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

In This Issue: 

• News from CMS
• Upcoming Educational Events
• Past Learning and Action Network (LAN) Events
• Expert Insights and Resources on:
  • Behavioral Health and Opioid Stewardship
  • Antibiotic Stewardship
  • Adverse Drug Events
  • Infection Prevention 
  • Sepsis
  • Patient Safety
  • Readmissions/Care Transitions
  • Health Equity
  • High Reliability Organization 
  • Workplace Violence Prevention 
• Best Practices Corner
• Success Stories

Final Rule Establishes Rural Emergency Hospitals as Medicare Provider
In November 2022, CMS published a final rule effective January 1, 2023, establishing initial policies for Rural Emergency Hospitals as a new Medicare provider type enacted in the Consolidated Appropriations Act of 2021. View Final Rule

Rural Emergency Hospital Education and Fireside Chat with an REH CEO
Thursday, February 8, 2024, from 2-3 p.m. ET
Join us on February 8, 2024, from 2 p.m.–3 p.m. ET to learn about the REH provider type and the no-cost technical assistance for hospitals considering a conversion available through the Rural Emergency Hospital Technical Assistance Center. This session will include a Fireside Chat where attendees will have the opportunity to hear directly from a CEO who worked with the Technical Assistance Center throughout their assessment and conversion journey. Register Here

Rural Emergency Hospital Map and Data 
The North Carolina Rural Health Research and Policy Analysis Center now provides REH data and a map on its website. Data available for download includes REH name, address, city, state, previous Medicare Payment Type, and REH participation date. The Center will continue to track new REHs and any REH status changes, making updates to the website as they occur. Visit Website

Educational Events

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Upcoming Learning and Action Network (LAN) Events

Key Components of an Effective Workplace Violence Prevention Program: Leadership Engagement and Communication 
Past Learning and Action Network (LAN) Events

Workplace Violence Prevention: Best Practices for Safer Care 

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. 

Preventing and Reducing Workplace Violence
Thursday, February 8

CMS is hosting a session with the American Hospital Association’s Hospitals Against Violence initiative to provide insights on addressing violence in health care communities and workplaces. The session will review the current state of workplace violence and showcase AHA’s tools for hospitals. Evangelical Community Hospital in Pennsylvania will also present its “Safe to Care” program, which includes staff training, policy revision, investment in equipment, and community outreach.

Register Here

Reducing Opioid Misuse: Alternative Pain Management Therapies
Recorded on January 11
This event featured alternative pain management therapies used to reduce opioid-related harms that can be implemented across health care settings. 

View Slides

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.

View past sessions: 

• Dec. 21, 2023 - View slides, recording and strategic planning
• Jan. 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.The next Office Hours-IP Chats will take place on:

• 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

Behavioral Health & Opioid Stewardship

Older Opioid Patients Experience More Adverse Events After Injury 
Chronic non-cancer pain Medicare patients with new opioid prescriptions who experience an injury—such as a fall or traumatic brain injury—have a 1.4 times greater risk of future opioid-related adverse events than those patients who did not experience an injury. According to an AHRQ-funded review in PLOS Medicine, the risk was highest in the 30 days before an adverse event. The findings indicated that identifying injuries that emerge after opioid initiation may assist in the early detection of older patients at high risk for adverse events such as overdoses. Read Study

Antibiotic Stewardship

Study: Empowerment of Nurses in Antibiotic Stewardship 
Inappropriate antibiotics use and antimicrobial resistance are increasingly becoming global health issues of great concern. Despite the established antibiotic stewardship programs (ASPs) in many countries, limited efforts have been made to engage nurses and clearly define their roles in ASPs. An exploratory qualitative study was conducted to understand the facilitators and barriers that impact nurses' involvement and empowerment in antibiotic stewardship. Read Study

Adverse Drug Events

Risk Factors for Opioid-Related Adverse Drug Events Among Older Adults After Hospital Discharge
According to a study published in the Journal of the American Geriatrics Society, potential opioid-related adverse drug events occurred within 30 days of hospital discharge in 7% of older adults discharged from a medical hospitalization with an opioid prescription. Identified risk factors can be used to inform physician decision-making, conversations with older adults about risk, and development and targeting of harm reduction strategies. Read Study

Hospital-Acquired Infections (HAIs)

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

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

Study: Readmissions Among Sepsis Survivors 
Post-sepsis hospital readmissions occur nearly as often as those due to congestive heart failure, acute myocardial infarction, pneumonia and chronic obstructive pulmonary disease. Learn more about risk factors for readmission among sepsis survivors here. 

Patient Safety

Study Influenza, Updated COVID-19, and Respiratory Syncytial Virus Vaccination Coverage Among Adults 
Collaborating with health care providers and understanding local vaccine rates and attitudes can increase influenza, COVID-19, and RSV vaccination rates. Read Study

Maximizing Safety with Checklists: The Importance of Mindful Implementation and Regular Review 
Checklists contain a list of processes or steps, usually in the order they should be completed. A checklist’s goal is to ensure no step is forgotten, thereby improving safety through standardization in communication and consistency in processes. Checklists are most effective when they are:

• Used as an evidence-based, “gold standard” safety practice, e.g., central line infection prevention bundles (processes) and surgical safety checklists.
• Used to offload reliance on memory of repetitious tasks often performed in a sequence.
• Used as a short, seamless integration into a process.

