Ready or Not, Here it Comes: Preparing to Submit the CMS Health Equity Structural Measure

Prepared by IPRO

Hospitals participating in the CMS Inpatient Quality Reporting (IQR) Program are required to submit structural measures for CY2023 into the CMS Hospital Quality Reporting system. Submissions are due between April 1, 2024 – May 15, 2024.

One of the required structural measures is the Hospital Commitment to Health Equity. In this 30-minute session, IPRO will share what you will need to report to CMS, which documentation you will need to support your submission, the optional Social Drivers of Health process measures, and what’s coming related to health equity for the CY2024 Hospital Quality Reporting programs.

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Presentation Slides

Hospital Commitment to Health Equity Submission Tool: This fillable PDF resource created by IPRO may be helpful for preparing for attestation of the CMS Hospital Commitment to Health Equity Measure.

IPRO HQIC SERIES – Sepsis: Lessons Learned

Prepared by IPRO

Sepsis mortality continues to be a challenge with sepsis and septic shock as leading causes of death worldwide. Adherence to clinical and operational best practices can profoundly reduce mortality rates and the costs associated with this disease.

The HQIC Sepsis Gap Assessment has shown several areas of improvement needed in the clinical and operational tasks of sepsis care and the CMS SEP-1 bundle. Join us to hear how organizations are innovating and improving sepsis care through:

  • Application of goals to implement the one-hour bundle,
  • Coordination,
  • Education,
  • Peer to peer feedback, and
  • Patient/family engagement.

Part one will provide a “current state” overview and highlight clinical teamwork focused on reducing barriers to timely antibiotic administration and fluid resuscitation. Part two will host a panel discussion of subject matter experts taking questions on both clinical and operational opportunities across the hospital space.

The sessions will be followed by our podcast series “Speaking of Sepsis”, IPRO HQIC’s unique spin on partnership with hospitals across the country to improve the care of sepsis patients and reduce mortality. “Speaking of Sepsis” highlights stories of hospitals and healthcare workers innovating and improving sepsis care through clinical and operational implementation of best practices and multi-professional collaboration.

REaL Data Collection Toolbox

Prepared by IPRO HQIC

This Learning Toolbox focuses on healthcare facilities collecting data on race, ethnicity, and language preference (REaL) as an important component of the provision of equity in the healthcare setting. It includes a quick primer on data collection, and provides links to articles, tools, and resources to educate providers on the importance of knowing the diverse patient population for which they provide care.

IPRO HQIC PFE LAN: Applying PFE Best Practice 5 to Reducing Unplanned Readmissions, June 2023

Prepared by IPRO HQIC

The June PFE Learning and Action Event focuses on ways the implementation of patient and family advisory councils, or the inclusion of patient and family advisors on hospital committees, can be applied to your hospital’s efforts to reduce unplanned readmissions.

Communicating With Doctors and Nurses While in the Hospital: A Tool for Patients and Family Caregivers to Improve Patient Safety

Prepared by the IPRO HQIC Patient Safety Committee

Two-way communication between clinicians and patients plays a critical role in delivering high-quality care and ensuring a positive experience. Developed by the IPRO HQIC Patient Safety Committee*, the goal of this tool is to help patients and their care partners clearly communicate with their healthcare team. Patients can use this tool to plan for and document conversations with a doctor or nurse. The tool has three sections: (1) a set of communication tips for patients; (2) a guide to help patients plan for conversations with their healthcare team; and (3) suggestions for how patients can use their notes from conversations with their health care team. Clinicians can also use this tool to invite and encourage patients to communicate clearly with their healthcare team so that they are partners in their care.

*The IPRO HQIC Patient Safety Committee is composed of patients, family caregivers, and quality improvement specialists from states participating in the IPRO HQIC. 

