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

In This Issue: 

• The latest news from CMS
• 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
• Best Practices Corner
• Success Story

Health Equity Stakeholder Updates 

• CMS OMH Quarterly Stakeholder Call – During the CMS Quarterly National Stakeholder Call on April 25, CMS Administrator Chiquita Brooks-LaSure announced multiple health equity advancements. Among them were measures to strengthen the Medicare Advantage program and the increasing number of states that have extended Medicaid/CHIP coverage from 12 months post-partum to 12 months. CMS OMH Acting Deputy Director Pamela Gentry also detailed how OMH is guiding health equity efforts across CMS, the upcoming Health Equity Conference, and the importance of a proactive communication outreach strategy as the Medicaid unwinding continues.
• National Association of Community Health Centers (NACHC) Policy & Issues Forum – The NACHC Policy & Issues Forum, held March 8-11, brought together Community Health Center professionals and other leaders to discuss critical health care issues. CMS OMH hosted an exhibit booth at the conference to share health equity resources with attendees.
• Society for Public Health Education (SOPHE) Annual Conference – CMS OMH served as a gold sponsor and exhibitor at SOPHE’s Annual Conference from March 21-24. The theme of this year’s conference was “The New Age of Civil Rights, Advocacy & Equity.”
• Tribal Public Health Conference – The Tribal Public Health Conference was held on April 11-13 and highlighted the theme of “Restoring Health and Uniting Community.” CMS OMH participated as a virtual exhibitor for the conference, sharing helpful materials and links for attendees looking to learn more about tribal public health.
• National Rural Health Association (NRHA) Health Equity Conference – Held May 15-16, the NRHA Health Equity Conference focused on health equity issues in rural communities. In addition to CMS OMH hosting an exhibit booth at the conference, Acting Deputy Director Pamela Gentry and Technical Director Darci Graves presented a session on “Applying a Rural Lens at the Centers for Medicare & Medicaid Services Office of Minority Health.”
• American Hospital Association (AHA) Accelerating Public Health Conference – The AHA Accelerating Public Health Conference, held May 16-18, highlighted community health and investment; diversity, equity and inclusion; population health management; and more. CMS OMH Director Dr. LaShawn McIver is hosting a session on “CMS OMH’s Collective Approach to Accelerating Health Equity,” with OMH also hosting a booth at the conference’s exhibit hall.

Educational Events

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Quality Leader Summit: Focus on Sepsis, Health Equity 
Tuesday, June 6, 2023, at 1 p.m. ET 
At the Quality Leader Summit, we will discuss the following:

• 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. 
• Provide health equity strategies to meet The Joint Commission accreditation and CMS regulatory requirements for screening social determinants of health (SDOH). 
• Educational events and updated valuable resources, such as coaching packages, the HQIC website, and the portal.

Register Here

Upcoming Learning and Action Network (LAN) Events

Enhancing Capacity — Reengineering Fall and Fall Injury Programs
Tuesday, June 20 from 2-3 p.m. ET/1-2 p.m. CT 
This webinar is designed to increase national and international awareness of and importance of fall prevention and, specifically, to provide guidance and resources to clinical, administrative, quality and safety improvement professionals to add precision to the design, redesign and strategic plan.
Register Here

Patient and Family Advisory Councils
Tuesday, July 25 from 1-:1:30 ET
Hospitals have begun to reengage and refresh their Patient and Family Advisory Councils (PFACs) after the adverse impact that the COVID-19 pandemic had on their health care systems. As a result, some hospital PFACs are even better and stronger than ever before. Wills Memorial Hospital, a 25-bed critical access hospital (CAH) in Washington, Georgia, will present on the rebuilding and reenergizing of their PFAC, how the members identified and prioritized several key areas of concern, and projects based on greatest need were implemented.  
Objectives:

1. Explain the five Patient and Family Engagement (PFE) metrics and other key measures of the HQIC program
2. Discuss the Patient and Family Advisory Council infrastructure and the importance of listening to the patient’s voice to improve patient car
3. 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

