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

In This Issue: 

• Environmental Safety Assessment 
• Upcoming and previous educational events
• Expert insights and resources on:
  • Behavioral Health and Opioid Stewardship
  • Antibiotic Stewardship
  • Patient Safety
  • Readmissions/Care Transitions
  • Patient and Family Engagement
  • Health Equity
  • Violence Prevention 
• Best Practices Corner
• Success Story

Environmental Safety Assessment 
Alliant HQIC is interested in learning more about specific topics related to your hospital safety operations. Please take our five-minute survey. Your responses will help us determine the best tools and resources. The survey should be completed by one person per hospital. The deadline is August 4. Thank you!

Educational Events

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Upcoming Learning and Action Network (LAN) Events

How to Rebuild, Reengage and Reenergize Your Patient and Family Advisory Council (PFAC)
Tuesday, July 25, from 1-1:30 p.m. ET
In recent months, hospitals have begun to reengage their Patient and Family Advisory Councils (PFACs) after the adverse impact that the COVID-19 pandemic had on their health care systems, including the ability to have in-person PFAC meetings. As a result, some hospital PFACs are even better and stronger than ever before. Wills Memorial Hospital, a 25-bed critical access hospital in Washington, Georgia, will present on the rebuilding and reenergizing of their PFAC, identifying and prioritizing several key areas of concern, and implementing projects based on the greatest need. 

Objectives:

• Explain the five Patient and Family Engagement metrics and other key measures of the Hospital Quality Improvement Contractor (HQIC) program.
• Discuss the PFAC infrastructure and the importance of listening to the patient’s voice to improve patient care.
• Illustrate how one hospital implemented training for the patient care team based on PFAC discussions and how the training has improved quality outcomes. 

Register Here

Is Your Board Bored? Demonstrating the Impact of Quality(hosted by Compass HQIC) 
Nursing CEs and CPHQ credits awarded
During this two-part presentation, you will learn the methods for engaging your board of directors during your quality reporting and discussions. Also, we’ll address simple techniques for ongoing communication with your senior team and demonstrate the impact of quality. By the conclusion, you will have practical concepts for leadership, steps for improvement related to your organizational goals, and tools and strategies for implementation.

• Session 1: Presenting Value to the Board – Thursday, July 27 at 2 p.m. ET
• Session 2: Quality in your Strategic Alignment – Thursday, August 24  at 2 p.m. ET

Register Here

Past Learning and Action Network (LAN) Event

Enhancing Capacity — Reengineering Fall and Fall Injury Programs
Recorded on June 20 
The webinar raised awareness about fall prevention and offered guidance and resources to professionals in clinical, administrative, quality, and safety improvement. It also aimed to make the design, redesign, and strategic planning of fall programs more precise.
View Presentation 

Quality Leader Summit: Focus on Sepsis, Health Equity 
Recorded on June 6 
During the Quality Leader Summit, we discussed:

• Patient safety areas meeting target goals and opportunities for improvement. 
• How a hospital improved sepsis bundle compliance rate by enhancing early recognition and diagnosis of severe sepsis and septic shock. 
• Health equity strategies to meet The Joint Commission accreditation and CMS regulatory requirements for screening for social determinants of health (SDOH).
• Educational events and updated valuable resources, such as coaching packages, the HQIC website, and the portal.

View Presentation | View 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. 

Innovative Approaches to Addressing Health Equity and Social Determinants in Rural Communities

Thursday, July 13
This event will feature a discussion of the Rural Health Information Hub’s Rural Health Equity Toolkit, including examples of how rural community health programs have sought to advance health equity. Considerations for implementation, evaluation, and sustainability of interventions will be included. Additionally, two HQIC hospitals will share promising practices for advancing health equity, including improved social determinants of health (SDOH), using SDOH data to identify patients at risk for increased length of stay and readmissions, and developing a robust patient and family advisory council in a diverse community.
Register Here

Monthly Office Hours-IP Chat

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.

