
Communication failures are a top root cause of adverse events in hospitalization. Has your team considered I-PASS? I-PASS is an evidence-based standardized hand-off communication tool.
I-PASS stands for:
- Illness severity: one-word summary of patient acuity ("stable," "watcher," or "unstable")
- Patient summary: brief summary of the patient's diagnoses and treatment plan
- Action list: to-do items to be completed by the clinician receiving sign-out
- Situation awareness and contingency plans: directions to follow in case of changes in the patient's status, often in an "if—then" format
- Synthesis by receiver: an opportunity for the receiver to ask questions and confirm the plan of care
Hospital-Acquired Infections (HAI)
Identifying and Reporting LabID Events
Need guidance on the MRSA and C. diff Lab ID reporting? Check out this 20-minute presentation by Alliant’s infection prevention technical advisor. Watch Presentation
Study: Overdiagnosis of Clostridium difficile Infection in the Molecular Test Era
Clostridium difficile is a major cause of healthcare-associated infection, but disagreement between diagnostic tests is an ongoing barrier to clinical decision-making and public health reporting. Molecular tests are increasingly used to diagnose C difficile infection (CDI), but many molecular test-positive patients lack toxins that historically defined disease, making it unclear if they need treatment. A study published by the National Center for Biotechnology Information determined the natural history and need to treat patients who are toxin immunoassay negative and polymerase chain reaction (PCR) positive (Tox−/PCR+) for CDI. Read Study
Readmissions/Care Transitions
Joint Commission Journal on Quality and Patient Safety: Assessment of Patient Retention of Inpatient Care Information Post-Hospitalization
Patient understanding of medical care improves readmission rates and patient satisfaction, yet the literature suggests that patients need better retention of care information post-hospitalization. The authors conducted this study to understand how well patients retain care information after hospital discharge and to assess patient perspectives on facilitators of this process. Read More
Health Equity
The Joint Commission National Patient Safety Goal
NPSG.16.01.01 Improving health care equity for the hospital’s patients is a quality and safety priority. This is applicable to the Hospital Accreditation Program effective July 1, 2023. Learn More
R3 Report Issue 38: National Patient Safety Goal to Improve Health Care Equity
Effective July 1, 2023, Standard LD.04.03.08, which addresses health care disparities as a quality and safety priority, will be elevated to a new National Patient Safety Goal (NPSG), Goal 16: Improve health care equity, and moved to NPSG.16.01.01 for ambulatory health care organizations, behavioral health care and human services organizations, critical access hospitals, and hospitals. The NPSG standard and 6 elements of performance (EPs) increase the focus on improving health care equity as a quality and safety priority, but the requirements for accredited organizations are not changing. While some of the original language from Standard LD.04.03.08 and its EPs were revised to focus on improving health care equity rather than reducing health care disparities, the intent behind the standard and associated EPs remains the same. Read More
CMS IQR Reporting
CMS added three measures to their IQR reporting that address Social Determinants of Health (SDOH) beginning in CY23.
*Screening for Social Drivers of Health includes food insecurity, housing instability, transportation needs, utility difficulties and interpersonal safety.
Details about the Health Equity and SDOH measures are below:
- IX. Quality Data – starts on p. 1101
- E. Hospital IQR Program - Measure Set pp. 1177-1180
- Table IX.E-01 Five Attestation Domains p. 1187
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Public Health Emergency Information and Resources
CMS Releases Guidance for the End of the COVID-19 Public Health Emergency on May 11 — Information on What You Need to Know
CMS is preparing the public for the transition forward from the COVID-19 public health emergency (PHE) and has outlined what to expect after this period ends. In a new fact sheet, CMS discusses COVID-19 testing, vaccines and treatments; telehealth services; continuing flexibilities for health care providers and inpatient hospital care at home. The Biden-Harris Administration and CMS will continue to provide guidance to the public to ensure a smooth and predictable transition as May 11 approaches. Download Fact Sheet
CMS is preparing the public for the transition forward from the COVID-19 public health emergency (PHE) and has outlined what to expect after this period ends. In a new fact sheet, CMS discusses COVID-19 testing, vaccines and treatments; telehealth services; continuing flexibilities for health care providers and inpatient hospital care at home. The Biden-Harris Administration and CMS will continue to provide guidance to the public to ensure a smooth and predictable transition as May 11 approaches. Download Fact Sheet
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Best Practices Corner
Insert Text HereTift Regional Medical Center in Tifton, Georgia, placed third in the Hospitals With 100-299 Beds category for Georgia Hospital Association (GHA)'s Patient Safety and Quality Award. Tift Regional Medical Center was awarded for its project HIT CLABSI, which prevented central line-associated bloodstream infections in patients.
"Prevention of infection is essential to the improvement of patient outcomes and the enhanced well-being of patients," said GHA President and CEO Earl Rogers. "We applaud Tift Regional Medical Center on this award and thank them for their efforts to ensure the safest and best possible care for their patients."
