The February 2024 issue of the Hospital Quality Improvement Newsletter features the latest insights and resources.
- Patient Safety Awareness Week
- Upcoming Educational Events
- Past Educational Events
- Expert Insights and Resources on:
- Behavioral Health and Opioid Stewardship
- Antibiotic Stewardship
- Adverse Drug Events
- Infection Prevention
- Sepsis
- NHSN Training
- Readmissions/Care Transitions
- Health Equity
- Patient and Family Engagement
- High Reliability Organization
- Electronic Health Records and Cybersecurity
- Best Practices Corner
- Success Story
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Alliant HQIC recognizes the importance of patient safety for improved quality outcomes and overall patient care. Patient Safety Awareness Week (PSAW) will be celebrated March 10-16, 2024. This year’s theme is Safer Together, emphasizing the importance of safety among the entire team, from the care providers to support staff to patients and families. Check out the free webinar and resources at the Institute for Healthcare Improvement (IHI) website and download the PSAW toolkit from the Center for Patient Safety. Learn more about how to improve patient safety by attending one of the educational events listed below.
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Join this live event to learn how the Alliant Hospital Quality Improvement Contractor (HQIC) program has improved patient safety for our 145 enrolled hospitals to date. This event will focus on our HQIC performance outcomes from the 42-month evaluation as well as overall accomplishments. In addition, Optim Health (GA) will share how they use the Professional Wheel of Life, a tool that helps you visualize important areas for professional life balance. The Wheel of Life tool will be provided upon registration to complete.
Register Here | View Agenda
Upcoming Learning and Action Network (LAN) Events
Workplace Violence Prevention: Uncovering Unconscious Bias for Safer Health Care Interactions
Join us for an insightful event focused on understanding and mitigating unconscious bias for respectful, inclusive, and, thereby, safer health care interactions. This session will explore the impact of unconscious bias on workplace interactions. Through engaging discussions and real-world scenarios, participants will gain insights to help identify, address, and counter unconscious bias. We’ll discuss how promoting a culture of respect and empathy within health care settings fosters a safer and more inclusive environment for health care providers and patients.
Register Here
Past Learning and Action Network (LAN) Events
Preventing and Reducing Workplace Violence
Recorded on February 8
CMS hosted this session with the American Hospital Association’s Hospitals Against Violence initiative to provide insights on addressing violence in health care communities and workplaces. The session reviewed the current state of workplace violence and showcased AHA’s tools for hospitals. Evangelical Community Hospital in Pennsylvania also presented its “Safe to Care” program, which included staff training, policy revision, investment in equipment, and community outreach.
View Slides
Workplace Violence Prevention: Best Practices for Safer Care
Recorded on January 23
This educational event discussed the prevalent types of workplace violence in health care and best practices to address The Joint Commission accreditation standards of Environment of Care, Human Resources, and Leadership. In addition, the speaker also reviewed key components of a workplace violence prevention program and its impact on workplace safety.
View Slides | View Recording
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.
Ready Set Go! Bridging the Gaps to Revolutionize Care Transitions
Thursday, March 14
This session, Convergence will share a new tool to help hospitals achieve a smooth, no-surprises discharge. Ready Set Go! was co-designed by hospital staff and patient family partners to address and connect the critical processes that take place between admission planning, bedside rounding and discharge planning to reduce hospital readmissions. This resource includes key insights into these three processes, plus five embedded tools to enhance current hospital processes.
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.
