The June 2021 issue of the Hospital Quality Improvement Newsletter featuring the latest insights and resources. Email not displaying correctly?
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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).
Centers for Medicare and Medicaid Services (CMS) Proposed Rule for Inpatient Prospective Payment System (IPPS) Released​​​​​
CMS has released their IPPS for 2022 (CMS-1752-P). In the rule they have proposed to adopt a maternal morbidity measure beginning October 1st, which would affect the FY2023 payment determination for PPS facilities. This is a completely different measure track for facilities as previously the measures have been more specific to the Medicare population. Learn More
​​​​​​Educational Events

Save The Date

Alliant Hospital Quality Improvement Contractor (HQIC) Onboarding
Monday, June 14 at 1:00 p.m. ET (60 min)
Join this exciting presentation as Alliant Health and collaborating partners welcome our enrolled hospitals of the CMS Hospital Quality Improvement Contractor (HQIC) program. Featured speakers will provide a program overview including goals, data measures, educational opportunities, technical assistance, and other resources for hospitals to succeed. Learn more about the hospital portal including how to network with other hospitals and peers.

  1. Discuss an overview of the HQIC program including core leadership team and goals 
  2. Explain the data metrics used to measure performance improvement for the program and individual hospitals
  3. Describe educational Learning and Action Network (LAN) events, subject matter experts and collaborating partners providing customized coaching to hospitals
  4. Provide a demo of the hospital portal including reports, assessments, and discussion boards
Register Now
Upcoming Learning and Action Network (LAN) Events

HQIC LAN: Monoclonal Antibody Therapy for High Risk COVID Patients
Tuesday, June 22 at 2:00 p.m. ET (30 min)
Since their initial emergency authorization in November, monoclonal antibodies have been an important weapon in the fight against COVID-19. These products have proven to be effective at preventing hospitalization and death due to COVID-19 in some of the highest risk patients. This presentation will provide an overview of these products, the data behind their emergency authorization, and the clinical considerations around their use.

Learning Objectives:
  1. Identity and review the currently authorized COVID-19 monoclonal antibody therapies and the requirements associated with their emergency use.
  2. Demonstrate how the use of monoclonal antibodies can reduce hospitalization and death in those at highest risk for negative outcomes from COVID-19.
  3. Share tools and resources available to providers and patients interested in monoclonal antibody therapy.
Register Now | Download Event Flyer

View All Upcoming Events Here

Past Learning and Action Network (LAN) Events

HQIC LAN: Antibiograms and Infection Prevention Efforts to Combat Antimicrobial Resistance During COVID-19
Recorded on May 25, 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.  
​​​​​​​​​​​​​​Watch Recording View Slides
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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

COVID-19, Health Equity and Vaccine “Hesitancy”
Wednesday, June 9 at 1:00 p.m. ET (60 min)
The coronavirus (COVID-19) pandemic has revealed deep-seated inequities in health care and amplified social and economic factors that contribute to poor health outcomes. These factors have also influenced how the COVID-19 vaccines were developed and how they have been rolled out. During this webinar hosted by the TMF, attendees will explore and discuss how these factors have and continue to impact our communities. 
Register Now

A Health Equity Perspective on Loneliness, Mental Health and COVID-19
Tuesday, June 22 at 1:00 p.m. ET (60 min)
Register today to attend this TMF Quality Innovation Network webinar, which will also feature Octavio N. Martinez, Jr, MD, MPH, MBA, FAPA, with the The Hogg Foundation for Mental Health at The University of Texas Austin. Loneliness was a mental health issue prior to COVID-19. The pandemic has exacerbated and contributed to increased isolation. During this webinar, attendees will explore and discuss this issue through a health equity lens. 
Register Now

New! HQIC Online Portal for Accessing Data and Peer-to-Peer Learning View Data Reports and Peer to Peer Discussions by Topic
Alliant Health and our HQIC partners have launched a new Alliant Quality portal for our participating hospitals. This portal allows you to view your assessments and measurement data, and chat with other HQIC-enrolled hospitals to share best practices, barriers, and solutions. Register today to quickly access your data when you need it and network with your peers! 
Download Portal Instructions to Get Started | Access Portal


Behavioral Health/Opioid Stewardship

Issue Brief: Reports of Increases in Opioid and Other Drug-Related Overdose and Other Concerns During COVID-19 Pandemic
The American Medical Association (AMA) has put together a brief on the nations opioid pandemic with updates related to COVID-19. Almost every state has reported an increase in opioid or drug-related mortality during the pandemic. This issue brief provides the latest updates to this ongoing issue with resources, action steps, and a summary of reports. Learn More

