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

In This Issue: 

• Thank You
• CMS News
• Upcoming Educational Events
• Expert Insights and Resources on:
  • Behavioral Health and Opioid Stewardship
  • Antibiotic Stewardship
  • Adverse Drug Events
  • Infection Prevention 
  • Sepsis
  • Readmissions/Care Transitions
  • Patient and Family Engagement
  • Health Equity
  • Workplace Violence Prevention
  • Well-Being
• Best Practice
• Success Stories

Recognizing Outstanding Performance Outcomes of Alliant Healthcare Quality  Improvement Contractor (HQIC) 
Alliant Health Solutions, your CMS Hospital Quality Improvement Contractor (HQIC), in collaboration with the Alabama Hospital Association, Comagine, KFMC, Konza, and the Georgia Hospital Association, would like to express our gratitude for your exceptional efforts and dedication over the past several years. Your hard work and commitment to excellence have significantly improved your quality outcomes. As a result of the hospitals’ commitment to quality improvement, we have saved 320 lives, avoided 1,888 harm events and had a total cost savings of $43,974,892.

Achieving these results was no small feat. It directly reflects your expertise, collaboration and perseverance. Whether you’ve been working on the frontlines, behind the scenes, or supporting in any other capacity, your contributions have made a tangible impact on our collective accomplishments.

The current CMS HQIC contract will end on September 17, 2024. You can access and download the many resources on the Alliant HQIC website until November 1, 2024. We are hopeful that we will have the opportunity to continue working with you on the next CMS contract, which is anticipated to begin on November 1, 2024.

FY 2025 IPPS Proposed Rule
Visit the CMS home page for the FY 2025 Hospital Inpatient PPS proposed rule. 

Hospital Quality Reporting (HQR) System Update 
An update is coming to the Hospital Quality Reporting (HQR) System. As of August 19, Reporting Requirements will be renamed Submission Requirements. To find this page, log into HQR and navigate over to the sidebar. Select Program Reporting, and then click Submission Requirements. The page will have a note that says ‘Formerly Reporting Requirements’ below the title. Questions? Watch a short video about the new Submission Requirements page.

Educational Events

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Past 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. 

Advances in Health Equity 

Thursday, September 12, 2024 

HSAG HQIC will present findings from the Health Equity Organizational Assessment (HEOA), highlighting advances, tools and resources used to help hospitals improve health equity. The session will include a case study from a large urban medical center on developing an innovation program that addresses social determinants of health through Community Health Educators who assist patients during and after their hospital stay.
Register Here
 

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 were 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. Discussions focused on health equity action planning and other questions from the hospitals, such as CEO engagement. 

View past sessions: 

• Dec. 21, 2023 – Strategic Planning: View slides and recording
• Jan. 16, 2024 - CMS Reporting for Health Equity Requirements: View slides and recording
• Feb. 15, 2024 - SDOH Data Collection and Coding: View slides and recording
• March 21, 2024 - Hospital Readmissions and SDOH featuring Georgia hospital: View slides and recording 
• April 18, 2024 - How to Submit the CMS Health Equity and SDOH Structural Measures: View slides and recording
• May 16, 2024 - Health Equity in Action: A Baptist Medical Center South Success Story: View slides and recording
• June 20, 2024 - Overview of Findhelp: View slides and recording
• July 16, 2024 - Navigating Health Equity Challenges in Complex Patients: A Case Study Exercise: View slides and recording
• Aug. 15, 2024  - Final Reflection and Celebration: View slides and recording

Office Hours-IP Chats 
Office Hours-IP Chats were quarterly networking events to build knowledge, share experience and provide support for hospital infection preventionists. The sessions were hosted by Amy Ward, MS, BSN, RN, CIC, FAPIC. 

