The April 2021 issue of the Hospital Quality Improvement Newsletter featuring the latest insights and resources.  

 

This monthly newsletter highlights the latest insights, resources, and evidence-based best practices.
Our hope is that this newsletter makes it easy for you to stay on top of trends and allows you to provide the best possible care for those you work with and serve. 


New Opportunity to Provide Feedback and Learn About Human-Centered Design (HCD) Approach to Quality Reporting
CMS is investing in modernizing the Hospital Quality Reporting (HQR) site with a human-centered design (HCD) approach to improve the user experience of HQR / QualityNet Secure Portal users. The HQR user experience team is interested in feedback from people who use HQR / QualityNet Secure Portal to submit data for the following programs:

  • Inpatient Quality Reporting (IQR)
  • Outpatient Quality Reporting (OQR)
  • Ambulatory Surgical Center Quality Reporting (ASCQR)
  • PPS-Exempt Cancer Hospital Quality Reporting (PCHQR)
  • Inpatient Psychiatric Facility Quality Reporting (IPFQR), and
  • Promoting Interoperability (PI, formerly Meaningful Use)
Learn More | Sign Up to Participate
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Request Access to Managed File Transfer (MFT) & Auto-Route Now to Ensure You Receive Reports
Manage File Transfer Users need to take action to receive Hospital-Specific Reports (HSRs); Facility-Specific Reports (FSRs); Inpatient Psychiatric Facility (IPF)- Specific Reports; and Claims-Detail Reports (CDRs) in Managed File Transfer (MFT). Users who historically received these reports through their AutoRoute Inbox in Secure File Transfer may need to request permissions in the Hospital Quality Reporting (HQR) system to continue to receive these reports for their facilities. If you are a basic user and do not request these permissions, you will not receive your facility’s reports in MFT. Read More

Patient Safety Organization (PSO)
Hospitals participating with a Hospital Quality Improvement Contractor (HQIC) are able to meet the PSO requirement since the HQIC is involved with implementation of evidence-based initiatives to improve health care quality through the collection, management and analysis of patient safety events that reduces all cause preventable harm, prevents hospital readmissions and/or improves care coordination. Hospitals (greater than 50 beds) would meet these patient safety standards outlined in 45 CFR 156.1110. 

Upcoming Submission Deadlines

New Deadline Extensions:
CMS is extending the Q3 2020 and eCQM data submission deadlines for certain quality programs in response to the Public Health Emergency. Please see the December 17, 2020 and February 8, 2021 memos that outlines the extended deadline dates.

Q4 2020 Reporting Deadlines for Hospitals

Hospital IQR Program:

  • Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS): April 7, 2021
  • Population and Sampling: May 3, 2021
  • Clinical, PC-01, and HAI: May 17, 2021

Hospital OQR Program:

  • Population and Sampling: May 3, 2021
  • Clinical: May 3, 2021

PCHQR:

  • HCAHPS: April 7, 2021
  • HAI: May 17, 2021
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Educational Events



Upcoming Learning and Action Network (LAN) Events

HQIC LAN: Digital Health Equity Breast Cancer Screening
Tuesday, April 27 at 2:00 p.m. ET (30 min)
Join this exciting presentation as a healthcare system describes a performance improvement project that focuses on reducing disparities in breast cancer screening. Based on race and ethnicity data, a program was designed to increase access, create demand and improve breast cancer screenings in geographic hot spots. Learn how your organization can commit to health equity and reduce health disparities in your patient population.
Register Now | Download Event Flyer

View All Upcoming Events Here


Past Learning and Action Network (LAN) Events

Opioid Use Disorder: Closing the Loop Between Hospital and Community
Recorded on March 23, 2021
In case you missed it, this webinar explored barriers of Opioid Use Disorder (OUD) diagnosis and treatment in the hospital setting. We covered various tools on screening for OUD while hospitalized, building a partnership within the community, and how treatment referral and peer support can be a key tool in the success of patients with OUD. 


