The May 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 Corder
• Success Story

CMS Guidance for the End of the COVID-19 Public Health Emergency: What You Need To Know 
CMS is preparing the public for the transition forward from the COVID-19 public health emergency (PHE) and has outlined what to expect after this period ends. In a new fact sheet, CMS discusses COVID-19 testing, vaccines and treatments; telehealth services; continuing flexibilities for health care providers and inpatient hospital care at home. The Biden-Harris Administration and CMS will continue to provide guidance to the public to ensure a smooth and predictable transition as May 11 approaches. Download Fact Sheet

Educational Events

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Quality Leader Summit: Focus on Sepsis 
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. 
• Educational events and updated valuable resources, such as coaching packages, the HQIC website, and the portal.

Register Here

Upcoming Learning and Action Network (LAN) Event

Patient Falls
Tuesday, June 20, 2023 (tentative) from 2-3 p.m. ET
Stay tuned for the registration link and flier.

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. 

Partnering With Patients and Families To Prevent All-Cause Harm
Thursday, May 11
This event will feature strategies for hospitals and patients/families to engage as partners to ensure the right care is being delivered to the right patient at the right time to foster improvements in patient safety, health care quality, as well as patient outcomes and equity.
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  

Updated Data Specifications
Data measurement changes for ADE measures include updated ICD codes. View HQIC Measurement Specifications
 

Behavioral Health & Opioid Stewardship

The Society of Hospital Medicine’s Reducing Adverse Drug Events Related to Opioids (RADEO) Guide
The RADEO Implementation Guide provides step-by-step guidance to assist hospital teams in implementing a quality improvement program to improve patient safety and reduce opioid-related adverse events for patients receiving opioids. Read the Study

Opioid Education Materials for Patients
Are you looking for educational materials surrounding safe opioid use, treatment and recovery, and frequently asked questions? Visit the CDC website for multiple downloadable resources and factsheets. Visit Website

Antibiotic Stewardship

Assessment of the Appropriateness of Antimicrobial Use in Hospitals 
A study published in the Journal of the American Medical Association (JAMA) evaluated the appropriateness of antimicrobial use for hospitalized patients treated for community-acquired pneumonia (CAP) or urinary tract infection (UTI) present at admission or for patients who had received fluoroquinolone or intravenous vancomycin treatment. Read the Study

Patient Safety

Review: Electronic Health Record-Based Prediction Models for In-Hospital Adverse Drug Event Diagnosis or Prognosis
A systematic review was conducted to characterize and critically appraise developed prediction models based on structured electronic health record (EHR) data for adverse drug event (ADE) diagnosis and prognosis in adult hospitalized patients. Read the Review

Study: Drug-Drug Interaction Between Dexamethasone and Direct-Acting Oral Anticoagulants
Dexamethasone, a drug used to treat COVID-19, did not reduce the effectiveness of two anticoagulants that prevent blood clots, according to an AHRQ-funded study published in BMJ Open. The authors analyzed data from a COVID-19 data repository for 172 patients who were taking dexamethasone and either apixaban or rivaroxaban for five or more days. Although there was concern that dexamethasone may reduce the effectiveness of the anti-clotting drugs, no connection was found. The authors suggested that the study of this interaction is important as the use of both drugs may be necessary for certain patients, particularly for those who have medium to severe COVID-19. Read Study 

Aligning Quality Measures across CMS – The Universal Foundation
The quality-measurement movement began more than 20 years ago and has resulted in transparent quality-performance information, accountability and improvements. At the same time, the proliferation of quality measures caused confusion, increased reporting burden and misalignment of approaches for common clinical scenarios. The CMS and public–private partnerships have therefore moved toward creating more parsimonious sets of measures. Although some progress has been made, a lack of alignment across CMS’s quality programs has contributed to challenges for clinicians, facilities and health insurers when it comes to prioritizing outcomes that are meaningful for patients. Learn More

Identifying Patient Harm
Are you using the IHI Global Trigger Tool as an additional tool to identify harm in your facility?  The use of the IHI Global Trigger Tool for Measuring Adverse Events provides an easy-to-use method for accurately identifying adverse events (harm) and measuring the rate of adverse events over time through a retrospective review of a sample of records by looking for specific triggers. A recent study validated the accuracy of the tool in identifying adverse events of greater harm. See the following resources:

• The Accuracy of the Global Trigger Tool 
• IHI Global Trigger Tool
• IHI Trigger Tool Information and Resources 

Readmissions/Care Transitions

Addressing Rural Health Inequities in Medicare
Rural communities often experience significant health inequities. Compared to urban Americans, rural Americans are more likely to have heart disease, stroke, cancer, unintentional injuries, suicide risk, and chronic lung disease, and have higher death rates from COVID-19. Addressing rural health inequities is a cornerstone of CMS’ effort to improve health equity. Read More

First, Do No Harm
Ensuring patient safety is at the heart of the Hippocratic Oath: First, Do No Harm. As the nation’s largest payer for health care, CMS is focused on patient safety and pushes for continued and significant improvements. CMS is using all the levers at its disposal, including expanded and improved measures of safety performance, increased transparency, and strong payment incentives to promote improved safety outcomes. Read Article

