The August 2024 issue of the Hospital Quality Improvement Newsletter features the latest insights and resources.

In This Issue: 

• CMS News
• Upcoming Educational Events
• Expert Insights and Resources on:
  • Behavioral Health and Opioid Stewardship
  • Antibiotic Stewardship
  • Adverse Drug Events
  • Infection Prevention 
  • Sepsis
  • Readmissions/Care Transitions
  • Patient and Family Engagement
  • Health Equity
  • Workplace Violence Prevention
  • Well-Being
• Success Stories

RHPTP Accepting Applications for Rural Healthcare Provider Support Program 
The Rural Healthcare Provider Transition Project (RHPTP), which began in 2020, provides direct support to five small rural hospitals and certified rural health clinics annually to help strengthen their organization's understanding of Value-based Care and learn strategies they can use to be effective participants in a health care system focused on value. The RHPTP is currently accepting applications for the next cohort. The project year deadline is August 15, 2024, with the next cohort selected by the end of September. For more information, watch this two-minute trailer.

CMS Releases Updated Health Equity Strategic Plan Summary 
The Health Equity Strategic Plan Summary is a new summary for health care providers and partners that outlines how CMS is advancing health equity by designing, implementing and applying policies and programs that support health for all people. Read Summary

Educational Events

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Upcoming Learning and Action Network (LAN) Events

• Consider the epidemiology of sepsis and sepsis bundle interventions (SEP-1) in the context of social determinants of health.
• Discuss best practices and challenges in following the evidence-based sepsis protocol.
• Using implementation science, describe appropriate interventions to address barriers. 
• Examine successes and challenges of implementing sepsis bundle compliance improvement strategies in Iowa CAHs.

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. 

Active Shooter: Is Your Hospital Prepared?

Thursday, August 8, 2024 

Being prepared and protecting patients and workforce is a priority for health care organizations. Learn how CHI St. Vincent Medical Center-North’s shared experience of preparing for a potential active shooter event, the results of that preparation, and lessons learned helped Baxter Health reassess and enhance response protocols to ensure their capability and readiness for workplace violence events. 
Register Here
Looking for resources on Workplace Violence Prevention? View Alliant HQIC’s coaching package here.

 

Check out other COP Call topics, such as Sepsis Mortality reduction, CAUTI, and Social Determinants of Health, on the Alliant HQIC website under Education on Demand. 

Office Hours-Ask the Experts

Health Equity Action Office Hours
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. The next session is Thursday, August 15.

View past sessions: 

• Jan. 16, 2024 - View slides and recording
• Feb. 15, 2024 - View slides and recording
• March 21, 2024 - View slides and recording 
• April 18, 2024 - View slides and recording
• May 16, 2024 - View slides and recording
• June 20, 2024 - View Slides and recording
• July 16, 2024 - View slides and recording

Office Hours-IP Chats 
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. 

View past sessions

• Jan. 24, 2024 – View slides
• April 24, 2024 – View slides
• July 24, 2024 – View slides

Visit the Alliant HQIC website under Education on Demand for past IP Office Hours slide presentations. To schedule a one-on-one meeting with Amy, please let your quality advisor know. Questions? Contact Amy Ward at amy.ward@allianthealth.org.

Expert Insights & Resources

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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

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

Patients With Physical and Mental Chronic Health Conditions Are Less Likely To Be Screened for Unhealthy Alcohol Use
Patients with multiple chronic conditions (MCC) affecting both their physical and mental health were less likely to be screened for unhealthy alcohol use than those who do not have MCC, according to an AHRQ-funded study published in the American Journal of Preventive Medicine. The authors analyzed 2020–2023 electronic health record data for more than 11,000 patients from 67 primary care practices in Virginia. Even though patients with chronic mental health conditions are more likely to screen positive for unhealthy alcohol use, researchers found that patients with both physical and mental chronic health conditions had 0.9 times lower odds of being assessed than those without. The authors suggested that further efforts are needed to improve delivery of alcohol preventive services in primary care, particularly for patients with high complexity and/or mental health conditions. Read Study