• Click Here to view the April 26 slides - COVID-19 data and PHE updates 

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

• Wednesday, July 26, from 2-2:30 p.m. ET
• Wednesday, October 25, 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

Joint Commission’s New Speak Up Campaign
A new patient safety campaign from The Joint Commission — Speak Up™ For Your Mental Health — is designed to educate patients on how to advocate for themselves and their mental health. Learn More

Association of Prescription Drug Monitoring Programs With Opioid Prescribing and Overdose in Adolescents and Young Adults 
The usage of prescription opioids has been linked to unfavorable substance-related outcomes in young adults and adolescents. This is due to a process involving prescription, diversion, misuse, addiction, and overdose. Evaluating the impact of existing prescription drug monitoring programs can guide efforts to mitigate opioid-related risks. Learn More

Antibiotic Stewardship

Implementation of an Electronic Alert to Improve Timeliness of Second Dose Antibiotics for Patients With Suspected Serious Infections in the Emergency Department: A Quasi-Randomized Controlled Trial 
Delays in the second dose of antibiotics in the emergency department (ED) are associated with increased morbidity and mortality in patients with serious infections. A study published in the Annals of Emergency Medicine analyzed the influence of clinical decision support to prevent delays in second doses of broad-spectrum antibiotics in the ED. Read More

Core Elements of Antibiotic Stewardship
CDC’s Core Elements of Antibiotic Stewardship offer providers and facilities a set of key principles to guide efforts to improve antibiotic use and, therefore, advance patient safety and improve outcomes. These frameworks complement existing guidelines and standards from key healthcare partner organizations, including the Infectious Diseases Society of America, Society for Healthcare Epidemiology of America, American Society of Health System Pharmacists, Society of Infectious Diseases Pharmacists, and The Joint Commission. 
Resources:

• Core Elements of Hospital Antibiotic Stewardship Programs
• Implementation Resources for Hospitals 
• Implementation of Antibiotic Stewardship Core Elements at Small and Critical Access Hospitals

Adverse Drug Events

Evaluation of Detected Medication Errors Within the Operating Room at an Academic Medical Center
Medication errors are preventable events that lead to inappropriate medication use and potential patient harm. This is especially prevalent within the operating room (OR), where one practitioner is involved in the entire medication-use process. Despite the recent implementation of BD Pyxis Anesthesia ES, Codonics Safe Label System, and Epic One Step at the University of Kentucky Healthcare (UKHC) to prevent medication errors, errors continue to be reported. A study published by Sage Journals found human error was the most frequent cause of medication error within the OR. Clumsy automation may be an explanation for this, which imposes burdens and promotes workarounds. This study endeavors to assess potential medication errors via chart review to identify risk reduction strategies. Read Study 

Patient Safety

Appreciative Inquiry Proves Successful for Managing Clinical Conditions 
Appreciative Inquiry (AI) is an organizational development process that is a strengths-based change approach rather than deficit-based. The AI process focuses on leveraging positive strength to design and redesign systems. The main components of AI are Discovery, Dream, Design and Destiny. AI is organizational and proved successful in working with patients to manage clinical conditions such as hypertension and weight loss. Furthermore, AI complements Safety II’s (or Safety 2) strength-based approach to learning from what goes right, even in adverse situations. Read More | Read Study

Readmissions/Care Transitions

Tips for Patients to Be More Engaged in Health Care
The Agency for Healthcare Research and Quality created tips your patients can use before, during, and after their medical appointment to ensure they get the best possible care. It’s important for patients to be active members of their health care team. View Tips

Health Equity

SDOH Screening: From A to Z-Codes 
Join this webinar on Tuesday, July 25, at 1:30 p.m. CT/2:30 p.m. ET to explore when, why, and how to use Z-codes to document your patients’ social needs. Julia Resnick, director of Strategic Initiatives at the American Hospital Association, will share a brief overview of Z-codes and how they relate to your efforts to screen for and address social drivers of health. 
The majority of the session will be an open-ended discussion and Q&A to explore how to operationalize a process to identify, document and analyze these codes in a way that spurs action to improve care and health. Register Here

On-Demand Pioneers in Quality Webinar: Introduction to Joint Commission’s New Health Care Equity Certification Standards 
On July 1, 2023, a new Health Care Equity (HCE) certification program will be available to recognize hospitals and critical access hospitals that strive for excellence in their efforts to provide equitable care, treatment, and services. This new, voluntary certification program demonstrates a hospital’s commitment to advancing its efforts to achieve health care equity by building upon the Joint Commission’s existing health care equity accreditation standards and recent requirements to reduce health care disparities.  

