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OVERVIEW:
The COVID-19 pandemic has presented unprecedented challenges and intensified systemic health disparities that have pushed the conversation around health equity from “why is this important?” to “how do we do this?” Based on regulatory requirements from the Centers for Medicare and Medicaid (CMS) and The Joint Commission (TJC), hospitals have a critical opportunity to be at the forefront of building more resilient communities and addressing social determinants of health (SDOH) across readmissions, chronic diseases, and other patient harm areas. This session will highlight best practices and examples for successfully implementing health equity strategies within hospital settings. Rosa Abraha, MPH, Alliant HQIC’s health equity lead, will address frequently asked questions from hospitals and engage in a discussion with participants.

LEARNING OBJECTIVES:
1. Discuss a model for embedding a health equity champion to meet the current regulatory requirements.
2. Describe how to expand on the collection of Race, Ethnicity and Language (REaL) data and begin to analyze health-related social needs, e.g., health literacy, transportation needs, food insecurity etc.
3. Discuss a framework for community and hospital partnership to advance health equity needs and improve patient outcomes.

According to the New England Journal of Medicine in February 2022, the strides made toward improving patient safety were quickly and severely reversed amid the unprecedented COVID-19 pandemic that swept the nation indicating that the healthcare system lacks a sufficient resilient safety culture and infrastructure. This has brought to light an opportunity and obligation to reevaluate healthcare safety with an eye toward building a more resilient healthcare delivery system. Successful and sustainable patient safety improvement rests heavily on an organizational culture of patient safety, in which leadership supports systemwide attitudes, actions, teamwork, and technology to reduce the risk of patient harm.

IP Chats are quarterly networking events to build knowledge, share experience and provide support for hospital infection preventionists. Have questions or ideas for content? Contact Amy Ward at Amy.Ward@Allianthealth.org.

Alliant HQIC developed a series of bite-sized learnings to assist hospital infection preventionists with some of their most frequently asked questions regarding the National Healthcare Safety Network (NHSN) database. Topics include:

• NHSN New User Introduction
• Adding, Assigning Rights and Deactivating Users in NHSN
• Location Mapping and NHSN Training
• NHSN Annual Survey and Monthly Reporting Plans
• LabID Reporting

IP Chats are quarterly networking events to build knowledge, share experience and provide support for hospital infection preventionists. Have questions or ideas for content? Contact Amy Ward at Amy.Ward@Allianthealth.org.

Alliant HQIC developed a series of bite-sized learnings to assist hospital infection preventionists with some of their most frequently asked questions regarding the National Healthcare Safety Network (NHSN) database. Topics include:

• NHSN New User Introduction
• Adding, Assigning Rights and Deactivating Users in NHSN
• Location Mapping and NHSN Training
• NHSN Annual Survey and Monthly Reporting Plans
• LabID Reporting

Join this exciting webinar to learn how the Alliant Hospital Quality Improvement Contractor (HQIC) program has improved patient outcomes for our 147 enrolled hospitals in the past two years. This webinar will also focus on patient and family engagement (PFE) and strategies to improve the five structural metrics. Hospitals will present their accomplishments and barriers to restarting and engaging their patient and family advisory councils (PFACS) to improve quality and patient safety. In addition, we will discuss educational and networking opportunities in 2023.

OBJECTIVES:

  1. Review performance to date and, 30-month target goals.
  2. Discuss the five structural metrics for patient and family engagement and opportunities for improvement among the enrolled hospitals.
  3. Learn how hospitals are restarting their patient and family advisory councils (PFAC) after suspending activities during the COVID pandemic.
  4. Discuss upcoming educational and networking opportunities in 2023.

Cheyenne County, a 16-bed critical access hospital located in St. Francis, KS has decreased catheter days per patient days in the last year and is currently maintaining a zero rate with Catheter Associated Urinary Tract Infections (CAUTI).

Cheyenne County HQIC Success Story Photo

Cheyenne County Memorial recently participated in the HQIC performance improvement cohort based on two CAUTIs identified in 2021. Through comprehensive review of current practices and analysis, inappropriate catheter use was identified as a root cause.

