Clinical Documentation, Coding and Billing for Sepsis: Best Practices and Compliance Webinar – September 11, 2024


Prepared by IPRO HQIC

This session will highlight best practices and examples to:

  • Consider approaches to evaluate the quality of sepsis data being reported to CMS (Centers for Medicare & Medicaid Services) and CDC (Centers for Disease Control and Prevention).
  • Identify common coding challenges that lead to under and overreporting of sepsis.
  • Apply sepsis coding knowledge to make suggestions to hospital quality improvement staff to improve the coding of sepsis.

View Slides Here

Collection: Antibiotic Stewardship Success Stories

Compiled by IPRO NQIIC

The following multimedia collection focuses on highlighting Antibiotic Stewardship success stories. Materials include PDFs, videos, and podcasts. This collection will be updated with additional resources as they become available.

  1. Astera Health (MN) Antibiotic Stewardship Success – Astera Health.
  2. Rockcastle Regional Hospital and Respiratory Care Center Antibiotic De-escalation Program – Rockcastle Regional Hospital

The Michigan Opioid Safety Score (MOSS): A Patient Safety and Nurse Empowerment Tool

Journal of PeriAnesthesia Nursing

The Michigan Opioid Safety Score (MOSS) was developed to incorporate patient risk, respiratory rate, and sedation into one bedside score that could be used to improve patient safety during inpatient opioid therapy. Scoring is based on a summation of risk data with objective bedside measures of over-sedation trumping a patient’s subjective reports of pain.

Your Guide to Controlling & Managing Pain After Surgery

MHA Keystone Center

This resource provides education to patients related to:

  • Understanding surgical pain
  • Understanding pain after surgery
  • Questions to ask before surgery, after surgery and before discharge
  • Tools to help manage pain
  • Keeping track of pain medications and frequency
  • Common pain medication side effects

Reliability Culture Implementation Guide

Michigan Health & Hospital Association, Illinois Health and Hospital Association, Wisconsin Hospital Association, Minnesota Hospital Association

Purpose: The Reliability Culture Implementation Guide combines the five principles of high reliability organizations (HROs) with elements of safety culture. This guide is broadly intended for executive level to frontline staff. Tools are available throughout this guide to support and advance the work done within high reliability.

All-Cause Harm Resource

IPRO HQIC

This resource explains what All-Cause Harm is, why it is important, and then dives into each of the processes it takes to prevent All-Cause Harm. Eight priority focus areas for the Hospital Quality Improvement Contract (HQIC) are illuminated and strategies to monitor compliance are provided.

All-Cause Harm Resource, Recording and Slides from the IPRO HQIC All-Cause Harm “launch” on March 29th, 2021.

How Patient and Family Advisory Councils Can Help Hospitals and Their Communities During the COVID-19 Pandemic

American Institutes for Research (AIR) for IPRO HQIC

COVID-19 is a perfect issue for PFACs to address. The experiences of patients and families can have a direct impact on how the hospital safely treats those with severe cases including those in isolation, prevents the spread of the virus, and minimizes the impact of the virus on health care and health outcomes (e.g., delayed care). This resource provides suggestions about how PFACs can help hospitals proactively communicate, educate, and engage with patients and families and the larger community to build trust and deliver high-quality care during a time of uncertainty and fear.

Hospital Roadmap for Person and Family Engagement (PFE): Achieving the Five PFE Best Practices to Improve Patient Safety and Health Equity

American Institutes for Research (AIR) for IPRO HQIC

This PFE Roadmap provides practical guidance to help hospitals implement five PFE best practices:

  1. Implementation of a planning checklist for patients who have a planned admission
  2. Implementation of a discharge planning checklist
  3. Conducting shift change huddles and bedside reporting with patients and families
  4. Designation of a PFE leader in the hospital
  5. Active Person and Family Engagement Committee or other committees where patients are represented and report to the board

Joint HQIC 3-Part Series: Workplace Violence Prevention

Prepared by the HQIC collaborative group (IPRO, Alliant, Compass, and Telligen)

Defined as “violent acts, including physical assaults and threats of assault, directed toward persons at work or on duty,” workplace violence (WPV) is a growing concern. An April 2020 Bureau of Labor Statistics Fact Sheet revealed that healthcare workers accounted for 73% of all nonfatal workplace injuries and illnesses due to violence in 2018. This number has been steadily growing since tracking these specific events began in 2011.

