The August 2022 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 Administrator's National Call Recording and Transcript Now Available 
The National Stakeholder Call with the CMS Administrator was held on July 19. The call featured CMS Administrator Chiquita Brooks-LaSure and her leadership team, who provided updates on CMS’ recent actions and how CMS cross-cutting initiatives (CMS Strategic Plan) are improving quality of care and expanding access to health coverage. Guest speaker Tom Coderre, deputy assistant secretary from the Substance Abuse and Mental Health Services Administration (SAMHSA), reviewed SAMHSA’s Suicide & Crisis Lifeline and the new 988 dialing code. Listen to the CMS National Stakeholder Calls

Biden-Harris Administration Takes Action To Expand Access to Emergency Care Services in Rural Communities
As part of the Biden-Harris Administration’s ongoing effort to strengthen rural health, CMS is releasing a new proposed rule protecting access to emergency care and additional outpatient services for people in rural communities. CMS is establishing the Conditions of Participation (CoPs) for REHs. The proposed rule will allow small rural hospitals to seek this new health care provider designation and provide continued access to emergency services, observation care, and additional medical and outpatient services. In accordance with the statutory legislation, REHs will be eligible to receive payment for services provided on or after January 1, 2023. Learn More

Conditions of Participation for Rural Emergency Hospitals and Critical Access Hospital COP Updates (CMS-3419-P)
Rural Emergency Hospitals (REHs) are a new provider type established by the Consolidated Appropriations Act of 2021 to address the growing concern over closures of rural hospitals. The REH designation provides an opportunity for Critical Access Hospitals (CAHs) and certain rural hospitals to avert potential closure and continue to provide essential services for the communities they serve. This new provider type will promote equity in health care for those living in rural communities by facilitating access to needed services. Learn More

​​​​​​Educational Events

​​​​​​Upcoming Learning and Action Network (LAN) Events
Sepsis Care in 2022: Identification and Management Strategies to Optimize Patient Outcomes
Thursday, August 25, 2022, at 1 p.m. ET  
The objectives of this webinar are to:
  1. Summarize the four-tier process for effective sepsis program development
  2. Examine the evidence for the sepsis bundles and share proven strategies to resolve barriers in implementation and measurement.
  3. Identify gaps between the evidence and your hospital’s sepsis program

View Agenda | Register Here

Past Learning and Action Network (LAN) Events

Infection Prevention Back to Basics: Multi-Drug Resistant Organisms (MDROs)
Recorded on July 28
This webinar featured strategies for getting “back to basics” when it comes to preventing MDROs, particularly hospital-onset C. difficile and Methicillin-Resistant Staphylococcus Aureus (MRSA) bacteremia. Participants also learned methods for integrating the patient voice into infection prevention.
View Slides

View All Upcoming Events Here

Did you find this LAN event useful?

If Yes, Click Below.
Click here if you attended the June 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

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 am. PT. The calls are open to all Alliant HQIC hospitals. 

Readmissions: Multiple-Admission Patients 
Thursday, August 11
EQIC developed the Multiple-admission Patient Program that provides best practices to identify patients frequently admitted to the hospital and address contributing factors for admission or readmission. EQIC’s four-step framework helps hospitals design a MAP program, identify patients that meet MAP criteria, assess risk factors upon admission and customize individual interventions to decrease admission or readmission. EQIC uses a collaborative approach by including care partners and community-based organizations to address patients' behavioral, social and clinical needs.
Register Here

Monthly Office Hours-IP Chat

Alliant Health Solutions hosts this chat on the 4th Wednesday of every month from 2-2:30 p.m. ET

IP Chats are monthly networking events to build knowledge, share experience and provide support for hospital infection preventionists. For more information, visit the Alliant website. Questions? Contact Amy Ward at
Register for each of the following sessions. 