This on-demand webinar will introduce each Standard and Element of Performance, offering examples of how they would be applied and highlighting resources available to assist organizations wishing to excel in their health care equity implementation efforts. There is no fee to attend this webinar, and CE/CEU credit is available. To claim a continuing education credit, participants must register individually.  Register Here 

The Joint Commission National Patient Safety Goal 
NPSG.16.01.01 Improving health care equity for the hospital’s patients is a quality and safety priority. This is applicable to the Hospital Accreditation Program effective July 1, 2023.  Learn More

R3 Report Issue 38: National Patient Safety Goal to Improve Health Care Equity 
Effective July 1, 2023, Standard LD.04.03.08, which addresses health care disparities as a quality and safety priority, will be elevated to a new National Patient Safety Goal (NPSG), Goal 16: Improve health care equity, and moved to NPSG.16.01.01 for ambulatory health care organizations, behavioral health care and human services organizations, critical access hospitals, and hospitals. The NPSG standard and 6 elements of performance (EPs) increase the focus on improving health care equity as a quality and safety priority, but the requirements for accredited organizations are not changing. While some of the original language from Standard LD.04.03.08 and its EPs were revised to focus on improving health care equity rather than reducing health care disparities, the intent behind the standard and associated EPs remains the same. Read More

CMS IQR Reporting
CMS added three measures to their IQR reporting that address Social Determinants of Health (SDOH) beginning in CY23.

Details about the Health Equity and SDOH measures are below:

• IX. Quality Data – starts on p. 1101
• E. Hospital IQR Program - Measure Set pp. 1177-1180
• Table IX.E-01 Five Attestation Domains p. 1187

View the FY 2023 IPPS Final Rule

New Health Literacy Videos
Check out our health literacy videos. We also created a playlist here.

• Bite-Sized Learning - CLAS Implementation

• Bite-Sized Learning - CLAS 101  

• Health Literacy with Dr. Iris Feinberg, PhD, CHES

• Bite-Sized Learning – Using Teach-Back

Violence Prevention

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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Emanuel Medical Center Boosts Local Economy
A recent report from the Georgia Hospital Association shows that Emanuel Medical Center in Swainsboro, Georgia, generated nearly $86 million for the local economy in 2021. The economic impact totaled almost $1 million more than the previous year. Read More

Children’s Hospital Staff Go 332 Days Without a CLABSI 
Collaborations between departments at a children’s hospital in Virginia led to just a single CLABSI in one year. Inova L.J. Murphy Children’s Hospital in Fairfax assembled an interdisciplinary team that included frontline nurses and technicians, physicians, OR/ED staff, and environmental services to hold regular harm prevention meetings to identify ways they could improve practices. The team focused on environmental cleaning practices, line access and maintenance, and auditing practices. These practices were observed by the infection preventionists at the hospital. Read More

Success Story

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Utah Critical Access Hospital Implements Plan to Reduce Readmissions

Blue Mountain Hospital, an 11-bed critical access hospital in Blanding, Utah, reviewed its data to establish improvement priorities as part of the HQIC program. Compliance Program Manager Cari Spillman, MBAHM, CHCO, CIC, (pictured right) chose to work on reducing readmissions because of the impact on patients and the surrounding community of Blanding. Several gaps in the current processes were identified, including an inefficient committee structure and the need for a designated discharge planner responsible for identifying discharge planning needs, assessing readmission risk, and planning follow-up.

During meetings with the Alliant HQIC partner, discharge planning and reporting requirements as well as quality improvement processes defined in the Conditions of Participation were reviewed. The first intervention focused on completely redesigning the hospital’s committee structure. Roles and reporting structures for each group were outlined, and the flow of information throughout the organization was clarified to promote effective performance improvement and readmission reduction. The diagram below demonstrates the finalized committee structure. 

After establishing the new structure, Blue Mountain implemented the following:

• 100% review of monthly readmissions utilizing an internal tool following guidelines from AHRQ. Hospital Guide to Reducing Medicaid Readmissions: Toolbox.
• Readmissions identified during weekly reviews are referred to the medical staff with enough detail so providers can discuss ways to prevent future readmissions for those patients.
• Follow-up calls to discharged patients. How To Conduct a Post-Discharge Follow-up Phone Call
• Expanded assessment of social determinants of health that impact readmission

Since Blue Mountain is a small critical access hospital, the cost of adding a discharge planning position required an evaluation of the return on investment. The quality improvement processes implemented by the compliance manager and reporting the findings to leadership resulted in the approval of the new position and its implementation in June 2023. 

