The October 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. 

In This Issue: 

New SDOH Quality Measures Start in 2023
The Centers for Medicare & Medicaid Services' new social determinants of health (SDOH) quality measures were published in the 2023 Medicare Hospital Inpatient Prospective Payment System rule. Hospitals must report what portion of their population is screened for various SDOH and how many screen positive in each category. Hospitals will capture screening and identification of patient-level, health-related social needs—such as food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety. By screening for and identifying such unmet needs, hospitals will be in a better position to serve patients holistically by addressing and monitoring what are often key contributors to poor physical and mental health outcomes. Read Full Report

Celebrating Health Care Quality Week
October 16-22 is Healthcare Quality Week. Alliant HQIC recognizes all health care quality professionals for their dedication to improving the quality of patient care every day. Thank you for all you do!

​​​​​​Educational Events

​​​​​​Upcoming Learning and Action Network (LAN) Events
Catheter-Associated Urinary Tract Infection Prevention in Action: Strategies from the Field
Thursday, October 27, 2022, at 1 p.m. ET  
This presentation will feature real-world examples of effective CAUTI prevention strategies shared by Alaska Native Medical Center and Campbell County Health infection prevention leaders. Our speakers will share their experiences developing staff education, optimizing surveillance, engaging physician champions and much more!
The learning objectives include:
  1. Identify and prioritize at least one strategy for implementation to prevent catheter-associated urinary tract infections (CAUTIs). 
  2. Review appropriate indications for catheter insertion and develop a plan for educating your staff to reduce catheter utilization. 
  3. Establish or augment your plan to routinely track and report CAUTIs in your facility.
View Agenda | Register Here

Antibiotic Stewardship: Quick Wins for Improving Duration of Therapy (hosted by IPRO HQIC) 
Tuesday, November 8, 2022, at 1 p.m. ET  
This session’s learning objectives include: 
  1. Describe CDC AS Core Elements and the current status of AS programs in acute care hospitals.
  2. Discuss national trending data on antibiotic use and DOT. 
  3. Review opportunities to improve prescribing practices and decrease antibiotic DOT at the time of patient discharge, including handoff to the next level of care. 
  4. Explain DOT evidence-based strategies and associated outcomes to enhance patient safety.
  5. Hear about a hospital’s challenges and successes with implementing practical electronic health record (EHR) solutions and other data-driven strategies to optimize DOT.

Keep Calm and Prevent CAUTI and CLABSI  
Recorded on September 27
In this webinar, we learned 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. 
View the slides, recording and change path (key takeaways and resources) here.

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. 

A Nationally Pace-Setting Initiative in Sepsis Prevention, Screening and Intervention at the Community Level
Thursday, October 13
Register Here

Past Community of Practice (CoP) Call

Recognizing and Addressing Hypoglycemia in the Hosptial Setting
Recorded on September 15
Click Here to view on the Alliant HQIC website 

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 

​​​​​​Alliant HQIC Data Update

CMS Claims Data
CMS claims and CSAT files update: We anticipate that the data will be available by mid-October. 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.

Behavioral Health/Opioid Stewardship

Opioid Dependence and Overdose After Surgery: Rate, Risk Factors and Reasons 
"Opioid never event" (ONE) is a proposed classification to describe dependence or overdose among opioid-naïve patients prescribed opioids at hospital discharge. Based on a retrospective review of patients' medical records at one academic medical center, researchers estimated that the ONE affected approximately 2 per 1,000 opioid-naïve surgical patients, and persistent opioid use 90 to 360 days after surgery was present in 45% of patients with ONEs. Learn More

Expanding Access to Medications for Opioid Use Disorder Through Locally-Initiated Implementation 
Despite demonstrated efficacy, medication treatment for opioid use disorder (MOUD) remains inaccessible to many patients, with barriers identified at the individual, clinic and system level. Many implementation strategies have guided efforts to expand access to MOUD, most centered around externally-facilitated approaches to practice change. While effective, such approaches may be inaccessible to those clinics and systems that lack the resources necessary to partner with an external team, suggesting a need to identify and describe change processes that are internally developed and promoted. Learn More

Adverse Drug Events 

Factors Influencing Medication Errors in the Prehospital Paramedic Environment: A Mixed Method Systematic Review 
There is limited research on safe medication management practices in emergency medical services (EMS), with most evidence-based medication safety guidelines based on research in nursing, operating theater and pharmacy settings. Prevention of errors requires recognizing contributing factors across the spectrum from the organizational level to procedural elements and patient characteristics. Read More

Antibiotic Stewardship

Antibiotic Overuse and Stewardship at Hospital Discharge: The Reducing Overuse of Antibiotics at Discharge Home Framework
Though opportunities exist to improve antibiotic prescribing across the care spectrum, discharge from acute hospitalization is an increasingly recognized source of antibiotic overuse. Antimicrobials are prescribed to more than 1 in 8 patients at hospital discharge, approximately half of which could be improved. Read More

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 

​​​​Hospital-Acquired Infections (HAIs) and Infection Prevention

Video: Guidance on MRSA and C. diff Lab ID Reporting
Need guidance on the MRSA and C. diff Lab ID reporting? Check out the 20-minute presentation by Alliant’s Infection Prevention Technical Advisor. Watch Presentation 