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 

Behavioral Health/Opioid Stewardship

CDC’s New Fatal Overdose Data Visualization Dashboard From the State Unintentional Drug Overdose Reporting System (SUDORS) 
The CDC’s Division of Overdose Prevention developed an interactive data visualization tool, the SUDORS dashboard, that displays fatal overdose data from 2020. Participating jurisdictions provide data abstracted from multiple data sources, including death certificates, medical examiner/coroner reports and postmortem toxicology. These sources offer valuable fatal overdose data about drugs involved in the following:

  1. Overdose deaths
  2. Demographic characteristics
  3. Circumstances surrounding overdose deaths 
  4. Potential opportunities for intervention

Learn More 

Wellstar West Georgia Medical Center Offering Acute Withdrawal Management Services for Alcohol and/or Opioid Addiction
Wellstar West Georgia Medical Center partnered with Evergreen Healthcare Partners to develop an inpatient three- to five-day acute withdrawal management service for adults requiring medical management of withdrawal symptoms. Read More  

CHIME Opioid Playbook

The CHIME Opioid Playbook was created by CIOs and CMIOs for CIOs and CMIOs to help them develop a program to help their providers, health care organizations and patients be successful. The playbook provides a framework to build IT-based supports for launching and maintaining system-wide initiatives to reduce the disease of opioid addiction in our communities. It is based on the knowledge, experience, and insights from the diverse membership of CHIME and CHIME Foundation partners, with real-world examples, best practices and links to valuable resources. The playbook is tailored to CIOs and CMIOs who serve as members of their organization’s Opioid Stewardship Committee, but others will find it to be a useful guide to understanding technology’s role in creating a solution. Learn More

​​​​​​Patient Safety​​​​​

Safety Awareness

Implementing Root Cause Analysis and Action: Integrating Human Factors To Create Strong Interventions and Reduce Risk of Patient Harm 
Human factors play an important role in contributing to and preventing adverse events. A study published by the Patient Safety Network found that integrating human factors into a new root cause analysis process led to an increase in the number of strong interventions implemented after adverse events. Learn More

​​​​​​Adverse Drug Events

Monitoring Preventable Adverse Events and Near Misses
Organizations may employ one or more methods for identifying and examining near misses and preventable adverse events, including structured record reviews, web-based incident reporting systems and daily safety briefings. Using each of the three methods, a study published by the Journal of Patient Safety identified the number and types of near misses and adverse events. Results indicate that each method identifies different numbers and types of adverse events, suggesting a multi-focal approach to adverse event data collection may more effectively inform organizations. Read the Study

Antibiotic Stewardship

AHRQ Program Lowers Antibiotic Prescribing by Nearly Half in Ambulatory Clinics: JAMA Study
Antibiotic prescribing in ambulatory care clinics was cut nearly in half after participating in an Agency for Healthcare Research and Quality (AHRQ) Safety Program, a new study in JAMA Network Open finds. AHRQ’s Safety Program was deployed in 389 ambulatory clinics to establish or improve stewardship programs, which are internal programs that promote appropriate antibiotic use. Researchers found that antibiotic prescribing at participating clinics was cut overall by nearly 48% while prescribing for acute respiratory infections was reduced by 37%. Read the Study

Infection Prevention and Control

Top Reasons to Report Infection Control Data to NHSN 
Stay up-to-date with your data collection and reporting by scheduling a monthly meeting with yourself to enter your infection control data into the
National Healthcare Safety Network (NHSN). The top reasons to report your infection control data are:

  • The “gold standard.” CDC’s NHSN is the nation’s most widely used healthcare-associated infection (HAI) tracking system.
  • Data: NHSN provides your hospital, state, region, and the nation with standardized data to identify problem areas and measure the progress of prevention efforts.
  • Reports: Instant access to user-defined and standard reports to track and trend to identify issues and confirm your excellence in prevention efforts.
  • Benchmarks: Provides benchmarks on the progress of infection prevention.
  • Regulatory: The CAH must have active facility-wide programs for the surveillance, prevention and control of HAIs and other infectious diseases and the optimization of antibiotic use through stewardship.
  • NHSN is a tool to help you track, monitor and report to your leadership and governing board.
  • Patient Safety: It’s all about your patients - a tool for patient safety.