Interventions to Reduce Acute Care Transfers (INTERACT): Interventions to Reduce Acute Care Transfers

Pathway Health: Project supported by the Centers for Medicare and Medicaid Services (CMS)

INTERACT (Interventions to Reduce Acute Care Transfers) is a quality improvement program that focuses on the management of acute change in resident condition. It includes clinical and educational tools and strategies for use in everyday practice in long-term care centers. INTERACT is designed to improve the early identification, assessment, documentation, and communication about changes in the status of residents. The goal of INTERACT is to improve care and reduce the frequency of potentially avoidable transfers to the acute hospital.

Website requires login, tools are free.

AHA Series: Social Determinants of Health

Prepared by the American Hospital Association (AHA)

The AHA is working to support hospitals and health systems as they address social determinants of health, eliminate health care disparities and provide comprehensive care to every patient in every community—all of which improve community health.

This series is organized by topic, and currently includes modules for: food, housing, transportation, health behaviors, violence, and more.

TAP: A Strategy to Prioritize and Implement HAI Prevention Efforts in Your Hospital

Prepared by Centers for Disease Control and Prevention (CDC) and IPRO HQIC

Date: Tuesday, April 18, 2023 Start Time: 3:00 – 4:00 PM ET

Join us for a webinar featuring subject matter experts from the Centers for Disease Control and Prevention (CDC) to learn about a comprehensive strategy to reduce hospital acquired infections (HAI). The Targeted Assessment for Prevention (TAP) Strategy is a CDC-developed framework for quality improvement that uses data to drive interventions that will prevent healthcare-associated infections.

The TAP strategy targets healthcare facilities and specific units within facilities that have a disproportionate burden of HAIs so that prevention efforts can be prioritized and implemented where they will have the greatest impact. Our speakers will discuss the latest updates in the strategy and tools, including adaptation for smaller facilities.

Your participation in this webinar will provide you with updated information on:

  • How to use NHSN collected data to identify opportunities for improvement by facility and unit.
  • How to calculate a cumulative attributable difference (CAD)* to identify a concrete infection reduction goal
  • How to use CDC assessments to target the focus of improvement work and identify high value interventions.

*The number of infections that must be prevented to achieve an HAI reduction goal. 

Pre-recorded Learning Modules on Person and Family Engagement

Prepared by AIR for IPRO HQIC

What is Person and Family Engagement and Why Does it Matter?

This presentation outlines the benefits of PFE to improve care and shows how hospital staff can invite patients and families to become partners with them in direct care or in general hospital improvement. A list of resources is shared at the end of the presentation. A transcript is available to accompany the recorded presentation in the IPRO HQIC Resource Library.

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How Can Person and Family Engagement Practices Help Reduce All-Cause Harms in Hospitals?

This 14-minute presentation expands on engaging patients and families to be partners and focuses on using PFE as a quality improvement strategy that can assist in reducing all-cause harms (e.g., falls, pressure injuries, infections) in the hospital. The presentation introduces the
five PFE Best Practices required by the Centers for Medicare & Medicaid Services for hospitals enrolled in the Hospital Quality Improvement Contract (HQIC). It explains how these best practices can be implemented and applied to improve patient safety at the hospital. A list of
resources is shared at the end of the presentation. A transcript is available to accompany the recorded presentation in the IPRO HQIC Resource
Library.

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Vaccine Storage and Handling Toolkit (Updated Addendum added April 12, 2022 )

Centers for Disease Control (CDC)

This toolkit addresses proper storage, handling, transport,
and emergency handling of COVID-19 vaccines.

The addendum has been updated to clarify COVID-19 vaccination provider requirements, include language related to FDA
authorization and approval of COVID-19 vaccine products, and storage and handling information on Pfzer-BioNTech Vaccine.

Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE)

National Association of Community Health Centers

This resource contains the set of national core measures as well as a set of optional measures for community priorities. It was informed by research, the experience of existing social risk assessments, and stakeholder engagement. It aligns with national initiatives prioritizing social determinants (e.g., Healthy People 2020), measures proposed under the next stage of Meaningful Use, clinical coding under ICD-10, and health centers’ Uniform Data System (UDS).