View past sessions

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

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: Opioid Misuse Rises After 11 Months of Chronic Use 
Prescription opioids are commonly used to manage surgical and non-surgical pain, but misuse of opioids is a serious patient safety concern. In a retrospective cohort study of Veterans Health Administration patients, researchers found that opioid misuse among previously opioid-naïve patients increases significantly after 11 months of chronic use, regardless of whether the opioid was prescribed for surgical or non-surgical pain. Read Study

Antibiotic Stewardship

Study: Sepsis Alert Systems Associated With Improved Patient Outcomes 
Early detection and management of sepsis is an important patient safety target. In a systematic review published in JAMA included 22 studies and examined the use of sepsis alert systems in the ED on patient outcomes. The researchers found that sepsis alert systems were associated with reduced risk of mortality and decreased length of stay and increased adherence to sepsis management guidelines, such as timely administration of antibiotics. Read Study

Adverse Drug Events

High Prevalence of Medication Errors Found in Emergency Departments 
The fast-paced and complex emergency department (ED) environment can threaten patient safety. In a meta-analysis published in Springer Link, the pooled prevalence of medication errors in the ED was 22%. The researchers estimated that 36% of patients experienced a medication error in the ED, with about 43% of these errors being potentially harmful but without leading to death. Read Study

NHSN 

Guide to CMS Hospital IQR Program Requirements
New to reporting NHSN data or need a refresher? Visit the NHSN Monthly Checklist for Reporting to CMS Hospital IQR Program

Infection Prevention 

Infection Control Guidance: Candida auris 
C. auris is an emerging fungus that can cause severe, often multidrug-resistant infections and spreads easily among patients in healthcare facilities. See the CDC’s resource for information on reducing, screening, and tracking C. auris. IPC Guidance provides a summary of recommendations.

New CDC Data on Antimicrobial Resistance Threats
New CDC data underscore antimicrobial resistance (AR) remains an urgent global public health threat. The CDC used new data to analyze the United States' burden of seven antimicrobial-resistant pathogens typically found in health care settings in 2021 and 2022 and compared against 2019 data. The new data show that six bacterial antimicrobial-resistant hospital-onset infections increased by a combined 20% during the COVID-19 pandemic compared to the pre-pandemic period, peaking in 2021 and remaining above pre-pandemic levels in 2022. Check out the new data and share it with others to continue the fight against AR. Read More 

Pressure Injuries

Webinar: Mastering Pressure Injury Assessment Across Diverse Skin Tones 
The Assessment and Identification Based on Skin Tone webinar provides valuable insights into recognizing pressure injuries across different skin tones. The webinar covers essential techniques and best practices to ensure accurate assessment, leading to better patient outcomes. Watch Recording

Patent Safety

Deprescribing Is Important Element of Medication Management 
An article from HealthLeaders Media emphasizes the importance of deprescribing as a strategy to improve patient safety and care quality for patients on multiple medications. The primary concern with multiple medications is the risk of drug interactions, which can lead to harmful side effects or reduced effectiveness of treatments. Additionally, the financial cost and potential waste associated with excessive medication use are significant issues. Read Article

Study Finds MT-SET Tool Improves Communication, but Challenges Persist 
Effective communication and coordination among care teams are essential to delivering high-quality, safe health care. An article published by the Agency for Healthcare Resource and Quality introduces the Multi-Team Shared Expectations Tool (MT-SET), which is used to improve team communication, engage teams in eliciting needs, and establish shared expectations among teams and individuals. A pilot evaluation of the MT-SET in perioperative and inpatient care units at Johns Hopkins University School of Medicine found that the MT-SET tool fostered better cross-unit teamwork and coordination. Still, issues such as care delays and inconsistent communication persist. Read Article 

Sepsis

Essential Sepsis Resources: Care Process Model and Webinar on Early Detection in Vulnerable Populations
Explore the Sepsis Care Process Model, a comprehensive guide for recognizing and managing adult severe sepsis and septic shock, designed to improve patient outcomes. Watch the "Think Sepsis" webinar recording to learn about early detection and response strategies in vulnerable populations. Click below to access these critical resources.