View past sessions:
- Dec. 21, 2023 - View slides, recording and strategic planning
- Jan. 16, 2024 - View slides and recording
- Feb. 15, 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
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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
Opioid Use in Older Adults Compendium of Resources
While there have been extensive efforts to address the opioid epidemic, little attention has been given to the risks and effects of opioid use, misuse and opioid use disorder (OUD) in older adults. Resources and tools for managing opioid use, misuse, and OUD cannot be one-size-fits-all; rather, their effectiveness depends on how well they address the specific concerns and conditions of patients and how clinicians apply those tools and resources. A change package, known as the Compendium, supports efforts by primary care practices and health care systems to improve opioid medication management and prevent opioid misuse and OUD in older adults in primary care. View Change Package
Antibiotic Stewardship
Enroll Now for Program on Improving Antibiotic Use in Telemedicine
The Agency for Healthcare Research and Quality (AHRQ) Safety Program for Telemedicine: Improving Antibiotic Use is recruiting primary and urgent care practices and retail clinics that use telemedicine for a no-cost, 18-month national program to strengthen antibiotic prescribing practices. The program will begin in June and provide expert coaching to promote sustainable improvements and improved patient satisfaction through actionable, evidence-based guidance. Participants may receive continuing education credits, continuing medical education credits and American Board of Internal Medicine Maintenance of Certification points through live and/or self-paced materials. Access the program portal to enroll or register for one of several brief informational webinars. Read More
Adverse Drug Events
A Systemic Review: Risk of Bleeding With Concomitant Use of Oral Anticoagulants and Aspirin
Patients are at higher risk of excessive bleeding when taking both blood thinners and aspirin together, according to an AHRQ-funded study published in American Journal of Health-System Pharmacy. Researchers reviewed 42 published studies and found that patients who took both oral anticoagulant medications (which are blood thinners such as warfarin) and aspirin had a higher chance of bleeding compared with those only taking blood thinners. Warfarin is prescribed for stroke prevention in atrial fibrillation.l/and for treatment and secondary prevention of venous thromboembolism, while aspirin may still be used to prevent primary cardiovascular events among high-risk patients. Read More
Infection Prevention
Joint Commission Eliminates 70% of Performance Elements for Infection Control Accreditation
The Joint Commission added new and revised standing requirements for accreditation of critical access hospitals and hospitals for infection control procedures. In addition, The Joint Commission also removed 70% of the elements of accreditation so hospitals can focus on the elements that strengthen other protocols and procedures related to infection control.
Waste reduction and responding to an influx of infectious patients were removed in the revisions since other emergency management techniques cover these. These changes will take effect July 1. The latest revisions to accreditation requirements by The Joint Commission are part of an ongoing effort from the organization to help hospitals focus more on strengthening essential policies and practices. Learn More
Sepsis Core Elements: CDC Webinar Series
During each one-hour webinar, CDC subject matter experts provide an overview of the Hospital Sepsis Program Core Elements followed by an in-depth focus on a specific sepsis core element(s). Watch Here
NHSN Office Hours
Reporting to the National Healthcare Safety Network (NHSN) Antimicrobial Use and Resistance (AUR) Module is now required under the Public Health and Clinical Data Exchange objective of the CMS Promoting Interoperability Program. Eligible hospitals and critical access hospitals are required to be in active engagement with the CDC to report both AU and AR data. To support NHSN facilities with this new requirement, the NHSN team will host Office Hours sessions. These sessions will start with a brief presentation, and the remainder of the hour will be used for Q&A with attendees.
The next Office Hours will take place on:
- Thursday, March 7, 3-4 p.m. ET
- Register Here
For more information and additional resources, view the materials in the Antimicrobial Use and Resistance section of the CMS Reporting Requirements for Acute Care Hospitals page.
NHSN Annual Training
Registration is now open for the 2024 Virtual NHSN Training. Live sessions will be held March 18-22, 2024. Early registration will allow you to access pre-recorded videos as well as download materials for the live session to prepare. Register Here
Topics include surveillance definitions and analysis for:
- Antimicrobial Use and Resistance
- Device-associated events
- New Digital Quality Measures (dQM)
- MRSA Bacteremia and C. difficile LabID events
- Outpatient Procedures
- Surgical Site Infection events
Study: Geriatric Distal Femur Fractures Treated With Distal Femoral Replacement Are Associated With Higher Rates of Readmissions and Complications
According to a study published in PubMed, Elderly patients with distal femur fracture have a 22.5% one-year mortality rate. Distal femur replacement (DFR was associated with significantly greater infection, device-related complication, pulmonary embolism, deep vein thrombosis, cost, and readmission within 90 days, six months, and one year of surgery. View Study
Health Equity
