The July 2024 issue of the Hospital Quality Improvement Newsletter features the latest insights and resources.
- CMS News
- Upcoming Educational Events
- Expert Insights and Resources on:
- Behavioral Health and Opioid Stewardship
- Antibiotic Stewardship
- Adverse Drug Events
- Infection Prevention
- Sepsis
- Readmissions/Care Transitions
- Patient Safety
- Patient and Family Engagement
- Health Equity
- Well-Being
- Best Practices Corner
- Success Story
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Presentations and video recordings of the 2024 CMS Quality Conference are now accessible with closed captions under the Past Conferences tab. View Presentations and Recordings
Download the Hospital Value-Based Purchasing Program Quick Reference Guide
Download the FY2026 Hospital Value-Based Purchasing Program Quick Reference Guide (updated August 2023). Note the performance periods in 2024. Download Here
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Implementing Patient and Family Engagement in Rural and Critical Access Hospitals: Finding Solutions and Strategies
This educational event will review the significance of each PFE best practice as well as discuss common challenges to implementation in the rural environment. Together, we will discuss implementation strategies that work in smaller hospitals. Join us!
Past Learning and Action Network (LAN) Events
Commitment to Transparency: Redesign of Daily Safety Huddles Using HRO Principles
*CE for Physicians and Nurses Available*
Recorded on June 25, 2024
Learn how a hospital system applied high reliability organization (HRO) principles to improve its daily leadership huddles and reporting of safety events to identify opportunities in real time. After renewing its focus on leadership engagement in patient safety, the Tier 2 Safety Huddle (T2SH) project was initiated with goals to encourage open and transparent reporting of events, drive high reliable performance, proactively identify and mitigate risk, and aggressively pursue zero harm. A core team of quality, safety, and risk management department members designed and implemented this process and have made enhancements such as adding “Mindful Considerations” and department-based Governance Councils within the past year.
If Yes, Click Below.
Click here if you attended an HQIC LAN event and were able to "use tomorrow" what you heard during the webinar.
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.
From High Reliability Organizations (HRO) to Resiliency Engineering-The Future of Patient Safety
Thursday, July 11
Patient safety remains at the forefront of our minds. Our challenge as health care leaders is to support our teams, particularly front-line staff, in making good patient safety choices by creating systems that prevent errors and encourage early identification and harm reporting. This presentation by Dr. Oren Guttman, Vice President, High Reliability & Patient Safety, Jefferson Health, will build knowledge to strengthen the skills and confidence of hospital staff to sustain ongoing patient safety work by deploying resiliency tactics.
Register Here
Active Shooter: Is Your Hospital Prepared?
Thursday, August 8, 2024
Being prepared and protecting patients and workforce is a priority for health care organizations. Learn how CHI St. Vincent Medical Center-North’s shared experience of preparing for a potential active shooter event, the results of that preparation, and lessons learned helped Baxter Health reassess and enhance response protocols to ensure their capability and readiness for workplace violence events.
Register Here
Looking for resources on Workplace Violence Prevention? View Alliant HQIC’s coaching package here.
Check out other COP Call topics, such as Sepsis Mortality reduction, CAUTI, and Social Determinants of Health, on the Alliant HQIC website under Education on Demand.
Alliant's Health Equity Action Office Hours are monthly networking events hosted by Rosa Abraha, Alliant Health Solutions health equity lead, and LeAnn Pritchett, system director of quality and safety at Tift Regional Medical Center-Southwell.
These office hours are participant-driven and without slide presentations. Discussions will focus on health equity action planning and other questions from the hospitals, such as CEO engagement. The office hours will be held on the third Thursday of the month from 3-4 p.m. ET. The next session is Thursday, July 18.