Get input from staff on the checklist during both the design and trial periods. Review your checklists regularly, as evidence, processes, or technology may change. Successful use of checklists requires leadership support and engagement in the implementation, emphasis on the importance of safety, monitoring the use of the checklist and providing feedback to staff. 
Coach staff to approach a checklist with mindfulness by using a two- to five-second pause to focus attention on what comes next. Use STAR (Stop, Think, Act, Review), a high-reliability tool shown to reduce error by a factor of 10 or more.  

• Stop: Pause for two- to five seconds to focus on what you are going to do.
• Think: Is this the right thing to do?
• Act: Concentrate and perform the task.
• Review: Check for the desired result.

Checklists are a critical tool in your patient safety toolbox, but remember it is not the checklist itself that keeps a patient safe. The person using the checklist must apply critical thinking skills as they go through the steps of a process to ensure safety. To learn more about checklists, see the following resources:

• American Hospital Association (AHA) Checklists Improve Patient Safety
• Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network (PSNet) Checklists 
• AHRQ PSNet What Makes a Good Checklist

Readmissions/Care Transitions

Study Shows Link Between Patient Well-being and 30-Day Readmission Rates in U.S. Hospitals
According to a recent Gallup study, there is a close link between the well-being of overnight hospital patients in the United States and 30-day readmission rates. Overnight hospital patients with high well-being are less than half as likely to be readmitted for the same major health condition within the next 30 days, compared to those with low well-being. This relationship still holds true even after considering various factors such as age, gender, race/ethnicity, household income, education, marital status, existing chronic conditions, and health insurance. The study suggests that healthcare organizations can take practical steps to reduce readmissions by prioritizing the well-being of their patients. Read Article

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

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 

A Formal Framework For Incorporating Equity Into Health Care Quality Measurement 
This article, published in October 2023, outlines a framework for incorporating equity, a key component of quality, into healthcare quality measurement. The authors propose a new health care measurement framework for equity called equity weighing. This framework addresses the shortcomings of existing approaches and explicitly calibrates incentives to align with equity goals. The equity framework considerably expands standard quality measurement that looks at average performance, and it expands stratified reporting that focuses on one group at a time. Read Article

Patient and Family Engagement

AHRQ: How Patient and Family Engagement Benefits Your Hospital 
Patient and family engagement continues to be an area of increasing importance for hospitals. A robust PFE strategy has many benefits, including improved patient safety and quality of care, better patient outcomes, and HCAHPS scores. Learn More

High Reliability Organization

Learn About High-Reliability Organizations in Health Care
A high-reliability organization (HRO) is an organization that consistently performs safely, efficiently, and with high quality, even in the face of complex challenges with high hazard potential. To learn more about high reliability in health care, watch Spreading Bundle Tools and Resources on High Reliability Culture, a full-day virtual event recorded on Dec. 7, 2023, with HQIC subject matter experts and hospital teams sharing their journeys to high reliable care. View Slides and Recording

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. 

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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Tift Regional Medical Center Foundation Donates Life-Saving Monitors to Irwin County EMS 
The Tift Regional Medical Center Foundation (TRMC) donated two Lifepak 15 monitors and defibrillators to Irwin County EMS. The devices perform a diagnostic EKG while en route to the hospital, and the results are sent directly to the physician’s mobile phone at Tift Regional, enabling the physician and staff to prepare for the cardiac victim before arrival and saving valuable time. Read Article 

How Cybersecurity Hygiene Can Help Rural Health Care Systems Stop Hackers 
Ensuring the safety of rural health care and pharmaceutical networks is a continuous process that necessitates a comprehensive approach to cybersecurity that surpasses traditional IT systems. This involves integrating technical solutions, educating employees, and remaining up-to-date with the latest cyber threats. Read Article

Success Stories

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How Contract Pharmacy Improved Antibiotic Stewardship in a Rural Community 

During the annual Georgia Hospital Association Patient Safety and Quality Summit, hospitals submit quality improvement projects for the chance to earn recognition and a GHA Patient Safety and Quality Award, which highlights the hospitals’ quality journey from the previous year. 
 
Recognizing that hospital readmissions create significant expenses for health care organizations, Crisp Regional Medical Center’s project focused on reducing readmissions. Approximately 2 million Americans are readmitted to the hospital every year, and an estimated $17 billion of U.S. health care costs associated with hospital readmissions is considered preventable. Additionally, research shows that patients with social risk factors are at higher risk for hospital readmissions than their counterparts. 

To focus on the prevention of avoidable readmissions for this vulnerable population, Crisp Regional created a readmission task force. The team identified areas that are especially important when targeting opportunities for diverse populations: transportation, culturally competent patient education, obtaining medications, linkage to primary care, connection to community-based resources, obtaining health insurance/disability benefits, and implementing an outpatient social worker. The team focused on multiple areas because research shows combining strategies is more impactful than focusing on single interventions. See graphics for health equity resource integration and transportation program patient destinations distribution.