Key Takeaways Include: 
  • Defining and understanding opioid use disorder (OUD)
  • Understand the process and benefits of initiating buprenorphine in the emergency department
  • Review the basics of building a strong community partnership with behavioral health treatment programs to promote long term recovery
  • Recognize the importance of buprenorphine initiation and knowledge of local substance abuse treatment services available
    Watch Recording View Slides

​​​​​​Related Takeaway Resources:
During the March HQIC LAN event, we heard from a few of you that your physicians were not yet prescribing buprenorphine in the ED. Physicians require 8 hours of training to apply to the Drug Enforcement Agency for a waiver to prescribe buprenorphine, one of three medications approved by the FDA for the treatment of opioid use disorder. Here are two resources to help your physicians get started:

Was This Event Useful? 
Click here if you attended the March LAN event and were able to "use tomorrow" what you heard during the webinar.
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View All Previous LAN Event Recordings
 
 
Upcoming Partner Events
 
Hospital Quality Reporting Programs Severe Sepsis and Septic Shock Management Bundle Q&A Webinar
Tuesday, April 13 at 12:30 p.m. ET
The Severe Sepsis and Septic Shock: Management Bundle (Composite Measure) v5.9 Measure Question and Answers webinar will be presented by Noel Albritton, MSN, RN, Lead Solutions Specialist and Jennifer Witt, RN, Senior Health Informatics Solutions Coordinator, Behavioral Development and Inpatient and Outpatient Measure Maintenance Support Contractor. The event will clarify frequently asked questions related to the SEP-1 measure and guidance in version 5.9 of the specification manual and will discuss updates to SEP-1 for patient cases with COVID-19. The webinar slides will be available for download from www.QualityReportingCenter.com under Upcoming Events the day before the presentation. This presentation has been approved for 1.0 continuing education (CE) credit. 
Register Now


Design Thinking for Human-Centered Health Care
Wednesday, April 14 at 1:00 p.m. ET
What is human centered health care? Hint, it’s not just putting the patient first. The sweet spot for health care improvement projects is at the intersection of what is good for the business, what is good for the users (patients and providers), and what is feasible for both technology and the system. Register for this month's webinar to hear Jennifer Calzada, Director for Simulation at Tulane School of Medicine, share insights on human centered health care and discuss why human centered design should start with what is desired by the users, versus putting the business needs first.
Register Now


ARHQ Patient Safety Network (PSNet) Training Catalog
Ongoing Trainings Available
The Agency for Healthcare Research and Quality (AHRQ) PSNet training catalog is an easy-to-use resource for healthcare professionals across all settings of care and specialties looking for educational opportunities to further their knowledge of patient safety practices and principles. Training opportunities are available as in-person meetings or through live or archived webinars. Opportunities are updated monthly and can be searched by fields such as event location, fee, and CE/CME availability. They are national in scope and identified from not-for-profit organizations, academic institutions, government agencies, and member associations. 
Search the Training Catalog​​​​


Past Partner Events

Racism, Bias, and Other Determinants of Health: Issues and Actions
Recorded on March 1, 2021
This webinar discussed racism and social determinants of health, and the role bias plays in healthcare decision making as well as its impact on adverse health outcomes. Also discussed was how our backgrounds inform our perspectives and how we relate to colleagues and patients. Learning objectives included: 
  • Describe social determinants of health
  • Describe the role of bias in medical decision making & impact on adverse health outcomes
  • Connect addressing bias to provision of equitable high-quality care
  • Explore strategies that students and physicians can employ to mitigate bias
Listen to the Conversation
 
​​​​​Simple STEPPS For Engaging Physician Partners to Sustain Your Safety Culture
Recorded on March 10, 2021
American Hospital Association (AHA) Team Training hosted a free webinar featuring Jason Cheng, D.O., Safety and Human Factors Education Co-Chair from the Kaiser Permanente Health Systems Southern California Region. They discussed how to improve physician engagement by facilitating healthy conversations around errors and mistakes with an emphasis on how both cognitive bias affects us on an individual level, and how system and teamwork failures affect us on a team level.
 