Opioid Prescribing for Older Adults with Alzheimer’s Disease and Related Dementias (ADRD) 
Potential inappropriate opioid prescribing may be more common among patients with Alzheimer’s Disease and Related Dementias (ADRD) than among patients without ADRD in community, hospital, or nursing home settings. Further studies aimed at understanding the factors and effects associated with opioid prescribing patterns that deviate from guidelines are warranted. Drug combinations can raise the risk of dangerous side effects, and in some cases hasten cognitive decline. Learn More

Chronic Pain Explained: Experts on What You Need to Know
The CDC reports that chronic pain is one of the most common reasons adults seek medical care. And the pain itself isn’t the only problem. Chronic pain is linked to anxiety, depression, a reduced quality of life and an increased risk of opioid addiction in the United States – not to mention other mental stresses that can lead to insomnia and chronic fatigue. Learn how pain becomes chronic and what you can do about it. Learn More

Patient Safety​​​​​

Antibiotic Stewardship

Appropriate Use of Short-Course Antibiotics in Common Infections: Best Practice Advice from the American College of Physicians (ACP)
The American College of Physicians (ACP) recently issued best practice advice for the appropriate use of short-course antibiotics in the treatment of four common infections. The report, published in the Annals of Internal Medicine, was based on available evidence for acute bronchitis with chronic obstructive pulmonary disease (COPD) exacerbation, community-acquired pneumonia (CAP), urinary tract infections (UTI) and cellulitis. Learn More

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


Resources to Prevent CLABSI - CDC TAP Implementation Guide & AHRQ Technical Interventions Guide
It may be time to review your CLABSI prevention efforts! Check out the CDC TAP Implementation Guide and the AHRQ Toolkit for Reducing CLABSI and consider completing a CLABSI prevention gap assessment this quarter! View CDC Tap Implementation Guide | View AHRQ Toolkit for Reducing CLABSI

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


Treatment patterns and clinical outcomes after the introduction of the Medicare Sepsis Performance Measure (SEP-1)
Starting in 2015, the Centers for Medicare & Medicaid Services has required hospitals to report adherence to the Severe Sepsis and Septic Shock Early Management Bundle (SEP-1). This study examined sepsis patient encounters at one health system two years before and two years after SEP-1 implementation. Results indicate variable changes in process measures but no improvement in clinical outcomes. The authors suggest revising the measure with more flexible guidelines that allow clinician discretion may improve patient outcomes. Read 'Treatment Patterns and Clinical Outcomes after the Introduction of the Medicare Sepsis Performance Measure (SEP-1)' from AHRQ

Health Equity​​​​
AHRQ: Annual Health Quality and Disparities Report
For the 17th year in a row, AHRQ is reporting on healthcare quality and disparities. The annual National Healthcare Quality and Disparities Report is mandated by Congress to provide a comprehensive overview of the quality of healthcare received by the general U.S. population and disparities in care experienced by different racial and socioeconomic groups. The report describes quality in terms of six priorities: patient safety, person-centered care, care coordination, effective treatment, healthy living, and care affordability and is based on more than 250 measures of quality and disparities covering a broad array of healthcare services and settings. Get the Report

Readmissions/Care Transitions​​​​

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).

COVID-19 Care

Protecting Workers: Guidance on Mitigating and Preventing the Spread of COVID-19 in the Workplace
OSHA updated guidance on January 29, 2021 for protecting workers (specific to COVID). View Updates

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

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

COVID-19 Updates for Vaccinated/Unvaccinated
The COVID-19 vaccines are changing how we protect ourselves and others. Guidance has been updated here for those who are fully vaccinated, unvaccinated and some other situations. Find the current update, as well as links to the COVID-19 tracking map, here: COVID-19 Updates

CDC and FDA Issue New Recommendations for Pfizer COVID-19 Vaccine
After months of usage and millions of doses given, the CDC and FDA have approved and made new recommendations for the use of Pfizer's COVID-19 vaccine with the removal of the recommendation for a two-week pre/post barrier from other vaccines. Storage recommendations are also being modified. These changes will better accommodate smaller clinics and immunizers and will assist in reversing the alarming trend in deferred childhood immunization rates. Read More About the New FDA Emergency Use Authorization: EUA amendment | Read the Fact Sheet

