The November 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. 

Hospital Readmissions Reduction Program 
The Hospital Readmissions Reduction Program is a Medicare value-based purchasing program that encourages hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans and, in turn, reduce avoidable readmissions. Learn More

Look Up Your Hospital: Is It Being Penalized by Medicare? 
Under programs set up by the Affordable Care Act, the federal government cuts payments to hospitals that have high rates of readmissions and those with the highest numbers of infections and patient injuries. Kaiser Health News offers look-up tools for each type of penalty. You can search by hospital name or location, look at all hospitals in a particular state and sort penalties by year. Access Look-Up Tools

CMS Updates Medicare COVID-19 Snapshot
The Centers for Medicare & Medicaid Services (CMS) released a monthly update of data that provides a snapshot of the impact of COVID-19 on the Medicare population. The updated data show over 4.9 million COVID-19 cases among the Medicare population and over 1.3 million COVID-19 hospitalizations. The updated snapshot covers the period from January 1, 2020, to August 21, 2021. It is based on Medicare Fee-for-Service claims and Medicare Advantage encounter data CMS received by September 17, 2021. In addition, CMS released a new supplemental COVID-19 Hospitalizations Trend Report that highlights trends in hospitalization rates over the same time period cut by month and various demographic characteristics. 
View the Updated Snapshot | View the New COVID-19 Hospitalizations Trend Report 

​​​​​​Educational Events

Upcoming Learning and Action Network (LAN) Events

HQIC LAN: One Hospital’s Journey to a Culture of Health Equity: Lessons Learned from a Rural Community
Tuesday, November 23 at 2 p.m. ET | 1 p.m. CT 

Join this exciting presentation to learn about the population health initiatives at Jefferson Healthcare, a rural health system located in Port Townsend, Washington. In 2020, a robust health equity initiative was started that strategically overlapped with hospital operations and focused on the quality and patient safety program. This session will give an overview of Jefferson Healthcare’s culture of equity journey, how data was used to drive decision making for performance improvement and highlight tools and resources to enhance health equity.
Register Now | View Agenda

View All Upcoming Events Here

Past Learning and Action Network (LAN) Events

HQIC LAN: Community Coalitions and HQIC LAN: Applying a Framework to Advance Health Equity
Recorded on October 26
Advancing health equity requires a multifaceted approach. 
Learn about the Brooks PETAL Framework and how to use the framework as a guide for integrating a community driven approach to health equity into our work.
View Slides 

​​HQIC LAN: Exploring Strategies to Prevent Hypoglycemia in Hospitalized Patients, Hosted by Compass (IHC HQIC)
Recorded on October 28
Key takeaways include:
  • Educate front line staff as to why hypoglycemia must be avoided in in-patients.
  • Implement simple ways of finding hypoglycemic events for QI improvement tracking.
  • Look at five charts using the Discovery Tool and find what processes need to be shored up in your hospital.  
View Slides 
Did you find this LAN event useful?

If Yes, Click Below.

Click here if you attended the October LAN event and were able to "use tomorrow" what you heard during the webinar.
View All Previous LAN Event Recordings

Community of Practice (COP) Calls

A series hosted by CMS on the second Thursday of each month at 1 p.m. ET/12 p.m. CT/11 a.m. MT/10 am. PT

Reducing Readmissions: Successful Rural Hospital Strategies  
Thursday, November 18 

Alliant HQIC is hosting this educational event with featured speakers from North Baldwin Infirmary and Marshall Medical Centers in Alabama and Coffee Regional Medical Center in Georgia. Join this presentation to learn how the implementation of tools and strategies that impact a hospital’s culture can significantly affect employee job satisfaction, retention and quality of patient care. That’s why it’s important for hospitals of all sizes to build a culture that values its patients and employees. You’ll learn how three rural hospitals implemented creative ways to build a culture of safety. Through improvement of current processes and the development of new processes, these hospitals have all successfully reduced readmission rates. 
Register Now


