The May 2024 issue of the Hospital Quality Improvement Newsletter features the latest insights and resources.

In This Issue: 

• CMS News
• Upcoming Educational Events
• Expert Insights and Resources on:
  • Behavioral Health and Opioid Stewardship
  • Antibiotic Stewardship
  • Adverse Drug Events
  • NHSN and Infection Prevention 
  • Sepsis
  • Patient Safety
  • Readmissions/Care Transitions
  • Health Equity
  • High Reliability Organization 
• Best Practices Corner
• Success Stories

Quality in Motion: Acting on the CMS National Quality Strategy
Quality in Motion: Acting on the CMS National Quality Strategy is CMS’s latest update to the 2022 National Quality Strategy, which was launched to improve the quality and safety of health care for everyone, focusing on those from underserved and under-resourced communities. In the action plan, you will learn how CMS is putting quality-focused goals into motion in four priority areas:

• Outcomes and Alignment
• Equity and Engagement
• Safety and Resiliency
• Interoperability and Scientific Advancement

The new action plan includes a call for payers to improve quality in high-priority clinical areas and reduce provider burden by implementing the Universal Foundation, including the newly published hospital, maternity care, and post-acute care/long-term care add-on sets. Read Quality in Motion 

Hospital Quality Reporting Outreach and Education Recording: Overall Hospital Quality Star Ratings: July 2024 Refresh 
Overall Hospital Quality Star Ratings: July 2024 Refresh, an outreach and education webinar for participants in Hospital Quality Reporting Programs, was held on April 25. This interactive session focused on the Overall Star Ratings methodology and the July 2024 results. The webinar slides are available at QualityReportingCenter.com under Upcoming Events.

Quick Reference Guide for FY2026 Hospital's Value-Based Purchasing Program 
Download the FY2026 Hospital Value-Based Purchasing Program Quick Reference Guide (updated August 2023). Note the performance periods in 2024. View Guide

Educational Events

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Upcoming Learning and Action Network (LAN) Events

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. 

Enhancing Capacity: Reengineering Fall and Fall Injury Programs: Infrastructure, Capacity and Sustainability 
Thursday, May 9
This session features national subject-matter expert and nurse consultant Pat Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP, who will discuss 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, will highlight 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.
Register Here

Pressure Injury Prevention (PIP): Zero Harm 

Recorded on April 11

This session featured a discussion with the Eastern U.S. Quality Improvement Collaborative (EQIC) team and a critical access hospital. Community Memorial Hospital described methods used to implement a Pressure Injury Prevention (PIP) program based on best practice research and innovative advances in prevention techniques. The presentation also highlighted the multidisciplinary approach necessary to promote PIP,

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. 

Office Hours-Ask the Experts

Health Equity Action Office Hours
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: 

• 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

Office Hours-IP Chats 
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 24, 2024, from 2-2:30 p.m. ET

View past sessions:

• Jan. 24, 2024 – View slides
• April 24, 2024 – View slides

Visit the Alliant HQIC website under Education on Demand for past IP Office Hours slide presentations. 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

Behavioral Health & Opioid Stewardship

Study: Treatment of Opioid Overdose: Current Approaches and Recent Advances
The United States has been struggling with the opioid epidemic for over two decades now, and unfortunately the situation seems to be worsening. The number of opioid overdose deaths has hit a new high of over 74,000 in a 12-month period that ended in April 2021. Naloxone is the primary medication used to reverse opioid overdoses, but there are concerns that it may not be effective against illicit high-potency opioids such as fentanyl and fentanyl analogs. Read More

Antibiotic Stewardship

Prevention in Adults of Transmission of Infection With Multidrug-Resistant Organisms
This rapid review summarizes the literature on patient safety practices intended to prevent and control the transmission of multidrug-resistant organisms (MDROs). Read Article

Adverse Drug Events

Analysis of Intervention Employability in Pharmacy-Related Medication Safety Reports at a Tertiary Medical Center
The Institute for Safe Medication Practice (ISMP) suggests that patient safety reports be addressed with systematic, fail-safe, actions to prevent error recurrence.  A study published by PubMed analyzes the intervention potential and quality of pharmacy-related medication safety reports. Read Study

NHSN

CMS Quality Reporting Program Deadline: May 15, 2024 
All hospitals participating in the CMP Quality Reporting Program must enter the following data into NHSN by May 15, 2024. 
2023 Quarter 4 (October 1 – December 31)