Over the past 12 months, the hospital has seen more than a 3% linear reduction in readmissions. Additionally, since establishing the readmission task force, there has been a 31% reduction in self-pay readmissions compared to the previous 12-month period.

Another benefit of the task force is that it allows key stakeholders to collaborate on the execution and integration of these processes to ensure a consistent, systematic approach to addressing health disparities. The Crisp Regional team is confident in their establishment of solid resources and oversight to manage patients identified with social needs and prevent readmissions. In addition, the team will continue to work to ensure resources are integrated and implemented to their fullest potential.

The resources and systems that Crisp Regional has in place to address health disparities go beyond readmission prevention and patients with social needs, which is why the team will next identify additional target populations and determine how to address those disparities.

Crisp Regional’s health equity journey will continue to be a plan, do, study, act cycle. A dependable, multidisciplinary team committed to addressing community needs is crucial to their success. Learn more about Crisp Regional’s health equity approach to readmissions on the Health Equity Office Hours scheduled for Thursday, March 21, from 3-4:00 p.m. ET. Register Here

Physician Engagement at Alabama Hospital is Key to Reducing Sepsis Mortality

DeKalb Regional Medical Center (DRMC), a 134-bed, full-service hospital in Fort Payne, Alabama, is accredited by The Joint Commission on Accreditation of Healthcare Organizations and was awarded the Leapfrog Hospital Safety Grade A in 2023. 

In early 2023, the quality department selected sepsis mortality as a performance improvement project. The sepsis bundle compliance rates were good compared to sepsis mortality rates; however, the team asked why their sepsis bundle compliance was above the benchmark SEP-1 CMS Care Compare National Rate (59.0%).

Still, the sepsis mortality did not meet the CMS Focused Population Sepsis Mortality Observed to Expected (1.0). After a coaching call with the Alliant HQIC partner, Alabama Hospital Association, an action plan was initiated to improve the identification and diagnosis of sepsis to meet the observed vs. expected benchmark. 

Using a cause and effect or fishbone diagram, the quality department identified the root cause as missing opportunities to identify sepsis after admission. The following actions were put in place to improve staff and patient education and awareness: 

• Sepsis information mouse pads were placed on computers throughout the facility to provide quick references for nursing staff and physicians 
• Nursing education was provided, and reference cards were placed at the nursing stations
• Sepsis education was added to the in-house patient education channel

The team agreed that despite the success of the sepsis mouse pads, reference cards, and nursing/patient education, more monitoring and preventive strategies were needed. However, the physicians questioned establishing the need for a Sepsis Committee because the bundle compliance scores were above the benchmark.  

This was around the same time the quality department staff attended a statewide Sepsis Event on March 14, 2023. The team again worked with the Alabama Hospital Association to request assistance in forming a committee involving more physicians. As a result, a virtual lunch and learn was scheduled for July 20, 2023, with the chief medical officer from a high-performing hospital discussing the need for a sepsis committee and sharing evidence-based practices and experiences at their facility. The attendance was positive and encouraging as physicians, nurse practitioners, medical students, and Emergency Department clinicians participated in the event. 

Immediately following the call, sitting at the boardroom table, a committee was established with a hospitalist serving as the sepsis physician champion, the ED physician medical director as the committee co-chair, and the quality abstractor as the sepsis nurse champion. Under their leadership, the Quality Department worked to establish the following:

• Mission statement: We must recognize sepsis earlier, increase survival rates of sepsis patients through early intervention and treatment, implement international sepsis guidelines, and educate professionals, policymakers, and the public about sepsis to increase awareness of this catastrophic "silent killer."
• The goal of the committee was to improve the rate of recognition and diagnosis of severe sepsis and septic shock from presentation to the ED and latent sepsis that could develop on the inpatient side. The committee aims to improve the sepsis mortality rate and decrease the sepsis mortality score in the process. 

Over a few months, a sepsis policy was reviewed and revised, a severe sepsis screening tool was created, an ED documentation checklist was approved, and a code sepsis process was established after input from the team members. In addition, a Quality Sepsis Memorandum Form was developed to send any sepsis failures to clinicians, which helps identify trends and opportunities for improvement.

As of October 2023, the severe sepsis screening form, sepsis policy, and other documents, including order sets, were finalized and received final approval from the Medical Executive Committee. The Quality team educated all inpatient nurses, directors, and house supervisors on properly using the sepsis screening form as a tool to determine if sepsis could be present. Following all staff education, several mock Code Sepsis drills were conducted and are in the process of going live.

In this past year, sepsis mortality performance has improved for DRMC and, according to Alliant HQIC data, has exceeded the relative improvement rate (9.0%) over baseline. To date, 17 patient deaths were avoided with a cost savings of $981,274. Other post-implementation data has demonstrated that benchmarks have been met and/or exceeded, and the team is confident that these initiatives, including improved physician engagement and a continued focus on sepsis bundle compliance, will be sustained in 2024. 

Click here for another success story about sepsis mortality and bundle compliance. 

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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:TO3-HQIC--5175-01/30/24