Past Learning and Action Network (LAN) Event

Transitions in Care: Preventing Sepsis Readmissions
Recorded on April 27
This event featured proactive transitions in care and hand-off strategies to the next level of care provider to improve patient outcomes and prevent sepsis-related readmissions. The patient’s voice was highlighted via a sepsis survivor story. 
View the Presentation

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 Hospital Onset C. Difficile Through DiagnosticStewardship

Thursday, June 8
This session explores diagnostic stewardship opportunities to reduce Hospital Onset-CDI through the lens of the UVA Health experiences, including tools, outcomes and lessons learned. The speaker will review the importance of the culture set by institutional leadership to generate and sustain engagement, the integral role of nurses in testing decisions, the IT support needed to build a dashboard, track data and develop EMR changes, and a case review in partnership with the frontline staff and its importance in understanding current state and plan next steps. The work to mitigate HO-CDI is time intensive but important and effective.
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.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  

Hospitals Against Violence: A National Day of Awareness To End Violence
#HAVhope is a national day of awareness to highlight how America’s hospitals and health systems combat violence in  their workplaces and communities. Learn about the Safety from Violence for Healthcare Employees (SAVE) Act, which is proposed federal legislation to give health care workers the same legal protections against assault and intimidation that flight crews and airport workers have under federal law. Learn More

Workplace Violence 
TMIT Global presents their workplace violence training on Thursday, June 15, 2023, from 1-2:30 p.m. ET/12-1:30 p.m. CT. 
Register Here

Behavioral Health & Opioid Stewardship

Total Cost of Care Associated With Opioid Use Disorder Treatment 
The opioid epidemic in the United States disproportionately affects Medicaid beneficiaries than other groups. This results in a significant financial burden on state Medicaid programs. A study published in ScienceDirect investigated the association of medication for opioid use disorder (MOUD) treatment initiation and linkage to ongoing care on overall health care costs of Medicaid Fee-for-Service patients. Read the Study

Antibiotic Stewardship

Nurse Engagement in Antibiotic Stewardship Programs: A Scoping Review of the Literature
Hospital-based antibiotic stewardship programs (ASPs) are an important strategy in combating antibiotic resistance. Four antibiotic stewardship interventions are recommended by the CDC as particularly well-designed to engage nurses. However, there is limited information on whether and how existing hospital-based ASPs reflect these practices. Read More

NHSN

COVID-19 Hospital Data Reporting Changes Post Public Health Emergency 
Hospitals will continue to report COVID-19 hospitalization data to NHSN, however, after the public health emergency declaration ended on May 11, 2023, required data elements and reporting frequency may be reduced. NHSN will offer training in June. Register in advance. 
COVID-19 Hospital Data Post-Public Health Emergency – Guidance Updates and FAQs

• Thursday, June 1, 2023, from 3-4 p.m. ET - Register

 COVID-19 Hospital Data Post-Public Health Emergency – Guidance Updates and FAQs (Replay)

• Monday, June 5, 2023, from 3-4 p.m. ET (replay) - Register

COVID-19 Hospital Data Guidance Update – Office Hours Session

• Thursday, June 15, 2023, from 2-3 p.m. - Register

Patient Safety

Geriatrics on Beers Criteria Medications at Risk of Adverse Drug Events Using Real-World Data
The established Beers Criteria consider side effects and safety concerns when prescribing drugs to the elderly. As the criteria suggest that attention should be paid to prescriptions rather than prescription prohibition lists, these Beers Criteria medications (BCMs) are used appropriately under unavoidable circumstances. Read More

Increased Sentinel Events 
According to the Joint Commission, there were 1,441 sentinel events reported in 2022, a 19% increase compared to 2021 and a 78% increase from 2020. A majority (90%) of sentinel events reported in 2022 were voluntarily submitted by accredited health care organizations. The remaining 142 sentinel events were reported either by patients (or their families) or employees (current or former) of the organization. View Study Summary

Ask Me 3
How can your facility’s staff assist patients with health literacy to prevent readmissions, reduce ED utilization, improve adherence to treatment and medication plans and improve outcomes for chronic conditions?  Implement Ask Me 3 in your clinics.
Ask Me 3 is an educational program that encourages patients and families to ask three specific questions of their providers to better understand their health conditions and what they need to do to stay healthy.