Antibiotic Stewardship

Lessons Learned from a National Hospital Antibiotic Stewardship Implementation Project Pumps 
The goal of antibiotic stewardship programs (ASPs) is to ensure that patients receive effective therapy while minimizing adverse events. To overcome barriers commonly faced in implementing successful ASPs, the Agency for Healthcare Research and Quality (AHRQ) established a multifaceted, nationwide Safety Program for Improving Antibiotic Use in 2018. This report summarizes the lessons learned from implementing this initiative based on structured interviews of personnel from participating sites. Read Report 

Adverse Drug Events

Study: Optimizing the Use of Dose Error Reduction Software on Intravenous Infusion Pumps
Smart pumps with dose error reduction software (DERS) can reduce adverse drug events, but alert fatigue can result in staff resistance and unsafe workarounds. In a study published by American Academy of Pediatrics, a pediatric hospital aimed to increase the use of smart pumps with DERS from 46% compliance at baseline to 75%. Updating the drug library resulted in the largest increase in compliance and decrease in alerts. Read Study

Infection Prevention 

Development of Patient Safety Measures to Identify Inappropriate Diagnosis of Common Infections
Hospitals working to improve diagnostic and antibiotic stewardship practices for urinary tract infections or community-acquired pneumonia should review the measures described in a study published by Oxford Academic and consider utilizing them in their improvement journey. Read Study

Infection Control Guidance: Candida auris
C. auris is an emerging fungus that can cause severe, often multidrug-resistant infections and spreads easily among patients in healthcare facilities. See the CDC’s resource for information on reducing, screening, and tracking C. auris. IPC Guidance provides a summary of recommendations.

Pressure Injuries

Quick Safety Issue 70: Early Identification and Evaluation of Severe Pressure Injuries
An article provided by the Joint Commission has a resource for early identification and evaluation of severe pressure injuries, including risk factors and warning signs and symptoms. It gives examples of safety actions to consider when dealing with pressure injuries to identify them as early as possible in order to provide an appropriate and timely treatment. Additionally, there are links available to previous Quick Safety newsletters to provide additional ways to prevent pressure injuries. Read Article

Implementing Four-Eyes Skin Assessment to Prevent Skin Breakdown 
At the University of Missouri Health Care, staff on the pulmonary and general medicine unit identify risks for skin breakdown by performing a “four-eyes skin assessment,” in which two unit nurses examine the entire skin of every individual. The process requires looking at and touching the skin from head-to-toe, with a particular emphasis over bony areas of the body. Read Article | View Four Eyes Skin Assessment

Sepsis

Access Webinar Materials: Clinical Documentation, Coding and Billing for Sepsis 
Check out the Clinical Documentation, Coding and Billing for Sepsis: Best Practices & Compliance webinar slides and recording from June 20, 2024. This webinar features a notable expert in medical billing and coding who discusses the need for improved diagnosis, documentation, and coding of sepsis to ensure accurate reimbursement and quality care. View slides and recording
 
Learning objectives included: 

• Consider approaches to evaluate the quality of sepsis data being reported to CMS and CDC. 
• Identify common coding challenges that lead to under and overreporting sepsis. 
• Apply sepsis coding knowledge to make suggestions to hospital quality improvement staff to improve the coding of sepsis. 

Readmissions/Care Transitions

Study: Predicting and Preventing Hospital Readmission for Exacerbations of COPD 
According to a study published by PubMed Central, more than a third of patients hospitalized for acute exacerbation of COPD are readmitted to the hospital within 90 days. Health care professionals and service providers are expected to collaboratively drive efforts to improve hospital readmission rates, which can be challenging due to the lack of clear consensus and guidelines on predicting and preventing readmissions. This review identifies these risk factors, highlighting the contribution of multimorbidity, frailty and poor socioeconomic status. Read Study 
  Patient and Family Engagement

