The December 2023 issue of the Hospital Quality Improvement Newsletter features the latest insights and resources.

In This Issue: 

• News from CMS
• Partner Educational Events
• Past Learning and Action Network (LAN) Events
• Expert Insights and Resources on:
  • Behavioral Health and Opioid Stewardship
  • Antibiotic Stewardship
  • Patient Safety
  • Readmissions/Care Transitions
  • Patient and Family Engagement
  • Health Equity
  • Workplace Violence Prevention 
• Best Practices Corner
• Success Stories

CMS OMH Recognizes National Rural Health Day 
The Centers for Medicare & Medicaid Services Office of Minority Health (CMS OMH) celebrates National Rural Health Day and the challenges faced by each community in rural areas, Tribal nations, territories, and other geographically isolated areas. Rural communities often face challenges with access to care, financial viability, and the critical link between health care and economic development. CMS recognizes the need to ensure those residing in rural communities can achieve their highest level of health. Explore the resources below to learn how to better serve these communities throughout the year.
Resources

• Visit the Rural Health webpage to explore rural health resources, reports, and publications that share information about rural, Tribal, frontier, and geographically isolated communities.
• Review the CMS Framework for Advancing Health Care in Rural, Tribal, and Geographically Isolated Communities, which describes how CMS will focus its efforts to advance rural health. The Rural Health Equity One-Pager outlines the framework’s six priority areas.
• Read the Advancing Health Equity in Rural, Tribal, and Geographically Isolated Communities: FY 2023 in Revie annual summary report to learn how CMS has met the needs of these populations throughout 2023.
• Download the Advancing Rural Maternal Health Equity Report to learn how the Rural Maternal Health Initiative was used to address maternal health disparities between June 2019 and November 2021.
• Share the Rural Health Information Hub to help program organizers develop programs designed for rural communities and learn more about issues affecting Americans living in rural areas.
• For more information about rural health:
  • Subscribe to the CMS Rural Health listserv to keep up with the latest news on rural health programs and policy.
  • Visit the CMS Rural Health Clinics Center​​​, which serves as a hub for information on rural health clinics, including educational resources, policy regulations, and billing/payment-related fact sheets.

Educational Events

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Upcoming Learning and Action Network (LAN) Events

Workplace Violence Prevention: Best Practices for Safer Care  Past Learning and Action Network (LAN) Events

Health Equity Strategy Series: How to Make It Work for Your Hospital
Want to learn how to meet CMS and The Joint Commission (TJC) health equity requirements and improve patient outcomes for your community? This two-part series breaks down what your health equity action plans and next steps should include.
View Session 1 Presentation and Recording | View Session 2 Presentation and Recording

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. 

National Antibiotic Stewardship Updates and Promising Practices 
Recorded November 9
Antibiotic Stewardship (AS) remains a national priority aimed at optimizing antibiotic use to effectively treat infections, protect patients from harms caused by unnecessary use and combat antibiotic resistance. This webinar featured insights from a CDC physician, a hospitalist lead for a statewide AS medicine safety initiative and a hospital AS pharmacist lead. 
View Presentation | View Recording

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 3-3:45 p.m. ET. The next office hours will take place on: 

• Nov. 16, 2023 - View slides and recording
• Dec. 21, 2023 - Register Here
• Jan. 16, 2024 - Register Here

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.The next Office Hours-IP Chats will take place on:

• Wednesday, January 24, from 2-2:30 p.m. ET
• Wednesday, April 24, 2024, from 2-2:30 p.m. ET
• Wednesday, July 24, 2024, 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.

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

Patient-Friendly and Provider-Friendly Resources
Alliant Health Solutions has updated its Quality website to make finding patient-friendly and provider-friendly resources even easier. Website visitors can now use the website’s filter functionality to quickly find patient-friendly or provider-friendly resources, events and blog posts. These resources and events will also be displayed with the unique icons shown below.

