The September 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 Assigns Star Rating to Hospitals Nationwide 
The Centers for Medicare & Medicaid Services (CMS) assigned star ratings to hospitals nationwide based on their performance across five quality categories. See the table below.

Mesure Group Weight Used in Calculation
Mortality 22%
Safety 22%
Readmissions 22%
Patient Experience 22%
Timely and Effective Care  12%

CMS updated Hospital Quality Star Ratings as of July 2022. Overall ratings include:

  • 1 Star, 198 hospitals (6.34%)
  • 2 Star, 702 hospitals (22.49%)
  • 3 Star, 895 hospitals (28.68%)
  • 4 Star, 895 hospitals (28.68%)
  • 5 Star, 431 hospitals (13.81%)

Congratulations to the following hospitals enrolled in the Alliant HQIC program that received 5 Stars! We are proud to work with you and celebrate your success.


  • Russell Medical Center


  • Emanuel Medical Center
  • Fairview Park
  • Meadows Regional


  • Cedar City (Intermountain Healthcare)
  • Park City (Intermountain Healthcare)
Read More

Public Comment to Promote Efficiency, Reduce Burden and Advance Equity within CMS Programs
CMS released a Request For Information (RFI) seeking public input on accessing health care and related challenges, understanding provider experiences, advancing health equity, and assessing the impact of waivers and flexibilities provided in response to the COVID-19 Public Health Emergency.
CMS will use the comments received in response to this RFI to identify potential opportunities for improvement and increased efficiencies across CMS policies, programs and practices. Read More 
​​​​​​Educational Events

​​​​​​Upcoming Learning and Action Network (LAN) Events
Keep Calm and Prevent CAUTI and CLABSI
Tuesday, September 27, 2022, at 2 p.m. ET  
Join this exciting presentation and discussion to learn how Northeast Alabama Regional Medical Center changed its healthcare-associated infection (HAI) review process from one person to a group of clinical and health care professionals, resulting in better outcomes in CAUTI and CLABSI prevention. 
​​​​​​Learning Objectives:
  • Understand how changing the HAI review process resulted in better patient outcomes. 
  • Gain insight into how the Root Cause Analysis process is used to identify missed opportunities to prevent CAUTI and CLABSI.
  • Learn how the team “shops at The Gaps” to implement best practice interventions.

View AgendaRegister Here

Past Learning and Action Network (LAN) Events

Sepsis Care in 2022: Identification and Management Strategies to Optimize Patient Outcomes 
Recorded on August 25
This webinar summarized the four-tier process for effective sepsis program development, examined the evidence for the sepsis bundles, shared proven strategies to resolve barriers in implementation and measurement, and identified gaps between the evidence and your hospital’s sepsis program.
Watch Recording

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. 

Recognizing and Addressing Hypoglycemia in the Hospital Setting
Thursday, September 15
This webinar will focus on sharing effective approaches to recognize the symptoms of hypoglycemia, identify patient risk factors, develop a task force, implement best practices and monitor data so that patient harm can be avoided. In addition, we will also share challenges and solutions from other hospitals, with an emphasis on small and rural facilities. This presentation will highlight practical strategies to improve hypoglycemic ADEs for all hospital sizes.
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

National Prescription Drug Take Back Day is October 29 
The Drug Enforcement Administration’s (DEA) National Prescription Drug Take Back Day reflects the DEA’s commitment to Americans’ safety and health, encouraging the public to remove unneeded medications from their homes to prevent medication misuse and opioid addiction from ever starting. They created a webpage of resources to help you dispose of unneeded medications in your home, seek substance abuse treatment and learn more about the drug overdose epidemic in the United States. Visit Webpage

Pain Management for People with Serious Illness in the Context of the Opioid Use Disorder Epidemic 
The National Academies of Sciences, Engineering, and Medicine sponsored a workshop on November 29, 2018, to examine the unintended consequences of the responses to the opioid use disorder epidemic for patients, families, communities and clinicians and to consider potential policy opportunities to address them. A publication summarizes the presentations and discussions from the workshop. Download Publication 

Adverse Drug Events 

Anticoagulation Stewardship Playbook to Help Improve Patient Safety
The National Quality Forum, in partnership with the Anticoagulation Forum, and with funding from the U.S. Food and Drug Administration, released “Advancing Anticoagulation Stewardship: A Playbook,” a new, publicly available guide to help health care organizations implement evidence-based strategies to promote patient safety in the use of anticoagulant medications. Download the Playbook

Antibiotic Stewardship

CDC Reports Increase in Drug-Resistant Infections During Pandemic
After declining in recent years, antimicrobial-resistant infections starting during hospitalization grew 15% from 2019 to 2020, the CDC reported, based on limited data for 2020. Read the Study