Enhance Diversity in Patient and Family Advisory Councils with IPFCC's New Resource
Does your hospital face a lack of diversity among patient and family advisory council members compared to the broader patient population? See the Institute for Patient and Family-Centered Care (IPFCC) resource, Strengthen the Diversity and Role of Patient and Family Advisory Councils (PFACs), which can help create meaningful partnerships with patients and families, bringing their voices into the planning, delivery, and evaluation of health care. Download Resource

Successes and Achievements of HQIC Georgia Hospitals’ Patient and Family Advisory Councils (PFACs)
Patient and Family Advisory Councils (PFACs) are an excellent way for hospitals to interact with the community. They help hospitals understand the needs of the community, thereby bringing patients, staff, and clinicians together through better communication. PFACs act as liaisons between hospitals and communities, reduce barriers and provide lasting improvements. HQIC hospitals in Georgia have been dedicated to advancing PFACs, resulting in enhanced relationships within their communities. Below are some of their achievements over the past year:

• Wills Memorial Hospital (Washington, Ga.): Training with patient care technicians to incorporate nursing into PFE. They are also creating an award for doing work with patient-centered care.
• Atrium Health Floyd Polk Medical Center (Cedartown, Ga): PFAC held a pickleball tournament featuring featured health fair-type activities. In addition, they are building a community playground and, with the help of 150 volunteers, are planning to build 60 to 80 beds in four hours. 
• Memorial Hospital & Manor (Bainbridge, Ga.): Started a PFAC.
• Candler County Hospital (Metter, Ga.): Launched a No Pass Zone campaign to prevent falls.
• St. Mary's Good Samaritan (Greensboro, Ga.): Officially recruiting PFAC members.
• Evans Memorial Hospital (Claxton, Ga.): Requested information to potentially start a PFAC in the fall.
• Colquitt Regional Medical Center (Moultrie, Ga.): PFAC held a health fair and lunch and learn for diabetics.

Health Equity

Unlocking Health Equity: Access Updated Z Codes for Social Determinants of Health Collection
Are you looking for updated Z codes for the collection of social determinants of health? See Improving the Collection of Social Determinants of Health (SDOH) Data with ICD-10-CM Z Codes. CMS OMH offers health equity technical assistance resources to help health care organizations take action against health disparities. If your organization is looking for assistance, email HealthEquityTA@cms.hhs.gov.

Workplace Violence Prevention

Addressing the Rising Tide of Workplace Violence in Health Care: Key Data and Resources for Prevention 
Workplace violence is an increasingly recognized safety issue in the health care profession. The most recent data from the U.S. Bureau of Labor Statistics indicates an increasing trend in violent incidents in the health care sector from 2011 to 2018, with almost three-quarters (73%) of all nonfatal injuries and illnesses requiring days away from work occurring among health care workers. Compared to private industry, workers in hospital settings were eight times more likely to experience nonfatal violence-related injuries from other persons (22.8 vs. 2.9 incidents per 10,000 full-time workers). 

Do you know the four types of workplace violence? To find out, click on the Learning and Action Network slide presentation recorded on January 23, 2024. and learn more about implementing a workplace violence prevention (WVP) program, including areas of focus and policy guidelines.  

Interested in additional resources on WVP? Check out Alliant HQIC’s coaching package for evidence-based interventions and the Change Path for additional webinars, common barriers, and links to staff training.

Well-Being

Joint Commission Launches Workforce Safety and Well-Being Resource Center
The Joint Commission has introduced a new resource center aimed at enhancing the safety and well-being of health care workers across hospitals. Launched on July 10, the Workforce Safety and Well-Being Resource Center provides tools and strategies focused on workplace violence prevention, clinician burnout, and hazard management. The center aims to support health care leaders in fostering a safe and supportive environment for their teams amidst ongoing challenges in the health care sector. Visit Website