Behavioral Health & Opioid Stewardship

AHRQ Stats: Adult Opioid Fills, 2020 to 2021 
Between 2020 and 2021, 6.4% of adults aged 18 to 64 filled at least one outpatient opioid prescription and 1.8% filled four or more annually. Read More 

Antibiotic Stewardship

Funding Available For Projects To Reduce Healthcare-Associated Infections and Antibiotic Resistance 
The Agency for Healthcare Research and Quality (AHRQ) is funding innovative research proposals to prevent healthcare-associated infections (HAIs) and combat antibiotic-resistant bacteria (CARB). Applications are due Jan. 25 for demonstration and dissemination projects (R18) and Feb. 5 for large research projects (R01). HAI projects in both grant categories should demonstrate new ways to detect, prevent and reduce HAIs. CARB projects should address ways to promote appropriate antibiotic use, reduce the transmission of resistant bacteria or prevent HAIs. The funding is available to support research in all healthcare settings: long-term care, ambulatory care, acute care hospitals, and those focusing on transitions between care settings. AHRQ encourages potential applicants to consider research in health care delivery areas with demonstrated health inequities and to address those equity issues in their proposed projects. Read More 

Adverse Drug Events

Study: Universal EHRs Clinical Decision Support for Thromboprophylaxis in Medical Inpatients 
Thromboprophylaxis for medically ill patients during hospitalization and post-discharge remains underutilized. Clinical decision support may address this need if embedded within the workflow, interchangeable among electronic health records, and anchored on a validated model. Read Study

Hospital-Acquired Infections (HAIs)

Infection Prevention Resources 
Check out updated NHSN and IP training resources. View Resources

CDC's 2022 HAI Progress Report Shows Decrease in Infections in Acute Care Hospitals 
The CDC released the 2022 National and State Healthcare-Associated Infections (HAI) Progress Report. While some settings saw no change or increase in infections, Acute Care Hospitals reported significant decreases in some HAIs between 2021 and 2022:

• Central line-associated bloodstream infections (CLABSI) (down 9%),
• Catheter-associated urinary tract infections (CAUTI) (down 12%),
• Ventilator-associated events (VAE) (down 19%),
• Hospital-onset methicillin-resistant Staphylococcus aureus (MRSA) bacteremia (down 16%)
• Hospital-onset Clostridioides difficile (CDI) (down 3%).

The 2022 HAI Progress Report continues to highlight the need for healthcare facilities to reinforce infection prevention and control practices. The report also reviews HAI surveillance data to identify areas that need improvement and address any gaps. Read the 2022 HAI Progress Report

Sepsis

Sepsis Core Elements: CDC Webinar Series 
The American Medical Association (AMA) and CDC’s Project Firstline have developed a webinar series focused on the new CDC Sepsis Core Elements. This series offers free continuing education (CE). Register Here | View Previous Sessions

Patient Safety

Improving Health Equity by Eliminating Biased and Stigmatizing Language in Medical Notes 
Health care providers are trained to use non-biased language in medical records, but studies of provider notes continue to show that implicit bias exists. The use of negative and stigmatizing language in medical record notes can make patients feel judged and less likely to engage in future care. These negative characterizations can follow the patient to future health visits. Studies have shown that providers read other providers’ notes and develop bias even before they’ve met the patient. An article published by the Better Care Playbook outlines ways that providers can improve medical notetaking using guidance and tools to increase understanding of which populations and medical conditions are described negatively and model best practices. Read Article 

I-Pass: A Communication Tool for High Reliability 
Effective communication is essential in health care, yet it is often hindered by various barriers such as lack of time, hierarchy, defensiveness, varying communication styles, distraction, fatigue, conflict, workload, education and literacy, and lack of standardized communication tools. According to The Joint Commission, communication issues are a common root cause of harm and sentinel events, and handoff errors are estimated to occur in 13% of cases. Physicians' handoffs are particularly prone to errors of omission.

To address these challenges, high reliability communication tools like I-PASS were developed to standardize patient transitions. I-PASS is recognized as the gold standard for handoff communication and has been shown to reduce preventable adverse events associated with communication errors.

