The January 2024 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
  • Hospital-Acquired Infections (HAIs)
  • Sepsis
  • Patient Safety
  • Readmissions/Care Transitions
  • Health Equity
  • Patient and Family Engagement
  • 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 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

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. 

Reducing Opioid Misuse: Leveraging Alternative Pain Management Therapies
Thursday, January 11
Please join this special Community of Practice Event open to all QIO program task orders. Speakers will include Dr. Roger Liu, CMS, Jennifer Brockman and Dr. Susan Bradley from the Iowa Healthcare Collaborative’s (IHC) Task Order 5 Opioid Prescriber Safety and Support Program. This event will feature alternative pain management therapies used to reduce opioid-related harms that can be implemented across health care settings. All quality improvement leaders across task orders who are working on opioids, opioid use disorder, and pain are encouraged to attend.

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

• Nov. 16, 2023 - View slides and recording
• Dec. 21, 2023 - View slides, recording and strategic planning
• 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

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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Atrium Health Floyd Polk Medical Center Earns Leapfrog Award
Atrium Health Floyd Polk Medical Center in Cedartown, Georgia, was named a Top Rural Hospital by the Leapfrog group. The hospital also earned the designation in 2009, 2018, 2019 and 2020. the Leapfrog Top Hospital award is one of the most competitive awards American hospitals can receive. The Top Hospital designation is bestowed by The Leapfrog Group, a national watchdog organization of employers and other purchasers known as the toughest standard-setters for health care safety and quality. Read Article 

Success Stories

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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. 

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. 

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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--5048-01/03/24