The June 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
- NHSN
- Sepsis
- Readmissions/Care Transitions
- Patient Safety
- Patient and Family Engagement
- Health Equity
- Well-Being
- Best Practices Corner
- Success Story
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The COVID-19 pandemic impacted rural hospitals more significantly than those in urban settings, according to two studies using data from AHRQ’s Healthcare Cost and Utilization Project (HCUP). One study published in Health Affairs revealed that 35% of rural hospitals experienced more than 20% increases or decreases in the daily patient volume during the pandemic, compared with just 13% of urban hospitals. Rural hospitals that were most impacted were likely to be small-sized, or owned by state or local governments, or classified as critical access hospitals. The other study published in JAMA Network Open found that the odds of in-hospital mortality for sepsis increased by 35% at rural hospitals during the pandemic, compared with an increase of 27% at urban hospitals. The authors of both studies suggested that tailoring responses to the unique needs of rural hospitals could reduce the uneven impact of future health crises.
Recap of National Stakeholder Call with CMS Administrator
The National Stakeholder Call with the CMS Administrator was held on April 30. The call featured CMS Administrator Chiquita Brooks-LaSure and her leadership team, who provided an update on CMS’ recent accomplishments and how our cross-cutting initiatives are advancing the CMS' Strategic Plan. The call also provided a more in-depth look at our recent policy announcements and an opportunity to learn how you can partner with us to help implement our Strategic Plan and key initiatives. View Call Recording and Transcript
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HQIC Reliability and Resilience Learning Action Series
Session 2: Stories From the Field: Hospital Case Studies of Reliability and Resilience in Action
The HQIC Reliability and Resilience Learning Action Series aims to educate and engage hospital leaders on the concepts and practices of resilience and high reliability in health care. This event has been created in collaboration with other HQICs and all hospitals are invited to attend.
Register Here | View Recording from April 16 Session
Commitment to Transparency: Redesign of Daily Safety Huddles Using HRO Principles
*CE for Physicians and Nurses Available*
Tuesday, June 25, 2024, at 1 p.m. ET
Join this live educational event to 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.
Register Here | View Agenda
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.
Infection Prevention and Sepsis Recognition in Home Care
Thursday, June 13
This session will review strategies for preventing infections that can lead to sepsis while receiving post-acute care in the home setting, whether from home health or families and caregivers. Patient, family, and staff education tools and resources will be shared to help support safe home care.
Register Here
Enhancing Capacity: Reengineering Fall and Fall Injury Programs: Infrastructure, Capacity and Sustainability
Recorded on May 9
This session featured national subject-matter expert and nurse consultant Pat Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP, who discussed essential elements and guidelines for fall and injury prevention programs to enhance infrastructure, capacity and sustainability. Samaritan North Lincoln Hospital, a 25-bed critical access hospital in Oregon, highlighted what they learned from Pat Quigley to redesign their falls program by organizing a team, conducting a gap analysis, developing a bundle and implementing risk-based interventions. 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.
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, June 20.
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
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
Rapid Initiation of Injection Naltrexone for Opioid Use Disorder
In a randomized clinical trial that included 415 individuals with opioid use disorder (OUD), more patients successfully initiated XR-naltrexone using the rapid procedure (62.7%) compared with a standard (12-14 days) procedure (35.8%). The rapid procedure was shown to be both noninferior and superior, but had a higher number of safety events and serious adverse events and required more staff attention. The findings of this trial suggest that a rapid approach to withdrawal management should be considered for patients with OUD attempting to start treatment with XR-naltrexone, but more intensive staffing needs may be a barrier to implementation. Read More
Antibiotic Stewardship
Active Surveillance Culturing of Clostridiodes difficile and Multidrug-Resistant Organisms: Methicillin-Resistant Staphylococcus aureus, Carbapenem-Resistant Enterobacterales, and Candida auris
Active surveillance culturing of asymptomatic individuals is a well-established and widely used patient safety practice in hospitals. However, questions remain about the cost and effectiveness of specific surveillance strategies in reducing clinical infection and transmission events. Two studies of high-risk patients (for Clostridioides difficile and carbapenem-resistant Enterobacterales) found that active surveillance culturing limited to high-risk patient populations could significantly reduce infections. However, these studies compared targeted screening to no screening. Read Study
Adverse Drug Events
Application of Trigger Tools for Detecting Adverse Drug Events in Older People: A Systematic Review and Meta-Analysis
Adverse drug events (ADE) are common in older adults. A systematic review published ScinceDirect identified 12 trigger tools for detecting ADE in older adults. Trigger tools designed or adapted for the older adult population performed better than those designed for the general population. Most studies assessed performance using positive predictive value (PPV), but there was no consensus of what constitutes a good or poor PPV. Read Study
Infection Prevention
On-Demand Pioneers in Quality Webinar: New and Revised Requirements for the Infection Prevention and Control Chapter for Critical Access Hospitals and Hospitals
Effective July 1, 2024, The Joint Commission approved new and revised requirements for the “Infection Prevention and Control” (IC) chapter for critical access hospitals and hospitals. The IC chapter has been fully rewritten and replaces the current IC chapter for both accreditation programs. The revised chapter focuses on the structures that support quality and safety. In addition, a reference guide showing where concepts from the old EPs have moved into the new EPs has been created.
This on-demand webinar will present the new and revised requirements for the IC chapter for critical access hospitals and hospitals. It will offer examples of how the requirements apply and highlight resources available to assist organizations in meeting them.