Patient and Family Engagement

Guide to Patient and Family Engagement in Hospital Quality and Safety 
Research shows that when patients are engaged in their health care, it can lead to measurable improvements in safety and quality. The Agency for Healthcare Research and Quality’s (AHRQ) Guide to Patient and Family Engagement in Hospital Quality and Safety focuses on strategies to promote patient/family engagement to improve hospital safety and care. Get the Guide to Patient and Family Engagement

Patient Safety a Patient Experience Issue for 25% of Medicare Members
One-quarter of Medicare
beneficiaries receiving treatment in an acute care hospital in 2018 experienced some sort of adverse patient safety event, according to a recent HHS Office of Inspector General (OIG) report. In addition, if the patient was readmitted within 30 days of initial discharge, their records were passed onto phase two of the analysis where physicians reviewed for possible harm events. Those physicians also looked at the severity of events, with every event included in the assessment regardless of whether it was preventable. Overall, 25 percent of Medicare members experience some sort of adverse patient safety event, 12 percent of which were considered adverse events or events that led to longer hospital stays, permanent harm, life-saving intervention or death. Read the Article 

​​​​​​Health Equity

Collecting REaL Data Scripts
Collecting patient demographic and language data across health care systems is an important first step toward improving population health. Comprehensive patient data on race, ethnicity and language (REaL) are key to identifying disparities in quality of care and targeting quality improvement interventions to achieve equity. Standardized scripting can help with asking questions. 
Click on the links below or check out the scripts on the Alliant HQIC website:  

  • AHA Disparities: How to Ask the Questions - We recommend that health care organizations/health plans provide a rationale for why they are asking patients/enrollees for information about their demographic and communications background. Suggested wording for the rationale is:
    "We want to make sure that all our patients get the best care possible. We would like you to tell us your racial/ethnic background so that we can review the treatment that all patients receive and make sure that everyone gets the highest quality of care."
  • Race, Ethnicity, and Language (REaL) Sexual Orientation and Gender Identity (SOGI) Data Collection Conversation - Collecting verbal self-reported REaL SOGI data from patients ensures your hospital has accurate information to improve care for all patients.
  • REaL data collection script and definition (HQIN) - This document can be provided to staff during orientation or training on collecting REaL data to ensure consistent screening and documentation are collected across all registration points. These are recommended scripts and suggested responses when screening patients.
​​​​​​Readmissions/Care Transitions 

Check out the August 11 educational webinar, Readmissions: Multiple-Admission Patients, under the Educational Events - Community of Practice Call section of this newsletter.

​​​​​​Alliant HQIC Data Update

CMS Claims Data
Due to delay issues with CMS data files, Alliant HQIC is unable to update trending charts for measures that rely on claims data. See below for a list of measures. As a result, no updated data will be available for March 2022 and subsequent months. CMS is projecting that we will receive the next data update in September, but no specific date has been confirmed. We will communicate when data and trending charts will be available as soon as this is known. Until then, quality improvement advisors may ask hospitals to share any internal or proxy data during coaching calls when discussing performance data. Please note: Measures based on NHSN data are not affected and are available in the hospital portal.
Measures based on claims data:

  • ADE hypoglycemic
  • ADE opioids
  • ADE anti-coagulants
  • Pressure injuries (3+)
  • Readmissions 30 day
  • Sepsis mortality
  • Sepsis shock (PSI-13)
  • Naloxone upon discharge (Claims Part D) 
  • High dose opioids at discharge (Claims Part D) 

NHSN Data 
While NHSN withholds the SIR calculation when predicted infections are <1.0, the Independent Evaluation Contractor (IEC) and CMS have instructed our data team to not suppress these values, as contract evaluation is based upon aggregate numbers. Using the aggregate of all enrolled hospitals eliminates the extreme fluctuations in a single calculation with expected <1.0, just as expanding the time period to analyze a SIR would. Although calculating a SIR with a denominator <1.0 may have extreme fluctuations, suppressing the SIR would hinder quality improvement personnel from detecting issues with high infection rates among small hospitals.