I-PASS is a structured handoff bundle that includes:

• A one-word summary of patient acuity (e.g., stable, watcher or unstable)
• A summary that outlines the patient’s diagnoses and treatment plan
• A to-do list for the clinician receiving the 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)
• An opportunity for the receiver to ask questions and confirm the plan of care

By implementing I-PASS, health care providers can improve patient safety and promote high reliability in their practice.

Resources:

• The Joint Commission Sentinel Event 2022 Annual Review 
• American Hospital Association (AHA) Center for Health Innovation Handoff Communication Toolkit with I-PASS Video 
• AHRQ Tool: I-PASS 
• AHRQ Patient Safety Network (PSNet) Handoffs and Sign-outs

Readmissions/Care Transitions

Reducing Readmissions While Supporting Substance Abuse Users
Check out the webinar “Creating Pathways to Stability” from another HQIC presented in May 2023. The presentation focused on the Most Visited Patients (MVP) model by Dr. Amy Boutwell. This webinar recording from the TMF Quality Innovation Network-Quality Improvement Organization describes a hospital and community health center collaboration that works to address the underlying needs of the patients who are most likely to become frequent visitors to hospital emergency rooms. The goal is to improve their quality-of-life outcomes and reduce readmissions while supporting substance users in central Houston.
View Webinar | Read an Article About Harris Health’s MVP Program

Study: Influence of Weekday and Seasonal Trends on Urgency and In-hospital Mortality of Emergency Department Patients
Given the scarcity of resources, the increasing use of emergency departments (ED) represents a major challenge for the care of emergency patients. Current health policy interventions focus on restructuring emergency care with the help of patient re-direction into outpatient treatment structures. According to a study published by Frontiers in Public Health, a precise analysis of ED utilization, taking into account treatment urgency, is essential for demand-oriented adjustments of emergency care structures. Read Study

Study: Clinical Complexity and Hospital Admissions in December
The Christmas and New Year’s holidays are risk factors for hospitalization, but the causes of this holiday effect are uncertain. In particular, clinical complexity (CC) has never been assessed in this setting. A study published by PubMed Central sought to determine whether patients admitted to the hospital during the December holidays had greater CC compared to those admitted during a contiguous non-holiday period. Read Study

Health Equity

Updated Infographic as of October 2023
Check out the updated infographic that explains how ICD-10-CM Z codes can help improve the collection of Social Determinants of Health (SDOH) data. It also outlines ways that collection of SDOH data can improve equity in health care delivery and research. View Infographic 

Patient and Family Engagement

CMS Person and Family Engagement Strategy 
CMS has developed the Person & Family Engagement Strategy with actionable goals and objectives to make people aware of and involved in person and family engagement. The document serves as a guide for incorporating PFE principles into clinical practice, program development, community health initiatives, and other areas and provides tools and methods providers can use to engage patients and their families in their care. Download Guide

EQIC Checklist of Practice Recommendations 
The Eastern US Quality Improvement Collaborative (EQIC) created a checklist of practice recommendations to provide process improvement strategies for consideration as hospitals work to implement a patient and family advisory council. View Checklist

Workplace Violence Prevention

New Workplace Violence Prevention Coaching Package
Alliant's new coaching package includes best practice interventions and resources. Check out the SAVE Act, guides, staff education and case studies. Download Coaching Package

New Survey Sheds Light on Workplace Violence in Health Care Settings 
A new survey polled clinical health care workers, health care administrative workers, and health care security personnel and found that 40% of health care workers experienced workplace violence in the past two years. At a time when several states are upping the penalties for assaulting health care workers, and there is currently legislation before Congress that would give health care workers the same legal protections against assault and intimidation as aircraft and airport workers, current data can arm health care leaders in advocating for change on behalf of their employees. Read More