• Recognition and Management of Adult Severe Sepsis and Septic Shock
• Think Sepsis video

Explore Essential Toolkits and Resources to Raise Sepsis Awareness
In honor of September being Sepsis Awareness Month, check out these sepsis awareness toolkits and resources to raise awareness about sepsis. 

• Sepsis Awareness Month 
• Get Ahead of Sepsis Materials for Patients 

Readmissions/Care Transitions

Improving Care for Older Adults: The 4Ms Framework
There are more than 54 million Americans aged 65 or over, and that number is projected to climb to about 95 million by 2060. Many older adults have more than one chronic disease and take multiple medications. Delivering care based on the 4Ms Framework — what matters, medications, mentation and mobility — helps reduce readmissions, decrease length of stay and improve health outcomes for older adults. Learn More
 
Patient and Family Engagement

Enhance Diversity in Patient and Family Advisory Councils with IPFCC's New Resource 
Does your hospital face a lack of diversity among patient and family advisory council members compared to the broader patient population? See the Institute for Patient and Family-Centered Care (IPFCC) resource, Strengthen the Diversity and Role of Patient and Family Advisory Councils (PFACs), which can help create meaningful partnerships with patients and families, bringing their voices into the planning, delivery, and evaluation of health care. Download Resource

Health Equity

Defining the Role of the Health Equity Officer: Guidance for Health Systems
The role of the health equity officer (HEO), a senior health care leader responsible for stewarding the crucial work of improving equity, has been emerging and evolving over many years. A publication from the Institute for Healthcare Improvement provides guidance and support for the HEO role, drawing on research and information supplied directly from HEOs. Download Publication 

CMS Public Listening Sessions for the New Medicare Health Equity Services
The CMS Office of Minority Health is hosting public, virtual listening sessions to hear your feedback on barriers and facilitators for adopting new Medicare billing codes among providers serving rural, Tribal, and geographically isolated areas. CMS invites you to join a listening session to provide input on the new Medicare billing codes and inform strategies that CMS and HHS can take to support providers serving rural, Tribal, and geographically isolated areas.
Who Should Attend: Individuals with lived experience supporting healthcare service delivery in rural communities, including Tribal Nations and U.S. territories, are encouraged to attend a listening session to provide real-time feedback.
Where: All listening sessions will be virtual. A Zoom link will be provided following your registration (see information below).  

• Monday, September 9, 3:30-4:30 p.m. ET
• IHS/Tribal Providers
• Register Here
• Tuesday, September 10, 3:30-4:30 pm ET
• Providers in U.S. Territories – Atlantic/Caribbean
• Register Here

Enhance SDOH Data Collection: Updated ICD-10-CM Z Codes and Health Equity Resources 
Are you looking for updated Z codes for the collection of social determinants of health? See Improving the Collection of Social Determinants of Health (SDOH) Data with ICD-10-CM Z Codes. CMS OMH offers health equity technical assistance resources to help health care organizations take action against health disparities. If your organization is looking for assistance, email HealthEquityTA@cms.hhs.gov.

Updated CMS Billing Guidelines: SDOH Risk Assessment for Annual Wellness Visits 
Discover the updated CMS billing guidelines for Social Determinants of Health (SDOH) risk assessment during Annual Wellness Visits. MACs will process code G0136 according to the Physician Fee Schedule Billing Clarification. Learn More

Workplace Violence Prevention

Addressing the Rising Tide of Workplace Violence in Health Care: Key Data and Resources for Prevention 
Workplace violence is an increasingly recognized safety issue in the health care profession. The most recent data from the U.S. Bureau of Labor Statistics indicates an increasing trend in violent incidents in the health care sector from 2011 to 2018, with almost three-quarters (73%) of all nonfatal injuries and illnesses requiring days away from work occurring among health care workers. Compared to private industry, workers in hospital settings were eight times more likely to experience nonfatal violence-related injuries from other persons (22.8 vs. 2.9 incidents per 10,000 full-time workers). 

