The May 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. 

CMS Proposes to Enhance the Medical Workforce in Rural and Underserved Communities to Support COVID-19 Recovery and Beyond
The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule (CMS-1752-P) for inpatient and long-term care hospitals that builds on the Biden Administration’s key priorities to close health care equity gaps and provide greater accessibility to care. Major provisions in the proposed rule would fund medical residency positions in hospitals in rural and underserved communities to address workforce shortages and require hospitals to report COVID-19 vaccination rates among their workers to contain the spread of the virus. Learn More

Care Compare and Provider Data Catalog April 2021 - Data Refresh for Hospitals​​​​​
Care Compare on reports information for over 4,000 Medicare-certified hospitals, including over 130 Veterans Administration (VA) Medical Centers and over 30 Department of Defense (DoD) military hospitals, across the country. The website provides information for patients and caregivers on hospital care delivery and encourages hospitals to improve the quality of their care by publicly displaying quality information. Learn More

Users can compare performance across many common conditions. The Overall Hospital Quality Star Rating summarizes data from existing quality measures on Care Compare so users can easily compare hospitals. With the Provider Data Catalog, users can explore and download hospital data, as well as data on ambulatory surgical centers, inpatient psychiatric facilities, and some cancer hospitals. The Centers for Medicare & Medicaid Services (CMS) updates data for hospitals on the Care Compare website quarterly, though not all data are updated each quarter. Learn More

Data Updates

  • On April 28, 2021, CMS updated data for hospitals on the Care Compare and Provider Data Catalog websites.
  • CMS also updated data for the Overall Hospital Quality Star Rating and Outpatient and Ambulatory Surgery CAHPS (OAS CAHPS).

4Q 2020 Clinical, HAI, and PC-01 Data Submission Deadline is May 17, 2021 ​​​​​
Hospitals participating in the Centers for Medicare & Medicaid Services (CMS) Inpatient Quality Reporting (IQR) and Hospital Acquired-Condition (HAC) Reduction Programs that the data submission deadline for the following requirements is May 17, 2021, at 11:59 p.m. Pacific Time:

  • Fourth quarter (4Q) 2020 Chart-Abstracted Clinical measures (SEP-1)
  • 4Q 2020 Perinatal Care (PC-01) measure
  • 4Q 2020 Healthcare-Associated Infection (HAI) measures

​​​​​​Learn More

CMS News on Value Based Purchasing (VBP) ​​​​​
The CMS Hospital Value-Based Purchasing (VBP) Program rewards acute-care hospitals with incentive payments for quality care to Medicare patients. This booklet explains how the Hospital VBP Program works and also lays out changes to future years.

Key Takeaways:
  • The Hospital VBP Program rewards acute care hospitals for their quality of care to Medicare patients, rather than the quantity of care
  • Under the VBP Program, Medicare makes incentive payments to hospitals based on how well they perform on measures compared to other hospitals’ performance or how much they improved their performance on measures compared to their own performance during a baseline period
  • CMS scores hospitals by comparing its Achievement and Improvement scores for each applicable VBP measure​​​​​
  • Clinicians, providers, hospitals, and facilities participating in quality reporting and VBP programs can get reporting relief due to the COVID-19 PHE under the extraordinary circumstances exception.
Download the Hospital Value Based Purchasing PDF
​​​​​​Educational Events

Save The Date

Alliant Hospital Quality Improvement Contractor (HQIC) Onboarding
Monday, June 14 at 1:00 p.m. ET (60 min)
​​​​​Join us for an overview of the HQIC program including goals, measures, and educational events. Learn how to navigate the hospital portal for access to assessments, data/graphs, and discussion groups. Registration coming soon.
Upcoming Learning and Action Network (LAN) Events

HQIC LAN: Antibiograms and Infection Prevention Efforts to Combat Antimicrobial Resistance During COVID-19                                                       
Tuesday, May 25 at 2:00 p.m. ET (30 min)
Antimicrobial resistance may have increased during COVID-19 pandemic due to the medications being used to treat the virus including steroids and other immune-suppressive medications, longer hospital length of stay, ICU length of stay, and duration of mechanical ventilator. During East Alabama Medical Center’s (EAMC) annual review of their antibiogram, the antimicrobial stewardship and infection prevention teams discovered dramatic changes in hospital-acquired infections as well as increasing resistance patterns. Join this webinar to learn how the team at EAMC further stratified their data and made significant changes to recommended antimicrobials.
Register Now | Download Event Flyer

View All Upcoming Events Here

Past Learning and Action Network (LAN) Events

HQIC LAN: Digital Health Equity Breast Cancer Screening
Recorded on April 27, 2021
In case you missed it, this webinar featured a presentation by a healthcare system who implemented a performance improvement project that focused 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.  