Clinical Recognition of Monkeypox
The CDC created a website to help health care providers find everything they need to know about monkeypox, including a map of cases in the United States. The CDC urges health care providers to be alert for patients who have rash illnesses consistent with monkeypox. Learn More

Alliant Health Solutions NCRN Year Two Recap
Alliant Health Solutions is a strategic partner in the Morehouse School of Medicine National COVID-19 Resiliency Network (NCRN) in mitigating the effects of COVID-19. Check out our Year Two Recap video. Watch the Video
Hospital Heroes​​​

Archbold's Grady General Hospital Receives Top Safety Score
In a recent nationwide report known as the Hospital Safety Score, The Leapfrog Group awarded Archbold's Grady General Hospital in Cairo, Ga., a grade of 'A' for the hospital's performance based on patient outcomes.
The Leapfrog Group, an independent nonprofit organization, uses a grading system of A, B, C, D and F to rate hospitals based on over 30 national performance measures reflecting errors, injuries, accidents and infections.
"Patients who enter our doors know that our team of physicians and clinicians will provide high-quality and safe care," said Crystal Wells, administrator at Archbold's Grady General Hospital. "It's rewarding to see our staff's efforts recognized nationally, and I'm so proud of what our team has accomplished."
The Leapfrog Hospital Safety Grade is the only hospital rating program based exclusively on hospital prevention of medical errors. The grading system is peer-reviewed, fully transparent and accessible to the public. Read the Article

Success Stories​​​

Jefferson Healthcare Shares Health Equity Journey
Jefferson Healthcare is a 25-bed critical access hospital in Port Townsend, WA. Even though this hospital is small, its impact on health equity for its patient population is mighty.
Jefferson Healthcare’s journey in health equity began in 2013 when a Patient and Family Advisory Council was created and later transformed into an Equity Committee. Since then, the hospital has developed an Equity Dashboard, participated in the IHI Pursuing Equity Learning and Action Network and now has health equity as a strategic priority. See timeline.

This strategic priority is led by Dunia Faulx, MPH, director of population health and care transformation, who leads the Health Equity committee and makes every effort to use health equity data to identify gaps or disparities in care. An improvement opportunity was quickly realized with the actual collection of Race, Ethnicity and Language (REaL) patient data, and the goals were:
  1. Decrease the “other” response by 25%.
  2. Create a training toolkit.
  3. At least 90% of staff complete training.
See an example of Jefferson Healthcare’s Plan-Do-Study-Act cycle for improvement. 

Lessons learned during the Study phase that were considered for the next PDSA cycle included:
  • Inconsistent process/emphasis on asking for race, ethnicity and language data
  • Belief that once a patient is in the system, the information does not need to be reassessed
  • Staff missing the connection to the ‘why’ 
  • Lack of standard onboarding and training materials in all departments
  • Staff Concerns: offending patients, assuming patients don’t want to answer, don’t want to put anyone on the spot
Jefferson Healthcare’s health equity journey has been successful due to its strategic priorities, committee members and dedication to quality improvement. Other keys to success include:
  • Start small and celebrate often
  • Leadership support and vision are vital
  • Involve patients, staff and the community
  • Data-driven approach
  • When it feels uncomfortable, lean into the conversation
See the Alliant HQIC website for Jefferson Healthcare’s presentation and recording and the change path for key takeaways, implementation strategies and resources.
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Hospital Quality Improvement Project Collaborators


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, 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-AHSQIN-QIO TO3-HQIC--2391-08/02/22 

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