CDC COVID-19 Vaccine Webinar Series
The Centers for Disease Control and Prevention (CDC) is offering a series of 15-20 minute interactive, web-based trainings to address issues related to COVID-19 vaccination. These trainings are intended for immunization providers, such as physicians, nurses, nurse practitioners, pharmacists, physician assistants, medical students, state and local immunization programs and others authorized to administer vaccines. Topics range from routine clinical and vaccine safety information to guidance for on-site clinic vaccination activities and patient education. Continuing education credits are available. Learn More

Building COVID-19 Vaccine Confidence Partner Webinar: Recording Now Available
On May 13, 2021, the Centers for Medicare & Medicaid Services Office of Minority Health (CMS OMH) hosted a Building COVID-19 Vaccine Confidence partner webinar to provide information and resources to help partners address vaccine hesitancy in their communities. Guest speakers from the Centers for Disease Control and Prevention (CDC) and the U.S. Food and Drug Administration (FDA) joined and shared their insights. Access the Webinar Recording and Slides
Leadership Corner & Best Practices

Data Transparency to Foster a Culture of Patient SafetyPhoto of Jackson Health's wall display of Trauma 3 A Performance Improvement data displayed
At Jackson Health System in South Florida, a key element of fostering a culture of patient safety is data transparency. Quality improvement measures and patient safety outcomes are displayed on performance improvement boards located on floors and units throughout the hospitals and highlight the number of consecutive months of “0” harm events. Isis Zambrana, Vice President and Chief Quality Officer, noted that they have a lot of processes in place and are diligently working to continue improving outcomes. She added, “What gets measured, gets managed.” Learn More

South Georgia Medical Center (SGMC) Launches Kindness Campaign
It's been said that kindness is the best medicine. With the past year being particularly challenging for health care professionals, South Georgia Medical Center is launching a campaign asking the community to help spread kindness among its team members. The campaign features a video of healthcare employees taking a moment to thank a fellow team member who made an impact on their life over the last year. The video ends with a call to action, to give a dose of kindness. View the Video and Participate in the Kindness Campaign

Telehealth Strategies - Emory Healthcare Links EMS Providers to Telehealth for Emergency Care
Emory Healthcare's new ER-TEMS program gives rural EMS providers a telehealth link to ER doctors and specialists at the Atlanta hospital, helping to triage and treat patients in an emergency. Telehealth strategies. Emory Healthcare is partnering with Grady EMS on the Emory Rural Tele-EMS Network (ER-TEMS), which aims to improve care coordination and management in 14 rural counties in the southern part of the state. The program is funded by a four-year $1.2 million grant from the Health and Human Services Department's Health Resources and Services Administration (HRSA). The program is designed to give EMS crews support in cases where access to ER physicians or specialists is critical. Through a virtual link, the Atlanta-based Emory care provider can work with the EMS crew or call-in specialists from the health system. The platform also enables providers at Emory to look at data from mHealth devices and the patient's medical record. Learn More

Hospital Heroes​​​

Optim Medical Center-Tattnall in Georgia is One of Only 332 Hospitals with the Lowest Rates of Catheter associated Urinary Tract Infections in the U.S.
Catheter-associated urinary tract infection (CAUTI) is the most common type of healthcare-associated infection, accounting for more than 30% of acute care hospital infections in the United States. It has been associated with increased morbidity, mortality, hospital cost, and length of stay. Every year there are 13,000 deaths associated with urinary tract infections (UTI) and an estimated 449,334 CAUTI events.

Optim Medical Center-Tattnall, located in Reidsville, Georgia, and part of the Optim Health System network, is one of only 332 hospitals nation-wide to receive the best possible score of zero, according to data from CMS' Hospital Compare website. In total, 2,203 hospitals received a numeric calculation of the standardized infection ratio on data collected from January 1, 2019, through December 31, 2019. “We are thrilled to have earned a perfect CAUTI score of zero,” commented Lora Duncan, Optim Health System’s Chief of Nursing and Clinical Operations. “Patient safety is at the forefront of everything we do at Optim Medical Center-Tattnall emphasizing the significant amount of attention we place on achieving superior outcomes for our patients. We take great pride in the fact that patients choose to come to our hospital knowing they’ll receive outstanding care and are proud of our clinical team for another outstanding accomplishment.”
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Hospital Quality Improvement Project Collaborators

For more information about Alliant Quality, visit the website:

For questions or information about free technical assistance, please contact: 

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Karen Holtz, Training and Education Lead, Hospital Quality

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This material was prepared by Alliant Quality, the quality improvement group of Alliant Health Solutions (AHS), the Hospital Quality Improvement Contractor (HQIC) under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No.
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