  • Jo Ann Nix, RN, BSN, CMSRN - Chief Nursing Officer, North Baldwin Infirmary
  • Lisa Bush, MSN, RN, CEN, CFRN - Manager of Emergency Department, North Baldwin Infirmary
  • Hollie Powell, LBSW, MPH - Director of Case Management, Marshall Medical Center
  • Wendy Griffis, BSN, RN - Administrative Director of Quality and Risk Management, Coffee Regional Medical Center
  • Shan Fields, BSN, RN - Director of Care Management, Coffee Regional Medical Center 

Upcoming Community of Practice (COP) Calls - Save the Date

  • Dec. 9, 2021
  • Jan. 13, 2022
  • Feb. 10, 2022
  • March 10, 2022
  • April 14, 2022
  • May 12, 2022

Let’s ReBoot: Examining Strategies to Reset Culture + Practices Around CLABSI Reduction (Part 2) 
Wednesday, November 10 at 12 p.m. ET | 11 a.m. CT  
Audience: Infection prevention, quality, and/or direct care staff
This second webinar will go beyond the guidelines for CLABSI to address some of the challenging areas of the maintenance bundles including ensuring daily discussion of removal, dressing disruption, variation in bathing practices and blood culture contamination. Strategies for overcoming those challenges are outlined. At the end of each webinar participants will be asked to work through a small test of change regarding a practice area that needs improvement. Register Here 

Patient Safety Network Series

Alliant Health Solutions and our HQIC Partners will continue the Patient Safety Network series beginning in November. These 30-minute sessions will provide resources to support improvement in the specific areas listed below. Register for the session(s) in which your hospital needs assistance. Subject matter experts and quality improvement advisors will offer guidance, resources and tools that will allow participants to identify and develop action plans to address gaps and drive improvement. In addition, participants will have an opportunity to ask questions and share experiences with HQIC improvement staff and peers from other HQIC hospitals.

Adverse Drug Event Opioids and Opioid Stewardship
Thursday, November 11 at 11:30 a.m. ET | 10:30 a.m. CT
Presenters: Jennifer Massey and Lynne Hall
Register Here

The ADE Opioids and Opioid Stewardship sessions will be held the 2nd Thursday of the month.

Thursday, November 11 at 12 p.m. ET | 11 a.m. CT
Presenters: Amy Ward and Rhonda Bowen
Register Here

The IP (C. diff/MRSA, CLABSI, CAUTI) sessions will be held the 2nd Thursday of the month.

Sepsis and Septic Shock
Wednesday, November 17 at 12 p.m. ET | 11 a.m. CT
Presenters: Amy Ward and Rhonda Bowen

Register Here
The Sepsis and Septic Shock sessions will be held the 3rd Wednesday of the month. 

Pressure Ulcers
Wednesday, November 17 at 12 p.m. ET | 11 a.m. CT
Presenters: Sarah Phillips and Tracy Rutland

Register Here
The Pressure Ulcers sessions will be held the 4th Wednesday of the month. The November session is being held on the 3rd Tuesday due to the Thanksgiving holiday.

Anticoagulants and Glycemic Adverse Drug Events
Tuesday, November 30 at 12:30 p.m. ET | 11:30 a.m. CT
Presenters: Jennifer Massey and Carol Snowden
Register Here
The Anticoagulants and Glycemic ADE sessions will be held the 4th Tuesday of the monthThe November session is being held on the 5th Tuesday due to the Thanksgiving holiday.

Wednesday, December 1 at 2 p.m. ET | 1 p.m. CT
Presenters: Mel Brown and Sarah Good
Register Here

The Readmission sessions will be held the 1st Wednesday of the month.

