The April 2024 issue of the Hospital Quality Improvement Newsletter features the latest insights and resources.
- Upcoming Educational Events
- Expert Insights and Resources on:
- Behavioral Health and Opioid Stewardship
- Antibiotic Stewardship
- Adverse Drug Events
- NHSN and Infection Prevention
- Sepsis
- Patient Safety
- Readmissions/Care Transitions
- Health Equity
- High Reliability Organization
- Best Practices Corner
- Success Stories
.
The CDC issued a Health Alert Network (HAN) Health Advisory to inform clinicians and public health officials of an increase in global and U.S. measles cases and to provide guidance on measles prevention for all international travelers less than six months old and all children aged 12 months who do not plan to travel internationally. Read Health Alert
In addition to sharing the above message with health care providers, hospital leadership should collaborate with facility infection preventionists to ensure the facility is prepared to identify and manage patients with presumed or confirmed measles. Learn More
A New Type of Hospital Is Coming to Rural America
Rural emergency hospitals receive more than $3 million in federal funding a year and higher Medicare reimbursements in exchange for closing all inpatient beds and providing 24/7 emergency care. While that makes it easier for a hospital to keep its doors open, experts say it doesn’t solve all of the challenges facing rural health care. Read Article
.
Join this live event to learn how the Alliant Hospital Quality Improvement Contractor (HQIC) program has improved patient safety for our 145 enrolled hospitals to date. This event will focus on our HQIC performance outcomes from the 42-month evaluation as well as overall accomplishments. In addition, Optim Health (GA) will share how they use the Professional Wheel of Life, a tool that helps you visualize important areas for professional life balance. The Wheel of Life tool will be provided upon registration to complete.
Register Here | View Agenda
Upcoming Learning and Action Network (LAN) Events
HQIC Reliability and Resilience Learning Action Series
Session 2: Stories From the Field: Hospital Case Studies of Reliability and Resilience in Action
The HQIC Reliability and Resilience Learning Action Series aims to educate and engage hospital leaders on the concepts and practices of resilience and high reliability in health care. This event has been created in collaboration with other HQICs and all hospitals are invited to attend.
Learning Objectives:
- Discuss the foundations, theories, and applications of resilience and high-reliability organizing in health care.
- Describe practical implementation strategies for activities that promote reliability and resilience, as well as tools and resources available to health care organizations.
- Identify one idea to test at the local level to address reliability and resilience.
Hospitals in Action: Promising Workplace Violence Prevention Strategies for Safer Care
Thursday, April 25 from 1-1:45 p.m. ET
Violence against health care workers continues to rise and hospital leaders are seeking strategies to enhance workplace safety while upholding patient care standards. According to data from 2023 by National Nurses United (NNU), 81.6% of nurses reported they experienced workplace violence, with half stating they have seen instances of violence increase in the last year.
Join us for Part 4 of the HQIC Workplace Violence (WPV) Prevention webinar series. This dynamic session will feature sharing of real-world experiences and promising WPV prevention practices from health care leaders in diverse roles at a rural hospital, community hospital and an urban health system.
Register Here
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.
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.
Pressure Injury Prevention (PIP): Zero Harm
Thursday, April 11
This session will feature a discussion among the Eastern U.S. Quality Improvement Collaborative (EQIC) team and a critical access hospital. Community Memorial Hospital will describe methods used to implement a Pressure Injury Prevention (PIP) program based on best practice research and innovative advances in prevention techniques. The presentation will highlight the multidisciplinary approach necessary to promote PIP, including early risk identification and comprehensive data collection methods that guide prevention and treatment decisions.
Enhancing Capacity: Reengineering Fall and Fall Injury Programs: Infrastructure, Capacity and Sustainability
Thursday, May 9
This session features national subject-matter expert and nurse consultant Pat Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP, who will discuss essential elements and guidelines for fall and injury prevention programs to enhance infrastructure, capacity and sustainability. Samaritan North Lincoln Hospital, a 25-bed critical access hospital in Oregon, will highlight what they learned from Pat Quigley to redesign their falls program by organizing a team, conducting a gap analysis, developing a bundle and implementing risk-based interventions.
Register Here
Ready Set Go! Bridging the Gaps to Revolutionize Care Transitions
Recorded on March 14
In this session, Convergence shared a new tool to help hospitals achieve a smooth, no-surprises discharge. Ready Set Go! was co-designed by hospital staff and patient family partners to address and connect the critical processes that take place between admission planning, bedside rounding and discharge planning to reduce hospital readmissions. This resource includes key insights into these three processes, plus five embedded tools to enhance current hospital processes.
View Slides
Alliant's Health Equity Action Office Hours are monthly networking events hosted by Rosa Abraha, Alliant Health Solutions health equity lead, and LeAnn Pritchett, system director of quality and safety at Tift Regional Medical Center-Southwell.