The team implemented solutions which included:

  • Physician champion and the infection preventionist working together to promote appropriate catheter use, increase staff awareness and provide education
  • Team completed a policy review and all staff who insert catheters now complete an annual competency for catheter insertion. Goal is 100% compliance by the end of 2022.
  • A standard protocol was approved by the Chief Medical Officer (CMO) that includes a nursing assessment/action flow sheet that guides the nurse through diagnosis, correct insertion, and alternatives to foley use
  • Alternative methods implemented such as external female catheters and more scheduled toileting

According to NHSN data, Cheyenne County Memorial is demonstrating a downward trend for CAUTI SIR All Units and is currently maintaining a zero rate. The two CAUTIs in 2021 were COVID patients.

In addition, Catheter Days per Patient Day demonstrates a downward trend from January 2021 through August 2022 and is below the CY2019 baseline. The lowest data point is in August 2022.

Katie Bunker, RN, Chief Nursing Officer/Infection Prevention complimented the performance improvement advisory services provided by KFMC Health Improvement Partners, a subcontractor of Alliant HQIC. Katie said, “Nadyne has been an amazing resource for coming up with new ways of approaching each subject. Thank you for sharing our success story and I hope we have many more.”

Congratulations to the team at Cheyenne County Hospital for their hard work and resiliency to improving patient care by decreasing CAUTI SIR All Units and Catheter Days per Patient Day.

To access other success stories, see the Alliant HQIC website.

Alabama Hospital Improves Process and Outcomes with Critical Assessment Team (CAT)

Regional Medical Center (RMC) is a 338-bed hospital located in Anniston, AL which lies in the foothills of the Appalachian Mountains, about 60 miles east of Birmingham.

Regional Medical Center (RMC)

The critical response team at Regional Medical Center consisted of an ICU nurse and a Respiratory Therapist who were responsible for stabilizing patients as quickly as possible within 30 minutes of the overhead page. The average time per month was 18.5 hours responding to Code Blues outside of the ICU and 31 hours per month responding to Critical Access Team (CAT) calls while still caring for their own patient load.

In November 2021, RMC recognized the need for early intervention and rolled out a pilot with a proactive approach and their motto “Catch the Spark before the Fire”.  A Critical Assessment Team (CAT) was designated and an algorithm provided warning signs for a decompensating patient. Staff were encouraged to call a 4-digit number routed to the CAT cell phone. Other duties of the ICU nurse and Respiratory Therapist included:

  • Proactively round on patients to review documentation, lab changes and vital sign changes on high acuity patients
  • Provide critical care support to medical floors such as removing CVLs, hard start IVs and hard stick ABGs
  • Provide education to staff including features of defibrillator to better document during the code
  • Mentor floor nurses and respiratory staff

In a six month period, Code Blues decreased approximately 95% and CAT calls decreased approximately 62% (excluding COVID patients) house-wide. In addition, an average of 9.4 hours was spent at the patient bedside. Other key tenets contributing to the success included:

  • Breaking the stigma of calling for help
  • Customer service mentality
  • Overall confidence in patent care with extra support

Alliant HQIC would like to recognize RMC Health System for their continued dedication and commitment to improving patient safety and quality of patient care.

Community of Practice (CoP) hosted by CMS

CMS releases Overall Hospital Quality Star Ratings which include clinical metrics for hospitals on an annual basis. Hospitals that achieve better outcomes and higher ratings tend to foster a patient safety and leadership culture in their organizations. During this webinar, we will provide an overview of the star ratings. We will also hear from a Risk, Compliance and Quality Director who will discuss his hospital’s quality dashboard that mirrors dimensions of the quality measures in the hospital star ratings. In addition, we will hear from Don Avery, President/CEO of Fairview Park Hospital (GA), who will discuss how his hospital team has successfully reached a five-star rating based on safety across the board, daily leadership huddles, and driving accountability.

Northeast Alabama Regional Medical Center is part of the Regional Medical Center (RMC) located in Anniston, AL. It is comprised of two campuses, NEARMC, a 338-bed hospital and Stringfellow, a 125-bed hospital.

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 Hospital-Acquired Infection (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 which 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.

Data from the Centers for Disease Control and Prevention (CDC)’s National Healthcare Safety Network (NHSN) show a significantly higher incidence of catheter-associated urinary tract infections (CAUTIs) in 2021 compared to 2019. Since the COVID-19 pandemic, prevention of CAUTIs remains a patient safety priority in hospitals to reduce patient harm and costs and improve outcomes.

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!