Florida DOH Creates Cohort for the Certification in Infection Control (CIC) Study Group 
The Florida Department of Health (DOH) Health Care-Associated Infection (HAI) Prevention Program has created a new cohort for the Certification in Infection Control (CIC) Study Group. This cohort is free to join and is geared to help anyone interested in taking the offered CBIC exams, including, but not limited to, the CIC, a-IPC, and the new LTC-CIP. The cohort will meet each Friday beginning October 7, 2022, for 26 weeks. Certification represents your commitment to the improvement of infection control practices and recognizes you as proficient in the field. Use the QR code to fill out the registration and you will receive a Teams invitation to join. For questions, email Register Here

CDC Updates Infection Prevention and Control Guidance for U.S. Health Care Settings
The CDC updated its infection prevention and control (IPC) guidance for U.S. health care settings on September 23 to reflect the high levels of vaccine- and infection-induced immunity and the availability of effective treatments and prevention tools. The update provides additional protection measures for patients and health care workers, especially in hospitals and nursing homes, where COVID-19 is more likely to spread quickly or cause severe disease if introduced.

The CDC recommends health care facilities reference updated Community Transmission metrics on a weekly basis to inform facility-level actions. Community Transmission remains the metric used to guide select actions in health care settings, which is different than the COVID-19 Community Levels used for non-healthcare settings. Community Transmission is used to allow for earlier intervention before there is strain on the health care system and better protect the individuals seeking medical care in these settings.  
Learn more:

Readmissions/Care Transitions 

Social Workers Coordination in Primary Health Care for Patients with Complex Needs: A Scoping Review 
Social work has been recognized as contributing to care coordination for long-term care for the elderly, according to the International Journal of Care Coordination. This article reviews social workers’ coordination activities for patients with complex needs in primary health care. Read Article


Sepsis Care in 2022
In case you missed the Sepsis Care in 2022: Identification and Management Strategies to Optimize Patient Outcomes webinar on August 25, see below for the slides, recording and change path (key takeaways and resources).
View Resources 

Patient and Family Engagement

Using CAHPS Surveys To Measure Patient Experience 
Patient experience encompasses the range of interactions that patients have with the health care system, including their health plans, doctors, nurses, and staff in hospitals, physician practices and other facilities. Understanding the patient experience is a critical step in moving toward patient-centered care. AHRQ’s Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys have become critical tools for organizations interested in assessing the patient-centeredness of the care they deliver and identifying areas for improvement. Learn More

​​​​​​Health Equity

Scrips for Collecting REaL Data 
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.

NCRN Resources for COVID Resiliency 
Alliant Health Solutions is a strategic partner in the National COVID-19 Resiliency Network. We assist in sharing resources to help mitigate the effects of COVID-19. Here are two of our resources developed to share broadly:
Best Practices Corner​​​

Phoebe Sees Positive Results With Virtual Remote Nurse Program 
To combat a nursing shortage due to the pandemic and an aging population, Phoebe Putney Memorial Hospital in Albany, Georgia, piloted a virtual remote nurse model of care to support bedside nurses. Since starting the program in April, the hospital has seen significant improvement in patient satisfaction with nurse communication and discharge education, according to Chief Nursing Officer Evelyn Olenick. Read More

Alabama Hospital Holds Skills Fair Focused on Patient Safety 
Decatur Morgan Hospital, a 273-bed hospital in Decatur, Alabama, held a weeklong frontline staff skills fair to build on several patient safety priorities. Their theme was “Building on the Basics” and the hospital used LEGO-themed decorations. Educators asked department directors to identify which topics and annual competencies were needed and developed checklists specific to the different disciplines. 

Success Stories​​​
Alabama Hospital Demonstrates Improvement with HAI Review Team
Northeast Alabama Regional Medical Center is part of the Regional Medical Center (RMC) located in Anniston, Alabama. It is comprised of two campuses, NEARMC, a 338-bed hospital and Stringfellow, a 125-bed hospital. 
Northeast Alabama Regional Medical Center RMC/Stringfellow

According to NHSN data, NEARMC has been maintaining zero rates for both CAUTI SIR All Units and CLABSI SIR All Units since November 2021. In addition, there are currently downward trends in both Catheter Days per Patient Day and Central Line Days per Patient Day. 

Debra Holmes, RN, BSN, CCDS, director of Case Management/Quality/Social Services/CDI, contributes their success to the multidisciplinary HAI team. Their team consists of nursing leadership and management, quality, infection prevention and medical staff. The HAI team meets every two weeks or more often to conduct a root cause analysis on each failure and apply inclusion/exclusion criteria. The team decides as a group if it is a true reportable CAUTI/CLABSI.
After the team reviews the data, they “shop at The Gaps” to identify and implement interventions that include the challenges and solutions listed here.  

Congratulations to NEARMC and RMC/Stringfellow for showing resilience throughout the pandemic to improve CAUTI and CLABSI outcomes. See Northeast Alabama Regional Medical Center’s webinar presentation recorded on September 27, 2022.
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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--2696-10/06/22

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