Sepsis Alliance Summit 2022 
The Sepsis Alliance is hosting its Sepsis Alliance Summit on Sept. 28-29, 2022. Set to coincide with Sepsis Awareness Month, the event will feature two days of learning and inspiration for health care professionals across the continuum of care, including nurses, physicians, pharmacists, allied health professionals, data/quality/safety/IT professionals, students, leadership, policymakers, and industry leaders. Free nursing CE credits are offered! Register Today

Sepsis in People Over 65 Years Old 
Sepsis can and does affect people of all ages. The very young (infants) and those who already have a chronic health problem or a compromised immune system are at higher risk of developing sepsis. But people who are aging, over 65 years old, particularly those who have health issues, are even more susceptible to sepsis than any other group. Adults aged 65 years and older are 13 times more likely to be hospitalized with sepsis than adults younger than 65, and 63% of older adults 60 years and older are admitted to the ICU with sepsis upon admission. Read More

Sepsis in Older Americans: Saving Lives through Early Recognition 
Two-thirds of all sepsis cases occur in people over 60. Older Americans with chronic health conditions such as heart disease and cancer are more likely to succumb to sepsis, but early detection can help. Watch the Video 

Code Sepsis Saves Lives and Improves Bundle Adherence
According to the results of a study published in the American Journal of Emergency Medicine, rapid deployment of a Code Sepsis Response Team significantly increased adherence to the SEP-1 bundle, improved times to empiric antimicrobial therapy, time to effective antimicrobial therapy and decreased mortality. This retrospective observational study was conducted in a 35-bed tertiary hospital and included 450 patient records. Read Study


NHSN Survival Guide 
Alliant Health Solutions created a National Healthcare Safety Network (NHSN) survival guide. See pages 4-6 of the guide for the HAI Data Quality Checklist. Download Survival Guide 

​​​​Patient and Family Engagement

Engaging Patients and Families in Their Health Care 
The Agency for Healthcare Research and Quality (AHRQ) offers free tools to help prioritize concerns and maximize interactions between providers, patients and families. The Guide to Patient and Family Engagement in Hospital Quality and Safety provides evidence-based resources that show how hospital staff can work as partners with patients and families to improve quality and safety. Get the Guide

​​​​​​Health Equity

Using Z Codes: Social Determinants of Health (SDOH) Data Journey Map 
This infographic describes the journey that social determinants of health (SDOH) data takes from the individual through the health system to data reporting as ICD-10-CM Z codes. It discusses data collection, documentation, coding, and reporting. It contains resources to help implement programs to collect and report SDOH data in a manner that can lead to better health outcomes for individuals. View Infographic

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.
Now Available: Updated Social Determinants of Health Database 
AHRQ’s Social Determinants of Health (SDOH) Database has been updated and now provides a central source for community-level SDOH data at the county, ZIP code and census tract levels. This one-stop approach can help remove data barriers that may slow progress on research and delay interventions to improve health outcomes. Developed with funding from the Patient-Centered Outcomes Research (PCOR) Trust Fund, the SDOH database is designed to enhance ongoing data collection and analysis efforts by providing standardized, well-documented, easy-to-use, linkable data spanning the SDOH domains of social context, economic context, education, health care and physical infrastructure. View SDOH Database

New Accreditation Standards for Health Equity 
The Joint Commission, an independent accrediting body for hospitals, will introduce new standards on January 1, 2023, aimed at reducing health care disparities, calling the effort a quality and safety priority. The commission’s new accreditation requirements will apply to organizations in its ambulatory care, behavioral health care and human services, critical access hospital and hospital accreditation programs. 
The new accreditation requirements for providers include:
  • Designating a leader or leaders to direct activities to reduce health care disparities within an organization.
  • Assessing patients’ health-related social needs and providing information about community resources and support services.
  • Identifying health care disparities in the patient population by stratifying quality and safety data using socio-demographic characteristics.
  • Developing a written action plan that describes how the organization will address at least one of the health care disparities identified in its patient population.
  • Taking action when the goals in its plan to reduce health disparities are not achieved or sustained.

Read More

​​​​​​Readmissions/Care Transitions 

Multi-Admission Patients (MAP) Webinar 
In case you missed the Multi-Admission Patients (MAP) webinar on August 11, see the slides on the Alliant HQIC website. The recording can be found here. Get Program and Resources

CMS Releases First-Ever Home- and Community-Based Services Quality Measure Set
The CMS is releasing the first-ever home- and community-based services (HCBS) quality measure set to promote consistent quality measurement within and across state Medicaid HCBS programs. The measure set is intended to provide insight into the quality of HCBS programs and enable states to measure and improve health outcomes for people relying on long-term services and support (LTSS) in Medicaid. The release of this voluntary measure set is also a critical step to promoting health equity among the millions of older adults and people with disabilities who need LTSS because of disabling conditions and chronic illnesses. Learn More

Preventable Transfer to the Hospital
The period following discharge from the hospital is an especially vulnerable time for patients. Hospitalizations have become progressively shorter despite the increasing complexity of patients, and as a result, patients are often discharged with ongoing care needs. The quality of the discharge process and effective transitions of care are critical in minimizing gaps in care and preventing unnecessary hospital readmissions. Read More

​​​​​​Patient Safety​​​​​

TMF HQIC: Cultivating Your Patient Safety Environment 
Improving patient safety has always been the top priority for hospitals and is fundamental to delivering quality health services. Hospitals should assess their processes, identify optimization opportunities, and implement evidence-based practices to cultivate a culture of safety. The TMF Health Quality Institute HQIC Network created an informational sheet highlighting some of the patient safety resources available to hospitals. Download Resource

​​​​​​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.