Best Practices Corner

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Phoebe’s Mobile Wellness Clinics Help Bridge Health Care Gaps
Phoebe Putney Memorial Hospital’s mobile health clinics provide vital medical services for communities across southwest Georgia. The Albany, Georgia-based hospital is dismantling barriers by strategically deploying two custom-built mobile wellness clinics. The mobile units are dedicated to enhancing the health care of underserved populations in medically disadvantaged regions across southwest Georgia. Read More

Success Stories

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How Contract Pharmacy Improved Antibiotic Stewardship in a Rural Community 

An increased focus on antibiotic stewardship (ABS) began for Trego County-Lemke Memorial Hospital, a 25-bed critical access hospital in WaKeeney, Kansas, about two years ago, shortly after the Kansas Department of Health and Environment (KDHE) released a statewide heat map showing the prevalence of E. coli resistance. This report included a ratio of antibiotic usage, and Trego County was high on the list. The health care system needed to do something to address the issue. 

As an infection preventionist and risk manager, Kiley Wheeles, BSN, RN, recognized the limitations of her role as it related to ABS. She could only see trends but was not comfortable making specific antibiotic recommendations. She sought to build an effective ABS program and provided new and fresh interventions to ensure a more responsible approach to antibiotic prescribing. Trego County-Lemke Memorial is a small hospital with no in-house pharmacy but has an existing relationship with a contract pharmacy that provides monitoring and oversight of medication programs. 

According to Janis Hughes, PharmD, augmenting hospital ABS programs is still a relatively new service line for Hospital Pharmacy Management (HPM), a hospital pharmacy service company based in Iola, Kansas. This service is offered in two phases: Phase 1) Development/review of an antibiogram and development of indication-specific order sets, and Phase 2) Longitudinal monitoring of usage patterns and rates. 

The project aimed to leverage the expertise of Iola’s HPM pharmacists to develop specific order sets based on disease processes that included recommendations for first-line and second-line antibiotic use. The idea was to make responsible and informed antibiotic prescribing easy for prescribers. Everything they needed for common conditions, including recommended antibiotics, labs and nursing orders, would be included in a single-step, electronic order set. For example, if the prescriber admits a patient for a urinary tract infection (UTI), the order set would recommend appropriate antibiotics based on the hospital’s formulary and community resistance patterns. This approach prompts prescribers rather than asking them to remember current or updated recommendations across various clinical conditions. For Trego County-Lemke Memorial Hospital, appropriate antibiotic use for UTIs was the initial quality improvement goal. UTI rates were high, specifically for the elderly population. Any patient with an abnormal urine result appeared to be receiving an antibiotic. 

PLAN: The initial KDHE heat map report got the attention of hospital leadership, which provided the essential leadership buy-in necessary to plan for change and implement new processes. As part of the planning process, this same heat map was shared with the hospital’s providers to demonstrate the need for change. Trego County-Lemke Memorial had an established ABS Committee. Membership included a pharmacy nurse*, the infection preventionist, the chief nursing officer and a physician champion. However, this did not have a real purpose and lacked pharmacist representation. 

HPM’s planning process includes working closely with the organization to identify the quality improvement activities/priorities the organization is interested in working on or an area they are specifically struggling with. Trego County-Lemke Memorial Hospital struggled to ensure patients with a UTI received the correct antibiotic. 

DO: Adding the HPM representative to the ABS committee changed the entire group dynamic and gave substance to the reports the committee produced. The initial interventions implemented included developing an antibiogram, developing indication-specific order sets and leveraging the 72-hour time-out setting within the Cerner electronic health record (EHR). The 72-hour time-out setting was not a part of the initial planning but was recommended by the pharmacist. This time-out setting is a feature that provider organizations can opt into. This feature provides a 72-hour notice to providers (based on the timing of the antibiotic start date/time) asking the prescriber if the patient still needs the antibiotic, suggesting that it could be discontinued, defining the duration of antibiotic therapy, changed to PO (by mouth), etc. 