View past sessions:
- Jan. 16, 2024 - View slides and recording
- Feb. 15, 2024 - View slides and recording
- March 21, 2024 - View slides and recording
- April 18, 2024 - View slides and recording
- May 16, 2024 - View slides and recording
- June 20, 2024 - View Slides and recording
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: View past sessions
- Jan. 24, 2024 – View slides
- April 24, 2024 – View slides
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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
Federal Study Examines Care Following Nonfatal Overdose Among Medicare Beneficiaries
Researchers from the Substance Abuse and Mental Health Services Administration (SAMHSA), the National Institutes of Health’s (NIH) National Institute on Drug Abuse (NIDA), Centers for Medicare & Medicaid Services (CMS), and the Centers for Disease Control and Prevention (CDC) found that among a cohort of 137,000 Medicare beneficiaries who experienced a nonfatal overdose in 2020, almost 24,000 (17.4%) experienced a subsequent nonfatal overdose, and about 1,300 (1%) died from overdose in the following year. Results were published today in JAMA Internal Medicine, identifying both effective interventions and significant gaps in care. Read More
Antibiotic Stewardship
Study: Antibiotics Not Associated with Shorter Duration or Reduced Severity of Acute Lower Respiratory Tract Infection
Antibiotic use remains common for the treatment of lower respiratory tract infections. The objective a study published by Springer Link was to evaluate the impact of antibiotic use on the duration and severity of acute lower respiratory tract infection. Read Study
Adverse Drug Events
Review: Incidence of Drug-Related Adverse Events Related to the Use of High-Alert Drugs
High-risk medications are classified as such due to their narrow therapeutic range and potential for serious adverse drug events (ADE). A review published in ScienceDirect analyzes the results of randomized clinical trials to identify effective interventions to reduce ADE related to high-risk medications in hospitals. The most cited medications were warfarin, cyclophosphamide, and cyclosporine. The most common intervention was developing protocols for safe use. Read Review
Infection Prevention
Utilizing Gap Analysis to Improve Health Care
A gap analysis is a tool used to assess the difference between actual practice and expected performance. It is useful to compare best practice guidelines against your currently accepted practices. It is important to assess practice through observation and audit rather than relying on whether a policy is in place, as practice can vary from policy. Check out gap assessment tools for CAUTI and CLABSI and many more resources under Infection Prevention on the Alliant HQIC website.
Implementing Four-Eyes Skin Assessment to Prevent Skin Breakdown
At the University of Missouri Health Care, staff on the pulmonary and general medicine unit identify risks for skin breakdown by performing a “four-eyes skin assessment,” in which two unit nurses examine the entire skin of every individual. The process requires looking at and touching the skin from head-to-toe, with a particular emphasis over bony areas of the body. Read Article | View Four Eyes Skin Assessment
Sepsis
Improving Sepsis Recognition and Management in Hospitals: Key Strategies and Case Study Insights
Want to learn more about the Hospital Sepsis Program Core Elements? Click on Implement Effective Sepsis Recognition and Management in Hospitals. Share this video from the American Medical Association (AMA) about tracking and managing sepsis data with hospital teams. In one example, the sepsis leaders at Henry Ford Jackson Hospital used nurse-driven protocols for early management, recruited pharmacy to assist in stocking common antibiotics for quick access, and implemented flow diagrams for better workflow.
Study: Nurses’ and Physicians’ Experiences After Implementation of a Quality Improvement Project to Improve Sepsis Awareness in Hospitals
A study published in the Journal of Multidisciplinary Healthcare reveals the experiences of nurses and physicians after implementing a QI project to improve sepsis awareness in hospitals. The sepsis intervention showed success in improving awareness of sepsis and improving collaboration between nurses and physicians. Health professionals still relied on their clinical judgment but started using objective measurements and communicating vital signs more frequently. Continuous repetition and education for new colleagues were crucial for sustaining the intervention. Overall, the study highlights the importance of standardized protocols and training for early detection and management of sepsis in health care settings. Read Study
Behavioral Health Comorbidities Linked with Higher Hospital Readmission Rates
Research recently released by the Massachusetts Center for Health Information and Analysis (CHIA) suggests hospitalized patients with a behavioral health comorbidity are at an increased risk for readmission. Learn More
Patient Safety
Focus on HARM: NQF’s New Patient Safety Initiative
The National Quality Forum (NQF), an affiliate of The Joint Commission, recently launched a “Focus on HARM” patient safety initiative to address the high rates of avoidable medical errors and preventable patient harms that continue despite decades of efforts to remediate these events. The Focus on HARM (Harmonizing Accountability in Reporting and Monitoring) initiative will begin by re-examining the most egregious events, often referred to as “never events” because they should never occur in health care. Read More.