As of February 2023 data, Blue Mountain has not yet reached their 42-month target goal of a 5% reduction over baseline; however, with the new committee structure and discharge planner position implemented in June, Cari and her team are confident that the rate will show an overall improvement and meet their goal by the end of 2023.

Salina Surgical Hospital Celebrates Successful Opioid Reduction Process

As part of the HQIC program, Salina Surgical Hospital (SSH), a 16-bed specialty/surgical hospital in Salina, Kansas, determined that opioid reduction would be a meaningful project since many total joint surgeries are performed at their facility. SSH aimed to improve opioid use during hospitalization and reduce narcotic use post-operation. They identified areas of improvement based on established best practices. After an internal assessment, SSH determined they were not within the best practice guidelines for pain management for total joint cases according to the CDC Prescribing Guidelines, Opioid Prescribing Engagement Networks-Prescribing Recommendations, and the Prescription Drug and Opioid Abuse Commission.  

The project’s goal was to revise routine pain management protocols for all total joint cases to align with best practices, including attempting to reduce overall usage at discharge for patients who had been on a preop narcotic. The evaluation revealed: 

• Nerve block (intra-operative) usage was 35%, which is below the goal of 75%
• Tylenol and NSAID (intra-operative) usage in the operating room was at 11%, below the goal of 75%
• Non-opioid pain medication use post-operatively (Tylenol, Ibuprofen, Toradol) fell below the recommended usage
• Discharge prescriptions for narcotics fell out of the best practice recommendations

Plan:
SSH evaluated best practices to ensure the safety of their patients while effectively managing their pain. During initial planning, SSH collected baseline data for current pain control modalities and medications for all total hip, knee and shoulder replacements. Data were collected from July 2021 through August 2021, and areas of improvement were identified. A physician champion assisted in developing a revised pain management protocol for all total joint cases, and the project team set percentage goals based on established guidelines. Additionally, a plan was developed to engage the ambulatory practice as well. 

Do:
The primary intervention was to adjust routine pain management protocols to reflect best practices. Those best practice protocols came from the tools and resources of the HQIC program. SSH worked with the physician champion to evaluate those best practices, identify changes and decrease the number of opioids patients. Those changes included: 

• Preoperative and intraoperative increases in the use of IV Tylenol/NSAID 
• Intraoperatively, using local anesthetic in the joint (Exparel, Lidocaine)
• Postoperative increase in the use of nerve blocks for total joint cases (adductor canal blocks, spinal block, pericapsular nerve group or PENG block)
• Continue preventative pain management modalities for inpatients, such as ice packs, chronic pain management, same-day physical therapy, etc.
• Routine inpatient use of postoperative NSAIDs
•  Routine inpatient use of postoperative oral Tylenol
• Routine inpatient PRN use of Oxycodone or Tramadol

Study
SSH tested implementation in a single provider practice first, and so data was collected only for the physician champion’s total joint cases with the new pain management protocol in place. The re-measurement period was from February 2022 through March 2022. Upon remeasurement, the following areas of improvement were noted: 

• Routine use of NSAIDS (Toradol/Ibuprofen)
• Routine use of Tylenol
• PRN Narcotic use decreased by 64% during a hospital stay
• Oxycodone used instead of Norco 7.5mg
• Only one Home Rx for Oxycodone 5mg #50 was given at dismissal

A formal letter with the findings and recommendations was sent to all orthopedic providers, including the hospital’s physician assistants (PAs). SSH’s nursing manager also visited orthopedic providers and PAs to initiate the new protocol in their practices. In addition, order sets were built into the electronic health record, and education was provided. The results showed significant improvement for those who used the new protocol in the amounts of opioids used for pain control during the patient’s hospital stay.

As of April 2023, SSH has seen an overall decrease in the number of opioids administered for these identified case types by 66%, consistent with the reduction observed with the individual physician champion’s results. SSH’s next steps include ongoing data collection to maintain current gains.