Nurse Retention Crisis: High Turnover Rate Plagues the Industry
Over 262,000 registered nurses (RNs) graduate yearly; 33% quit within the first two years. Nurse retention is not a new issue, but it has been exacerbated in the last few years and remains a top priority. Nurses cite many reasons for quitting, including burnout, stressful work environments, poor staffing ratios, lack of leadership, and low pay and benefits topping their list. Learn More 

Success Stories

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Georgia Hospital Uses High Reliability Organization (HRO) Principles to Redesign Daily Safety Huddles 

Southeast Georgia Health System (SGHS), a 300-bed hospital in Brunswick, Georgia, began a journey in 2022 with new leadership to improve transparency in reporting quality and patient safety outcomes. The senior team identified gaps between the current practice of their leadership huddle, an information sharing and general announcement meeting, and high reliability organization (HRO) principles. The current state of having leaders stand around a room and call out “no report” was not providing an ideal model for communication of safety issues and concerns.

Based on research by the patient safety team, the Tier 2 Safety Huddle (T2SH) was established to focus specifically on safety, including a dedicated conference room with the capability for virtual access and the chief medical officer (CMO) serving as a facilitator of daily huddles. To monitor and track issues, a shared computer drive and folder were created for all leaders to access and a tracking spreadsheet was used for following up on unresolved issues. Education and training were provided, as well as “how to” guides to assist staff in engaging in the new process and reporting patient safety events. 

In January 2024, a pilot program of department-based governance councils was launched. It consisted of eight departments, both clinical and non-clinical. Their first assignment was to implement a Tier 1 Safety Huddle, a process that provides leaders with a current state overview from frontline team members regarding patient safety risk issues. The huddle would occur routinely and before the T2SH.

Tiered Patient Safety Huddle model used at Southeast Georgia Health System

Overall wins included clinical leaders being more comfortable speaking up, frontline team members having the opportunity to participate in T2SHs, the CMO and risk manager stopping prompting leaders, and increased reporting of safety events.

For more information on the principles of an HRO and the tracking spreadsheets and dashboard used by SGHS, see the June 25, 2024, Learning and Action Network webinar. View Slides and Recording.

Alabama Hospital Develops Community Program to Decrease Health Disparities  

Baptist Medical Center South, a 492-bed hospital in Montgomery, Alabama, is addressing health disparities in their communities. Their focus is on uncontrolled diabetes in younger African-American patients, and the priority population is African-American patients under the age of 55 years and with an A1c of 7 or greater.

Short-term goals include: 1) Provide patient and family education on budget-friendly nutrition, know your numbers, medication management, and living with diabetes; and 2) Address barriers to care by offering wellness checks closer to home, incorporating a focus on priority population into Community Connection as well as outreach visits with churches and community organizations throughout the service area.

Long-term goals include: 1) Develop an engaging community program for African-American patients with A1c 7 or greater, incorporating quarterly health checks, nutrition and fitness education, virtual peer-group sessions, and incentives.

Action Steps Underway:

1. Staff education on diabetes care and resources added to the nurse residency program and patient care technician training curriculum
2. Community Connection events with partner churches and community centers
   • Assistance provided for establishing PCP relationships for elevated stats
   • Year-over-year change for two sites visited in Q1 of both years: 182 (2023); 124 (2024)
3. Social Determinants of Health (SDOH) pilot in PCP office
4. Promotion of The Center for Wellbeing’s Pre-Diabetes Classes
5. Abridged Diabetes Education Booklet, available with QR code

To date, there is a decrease in the A1c values for African-American patients under the age of 55 years in CY2023 compared to CY2022. See the table below.

Future Plans:

1. Heat map of AICs for focused community engagement+
2. Adding diabetes information to patient TV channel
3. Extend staff education on diabetes care and resources to our virtual care nursing partners
4. Consideration for a virtual platform for diabetes classes
5. Improved partnership with food bank for vouchers (e.g., diabetes meal boxes in key locations)
6. Additional team members from the primary care staff

For more information on Baptist Medical Center South’s project, click here for the slides and recording of Alliant HQIC’s Health Equity Office Hours.

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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-QIO TO3-HQIC--6099-07/31/24