Patient and Family Engagement
Rural Hospital Patient and Family Engagement Toolkit
This toolkit provides key strategies to improve upon efforts to address the domains in which hospitals struggle the most, including leadership commitment, data collection, evaluation, and language services. Download Toolkit
Training: How to Establish and Sustain Effective Patient and Family Advisory Councils
Wednesday, July 24, from Noon-1 pm ET
To establish or sustain productive Patient and Family Advisory Councils (PFACs), structure and processes are needed. This discussion will focus on practice-based strategies that support PFACs and ensure that the work of PFACs is meaningful and leads to improvement and change. Register Here
Health Equity
Stay Abreast of Z-Code Updates
New SDOH Z codes may become effective each April 1 and October 1. The new codes are announced prior to their effective date on the CDC website. Use the CDC National Center for Health Statistics ICD-10-CM browser tool to search for the current Z codes. Learn More
National Healthcare Quality and Disparities Report: Chartbook on Patient Safety
The Patient Safety Chartbook is part of a family of documents and tools that support the National Healthcare Quality and Disparities Report (NHQDR). The NHQDR is an annual report to Congress mandated in the Healthcare Research and Quality Act of 1999 (P.L. 106-129). The NHQDR provides a comprehensive overview of the quality of health care received by the general U.S. population and disparities in care experienced by different racial and socioeconomic groups. The purpose of the reports is to assess the performance of our healthcare system and to identify areas of strength and weakness in the healthcare system along three main axes: the portrait of American healthcare, special emphasis topics, and quality and disparities tables.
The reports are based on more than 700 measures of quality and disparities covering a broad array of healthcare services and settings. Data generally cover 2000 through 2023. The reports are produced with the help of a federal interagency work group led by the Agency for Healthcare Research and Quality (AHRQ) and submitted on behalf of the Secretary of the U.S. Department of Health and Human Services (HHS). Learn More
NIOSH Releases Impact Wellbeing Guide To Improve Health Care Worker Well-Being
Well-being refers to the state in which individuals perceive their lives as going well, including aspects of their physical, emotional, and psychological health, and productivity. The CDC has launched a campaign to address health care worker burnout. As part of this initiative, the federal government has released the Impact Wellbeing™ Guide: Taking Action to Improve Healthcare Worker Wellbeing. This guide is an evidence-informed and actionable resource for hospital leaders to improve the well-being of healthcare workers. NIOSH's Impact Wellbeing Guide offers a step-by-step systems approach to improving well-being and building trust between leaders and healthcare workers. Learn More
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AdventHealth Murray (Chatsworth, Georgia) and AdventHealth Gordon (Calhoun, Georgia) are recognizing their team members for their years of service to AdventHealth. Team members are honored at five-year increments. Read Article
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Long-term goals include: 1) Develop an engaging community program for African-American patients with A1c 7 or greater, incorporating quarterly health checks, nutrition and fitness education, virtual peer-group sessions, and incentives.
Action Steps Underway:
- Staff education on diabetes care and resources added to the nurse residency program and patient care technician training curriculum
- Community Connection events with partner churches and community centers
- Assistance provided for establishing PCP relationships for elevated stats
- Year-over-year change for two sites visited in Q1 of both years: 182 (2023); 124 (2024)
- Social Determinants of Health (SDOH) pilot in PCP office
- Promotion of The Center for Wellbeing’s Pre-Diabetes Classes
- Abridged Diabetes Education Booklet, available with QR code
- Heat map of AICs for focused community engagement+
- Adding diabetes information to patient TV channel
- Extend staff education on diabetes care and resources to our virtual care nursing partners
- Consideration for a virtual platform for diabetes classes
- Improved partnership with food bank for vouchers (e.g., diabetes meal boxes in key locations)
- Additional team members from the primary care staff
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For questions or information about free technical assistance, please contact:
Donna Cohen, Director, Quality Projects
Karen Holtz, Training and Education Lead, Hospital Quality
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This material was prepared by Alliant Health Solutions, a Quality Innovation Network-Quality Improvement Organization (QIN – QIO) under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. Publication Number:12SOW-AHS-QIN-QIO TO3-HQIC--5996-07/10/24