Key Takeaways Include: 
  • Define a data driven approach to selecting a project that focuses on meaningful health inequity
  • Describe the use of breast cancer disparity data and the way in which a hospital system may approach disparity reduction using digital technology
"Use Tomorrow" Knowledge:
  • Collect and stratify patient demographic data to reduce health disparities in a selected patient population, e.g., readmissions for heart failure, colorectal screening​​​​​​​​​
Watch Recording View Slides
Did you find this LAN event useful?

If Yes, Click Below.

Click here if you attended the April LAN event and were able to "use tomorrow" what you heard during the webinar.

View All Previous LAN Event Recordings

Upcoming Partner Events
A Culture of Team-Based Care Improves Value
Wednesday, May 12 at 1:00 p.m. ET
Interdisciplinary team-based care enables health care organizations to improve outcomes and the patient experience while reducing cost. This webinar, co-hosted by AHA Team Training and The Value Initiative, will explore how health care organizations can build a culture of team-based care that improves value. In conversation with AHA’s Julia Resnick, leaders from CHI Health Creighton University Medical Center will share the story of how they designed University Clinic around inter-professional care teams to meet their patients’ needs. They will discuss what it took to build a culture of team-based care at their organization and how the model has improved outcomes, reduced cost and enhanced the experience for both patients and providers. Presenters will then discuss how other health care organizations can make the value-case for the transformation to team-based care.
Register Now​​​​

Behavioral Health/Opioid Stewardship

HHS Releases New Buprenorphine Practice Guidelines
In an effort to get evidenced-based treatment to more Americans with opioid use disorder, the Department of Health and Human Services (HHS) is releasing new buprenorphine practice guidelines that among other things, remove a longtime requirement tied to training, which some practitioners have cited as a barrier to treating more people. Learn 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​​​​​

Adverse Drug Events (ADEs)

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


CAUTI Prevention
As we continue into the 2nd quarter of 2021, it may be time to review your CAUTI prevention efforts! Check out the CDC TAP Implementation Guide and the AHRQ Technical Interventions Guide and consider completing a CAUTI prevention gap assessment this quarter! Pressure Ulcers

Preventing Pressure Ulcers in Hospital
Each year, more than 2.5 million people in the United States develop pressure ulcers. These skin lesions bring pain, associated risk for serious infection, and increased health care utilization. The aim of this toolkit is to assist hospital staff in implementing effective pressure ulcer prevention practices through an interdisciplinary approach to care. Learn More

Health Equity​​​​
CMS Health Equity Awards
The 2020 CMS Health Equity Award recipients are UnitedHealthcare and Atrium Health, who have demonstrated their commitment to health equity through a strategic approach to identifying, prioritizing, and addressing health disparities. Learn More

Readmissions/Care Transitions​​​​

Patient Discharge Transition Records 
Do patients or their caregivers receive a transition record at the time of discharge including all of the following elements (and with whom a review of all included information was documented)?

Inpatient Care:
  • Reason for inpatient admission
  • Major procedures and tests performed during inpatient stay and summary of results
  • Principal diagnosis/discharge diagnosis

Post-Discharge/Patient Self-Management:

  • Current medication list
  • Studies pending at discharge (e.g. laboratory, radiological)
  • Patient instructions

Contact Information/Plan for Follow-up Care:

  • 24-hour/7-day contact information including physician for emergencies related to inpatient stay
  • Contact information for obtaining results of studies pending at discharge
  • Primary physician, other health care professional, or site designated for follow-up care

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

Congestive Heart Failure (CHF) Resources
Patient facing information to help understand, monitor, and manage CHF. The American Heart Association has provided several resources for patients and healthcare professionals called Rise Above Heart Failure (RAHF).

​​​My Mother's Story: The Importance of Discharge Planning
In October 2013, my mother was diagnosed with leukemia. While in the hospital receiving her cancer treatment, she injured her foot, which caused her to become septic. This led to a time where she was intubated, and my family did not know if she would live or die. Ultimately, she was able to overcome the sepsis but was no longer on track to receive her bone marrow transplant because the wound on her foot needed immediate care. In her weakened state, she was discharged from the hospital, in fact, I had to pick her up and physically put her into the car from her wheelchair so she could go home. My parents were not provided with adequate support upon discharge to give her the care she needed and before the day was over, she was back in the emergency department and readmitted to the hospital.