• CAUTI and CLABSI data for all ICU, adult and pediatric medical and surgical or med/surg wards
• MRSA and C. difficile LabID for FacWideIN, ED, and Observation locations
• Inpatient Procedure data for COLO and HYST 
• Weekly Healthcare Personnel COVID-19 Vaccination Summary data 

2023 Quarter 4 & 2024 Quarter 1 (October 1 – March 31) 

• Annual Healthcare Personnel Influenza Vaccination Summary data

CMS Promoting Interoperability Program - NHSN Antimicrobial Use and Resistance (AUR) Reporting
See the following resources and information regarding the AUR reporting for the CMS Promoting Interoperability Program.  

• CMS Promoting Interoperability Program Resource Library  
• NHSN FAQs: AUR Reporting for the CMS Promoting Interoperability Program
• Register for the upcoming NHSN Office Hours Session 
  • Wednesday, May 8 – 3-4 p.m. ET 
  • Register Here

Readmissions/Care Transitions

Engaging Family Caregivers with Structured Communication for Safe Care Transitions
An Agency for Healthcare Research and Quality (AHRQ) rapid review focuses on care transitions involving family caregivers within or between health care settings (e.g., intensive care unit to hospital; hospital to skilled nursing facility), or from an inpatient or emergency setting to an outpatient setting where caregivers are primarily responsible for continuing care for the patient. Clear communication between health care professionals,caregivers and patients is an important part of delivering quality care and is key to improving patient safety during transitional care. Patients and caregivers desire and may benefit from better communication at transitions of care. Read Review 

Article: Risk of Hospital Readmissions after surgery is high for older Americans
This article published by Yale News discusses a study by a Yale University team examining the risk if hospital readmission among older Americans after major surgery. The research, which is the first of its kind, reveals high rates of readmission within short-term (30 days) and long-term (180 days) periods post-surgery. The study, based on a sample of 1,477 older Americans, highlights the significant impact of geriatric-specific conditions like frailty and dementia on readmission rates. These findings underscore the importance of recognizing and addressing such conditions preoperatively. The article also emphasizes the substantial economic burden and negative consequences associated with hospital readmissions for older adults, including compromised independence and function. Moving forward, the researchers aim to delve deeper into the underlying reasons for high readmission rates and suggest strategies to mitigate the risk. Read Article  Patient and Family Engagement

Patient and Family Advisory Councils: Empowering Patients and Enhancing Health Care Services  
A Patient and Family Advisory Council (PFAC) comprises of patients and family members who received care at an organization and administrators, clinicians, and staff. The PFAC provides a mechanism to seek and learn from the patient and family perspective, promote a culture of patient- and family-centered care, collaborate to improve services and policies as well as enhance the delivery of high quality and safe care. According to The Institute for Patient- and Family-Centered Care, there are several common characteristics of effective PFACs. Read More

• At least 50% of members are patient and family advisors (PFAs), reflecting the diversity of the community
• Chair or co-chair is a PFA
• Have established guidelines (e.g., bylaws)
• Meet regularly (10-12 times per year)
• Have an agenda and maintain minutes
• Provide orientation and ongoing training to members
• Establish annual goals
• Document the impact of PFAC on safety and quality

Health Equity

Words Matter Wednesdays: Advancing Equity Through Language 
This series will explore equitable terminology that promotes social justice for populations where language has often been used to shame individuals, patronize, enforce prejudice, or limit visibility. Each session will provide updated language that helps advance equity within these populations. We encourage behavioral health professionals and those who interact with or write about these populations to attend. Register Here

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

Voluntary Submission of CY 2023 SDOH Data Now Available on HQR System 
The voluntary submission of the CY 2023 Screening for Social Drivers of Health (SDOH-1) and Screen Positive Rate for Social Drivers of Health (SDOH-2) measure data is now available on the Facility, State and National (FSN) Report and Provider Participation Report (PPR). 
Access your reports by logging into the Hospital Quality Reporting (HQR) System and navigating to Program Reporting.
To download your PPR, select Reporting Requirements, select IQR as the Program, and the appropriate Discharge Quarter. Click Export CSV.
To download your FSN, select Performance Reports, select IQR as the Program, and the appropriate Period. Click Export CSV. Visit CMS website