Do you know the four types of workplace violence? To find out, click on the Learning and Action Network slide presentation recorded on January 23, 2024. and learn more about implementing a workplace violence prevention (WVP) program, including areas of focus and policy guidelines.  

Interested in additional resources on WVP? Check out Alliant HQIC’s coaching package for evidence-based interventions and the Change Path for additional webinars, common barriers, and links to staff training.

Well-Being

Resources Boosting Health Care Worker Well-Being 
According to a McKinsey & Company report, the top three initiatives supporting well-being are:

• More appropriate and sufficient recognition
• Open lines of communication
• Embedding more breaks and flexibility in the operating model

The NIOSH’s Impact Wellbeing Guide provides a step-by-step systems approach to improving well-being and building trust between leaders and health care workers. It is designed to help hospital leaders and executives accelerate or supplement professional well-being work at the operational level and consists of six action steps. In Action 5, integrate professional well-being measures into your hospital's ongoing quality improvement project. See the example measures below.

Professional well-being measures to consider:

• Leading indicators (meaning predictive measurements) might include:
  • A reduction in time spent on hospital work outside of work hours
  •  A reduction in the amount of time healthcare workers spend reading messages in their inbox
  • A decrease in the number of nightshifts worked by non-nocturnists
• Lagging indicators (meaning output measurements) might include:
  • A reduction in staff turnover
  • A reduction in involuntary terminations
  • Improved patient experience scores

Joint Commission Launches Workforce Safety and Well-Being Resource Center
The Joint Commission’s Workforce Center and Well-Being Resource Center identify actionable strategies and tools that organizations can use to address workforce violence, worker well-being, and preventing workers from hazards regardless of where they are on their journey. Sign up for e-alerts to stay current on the latest workforce safety and well-being resources. Sign Up for E-Alerts

Success Stories

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Check out the Success Stories highlighting our HQIC hospitals’ quality improvement and patient safety achievements during the four-year HQIC contract.

Georgia Hospital Uses High Reliability Organization (HRO) Principles to Redesign Daily Safety Huddles 

Southeast Georgia Health System (SGHS), a 300-bed hospital in Brunswick, Georgia, began a journey in 2022 with new leadership to improve transparency in reporting quality and patient safety outcomes. The senior team identified gaps between the current practice of their leadership huddle, an information sharing and general announcement meeting, and high reliability organization (HRO) principles. The current state of having leaders stand around a room and call out “no report” was not providing an ideal model for communication of safety issues and concerns.

Based on research by the patient safety team, the Tier 2 Safety Huddle (T2SH) was established to focus specifically on safety, including a dedicated conference room with the capability for virtual access and the chief medical officer (CMO) serving as a facilitator of daily huddles. To monitor and track issues, a shared computer drive and folder were created for all leaders to access and a tracking spreadsheet was used for following up on unresolved issues. Education and training were provided, as well as “how to” guides to assist staff in engaging in the new process and reporting patient safety events. 

In January 2024, a pilot program of department-based governance councils was launched. It consisted of eight departments, both clinical and non-clinical. Their first assignment was to implement a Tier 1 Safety Huddle, a process that provides leaders with a current state overview from frontline team members regarding patient safety risk issues. The huddle would occur routinely and before the T2SH.

Tiered Patient Safety Huddle model used at Southeast Georgia Health System

Overall wins included clinical leaders being more comfortable speaking up, frontline team members having the opportunity to participate in T2SHs, the CMO and risk manager stopping prompting leaders, and increased reporting of safety events.

For more information on the principles of an HRO and the tracking spreadsheets and dashboard used by SGHS, see the June 25, 2024, Learning and Action Network webinar. View Slides and Recording.

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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--6256-09/04/24