What You Need To Know About Monkeypox
Utilizing the most up-to-date CDC guidelines, Alliant Health Solutions created a Monkeypox informational sheet that discusses how it spreads, signs and symptoms, and important infection prevention topics such as precautions and personal protective equipment required, cleaning and disinfection, patient placement, and health care worker monitoring and restriction. Download the Monkeypox Informational Sheet
Best Practices Corner​​​

Alliant Resources Available for Co-Branding
Like our resources and want to co-brand for your hospital? ​​​​​​Send us an email and let us know! We can co-brand any Alliant resource that is on our website. See the example below. Visit Our Website to View Resoruces 

Hospital Heroes​​​

Southeast Georgia Health System Selected to Participate in Groundbreaking Sepsis Study
The Southeast Georgia Health System Brunswick Campus has been chosen as the only site in the southeastern United States to participate in the PURIFYRCT study. The study will evaluate using the Seraph 100 Microbind Affinity Blood Filter to treat patients with bacteria in their bloodstream or who have developed septic shock. The health system was chosen to participate in the multicenter study because it pioneered the use of Seraph 100 in patients with COVID-19. Read More

St. Mary’s CHNA Identifies Region’s Top Health Care Priorities 
According to a 2022 Community Health Needs Assessment (CHNA) conducted by St. Mary’s Health Care System, the top health care needs in a 17-county area of northeast Georgia include access to health care services, mental and behavioral health, chronic disease prevention and management, and the need to address social influencers of health such as transportation and food access.
The CHNA also highlighted the need to continue effectively responding and adapting to COVID-19 as the pandemic evolves and its impact on patients and communities changes.
Every three years, as required by law, St. Mary’s conducts a CHNA to better understand its communities’ current health needs and identify local resources and assets. For the 2022 report, St. Mary’s Community Health and Well-being Department held community conversations and individual interviews with representatives from community-based health and public service organizations, medical professionals and hospital staff across the region.
These conversations provided critical and nuanced information on health data from the hospitals’ emergency departments as well as from external sources like the U.S. Census Bureau’s American Community Survey. Results from the 2022 CHNA will help inform St. Mary’s community outreach and health education programs through 2025.
Read the Article 


Success Stories​​​

Florida Hospital Maintains Zero Rates for CAUTI and CLABSI
Keralty Hospital is a 125-bed hospital  in Miami, Florida, and a top performer in Catheter-Associated Urinary Tract Infections (CAUTI) and Central Line Associated Blood Stream Infections (CLABSI) prevention. 
According to NHSN data, Keralty Hospital is currently maintaining a zero rate for both CAUTI and CLABSI. If CAUTI and CLABSI are reported, a root cause analysis is completed. Regarding device utilization, Keralty Hospital has improved 41.9% over the 2019 baseline for Catheter Utilization Ratio Per Patient Day and maintains low rates for Central Line Utilization Ratio Per Patient Day near the 2019 baseline (3.35%) and reported the lowest ratio to date (0.72%) in March 2022. 

Gretel Herrera, infection preventionist at Keralty Hospital, reports that the following interventions have contributed to their achievements and success: 
  1. Nurse-driven protocol to avoid CLABSI and CAUTI\
    • Avoid catheter if possible
    • Ensure aseptic placemen
    • Maintain awareness and proper care of catheters in place 
    • Promptly remove unnecessary catheters
Specifically, to avoid CLABSI, nurses maintain a closed system, scrub access ports (needleless caps) with antiseptic solution (70% alcohol) for at least 15-20 seconds before access, and use intermittent infusion caps of luer-lock design to ensure a secure junction.
To avoid CAUTI, nurses do screening and assessment and evidence-based management of urinary retention and incontinence. This is essential to reduce catheter overuse. Nurses use the aseptic technique during catheter placement. Additionally, to prevent CAUTI, nurses take special consideration for proper hand washing and not using urine drain tubes and, if they must be used, inserting them properly and keeping them clean. Catheters are utilized only when necessary and removed as soon as possible.
  1. Daily assessment or rounds - Infection control nurse does rounds daily to check and do an assessment on central lines and Foley catheters in the hospital. This is documented two times during the week using survey tools and forms.
  2. Staff education/competence for insertion and maintenance – In-services completed by Infection Control nurse according to schedule. If any action or correction is needed, one-on-one education is provided to the nurse caring for the patient.
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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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