Expert Insights & Resources 



Behavioral Health

National Prescription Drug Take Back Day - April 24
According to the 2018 National Survey on Drug Use and Health, 9.9 million Americans misused controlled prescription drugs. The study shows that a majority of abused prescription drugs were obtained from family and friends, often from the home medicine cabinet. The DEA’s Take Back Day events provide an opportunity for Americans to prevent drug addiction and overdose deaths. Learn More

April is Alcohol Awareness Month
Alcohol Awareness Month is a public health program organized by the National Council on Alcoholism and Drug Dependence as a way of increasing outreach and education regarding the dangers of alcoholism and issues related to alcohol. Learn More

Alliant Quality has produced the following Alcohol Awareness resources available for download:

AAEM White Paper on Acute Pain Management in the Emergency Department
This white paper is endorsed by the American Academy of Emergency Medicine (AAEM) and outlines the Academy’s position on pain management in the Emergency Department setting. A quote from the article states, "Emergency Medicine clinicians are uniquely positioned to combat the opioid epidemic by thoughtful prescribing of parenteral and oral opioids in the ED and upon discharge, and through their engagement with opioid addicted patients in the ED. Given the known harms of opioid analgesics, EM clinicians should make every effort to utilize non-pharmacological modalities and non-opioid analgesics to alleviate pain in the ED and especially on discharge, and to use opioid analgesics only when the benefits of opioids are felt to outweigh the harms."  Read More

Geisinger’s Outpatient Addiction Medicine Specialty Program Uses Data-Driven Decision Making and MAT to Reduce Mortality Rates
The Agency for Healthcare Research and Quality (AHRQ)'s Patient Safety Network (PSNet) has released an article about medication-assisted treatment (MAT). Read More

Opioid Plan for Physicians
The National Academy of Medicine’s Action Collaborative on Countering the U.S. Opioid Epidemic has provided the following resource titled “Priorities and Strategies to Preserve the Health and Well-Being of Individuals with Substance Use Disorders and Chronic Pain during COVID-19". Read More


Patient Safety​​​​​

Anticoagulation (Blood Thinner) Zone Tool
This Anticoagulant (Blood Thinner) Zone Tool was designed in collaboration with those prescribed medications as well as those that are prescribing and administering anticoagulants. The intended use is to educate patients/residents and family caregivers as they are being readied for discharge back home. Additionally, this serves as a reminder of what to do in case of a possible adverse event to have the very best outcome with quicker responses. Download Tool

Colquitt Regional Preventing Type 2 Diabetes with Proven Program
In Moultrie, Georgia, Colquitt Regional is leading the case in helping prevent type 2 diabetes among its employees by implementing the CDC’s Prevent T2 lifestyle change program. The hospital recently received preliminary recognition from the CDC for effectively delivering a quality, evidence-based program. Developed to target those who are pre-diabetic, participants learn the skills they need to make lasting changes such as losing a modest amount of weight, being more physically active, and managing stress. ​​​Learn More 
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Joint Commission Study on Hip Fracture Repair Complications and Mortality
A new study published in The Joint Commission Journal on Quality and Patient Safety assessed which complications are associated with the highest mortality rates for older patients that undergo hip fracture repair. The study found that postoperative delirium affected 29.8 percent of patients and was associated with 30-day mortality (11.5 percent), prolonged hospitalization (43 percent), and 30-day hospital readmission (11.9 percent). Pneumonia affected 4.1 percent of patients and was associated with 30-day mortality (27.3 percent), prolonged hospitalization (66 percent), and 30-day hospital readmission (28.1 percent). Read More

Diversity and Patient and Family Advisory Councils
Many healthcare organizations are looking for better ways to understand diverse patient and family experiences. Knowing how patients and families from minority racial, ethnic, age and language groups experience the healthcare system is important to eliminating health gaps. Diversity helps your Patient and Family Advisory Council (PFAC) have a wider range of views and represent the patients you serve in your community. Check out this resource from the Institute for Patient and Family-Centered Care for strategies and checklists to improve the diversity of your PFAC. Download "Diverse Voices Matter" PDF

JAMA Article - Assessment of the Appropriateness of Antimicrobial Use in US Hospitals
New JAMA article describes how standardized assessments of hospital antimicrobial prescribing quality can be used to estimate appropriateness of antimicrobial use in groups of hospitals. Read Article

CDC Antibiotic Resistance (AR) Investment Map
The Centers for Disease Control and Prevention (CDC) have provided an online tool to help you explore Antibiotic Resistance investments in your state. View Map

U.S. National Action Plan for Combating Antibiotic-Resistant Bacteria (National Action Plan)
Learn about the CDC’s National Action Plan which accelerates response to antibiotic resistance by presenting coordinated, strategic actions to improve the health and well-being of all Americans across the One Health spectrum. The 2020-2025 Plan builds on the first National Action Plan released in 2015 by expanding evidence-based activities that have been shown to stop the spread of antibiotic resistance, such as increasing infection prevention and control and improving the way antibiotics are used. Learn More
 