These office hours are participant-driven and without slide presentations. Discussions will focus on health equity action planning and other questions from the hospitals, such as CEO engagement. The office hours will be held on the third Thursday of the month from 3-4 p.m. ET.
View past sessions:
- Jan. 16, 2024 - View slides and recording
- Feb. 15, 2024 - View slides and recording
- March 21, 2024 - View slides and recording
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: View past sessions:
- Jan. 24, 2024 – View slides
.
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
Updated Patient Safety Coaching Packages
Updated coaching packages with best practice interventions and resources are now available on the HQIC website. View Coaching Packages
Behavioral Health & Opioid Stewardship
White House Initiated National Challenge to Save Lives from Overdose
The White House Initiated National Challenge to Save Lives from Overdose is a nationwide call to action to stakeholders across all sectors to save lives by committing to increase training on and access to lifesaving opioid overdose reversal medications. An opioid overdose can happen to anyone at any place. Improving access to naloxone (Narcan), a lifesaving opioid overdose reversal medication, can save lives. Last year naloxone was made available for the first time as an over-the-counter medication available at pharmacies. This challenge is encouraging all organizations and businesses to ensure that communities are trained and have access to this life-saving medication. Learn More
Antibiotic Stewardship
Novel Training Program in Public Health for Infectious Diseases Physicians
The Leaders in Epidemiology, Antimicrobial Stewardship, and Public Health (LEAP) is launching a single-year in-place, structured training for senior trainees and early career ID physicians. Read Article
Adverse Drug Events
Adverse Events Associated With COVID-19 Pharmaceutical Treatments
Serious adverse events associated with COVID-19 pharmaceutical treatments were abstracted from peer-reviewed journal articles, clinicaltrials.gov, and submissions for FDA emergency use authorization. Read More
NHSN and Infection Prevention
CMS Promoting Interoperability Program-NHSN Antimicrobial Use and Resistance (AUR) Reporting
Please see the following resources and information regarding the AUR reporting for the CMS Promoting Interoperability Program.
- CMS Promoting Interoperability: Program Resource Library
- NHSN FAQs: AUR Reporting for the CMS Promoting Interoperability Program
- In addition, NHSN held an office hours session where they discussed frequently asked questions from enrolled hospitals. View NHSN Office Hours Slides
CMS Inpatient Quality Reporting Program Data Submission Deadline Is May 15, 2024
Hospitals participating in the CMS Inpatient Quality Reporting Program must submit the following data to the NHSN database by May 15, 2024. Data includes the following:
- 2023-2024 Seasonal Influenza vaccination summary data for health care personnel
- Quarter 4 2023 COVID-19 vaccination data for health care personnel
- Quarter 4 2023 CAUTI data
- Quarter 4 2023 CLABSI
- Quarter 4 2023 C. difficile LabID
- Quarter 4 2023 MRSA LabID
- Quarter 4 2023 Procedure Associated Infections
NHSN Monthly Checklist for Reporting to CMS Hospital IQR
For technical assistance, email PatientSafety@AlliantHealth.org to schedule a free meeting with technical advisors.
Joint Commission Eliminates 70% of Performance Elements for Infection Control Accreditation
The Joint Commission added new and revised standing requirements for accreditation of critical access hospitals and hospitals for infection control procedures. In addition, The Joint Commission also removed 70% of the elements of accreditation so hospitals can focus on the elements that strengthen other protocols and procedures related to infection control.
Waste reduction and responding to an influx of infectious patients were removed in the revisions since other emergency management techniques cover these. These changes will take effect July 1. The latest revisions to accreditation requirements by The Joint Commission are part of an ongoing effort from the organization to help hospitals focus more on strengthening essential policies and practices. Learn More
Sepsis Core Elements: CDC Webinar Series
During each one-hour webinar, CDC subject matter experts provide an overview of the Hospital Sepsis Program Core Elements followed by an in-depth focus on a specific sepsis core element(s). Watch Here
Cognitive Interviewing After An Adverse Event
Cognitive interviewing uses knowledge about how memory works and applying that knowledge when conducting an interview. Cognitive interviewing is a tool for increasing recall through a series of steps that encourage recollection and improve the quality of fact-finding and analysis of adverse events. A few basic steps:
- Establish rapport.
- Reestablish the context by letting the interviewee do the talking – spend the most time listening. Ask that they report everything as they remember. Do not interrupt.
- Ask open-ended questions.
- Have the interviewee draw pictures when applicable to help recall.
- Ask the interviewee to tell the event backward – from end to beginning.
- Change perspective—Ask the interviewee to recall the event from different perspectives, like the viewpoint of another person present during the event. This technique can help uncover new details and views on the event.
- Tailor questions to what the interviewee has focused on.
- Retell the event in the interviewee's words to ensure your understanding – this often leads to additional information.