How Workflow Factors Sway Social Determinants of Health Screening Rates
Researchers found links between provider type, survey length, payer type and social determinants of health screening rates. Read Article
Patient Visitation Rights
The Department of Health and Human Services’ Office for Civil Rights has released guidance reminding hospitals, critical access hospitals and long-term care facilities of their obligation under Centers for Medicare & Medicaid Services regulations to ensure that their visitation policies do not unlawfully discriminate based on religion or other protected bases under federal civil rights laws, including during a public health emergency. View FAQs
Learn About High-Reliability Organizations in Health Care
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. Download HRO Coaching Package
Electronic Health Records and Cybersecurity
Podcast: Maintaining and Optimizing EHRs
A HealthcareIT News article and podcast discuss the importance of maintaining and optimizing Electronic Health Records (EHRs) in health care organizations. Peyman Zand, chief strategy officer at CereCore and former provider CIO, offers insights on when to optimize EHRs, where to start, and who should be involved. EHRs are essential to health care IT but require ongoing attention. Zand provides expert advice on strategies for optimizing and maintaining these critical systems. Read Article
How HHS Cybersecurity Performance Goals Will Impact Health Care
Recently, the Department of Health and Human Services (HHS) unveiled health care-specific cybersecurity performance goals (CPGs) with the intent of helping the industry prioritize the implementation of key security best practices. While the goals themselves may not be revelatory, their existence in this format, their voluntary nature, and how they fit into HHS’ overall health care and public health (HPH) sector security strategy are a significant step forward for the industry and are a sign of what’s to come, particularly in light of increasing ransomware and cyber-threats in health care. Read Article
Health Technology Hazards
ECRI is a global, independent authority on health care technology and safety. Each year ECRI publishes top safety issues. In ranked order, ECRI's Top 10 Health Technology Hazards for 2024 are:
- Usability challenges with medical devices in the home
- Insufficient cleaning instructions for medical devices
- Drug compounding without technology safeguards
- Environmental harm from patient care
- Insufficient governance of AI in medical technologies
- Ransomware as a critical threat to the healthcare sector
- Burns from single-foil electrosurgical electrodes
- Damaged infusion pumps risk medication errors
- Defects in implantable orthopedic products
- Web analytics software and the misuse of patient data
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Elbert Memorial Hospital in Elberton, Georgia, was recently awarded a Patient Safety and Quality award as well as the Circle of Excellence award for sustained commitment to patient safety and quality by the Georgia Hospital Association. Read Article
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- Infection Prevention found the standardized infection ratio (SIR) was greater than the recommended goal of <1.0.
- difficile infection reviews found that education was needed regarding diagnostic stewardship.
- Only a Nucleic Acid Amplified Test (NAAT) was utilized for diff. Two-step testing, which includes a toxin result, was not available.
- Increased antimicrobial usage and patient’s length of stay
- Specimen integrity was a concern.
- Did it need to be tested? Was it truly diarrhea? Has the patient been on any type of laxative, tube feedings, or IV contrast in the last 24-48 hours?
- Testing ordered and specimens sent to the lab were>48 hours apart.
- The specimen was not collected within an appropriate time frame.
- During this time, many changes can happen, potentially increasing the risk of false positives, such as tube feeding and IV contrast.
- Patients are also placed in isolation during the collection time frame. We have seen patient satisfaction decrease due to an elongated isolation time.
- Specimens collected and sent to the lab were not optimal for testing
- Many formed stools were rejected
- The specimen was not collected within an appropriate time frame.
- Only a Nucleic Acid Amplified Test (NAAT) was utilized for diff. Two-step testing, which includes a toxin result, was not available.
Initiatives:
- Two-step testing was put in place to identify active infection vs colonization.
- Hospital now tests for C diff If the NAAT is positive, the orderable will reflex to test the toxin.
- If the toxin is negative, the patient is colonized. Treatment is unnecessary, and the patient will remain isolated until symptoms resolve.
- If the toxin is positive, an active infection is indicated. Treatment would then be initiated, and IP would continue to monitor for isolation purposes.
- Only toxin + results are included in HO-c diff criteria. This initiative significantly decreased our reportable HO-c diff.
- To help ensure a high-integrity specimen was collected appropriately, IP worked with the IT and Lab departments to cancel any C diff testing not collected within 48 hours.
- The provider and nursing reassess the patient and re-order the test if needed.
- IP also implemented a diarrhea decision tree to help nurses have a tool to follow when a C diff test is ordered. See graphic.
- Hospital now tests for C diff If the NAAT is positive, the orderable will reflex to test the toxin.
Their goal was met as the number of hospital-onset C. diff significantly decreased from 2021 through 2023.
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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:TO3-HQIC--5383-03/06/24