COVID Office Hours - IP Chat

Alliant hosts weekly COVID Office Hours–IP Chat for Infection Preventionists and other healthcare providers to discuss the challenges and solutions of COVID patients in hospitals. The Office Hours–IP Chat is led by Alliant’s Infection Prevention Specialist Amy Ward, MS, BSN, RN, CIC, who facilitates the open discussion and answer any questions. Questions? Email Amy Ward at Click Here for the Schedule and to Join a COVID Office Hours-IP Chat.

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 

Discontinuing Use of Alliant Quality 
On Monday, Nov. 1, Alliant Health Solutions officially discontinued use of the Alliant Quality name, logo and brand. Alliant will now use the Alliant Health Solutions name, logo and brand in mention of all HQIC work.
So what has changed?

  • Website visitors who visit are now redirected to
  • Our social media channels (Facebook, Twitter, YouTube) now have the Alliant Health Solutions logo.
  • All of our materials and collateral will have the Alliant Health Solutions logo.

If you produce any collateral or presentations using our logo, Click Here to download the Alliant Health Solutions logo for official use.

Behavioral Health/Opioid Stewardship

Pandemic Created a Record High Number of Drug Overdose Deaths
The Covid-19 pandemic has impacted America in numerous ways. One of those ways can be seen in recent opioid-related overdose data. A record high of 96,779 drug overdose deaths occurred between March 2020 and March 2021, representing a 29.6% rise, according to statistics from the U.S. Centers for Disease Control and Prevention's National Center for Health Statistics. However, the numbers are provisional, and the CDC's estimate for predicted deaths totals more than 99,000 from March 2020 to March 2021, CNN reported.

Naloxone saves lives! Naloxone is an overdose reversal agent that can be easily administered if it is available. The CDC reports that only one Naloxone prescription is dispensed for every 70 high-dose opioid prescriptions. However, co-prescribing Naloxone is recommended for patients at risk for opioid overdose. 

Ask your doctor or pharmacist for a naloxone prescription if you are a loved one are taking high-dose opioids or have a substance use disorder. Find sources for Naloxone and other harm reduction resources near you. Find Harm Reduction Resources Here

Clinical Decision Support (CDS)
CDS Connect demonstrates how evidence-based care can be rapidly incorporated into clinical practice through interoperable decision support. CDS Connect has built several projects around helping patients, clinicians and health systems respond to the opioids crisis.

  • The Pain Management Summary gives providers a structured view of relevant medical record data and decision support to guide individualized chronic pain management.
  • Two recently funded projects will build on the CDS Connect experience to include developing, implementing, disseminating and evaluating CDS for both patients and clinicians in the area of chronic pain management.
    • Project one focuses on evaluating and developing reusable and shareable CDS knowledge artifacts to reduce the time to implementation.
    • Project two will track and manage pain and daily function to support opioid-dose reductions.
  • Opioids and Pain Management artifacts facilitate the integration of recommendations from the CDC 2016 Opioid Prescribing Guidelines directly into an EHR.

Patient Safety​​​​​

Adverse Drug Events

Incidence of Prescription Errors in Patients Discharged from the Emergency Department
The Emergency Department (ED) is known for its high rates of medication errors secondary to many characteristics, such as unfamiliar patients, lack of continuity of care, increasing patient volumes, reliance on verbal orders and fewer safety mechanisms. ScienceDirect published a study to quantify and characterize the medication errors in patients discharged from the ED. Read the Study

Pain Assessment and Management Initiative (PAMI) at UF College of Medicine-Jacksonville
The overall goal of PAMI is advancement of multimodal, safe pain management in healthcare systems to improve outcomes and reduce opioid risk. Multimodal management includes a variety of pharmacologic and non-pharmacologic interventions to address opioid stewardship, discharge planning and safe pain management.
Visit the PAMI website for free educational materials on safe pain management practices for clinicians and patients and access to all PAMI products. Educational materials include: 

  • Pain Management and Dosing Guide
  • Discharge Planning Toolkit for Pain
  • Patient Educational Videos
  • Non-pharmacologic and Distraction Toolkit/Toolbox
  • Communication cards in Spanish and Creole with pain terms