"Prevention of infection is essential to the improvement of patient outcomes and the enhanced well-being of patients," said GHA President and CEO Earl Rogers. "We applaud Tift Regional Medical Center on this award and thank them for their efforts to ensure the safest and best possible care for their patients."
LeAnn Pritchett, Tift Regional's system director of quality and patient safety, with GHA Chair Dan Owens (L) and GHA President and CEO Earl Rogers (R).
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Success Story
Athens-Limestone Hospital Committed to Opioid Stewardship and Reducing Patient Harm
Athens-Limestone Hospital, a 71-bed hospital in Athens, Alabama, is improving opioid stewardship by implementing steps to reduce patient harm from opioids through leadership commitment, partnership with physicians and the formation of an opioid stewardship committee.
Previous improvement work in opioid stewardship was not continued during the COVID pandemic as the focus shifted to more urgent matters. An opioid stewardship committee is now in place and includes a diversion task force subcommittee.
Previous improvement work in opioid stewardship was not continued during the COVID pandemic as the focus shifted to more urgent matters. An opioid stewardship committee is now in place and includes a diversion task force subcommittee.
Representatives are from the following areas with higher opioid use:
1. Identify order sets containing opioids. The focus was on post-op and Ortho order sets because of the high use of opioids post-op and the use of range orders allowing the nurse to select a higher dose of opioids for pain. The goal was to eliminate all range orders and reduce the total MME amount available to the patient post-op.
Challenges and successes included: 1) Reaching consensus on order sets. Success followed with a physician champion supporting the changes and leading the change; 2) Continued to see old order sets from physician offices. Success was followed by removing old order sets from circulation.
2. Educate prescribers on recommendations for safe opioid prescribing. The team provided category 1 CME credit covering safe opioid prescribing. This is a requirement for physicians in Alabama. The goal was to offer free and on-site and target safe opioid prescribing in the outpatient setting
Challenges and successes included: Good physician turnout for the CE program. The event opened the door for good discussion and lots of questions from providers. Several physicians were unable to make it and expressed interest in the topic. The team would recommend offering a live virtual event in the future.
3. Standing order for Naloxone at discharge. The goal was to include a prescription for Naloxone on all post-op orthopedic opioid discharge prescriptions.
Challenges and successes included: Physician agreement as some did not want it pushed on patients, including a perceived cost to patients. A compromise was a standing order for naloxone available to patients at our retail location. Currently in the final stages of development.
To view the January 17, 2023 presentation Connecting Your Hospital Culture of Safety to Patient Harm Reduction and Athens-Limestone Hospital’s presentation on Opioid ADEs, visit the Alliant HQIC website.
- OR/PACU
- One Day Admission
- Emergency Department
- Anesthesia
- Pharmacy
- Nursing
- Physician
1. Identify order sets containing opioids. The focus was on post-op and Ortho order sets because of the high use of opioids post-op and the use of range orders allowing the nurse to select a higher dose of opioids for pain. The goal was to eliminate all range orders and reduce the total MME amount available to the patient post-op.
Challenges and successes included: 1) Reaching consensus on order sets. Success followed with a physician champion supporting the changes and leading the change; 2) Continued to see old order sets from physician offices. Success was followed by removing old order sets from circulation.
2. Educate prescribers on recommendations for safe opioid prescribing. The team provided category 1 CME credit covering safe opioid prescribing. This is a requirement for physicians in Alabama. The goal was to offer free and on-site and target safe opioid prescribing in the outpatient setting
Challenges and successes included: Good physician turnout for the CE program. The event opened the door for good discussion and lots of questions from providers. Several physicians were unable to make it and expressed interest in the topic. The team would recommend offering a live virtual event in the future.
3. Standing order for Naloxone at discharge. The goal was to include a prescription for Naloxone on all post-op orthopedic opioid discharge prescriptions.
Challenges and successes included: Physician agreement as some did not want it pushed on patients, including a perceived cost to patients. A compromise was a standing order for naloxone available to patients at our retail location. Currently in the final stages of development.
To view the January 17, 2023 presentation Connecting Your Hospital Culture of Safety to Patient Harm Reduction and Athens-Limestone Hospital’s presentation on Opioid ADEs, visit the Alliant HQIC website.
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For more information about Alliant Health Solutions, visit: www.allianthealth.org
For questions or information about free technical assistance, please contact:
Donna Cohen, Director, Quality Projects
Karen Holtz, Training and Education Lead, Hospital Quality
For questions or information about free technical assistance, please contact:
Donna Cohen, Director, Quality Projects
Karen Holtz, Training and Education Lead, Hospital Quality
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This material was prepared by Alliant Health Solutions, a Quality Innovation Network–Quality Improvement Organization (QIN – QIO) under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. Publication Number: 12SOW-AHS QIN-TO3-HQIC--3040-12/29/22