Patient Safety

Suicide Prevention Following Hospital Discharge
A new study, funded by Pew Charitable Trusts, published in The Joint Commission Journal on Quality and Patient Safety (JQPS), evaluated the prevalence of four suicide prevention activities following hospital discharge. Activities included formal safety planning, planning for lethal means safety, warm hand-off to OP care, and follow-up contact after discharge. Read More

Public Health Emergencies (PHE)

CDC Health Alert Network: Increase in Global and Domestic Measles Cases and Outbreaks
The Centers for Disease Control and Prevention (CDC) is issuing a Health Alert Network (HAN) Health Advisory to inform clinicians and public health officials of an increase in global and U.S. measles cases and to provide guidance on measles prevention for all international travelers aged ≥6 months and all children aged ≥12 months who do not plan to travel internationally. Read More 

Well-Being

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

Best Practices Corner

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Celebrating Patient Safety Awareness Week
The Southeast Georgia Health System (SGHS) celebrated Patient Safety Awareness Week on March 10-16, 2024, with heartfelt discussions and invaluable insights from distinguished nation speaker and author Ridley Barron. He shared his story and advice for health care professionals, emphasizing the critical importance of empathy and compassionate care. Mr. Barron’s story further highlighted SGHS’ journey to become a high reliability organization (HRO). Photo of SGHS HRO champions with Ridley and Lisa Barron.

Success Stories

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Pullman Regional Hospital’s Journey to a High Reliability Organization (HRO) 

Pullman Regional Hospital, a critical access hospital in Pullman, Washington, has demonstrated commitment to a high reliability organization that aligns and integrates systems of safety, clinical practice, quality and risk management, human resources, finance, and operational performance improvement. 

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.

Building a high reliability program from 2020-2022 included: 

• 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)

Key learnings along the way included:

• 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

Benefits of a high reliability approach gives a collaborative 360º risk perspective, gives staff a voice, engages staff in the process and connects staff to the work of the organizational metrics.

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

Hospitals Improve Readmissions Rate Using KONZA Health Information Exchange (HIE) 

KONZA Health Information Exchange (HIE) recognized an opportunity to work with KFMC Health Improvement Partners with the four-year CMS-funded Hospital Quality Improvement Contractor (HQIC) program. Currently, seven hospitals in Kansas are enrolled in the Alliant HQIC program that can access the KONZA HIE dashboard for performance improvement efforts.

Technical assistance includes data analysis and monthly one-on-one coaching calls. The KONZA HIE Workflow Specialist and KFMC Quality Consultant meet with hospital improvement teams to identify opportunities based on data and trends and provide evidence-based interventions. Training is also provided to the hospitals, as the HIE dashboard serves as a source for readmission data. See the HIE dashboard for hospital readmissions.

Hospitals have benefitted from the HIE dashboard and recommended interventions, including Trego County Lemke Memorial and Hanover Hospital.

Trego County Lemke Memorial is a 25-bed critical access hospital in WaKeeney, Kansas. The tool is valuable to the hospital team as readmission reports are discussed at meetings and can be printed out for regulatory requirements. 

To decrease readmissions, their hospital team is currently reviewing health disparities data and health-related social needs and has implemented the following interventions:

• Leadership meetings to review readmission data
• Risk assessment conducted properly upon admission
• Discharge follow-up calls within 48 hours by Infection Preventionist
• Discharge follow-up appointments with a primary care physician and/or specialist

As of October 2023, their relative improvement rate (RIR Achieved) for hospital readmissions rate improved by 28.54% compared to the baseline and RIR goal (5.0%). Four readmissions have been avoided to date, with $65,612 in cost savings.

Hanover Hospital, a 25-bed hospital in Hanover, Kansas, also uses the dashboard and readmissions reports. To decrease readmissions, their hospital team is currently reviewing health disparities data and health-related social needs and has implemented the following interventions:

• Leadership engaged in meetings to review
• A transitional care program or department assists with post-discharge needs
• Meds to Beds program
• Medication reconciliation for patients with high readmission risk

As of October 2023, their RIR Achieved for hospital readmissions rate improved 52.78% compared to baseline and RIR goal (5.0%). Hanover has been maintaining a zero readmissions rate since January 2023. Technical assistance, including the KONZA HIE dashboard, adds value to the way the Alliant HQIC hospitals use technology tools for data analysis.

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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