Healthcare-Associated Infections

Sepsis Opportunities: Lessons from the COVID-19 Pandemic 
The ongoing COVID-19 pandemic has caused hundreds of millions of infections, millions of deaths and disrupted daily life worldwide. We rapidly learned about the pathogenesis, prevention and treatment of this disease. Severe COVID-19 is characterized by the body’s extreme reaction to the infection, which means it could be considered a form of sepsis requiring specific interventions and typical sepsis supportive care. Many hospitalized COVID-19 patients are diagnosed with sepsis. We can draw several lessons from global efforts to track and mitigate the impact of COVID-19, or SARS-Cov-2 infection. Read More

Behavior, Behavior Change and Hand Hygiene 
Help your hospitals learn why and how to facilitate hand hygiene compliance. Share the Centers for Medicare & Medicaid Services Behavior, Behavior Change and Hand Hygiene free online learning module. This is one of four modules available to your hospitals as a part of the Standards, Approaches and Tactics for Infection Control & Prevention (StAT) Learning Series for hospital clinical staff and leaders. Visit to learn more. 

Antibiotic Stewardship

Toolkit to Improve Antibiotic Use in Acute Care Hospitals 
The Agency for Healthcare Research and Quality's (AHRQ) Acute Care Hospital Toolkit helps hospitals improve antibiotic stewardship and promote safer prescribing. The toolkit explains the Four Moments of Antibiotic Decision Making, and has tools to support their implementation and improve prescribing in three areas: developing and improving an antibiotic stewardship program, creating a safety culture around antibiotic prescribing, and disseminating best practices for common infectious diseases. Get the Toolkit

Toolkit for Reduction of Clostridium difficile Infections Through Antimicrobial Stewardship 
This AHRQ toolkit assists hospital staff and leadership in developing an effective antimicrobial stewardship program with the potential to reduce Clostridium difficile (C. difficile). Get the Toolkit

Pressure Injuries

COVID-19 Resources for Pressure Injury Prevention 
The National Pressure Injury Advisory Panel (NPIAP) is an independent not-for-profit professional organization dedicated to the prevention and management of pressure injuries. Click Here to read a paper entitled Unavoidable Pressure Injury during COVID-19 Pandemic: A Position Paper from the NPAIP.

NHSN Reporting 

Report Healthcare Associated Infection Data to NHSN Every Month 
All enrolled hospitals are highly encouraged to report Healthcare Associated Infection data to the National Healthcare Safety Network (NHSN) database every month ​​​so meaningful data analysis and opportunities for improvement can be identified. Contact Alliant Quality’s Infection Prevention Specialist, Amy Ward, at with any questions or technical assistance needs. NHSN Monthly Reporting Checklist

Patient and Family Engagement

Restarting and Energizing PFACs–Easy to Implement How-To-Lists 
The Consumers for Advancing Patient Safety (CAPS) is an organization that envisions a partnership between consumers and providers to create global healthcare systems that are safe, compassionate and just. Join the Zoom series for Restarting and Energizing PFACs–Easy to Implement How-To-Lists hosted by CAPS and Healthcare and Patient Partnership Institute (H2Pi). Click here for Building and Using an Agenda How-To-List
Next Zoom Webinar: Meeting Facilitation
Nov 9, 2021 at 4 p.m. ET | 3 p.m. CT 
Register Here 

Health Equity

Better Health Literacy Improves Patients’ Outcomes 
As a new AHRQ Views blog explains, care and outcomes improve when patients communicate effectively with their healthcare team. Therefore, during this Health Literacy Month, AHRQ encourages healthcare organizations to adopt health literacy strategies to help patients better understand health information. Check out some of AHRQ’s many free resources to help organizations become more health-literate: 

Health literacy is a foundational principle and overarching goal of Healthy People 2030, which established three core objectives for improving organizational health literacy. AHRQ tools can help our country achieve these objectives. 