1. What is my main problem?
2. What do I need to do?
3. Why is it important for me to do this?

Learn More
 

Readmissions/Care Transitions

The Hospital Guide to Reducing Medicaid Readmissions 
Reducing readmissions is a national priority for payers, providers and policymakers seeking to improve health care and lower costs. Readmissions are a significant issue among patients with Medicaid. The Agency for Healthcare Research and Quality (AHRQ) commissioned a guide to identify ways evidence-based strategies to reduce readmissions can be adapted or expanded to better address the transitional care needs of the adult Medicaid population. The guide offers new tools that can be used in the day-to-day working environment of hospital-based teams and cross-setting partnerships. View Guide 

Health Equity

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

Best Practices Corner

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Tift Regional Offers Emergency Room Alternatives
Like most hospitals around the state and country, Tift Regional Medical Center in Tifton, Georgia, is facing high volumes in the emergency room that can sometimes result in extended wait times. According to Dr. Eric Paulk, medical director of Emergency Medicine at TRMC, nearly half of the patients in the ER are seeking treatment for minor injuries or illnesses that could be addressed in the primary care or convenient care setting. Southwell, the parent organization of TRMC, offers convenient care clinics in Tifton and Adel with evening and weekend hours. Read Article
 

Success Story

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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.  

Elbert Memorial Hospital Reduces Hospital-Acquired Infections 

Elbert Memorial Hospital, a 25-bed critical access hospital in Elberton, Georgia, set out to reduce healthcare-acquired infections (HAIs) with a goal of 0 infections after an increase in early 2022. The team realized that just one patient contracting an HAI could be detrimental to the whole patient population. It focused on proper handwashing and teaching universal standards to all who encountered patients and their environment. The team followed the Plan-Do-Study-Act model for improvement to reach their goal.

Plan

• The implementation of reduction protocols was driven by the nurses caring for patients.
• Include all employees with a heightened focus on direct patient care, such as the nursing staff, including registered nurses, licensed practical nurses, certified nursing assistants, and providers.
• The nursing leadership team keeps the project at the forefront by sharing hand hygiene compliance results in shift huddles and team meetings with the frontline staff and the quality, medical staff and pharmacy and therapeutics committee.

Do

• Include staff involvement and training, data collection and education tools.
• Education included the importance of proper perineal hygiene, hand hygiene, the correct procedure for specimen collection and training on appropriate catheter use.
• Provide education through employee newsletters, departmental huddles and leadership meetings.
• Infection control nurse rounded to ensure compliance and to provide further education.

Study

• The team used data, tables and charts to explain data collection, measurement and analysis.
• Data was tracked on the Infection Control section of the Quality Dashboard.
• Three opportunities for improvements were noted:
  • Communication with the provider needed improvement. To ensure communication was relayed to the provider, the infection control nurse received all culture results and was responsible for notifying the provider.
  • The collection timeframe was initially identified as a barrier that needed improvement. Nurses were educated on the importance of the early collection and how this would benefit the patient and facility. Early identification would reduce any delay in treatment.
  • Clinical staff were provided education, reminding them of the importance of timely specimen collection. To reduce oversight, the admission order set was updated to include a urinalysis.

Act

• Infection control is the point of contact for follow-up of culture reports.
• The admission order set was changed to include a urinalysis.
• The standard process for obtaining urine culture was added to clinical orientation and ongoing education.
• Work has begun on a sepsis campaign to include risk reduction through continual reassessment and flowchart alerts.
• MDRO infections are tracked and reported at the quality council meetings and through NHSN.
• The medical executive committee and the board receive quarterly updates on progress and trends.

In the graph below, there is demonstrated improvement from Sep 2021–Jul 2022.

As a result of the dedication and hard work of the team, Elbert Memorial Hospital was awarded second place in the Patient Safety and Quality Awards in the critical access hospital category at the Georgia Hospital Association Summit in January 2023.