Care Transitions
 
Inter-Facility Infection Control Transfer Form Including COVID-19 Info 
This updated Inter-Facility Infection Control Transfer Form includes new fields for hospitals and receiving facilities to document and communicate COVID-19 infection history and date of diagnosis, COVID-19 treatments received, and COVID-19 vaccination status. This form also includes important details surrounding current infections or colonization with drug resistant organisms or pathogens of interest, antimicrobial therapy, and invasive devices. Please consider using this form to enhance communication regarding patients as they transition between facilities. Download Form
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CMS - Fiscal Year 2021 Fact Sheet on Hospital ​​Readmissions Reduction Program
CMS has produced a brief overview of the Hospital Readmissions Reduction Program (HHRP). Download Fact Sheet
 

Public Health Emergency Information & Resources



COVID-19 Care

New COVID-19 Self-Management Zone Tool
The COVID-19 Self Management Zone Tool is now available to assist providers across the continuum of care in the education and preparation of patients and their families for safe self-management of COVID-19 illness. Download Zone Tool

April is National Minority Health Month
HHS Office of Minority Health has announced #VaccineReady as the theme for National Minority Health Month this April. Learn More

National COVID-19 Resiliency Network (NCRN)
Alliant Health Solutions is partnering with Morehouse School of Medicine (MSM) on a national initiative to mitigate the impact of COVID-19 on vulnerable populations. As an NCRN community partner, we invite everyone to join, engage, and subscribe to the newsletter to receive updates and information. It will take a collaborative effort to combat the negative impact of this pandemic. Subscribe Now

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COVID-19 Vaccine Resources

​​​​​Alliant Quality COVID-19 Vaccine Resources
Curated resources and best practices to support long-term care facilities, clinics, providers, and staff as they navigate vaccine distribution. Alliant Quality COVID-19 Vaccine Resources

CDC Vaccine Finder
The Centers for Disease Prevention and Control (CDC) has launched a new online COVID-19 vaccine search tool called VaccineFinder to help Americans find which vaccine providers in their area have COVID-19 vaccines in stock. Alliant Quality has created a flyer to help spread the word. Download Flyer | Visit VaccineFinder.org

New COVID-19 Vaccine Guidance and Resources for Partners During the Pandemic
As COVID-19 vaccines are becoming more available across the country, CMS is taking action to protect the health and safety of our nation’s patients and providers and keeping you updated on the latest COVID-19 resources from HHS, CDC, and CMS. CMS has compiled resources and materials to help you share important and relevant information on the COVID-19 vaccine with the people that you serve. View All CMS COVID-19 Updates Here
 

Hospital Heroes​​​



Phoebe Putney Health System in Georgia Marks One Year of COVID-19 Battle
In Albany, Georgia, Phoebe Putney Health System hosted a Day of Remembrance on March 10th to mark the anniversary of the beginning of its COVID-19 fight. Each of Phoebe’s hospital campuses held special events Wednesday to recognize the region’s healthcare heroes, thank community members for their support, encourage southwest Georgians battling COVID-19 and honor those whose lives were taken by the virus. Events included tribute walks along paths lined with signs highlighting COVID-related milestones over the last year and Day of Remembrance ceremonies featuring remarks from patients, community leaders and healthcare workers who have been on the frontlines of the COVID-19 battle. To ensure proper social distancing, the public was not invited to the walks and ceremonies. Members of the community in Albany, Americus and Sylvester were invited to attend drive-through luminary events at each hospital campus Wednesday night. Luminaries lit up the hospital driveways and areas of each campus were illuminated in red in honor of healthcare heroes. At the main campus, a laser light show flashed messages of thanks, support and unity on the side of one of the medical towers. “We definitely wanted to find a safe way to include our communities in our commemorations, because they have been so supportive of the Phoebe Family and so vital to all we have been able to accomplish over the last year. We thought this was a great way to thank them and to allow them to express their condolences to families who have lost loved ones and to show their support for our staff and current patients,” said Joe Austin, Phoebe Putney Memorial Hospital Chief Executive Officer. Read the Full Story
​​Woman wearing mask speaking at podium during outdoor event. Sign that reads "Heroes Work Here" on Phoebe hospital building. Socially distanced outdoor gathering of people wearing masks.

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