An Equity Agenda for the Field of Health Care Quality Improvement 
A new National Academy of Medicine study identified health equity as an immediate strategic priority for the health care quality movement in the next 20 years. Particularly, racial equity in discussions of quality could be resolved by revisiting existing recommendations, ensuring diversity in leadership, improving data collection and reporting on demographics and patient experiences, engaging and partnering with communities and re-evaluating current care delivery and payment infrastructures. Read the Study

Rural Health Promotion and Disease Prevention Toolkit Lists 
This toolkit for rural health settings is designed to help organizations identify and implement a health promotion program. It also provides resources and best practices for health promotion and disease prevention tailored to rural communities. Get the Toolkit

Achieving Health Equity 
Are your NQIIC communities re-examining their health equity initiatives? This two-hour online course from the CMS Medicare Learning Network presents  education on identifying and eliminating health disparities in organizations. Health equity improves the quality of health care for the individuals and families in NQIIC communities and aligns your stakeholders’ efforts with CMS strategic goals. Take the Course

​​Readmissions/Care Transitions​​​​

Interventions To Improve Communication at Hospital Discharge and Rates of Readmission 
Discharge from the hospital represents a vulnerable time for patients. A systematic review from the Patient Safety Network assessed the impact of discharge communication on hospital readmissions, adherence to treatment regimen, patient satisfaction, mortality, and emergency department visits 30 days after hospital discharge. Findings suggest that improved communication at discharge reduced 30-day hospital readmissions and increased adherence to treatment regimen. Read the Review 

Reduce Readmissions by Partnering With Patients and Families 
The principles and recommendations in Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human still hold true. Recommendation #7, Partner with Patients and Families for the Safest Care, is being emphasized in the literature and was a recent learning event held by CMS. Learn more by watching the Oct. 14 CMS Communities of Practice call. Readmission Reduction: Transforming into a Care Partner Hospital | Download the Free from Harm Report (Must sign in to IHI) 

Readmissions and Medications 
One of the top reasons for readmission is the lack of understanding and adherence to medications. Studies have consistently shown that 20%-30% of medication prescriptions are never filled and that approximately 50% of medications for chronic disease are not taken as prescribed. For education on how to improve medication adherence, see: AMA Medication Adherence Steps to Improve Patient Outcomes and Reduce Costs and Medication Adherence as a Predictor of 30-day Readmissions

Evolving Factors in Hospital Safety: A Systematic Review and Meta-Analysis of Hospital Adverse Events 
Hospital adverse events are common and can contribute to serious patient harm. A systematic review from the Patient Safety Network included 94 studies (representing 590 million admissions from 25 countries) examining trends in hospital adverse events from 1961 to 2014. Findings indicate that hospital adverse events have increased over time and that over half are considered preventable. Read the Review 

COVID-19 Care

Special and Vulnerable Populations COVID-19 Forum 
Beginning Friday, November 19 at 2 p.m. ET 
Join the upcoming Special and Vulnerable Populations Forum! The forum will begin with four, one-hour sessions that will address how COVID-19 has impacted health centers across the country and the special populations they serve. Suma Nair, Ph.D., MS, RD, director of the Bureau of Primary Health Care's Office of Quality Improvement, will provide health centers with up-to-date information about COVID-19, specifically how health centers may be supported as they recover and stabilize their workforce while continuing to respond to the national pandemic. The forum will identify, share and promote promising practices, while highlighting and addressing challenges. Register Here

Micro Grant Funding Opportunity: National COVID-19 Resiliency Network (NCRN)
The Morehouse School of Medicine NCRN Community Engagement Core is happy to announce the third round of funding opportunities for the Regional Community Coalition (RCC) micro grant. We are now inviting non-profit community-based organizations (CBOs) to submit proposals to apply for funding. The proposal must detail a program(s) designed to connect racial and ethnic minorities to COVID-19 mental health resources and services to help individuals and communities become more resilient and promote strategies for improved mental and emotional health. Apply for the Grant 