Discharge planning is one of the key elements in successful patient transfers between facilities or to the home. The discharge process varies between hospitals but there must be an effective discharge planning process that meets the goals of the patient. A best practice is starting the discharge process upon admission. The CMS, “Your Discharge Planning Checklist” gives lists of action items to use during the patients stay to prepare for a successful patient discharge. Read the Checklist

On April 25, 2021, my mom celebrated her 7th "birthday" from when she received her bone marrow transplant. Our family will always be grateful for the college student from Wisconsin that was her bone marrow match.

Take Heart Cardio Rehab
Below are two key updates from our colleagues at TAKEheart.

  • TAKEheart is offering an opportunity to add a limited number of additional hospitals interested in working with the current Partner Hospitals to implement automatic referral and enhanced care coordination. See the information below and the attached promotional flyer for more information.
  • The AHRQ-funded TAKEheart initiative invites you to participate in the next session of the TAKEheart Affinity Group: Innovations that Can Improve Your Cardiac Rehabilitation Program, scheduled for Thursday, May 20th, 2021 from 12:00pm-1:00pm ET.  

Many CR programs made adjustments in response to the COVID-19 pandemic that they found were beneficial for their patients and programs. New online support resources were developed, check-in processes were modified, rehab sessions were adjusted, schedules were modified, and virtual rehab activities were introduced in some programs.  In some cases, these changes have been made permanent because they improved the CR patient experience or the program's efficiency.

Please join us for the second affinity group session of 2021 where you can learn about WHAT changes your peers have implemented and made permanent as well as HOW they made the changes successfully and what they learned along the way.  You'll also be able to share your own changes with your peers and contribute to ongoing efforts to best serve the needs of CR patients and programs. This session will be moderated by Dr. Hicham Skali. 

This session is open to participating TAKEheart hospitals and others committed to addressing and responding to the needs of CR patients. Feel free to share this invitation with others who may be interested in attending. Register Here

COVID-19 Care

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. Click Here to Subscribe to NCRN Updates

"I Got My COVID-19 Vaccine" Facebook Profile Photo Frame
Share your excitement about COVID-19 vaccination and inspire your friends. When you have received your COVID-19 vaccine, add IAC's new "I Got My COVID-19 Vaccine" Facebook photo frame to liven up your profile picture! You can obtain the frame in two ways:​​​
  • Click your profile picture, select “update picture,” and then select “add a frame.” Search for #igotmycovid19vaccine and select it.
  • Accept the frame by clicking this link. Together we can end the COVID-19 pandemic!

Five Tips to Help Stop the Spread of COVID-19 (Video)
Be sure to share this short "5 Tips to help Stop the Spread of COVID-19” video from the National Foundation for Infectious Diseases, you never know whom you might reach! Watch the Video

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

Johnson & Johnson Vaccine Update
Following a thorough safety review, including two meetings of the CDC’s Advisory Committee on Immunization Practices, the U.S. Food and Drug Administration and the U.S. Centers for Disease Control and Prevention have determined that the recommended pause regarding the use of the Janssen (Johnson & Johnson) COVID-19 Vaccine in the U.S. should be lifted and use of the vaccine should resume. Learn More

Have you checked out the CDC YouTube Channel? ​​​​​​
The CDC has a series of vaccine safety videos explaining how we know that the COVID-19 vaccine is safe. You can share these videos on your social media platforms to help boost vaccine rates. Watch the Videos

Morbidity and Mortality Weekly Report (MMWR) from the CDC Highlights Vaccine Effectiveness
On April 28th, 2021, the CDC published an early release of the MMWR publication on "Effectiveness of Pfizer-BioNTech and Moderna Vaccines Against COVID-19 Among Hospitalized Adults Aged ≥65 Years —United States, January–March 2021." In a multistate network of U.S. hospitals during January–March 2021, receipt of the Pfizer-BioNTech or Moderna COVID-19 vaccines was 94% effective against COVID-19 hospitalization among fully vaccinated adults and 64% effective among partially vaccinated adults aged ≥65 years. This is great evidence to encourage vaccination for those who are eligible. Learn More

Coffee Regional Vaccination Clinic offers FREE Shot & a FREE Meal
April 23, 2021, Lyon Management, in Douglas, graciously agreed to provide **1,000** FREE food vouch