Reliability Culture Implementation Guide

This material was prepared by Michigan Health & Hospital Association, Illinois Health and Hospital Association, Wisconsin Hospital Association, and Minnesota Hospital Association. It is redistributed by IPRO HQIC, a Hospital Quality Improvement Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS).

The Reliability Culture Implementation Guide combines the five principles of high reliability organizations (HROs) with elements of safety culture. The Reliability Culture Implementation Guide was created to provide resources for healthcare organizations, with an emphasis on safety culture, regardless of where they are in their high reliability journey. This guide is not a step-by-step
process, but rather a guide that helps facilities after completing an initial assessment.

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

This material was prepared by American Institutes for Research (AIR). It is redistributed by IPRO HQIC, a Hospital Quality Improvement Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS).

A growing body of work—captured in peer-reviewed
literature and the experiences of hospitals and health
systems across the United States—highlights the benefits
of PFE, suggesting that successful implementation of PFE
practices can contribute to better outcomes. This PFE Roadmap provides practical guidance to help hospitals implement five PFE best
practices.

PfP Strategic Vision Roadmap for Person and Family Engagement (PFE)

This material was prepared by American Institutes for Research (AIR). It is redistributed by IPRO HQIC, a Hospital Quality Improvement Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS).

The purpose of the revised Roadmap is to provide practical guidance to help the Hospital Improvement Innovation Networks (HIINs), hospitals, and other PfP partners achieve a shared vision of PFE and meet the five PFE metrics.

The Roadmap contains information about:
• definition and core principles of PFE;
• role of PFE in patient safety;
• the intersection of PFE and health equity;
• definition, intent, and benefits of each PFE metric, as well as tips and resources to help
meet each metric and hospital success stories; and
• six PFE strategies to meet the five PFE metrics.

Strategies to Prevent Clostridioides difficile Infection in Acute Care Facilities

Centers for Disease Control (CDC)

Provides information on the basic principles and interventions recommended for the prevention of Clostridioides (formerly known as Clostridium) difficile infection (CDI) in acute care facilities. The strategies are intended to facilitate implementation of CDI prevention efforts by state and local health departments, quality improvement organizations, hospital associations, and healthcare facilities. Core strategies for the prevention of CDI in acute care facilities include:

1. Isolate & Initiate Contact Precautions

2. Confirm CDC in Patients

3. Perform Environmental Cleaning

4. Develop Infrastructure

5. Engage the Facility Antibiotic Stewardship Program

Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guidelines

European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance

In 2019, a full set of Clinical Practice Guidelines were developed, by the European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guidelines, The International Guideline and can be purchased for a fee. In addition, a Quick Reference Guide (QRG), which provides a summary of the recommended guidelines can be downloaded for no charge.

Prescription Drug Monitoring Programs (PDMPs): Drug Overdose:

Center for Disease Control and Prevention (CDC)

Clinical practice guidelines encourage use of the PDMP prior to prescribing to assess a patient’s history of controlled substance use. It is possible to improve the way opioids are prescribed, reducing the number of people who misuse, abuse, or overdose from them, while making sure patients have access to safe, effective pain management. A prescription drug monitoring program (PDMP) is an electronic database that tracks controlled substance prescriptions. PDMPs can help identify patients who may be misusing prescription opioids or other prescription drugs and who may be at risk for overdose.

Managing the Risks of Direct Oral Anticoagulants

The Joint Commission: Sentinel Event Alert

While DOACs offer ease of use to patients, stopping bleeding events in patients on DOACs is more complicated, requiring different strategies than those for patients on warfarin (Coumadin®) and heparin. Unlike the more widely available reversal agents for warfarin and heparin, reversal agents for DOACs are lesser known and may not be available in every care setting. Also, some DOACs have no FDA-approved reversal agent at this time. Therefore, bleeding complications can be severe if these patients are not assessed according to guidelines on the management of DOACs. Intracranial hemorrhage is the most serious emergent bleeding risk.

In response to an increase in adverse events related to these widely prescribed medications, this alert provides guidance on the safe use and management of DOACs to all medical practitioners and health care organization leaders, particularly chief medical officers, pharmacists, emergency department clinicians, and quality and safety officers.

Anticoagulation FORUM: Numerous Resources and Expert Guidance

Anticoagulation FORUM

  • Education & Guidance
  • Webinars and Events
  • Centers of Excellence
  • Anticoagulation Stewardship

Established more than 25 years ago, the Anticoagulation Forum is the largest organization of its kind helping practitioners improve patient care by providing current and relevant information on best practices. The flagship program, the Anticoagulation Centers of Excellence, embodies our commitment to the clinical application of evidence-based practices and improved patient outcomes. Expert Guidance is provided by the Board of Directors, who are regularly relied upon for their expert opinion. Their contributions to research and guideline development have influenced all aspects of anticoagulation therapy.

Preventing Hospital-Associated Venous Thromboembolism: A Guide for Effective Quality Improvement

Agency for Healthcare Research and Quality (AHRQ)

Pulmonary embolism resulting from deep vein thrombosis—collectively referred to as venous thromboembolism—is the most common preventable cause of hospital death. Pharmacologic methods to prevent venous thromboembolism are safe, effective, cost-effective, and advocated by authoritative guidelines, yet large prospective studies continue to demonstrate that these preventive methods are significantly underused. Based on quality improvement initiatives undertaken at the University of California, San Diego Medical Center and Emory University Hospitals, this guide assists quality improvement practitioners in leading an effort to improve prevention of one of the most important problems facing hospitalized patients, hospital-acquired venous thromboembolism.

Eliminating Disparities to Advance Health Equity and Improve Quality

MHA Keystone Center

The MHA Keystone Center encourages organizations to use this guide to assess the current level of hospital implementation around key strategies aimed at reducing disparities to achieve equity and improving quality. This resource will guide organizations to prioritize and act on identified gaps so that deliberate and purposeful action is taken to ensure that the outcomes across all patient populations are equitable. Sections of the guide include:

Section 1: Understanding Key Terms

Section 2: Why Equity in Care Matters

Section 3: Strategic Pillars on the Journey Toward Equity

Section 4: Recommendations for Action

Section 5: Levels of Implementation

Section 6: The MHA Keystone Center’s Dedication to

Achieving Health Equity

Section 7: Resource Compendium

HHS Releases New Buprenorphine Practice Guidelines, Expanding Access to Treatment for Opioid Use Disorder

Health and Human Services (HHS) April, 2021

In an effort to get evidenced-based treatment to more Americans with opioid use disorder, the Department of Health and Human Services (HHS) is releasing new buprenorphine practice guidelines that among other things, remove a longtime requirement tied to training, which some practitioners have cited as a barrier to treating more people.

Signed by HHS Secretary Xavier Becerra, the Practice Guidelines for the Administration of Buprenorphine for Treating Opioid Use Disorder exempt eligible physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists and certified nurse midwives from federal certification requirements related to training, counseling and other ancillary services that are part of the process for obtaining a waiver to treat up to 30 patients with buprenorphine.

MODERNIZING HEALTH CARE TO IMPROVE PHYSICAL ACCESSIBILITY

Centers for Medicare and Medicaid Services (CMS)

The resources in this inventory include guidance on how to increase physical accessibility of medical services, tools to assess your practice or facility’s accessibility for individuals disabilities, and tips and training materials to support efforts to reduce barriers and improve quality of care. This document is intended to provide recommendations on how to improve accessibility in order to improve quality of care for patients with disabilities.