Initially, Trego County-Lemke Memorial focused only on its inpatient and emergency department populations. Adopting improved order sets helped clinical staff evaluate the whole person being treated, rather than providing an antibiotic to every patient with an abnormal urine result, even if they were asymptomatic.

STUDY: As treatment behaviors and patterns were observed after implementation, clinical staff began to focus on why they were treating patients. Based on the established order sets and updated ABS committee recommendations, nursing staff must critically think through the next steps based on specific clinical indicators or a combination of clinical indicators. Some of the incidental findings include: 

• Reduction in testing for Clostridioides difficille (C. diff) potentially indicating previous over-testing.
• Improved instruction and effectiveness of “clean catch” urinalysis (UA) samples: The hospital could also initiate a standing order for a straight catheter UA sample if the patient cannot give a clean catch specimen within four hours of admission. This has resulted in better specimen collection and allowed clinical staff to treat the patient’s condition more accurately. 
• Reduced contamination when accessing ports for culture samples: Culture results did not match the patient’s presentation, requiring clinical staff to consider what could be causing the culture results. It has been interesting to see how much E. coli resulted from contamination rather than an actual infection. 

While it hasn’t been formally studied, infection prevention and clinical pharmacists believe that overall antibiotic usage, specifically IV antibiotics, has decreased, and de-escalating to oral antibiotics has also improved. It hasn’t yet been a whole year that the new processes have been in place, but this is a planned area for study. 

ACT TO HOLD THE GAINS: The current plan is to continue the process. It seems that the monthly review of progress continues to result in identifying other improvement opportunities (i.e., C. diff cultures, clean catch process). Additionally, the changed process is still new enough that prescribers are at risk of slipping back into old prescribing habits. Hence, continuing education is vital until it becomes a permanent change. The timing is perfect for continued education and enhancements to the process, as provider organizations are just starting to step back from COVID response and focus on priorities other than COVID. 

Some key takeaways from the program’s development and implementation include: 

• Pharmacists are an essential part of the care team, and small hospitals can successfully incorporate this discipline into their care teams through contract arrangements even if they don’t have employed pharmacy staff. 
• The most impactful intervention was the order sets for specific disease processes, and they have been received very well by providers. Smaller hospitals may have an easier time implementing this intervention because it’s easier to identify the types of common admissions (smaller population) and pre-define the necessary order sets. 
• How order sets are presented to providers is important. You’re not telling them what to do or prescribe; you're just giving them options based on current evidence, thereby saving time. Providers can still select from the provided recommendations.  

One additional consideration that Trego County-Lemke Memorial Hospital and HPM had hoped to implement included a hard stop for laboratory orders if appropriate indication was not provided. For example, if the system could prompt response to specific clinical questions (i.e., is the patient symptomatic), the hospital could potentially avoid unnecessary reflex micro-testing; if the patient is not symptomatic, there is no reason to send the urinalysis for further testing. However, this function does not currently exist in their EHR and was not a priority for their vendor to add. 

Understanding and Enhancing the Contracting Pharmacy Role: Most small hospitals without an on-site pharmacy department/employed pharmacist have a relationship with a consultant or contract pharmacists. There is no reason to reinvent a role to support medication management programs. While there are differences in the contract pharmacy role from state to state (i.e., time to review orders from 72 hours to seven days), most state boards of pharmacy require that facilities have a pharmacist in charge (PIC) designated. However, this role primarily provides a retrospective review of initiated pharmacy orders. In smaller communities, most hospitals contract with their local community pharmacist to meet this requirement.

However, the retail/community pharmacy role differs from a health system or hospital pharmacy perspective. The health system approach can provide a prospective relationship whereby orders are reviewed as they come in by the pharmacy consultant, reviewing renal function and allergies and adjusting the orders before they reach the patient. Small hospitals may consider re-evaluating their contract pharmacy relationship to leverage hospital or health system pharmacy experience or approaches. 

*Pharmacy Nurse – A nurse with specific experience in pharmacy and nursing manages the hospital’s formulary and liaisons between departments. 

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:TO3-HQIC--4920-12/05/23