This webinar is approved for one continuing education credit. CE/CEU Credits are available for six weeks (May- June 18). Register Here
NHSN
Hospitals No Longer Required to Report COVID-19 Data to CDC's NHSN Starting May 1, 2024
Effective May 1, 2024, hospitals are no longer required to report COVID-19 hospital admissions, hospital capacity, or hospital occupancy data to HHS through CDC’s National Healthcare Safety Network (NHSN). CDC encourages ongoing, voluntary reporting of hospitalization data. Data voluntarily reported to NHSN after May 1, 2024, will be available starting May 10, 2024, at COVID Data Tracker Hospitalizations.
Continuing Our Work on Improving Sepsis Outcomes
Sepsis is under-recognized and progresses quickly. Rapid identification and treatment of sepsis are critical to patient outcomes.
Improvement strategies include:
- Screening and early recognition
- Partner with your local EMS system through the use of a sepsis screening tool.
- Know signs and symptoms: NEWS, MEWS, SIRS
- Activate alerts in the EHR
- Act quickly with “code sepsis.”
- Teams in place ready to do their part.
- Bundles/order sets
- Assess for signs of sepsis each shift. Staff awareness and recognition of clinical deterioration:
- Deterioration begins with subtle changes in physiological parameters with critical event following four to six hours. Staff’s ability to perceive subtle changes as cues is essential.
- Did you know? Acute postsurgical nurses may have a decreased tendency to classify patient cues as indicators of clinical deterioration. Nurses reported workload, fatigue, and time constraints as barriers hindering increased patient surveillance, such as frequent vital sign monitoring for multiple patients and managing post-operative pain.
- Transparency: Share your data with staff as close to real time as possible and regularly. What is falling out and why? Talk to those doing the work.
- All staff initial and annual education tailored to the audience. Build staff awareness through basic information about sepsis and sepsis awareness.
- Community education
- Use the CDC education resources for videos, press releases, social media messages, infographics, articles and more!
- Partner with your marketing department to place information on your facility's social media websites such as YouTube: 4 ways to get ahead of sepsis (1.58 minutes)
Study: Interoperable Prescription Systems Enhance Patient Safety and Efficiency
According to a study published by BMJ Journals, an interoperable prescription information system could provide major benefits for patient safety. Likely benefits include health care professional time saved, improved patient experience and care quality, quicker discharge and enhanced cross-organizational medicines optimization. The study findings provide vital safety and economic evidence for the case to adopt interoperable prescription information systems. Read Study
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
Patient and Family Advisory Councils (PFAC) Evaluation and Reporting
Visit the Institute for Patient- And Family-Centered Care website for examples of annual reports for PFACs. View Example PFAC Reports
Empowering Patient and Family Engagement: Essential for Quality and Safety in Health Care
Establishing a partnership with patients and families is imperative to improve patient quality and safety. Watch these short, 30-minute presentations to assist your facility in improving your patient and family engagement (PFE).
- Episode 5: Engaging Patients and Family to Prepare for Hospital Discharge
- Demonstrate methods of assessing patient social needs prior to discharge
- Summarize the concept of discharge planning beginning at admission
- Review how to use checklists to prepare patients for discharge
- Refer to care coordination quickinars for more information on health literacy
- Episode 6: Role of Patient and Family Engagement in Readmission Prevention
- Show the relationship of PFE to Value-Based Purchasing
- Discuss how social drivers impact the patient's likelihood of being readmitted
- Give examples of ways to prepare patients for self-care outside the hospital
- Define Teach-Back
- Episode 7: How Bedside Hand Off Can Improve Patient Outcomes
- Describe how to engage staff in bedside handoff
- Identify the types of nursing units successful with bedside shift report\\
- Discuss multiple rounding processes in the bedside report
- Identify opportunities to engage the patient and care partner in a shift report
How to Submit Hospital Commitment to Health Equity (HCHE) and Social Drivers of Health (SDOH) Data
Check out this quick tutorial on how to submit for the Hospital Commitment to Health Equity and Social Drivers of Health measures. Watch Video
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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In an interview, Ravinder Singh, senior vice president of consulting at Citius Tech, discusses how AI is reshaping infection prevention in hospitals, driving efficiencies, and safeguarding patients and the community. Mr. Singh also discusses how leveraging AI enables advancing standard and generic infection control methods to a risk-based model and create a targeted control plan. For example, understanding patterns of post-operative infections vs. central line infections or ventilator-associated pneumonia can help drive prevention plans at the procedure level or even be personalized to a patient’s treatment journey. Read Article
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Pullman Regional uses a Just Culture Screening Tool to assist in determining human error, at-risk choice and reckless choice. When a staff member makes a mistake, the team focuses on learning and not blaming individuals. As a result, non-punitive response to errors has increased from 50% in 2011 to 79% in 2022.
- Developed a high reliability team
- Melded vision of Collaborative High Reliability Program and integrated it with DNV’s International Organization for Standardization (ISO) standards and certification
- Received Board of Commissioner approval in 2021 through the Quality Management System Committee for establishment of a Collaborative High Reliability Program
- Hired a Chief Reliability Officer in 2022
- DNV Beta Survey in February 2022 for Collaborative High Reliability/Reliability Management Team (RMT)
- Alignment of policies to integrate across the organization, i.e., HR policies and Employee Handbook, Code of Conduct, Compliance, Quality Management, Risk/Safety plans, Performance Improvement, and Labor Union contracts (invited to participate)
- Wording, definitions, and concepts have to be the same throughout
- Confidential risk reporting available to all employees
As a result of the organizational commitment, qualification certificates for the collaborative just culture program and reliability management team were awarded January 2023. Pullman Regional Hospital is the first Critical Access Hospital to receive this DNV qualification.
To learn more about high reliability in health care, see the slides and recording from 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 Event
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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--5696-05/01/24