Important dates to note:

  • Deadline for submitting applications: Wednesday, Nov. 10 at 11:59 p.m. EST​
  • Decisions will be announced on or before Nov. 22
  • Grant period: Jan. 15, 2022 – March 15, 2022
  • NCRN will fund up to five $10,000 grants among the 10 Health and Human Services U.S. regions. NCRN expects to have one awardee per region but may award more per region depending on the number of applications received. For questions, email NCRN at or Stacy Hull, Alliant NCRN program director at

Alliant Health Solutions is a strategic partner in the National COVID-19 Resiliency Network.

COVID-19 Vaccine Resources

​​​​​​Immunization Action Coalition Provides Weekly News and Updates 
The Immunization Action Coalition (IAC) provides information, updates and resources for vaccinators. Their newsletter includes new and updated vaccine information sheets in 14 languages. View the IAC August Newsletter 

COVID-19 Vaccination Coverage Among Healthcare Personnel 
On Oct. 12, the American Hospital Association hosted a webinar to provide an overview of the new CMS HCP COVID-19 Vaccination measure. The online event gave helpful information on the Hospital Quality Reporting Program, including Hospital IQR and NHSN reporting requirements. Webinar Recording | Presentation Slides 

Immunocompromised Medicare Patients Can Receive an Additional COVID-19 Dose at No Cost 
In response to the Food and Drug Administration’s (FDA) recent action that authorizes an additional dose of the COVID-19 vaccine for immunocompromised individuals, CMS is assuring people with Medicare who qualify for an additional dose that they can receive it at no cost. Medicare will pay for administering an additional dose of COVID-19 vaccines consistent with the modified FDA emergency use authorization announced in August. View the FDA Announcement | CMS COVID-19 Provider Toolkit

​​​​​Alliant Health Solutions 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 Health Solutions COVID-19 Vaccine Resources
Best Practices​​​

Wellstar Appoints Chief Diversity, Equity & Inclusion Officer 
Wellstar Health System, one of Georgia’s largest and most integrated healthcare systems, has hired Le Joyce Naylor as senior vice president and chief diversity, equity, & inclusion officer. Naylor began her role on Aug. 2 to provide system-wide thought leadership, strategic planning and implementation of DE&I initiatives at Wellstar. Read More 

Phoebe Begins Offering Booster Shots and Urges Vaccination for Pregnant Women 
Phoebe (Albany, Ga.) began administering COVID-19 booster shots to eligible southwest Georgians at mass vaccination sites in Albany and Sylvester. To date, 596 community members received a third dose. Phoebe is also providing the booster shots to its employees and will open a community mass vaccination site in Americus, Ga.
​​​​​​Phoebe is also urging pregnant women to get vaccinated after the CDC issued an urgent health advisory this week strongly encouraging pregnant women to get vaccinated. The vaccination rate among pregnant women in the United States is less than half of the overall vaccination rate, and evidence shows pregnant women are at increased risk for severe illness from COVID-19. Read More

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Hospital Quality Improvement Project Collaborators

Copyright © 2021, All rights reserved.

Our mailing address is:

Alliant Health Solutions
1455 Lincoln Pkwy
Suite 800
Atlanta, GA 30346

For more information about Alliant Health Solutions, visit the website:

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

Donna Cohen, Director, Quality Projects

Karen Holtz, Training and Education Lead, Hospital Quality

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This material was prepared by Alliant Health Solutions, the Medicare Quality Innovation Network-Quality Improvement Organization for Alabama, Florida, Georgia, Kentucky, Louisiana, North Carolina, and Tennessee, 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 document 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 or that product or entity by CMS or HHS. 12SOW-AHS-TO3-HQIC-1072-11/03/21
Copyright © 2021, All rights reserved.

Our mailing address is:

Alliant Health Solutions
1455 Lincoln Pkwy
Suite 800
Atlanta, GA 30346