Transitions of Care: What Really Works
Discharging patients from the hospital setting is a complex process with many moving parts. Multiple interventions to ensure a smooth transition from one level of care to the next have been identified as best practices. What really works? In a study recently published in UpToDate, researchers in the field of transitions of care evaluated the effectiveness of various approaches to improve the discharge process. Read Article

Patient and Family Engagement

Learning From Experience: Exploring the Impact of Approaches to Family Presence in Hospitals During COVID-19
Throughout the pandemic, the Institute for Patient- and Family-Centered Care (IPFCC) remained firmly committed to advancing patient- and family-centered approaches that adhere to the safest guidelines and pose the least burden on health care professionals. Several resources were developed that relate directly to family presence and partnerships during a pandemic. View Resources 

Health Equity

CMS Proposes Policies To Improve Patient Safety and Promote Health Equity
CMS released a press release and factsheeton a proposed rule addressing health equity in fiscal year (FY) 2024. Here are a couple of key points in the proposed rule:

• CMS is proposing to make health equity adjustments in the Hospital Value-Based Purchasing Program by providing incentives to hospitals to perform well on existing measures and to those who care for high proportions of underserved individuals, as defined by dual eligibility status.
• CMS is proposing to recognize homelessness as an indicator of increased resource utilization in the acute inpatient hospital setting, which may result in higher payment for certain hospital stays.
• CMS is proposing to change the severity designation of the three ICD-10-CM diagnosis codes describing homelessness (e.g., unspecified, sheltered, and unsheltered) from non-complication or comorbidity (NonCC) to complication or comorbidity (CC) based on the higher average resource costs of cases with these diagnosis codes compared to similar cases without these codes.
• CMS is proposing to add 15 new health equity hospital categorizations for the FY 2024 IPPS payment impacts. Moving forward, one of the priorities of the CMS Framework for Health Equity 2022-2032 is to expand the collection, reporting, and analysis of standardized health equity data.
• CMS is also proposing that rural emergency hospitals could be designated as graduate medical education training sites. As a result, more medical residents would be able to train in rural settings, which can help address workforce shortages in these communities. 

There will be a 60-day public comment period beginning on May 1, and comments can be posted 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

Best Practices Corner

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St. Mary’s Good Samaritan Hospital Celebrates Successful Campaign, Dedicates Garden and Peace Pole
St. Mary’s Good Samaritan Hospital, located in Greensboro, Georgia, celebrated the successful conclusion of a $3 million capital campaign, the dedication of the Shane Meder Memorial Garden, and the planting of a Rotary International Peace Pole. Read Article

Success Story

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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.

Athens-Limestone Hospital Committed to Opioid Stewardship and Reducing Patient Harm 

Athens-Limestone Hospital, a 71-bed hospital in Athens, Alabama, is improving opioid stewardship by implementing steps to reduce patient harm from opioids through leadership commitment, partnership with physicians and the formation of an opioid stewardship committee. 

Previous improvement work in opioid stewardship was not continued during the COVID pandemic as the focus shifted to more urgent matters. An opioid stewardship committee is now in place and includes a diversion task force subcommittee. 

Representatives are from the following areas with higher opioid use:

• OR/PACU
• One Day Admission
• Emergency Department
• Anesthesia
• Pharmacy 
• Nursing
• Physician 

Lauren Woller, PharmD, BCPS, director of pharmacy services at Athens-Limestone Hospital, championed the efforts and implemented the following strategies to reduce patient harm and overcome challenges.   

1. Identify order sets containing opioids. The focus was on post-op and Ortho order sets because of the high use of opioids post-op and the use of range orders allowing the nurse to select a higher dose of opioids for pain. The goal was to eliminate all range orders and reduce the total MME amount available to the patient post-op.  

Challenges and successes included: 1) Reaching consensus on order sets. Success followed with a physician champion supporting the changes and leading the change; 2) Continued to see old order sets from physician offices. Success was followed by removing old order sets from circulation.

2. Educate prescribers on recommendations for safe opioid prescribing. The team provided category 1 CME credit covering safe opioid prescribing. This is a requirement for physicians in Alabama. The goal was to offer free and on-site and target safe opioid prescribing in the outpatient setting

Challenges and successes included: Good physician turnout for the CE program. The event opened the door for good discussion and lots of questions from providers. Several physicians were unable to make it and expressed interest in the topic. The team would recommend offering a live virtual event in the future. 

3. Standing order for Naloxone at discharge. The goal was to include a prescription for Naloxone on all post-op orthopedic opioid discharge prescriptions.

Challenges and successes included: Physician agreement as some did not want it pushed on patients, including a perceived cost to patients. A compromise was a standing order for naloxone available to patients at our retail location. Currently in the final stages of development.

To view the January 17, 2023 presentation Connecting Your Hospital Culture of Safety to Patient Harm Reduction and Athens-Limestone Hospital’s presentation on Opioid ADEs, visit the Alliant HQIC website.