Now, it is time to act!
Why Now? According to OSHA (2016), workplace violence rates among healthcare workers between 1993 and 2009 were 20% higher than that for other industries. The COVID-19 pandemic increased the factors leading to workplace violence, such as staffing shortages leading to a decrease in the amount of staffed (available) beds, a high workload causing stressed staff, and frustrated patients and families who feel as though their needs are not being met. A memo to State Survey Agency Directors dated November 28, 2022, states CMS’ continued enforcement of regulatory expectations that patients and staff have an environment that prioritizes their safety while effectively delivering healthcare. To effectively maintain a safe environment for healthcare delivery, hospitals can develop policies and procedures to mitigate the risk of workplace violence.


The HQIC collaborative group consisting of Alliant, Compass, IPRO and Telligen appreciates your interest in the Workplace Violence Prevention series. Access event materials here:

IPRO HQIC Workplace Violence Prevention Change Pathway

Part 1:  Workplace Violence Prevention (WPV): Best Practices for Safer Care

  • WPV is defined as an act or threat occurring at the workplace from physical and verbal assaults.
  • 2020 Bureau of Labor Fact Sheet found that health care workers accounted for 73% of all nonfatal workplace injuries and illness due to violence in 2018.
  • WPV prevention takes more than security.  Requires commitment from organizational leadership, interdisciplinary, collaboration and allocation of resources.
  • It is an investment in our workforce not a cost.

SLIDES.

Part 2:   Key Components of an Effective Workplace Violence Prevention Program: Leadership Engagement and Communication

  • Workplace violence is more than a written Policy, it is a series of action steps that serve as a foundational guide for educating staff and acting quickly in an emergency.
  • Communication is critical. WPV prevention policies must be communicated to patients and families in a way that is non-threatening, clear, concise and at the appropriate reading level.   
  • The way an organization addresses WPV AFTER an event (debriefing, counseling, performance improvement action plan) is just as important as how your organization responds during the event.
  • Leadership is a partnership. At the heart of all good policies, procedure, and programs is good two-way communication. Find what’s missing by including all perspectives.

SLIDES.

Part 3:   Uncovering Unconscious Bias for Safer Healthcare Interactions

  • Unconscious bias affects healthcare interactions and can lead to poor, inequitable outcomes.
  • Self-reflection is crucial for bias identification and improvement.
  • De-escalation must be a priority to promote safe, healing environments.
  • Organizations must implement training, diversity initiatives, reporting mechanisms, and community engagement to address and mitigate bias in healthcare.

SLIDES.

Video: Uncovering Unconscious Bias for Safer Healthcare Interactions

Patient Family Advisory Councils Toolkit

Colorado Hospital Association

With the shift in the health care landscape from volume to value, more hospitals are engaging patients in their everyday hospital activities. Like any profession, learning from the consumer can provide great insight on how to provide better service. Integrating patient and family advisory councils (PFACs) within the hospital setting is an excellent approach to learn from patients and increase the quality of care delivered in a hospital. The toolkit underscores PFAC support with quality and safety, patient satisfaction, patient outcomes and market share.

Direct Oral Anticoagulant: DOAC Playbook

Anticoagulation Forum

Although DOACs require less intensive dose management than warfarin, they are not devoid of potential complications. Anticoagulants have consistently ranked as the class of medications most frequently leading to emergency room visits and hospital admissions for adverse drug events. This toolkit explains how to use DOACs safely and effectively requires that all aspects of anticoagulation therapy are addressed, including appropriate patient selection, dosing, monitoring, transitions between therapies and between care settings, periprocedural guidance, management of risks (including DOAC associated
bleeding), drug-drug interaction management, ongoing assessment of patient and family educational needs, and incorporation of evidence-based practices into workflow.