Study: Chronic Obstructive Pulmonary Disease Risk Assessment Tools
Risk assessment tools are essential in COPD care to help clinicians identify patients at higher risk of accelerated lung function decline, respiratory exacerbations, hospitalizations, and death. Read Study
Health Equity
Frequency of Discordant Documentation of Patient Race and Ethnicity
According to a 2024 study, 1.7% of adults and 7% of children have discordant racial and ethnic data across multiple visits to the emergency department (ED). This means that the patient’s race and ethnicity are categorized differently across visits. Race, ethnicity and language affect health beliefs, risks, behaviors, and outcomes. Therefore, it’s important to collect this information so that hospital staff can identify and address unique patient needs and show that increased investment in outlining best practices in primary data collection is needed. Read Study
Learn About High-Reliability Organizations in Health Care
Alliant HQIC’s HRO coaching package includes evidence-based interventions, links to resources, and relevant webinars. This package covers various categories, including culture assessment, leadership, HRO framework, staff education, process improvement tools, and more. Download HRO Coaching Package
.
Due to the significant value of ambulances and emergency medical service (EMS) professionals, team members with AdventHealth Gordon, located in Calhoun, Georgia, and local first responders gathered to dedicate a new vehicle, its fleet and its service to the surrounding community. Read Article
.
Technical assistance includes data analysis and monthly one-on-one coaching calls. The KONZA HIE Workflow Specialist and KFMC Quality Consultant meet with hospital improvement teams to identify opportunities based on data and trends and provide evidence-based interventions. Training is also provided to the hospitals, as the HIE dashboard serves as a source for readmission data. See the HIE dashboard for hospital readmissions.
Trego County Lemke Memorial is a 25-bed critical access hospital in WaKeeney, Kansas. The tool is valuable to the hospital team as readmission reports are discussed at meetings and can be printed out for regulatory requirements.
To decrease readmissions, their hospital team is currently reviewing health disparities data and health-related social needs and has implemented the following interventions:
- Leadership meetings to review readmission data
- Risk assessment conducted properly upon admission
- Discharge follow-up calls within 48 hours by Infection Preventionist
- Discharge follow-up appointments with a primary care physician and/or specialist
Hanover Hospital, a 25-bed hospital in Hanover, Kansas, also uses the dashboard and readmissions reports. To decrease readmissions, their hospital team is currently reviewing health disparities data and health-related social needs and has implemented the following interventions:
- Leadership engaged in meetings to review
- A transitional care program or department assists with post-discharge needs
- Meds to Beds program
- Medication reconciliation for patients with high readmission risk
- Infection Prevention found the standardized infection ratio (SIR) was greater than the recommended goal of <1.0.
- difficile infection reviews found that education was needed regarding diagnostic stewardship.
- Only a Nucleic Acid Amplified Test (NAAT) was utilized for diff. Two-step testing, which includes a toxin result, was not available.
- Increased antimicrobial usage and patient’s length of stay
- Specimen integrity was a concern.
- Did it need to be tested? Was it truly diarrhea? Has the patient been on any type of laxative, tube feedings, or IV contrast in the last 24-48 hours?
- Testing ordered and specimens sent to the lab were>48 hours apart.
- The specimen was not collected within an appropriate time frame.
- During this time, many changes can happen, potentially increasing the risk of false positives, such as tube feeding and IV contrast.
- Patients are also placed in isolation during the collection time frame. We have seen patient satisfaction decrease due to an elongated isolation time.
- Specimens collected and sent to the lab were not optimal for testing
- Many formed stools were rejected
- The specimen was not collected within an appropriate time frame.
- Only a Nucleic Acid Amplified Test (NAAT) was utilized for diff. Two-step testing, which includes a toxin result, was not available.
Initiatives:
- Two-step testing was put in place to identify active infection vs colonization.
- Hospital now tests for C diff If the NAAT is positive, the orderable will reflex to test the toxin.
- If the toxin is negative, the patient is colonized. Treatment is unnecessary, and the patient will remain isolated until symptoms resolve.
- If the toxin is positive, an active infection is indicated. Treatment would then be initiated, and IP would continue to monitor for isolation purposes.
- Only toxin + results are included in HO-c diff criteria. This initiative significantly decreased our reportable HO-c diff.
- To help ensure a high-integrity specimen was collected appropriately, IP worked with the IT and Lab departments to cancel any C diff testing not collected within 48 hours.
- The provider and nursing reassess the patient and re-order the test if needed.
- IP also implemented a diarrhea decision tree to help nurses have a tool to follow when a C diff test is ordered. See graphic.
- Hospital now tests for C diff If the NAAT is positive, the orderable will reflex to test the toxin.
Their goal was met as the number of hospital-onset C. diff significantly decreased from 2021 through 2023.
.
For questions or information about free technical assistance, please contact:
Donna Cohen, Director, Quality Projects
Karen Holtz, Training and Education Lead, Hospital Quality
.
.
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-QIO TO3-HQIC--5536-04/03/24