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.


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.


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.


Video: Uncovering Unconscious Bias for Safer Healthcare Interactions

Advancing the Culture of Patient Safety: Strategies to Prevent CLABSI and CAUTI

Prepared by IPRO HQIC

Hospital-Acquired Infections (HAIs) are among the most common complications in hospitals and continue to be a significant concern in the healthcare system. The Agency for Healthcare Research and Quality estimates that approximately 633,300 patients contract one of these infections annually, costing billions for healthcare organizations. These infections can lead to significant morbidity and mortality, with tens of thousands of lives lost each year.

To improve the overall quality of care, it is important that healthcare professionals direct their focus toward identifying and creating opportunities for improving performance and outcomes. In this Lunch & Learn we will cover:

  • The prevalence of Central Line Associated Blood Stream Infection (CLABSI) and Catheter-Associated Urinary Tract Infection (CAUTI).
  • The causative factors and evidence-based strategies for CLABSI and CAUTI prevention.
  • How the Appalachian Regional Healthcare System successfully implemented evidence-based strategies that resulted in a significant decrease in CLABSI and CAUTI rates.

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.

SERIES: IPRO HQIC Health-Related Social Needs

Prepared by IPRO NQIIC

Addressing health-related social needs (or social drivers of health) can improve health outcomes. Health-related social needs include food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety.

Join IPRO QIN-QIO for the Health-Related Social Needs Series to learn, collaborate, share best practices and lessons learned on how best to screen for, capture information about, and address social needs.

  • Engage in interactive sessions where participants learn about health-related social needs and specific issues when screening, collecting, and addressing this information.
  • Participate in a collaborative forum to share best practices, challenges, and lessons learned, including ways to streamline reporting to CMS.
  • Share tools, resources, and other material with your peers.

This series is comprised of six sessions from 12 to 12:45 pm ET on:

  • September 13
  • October 11
  • November 8
  • December 13
  • January 10
  • February 14

April 18, 2023 LAN Event – Using TAP Strategy for HAI Reduction: CAUTI, CLABSI, C. diff, MRSA

Prepared by IPRO HQIC

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 Worst Day: Emergency Preparedness and Response Educational Series

Prepared by IPRO QIN-QIO

This Emergency Preparedness and Response Webinar series features real life experiences told through the lens of those who have experienced emergencies and will help you prepare and train for emergencies and anticipate potential hazards when an emergency occurs.

For healthcare workers, it is not of question of if, but when an emergency will strike. Emergencies can take many forms and are among the most disruptive experiences that healthcare workers might encounter. Being prepared can save lives, prevent financial/property loss, and ensure the safety and well-being of entire communities. Having a plan helps staff, patients, families, and residents know what to do, where to go, and how to keep themselves safe during an emergency, and ensures access to essential information and equipment.

Session 1: When Things Get Real! (4/20/2023)

Session 2: You Don’t Know What You Don’t Know (4/27/2023)

Session 3: The Impact of Trauma (5/4/2023)

Session 4: The Media at Your Door (5/11/2023)

How to Rebuild, Reengage and Reenergize Your Patient and Family Advisory Council (PFAC)

Prepared by IPRO HQIC

In recent months, hospitals have begun to reengage their Patient and Family Advisory Councils (PFACs) after the adverse impact that the COIVD-19 pandemic had on their healthcare systems, including the ability to have in-person PFAC meetings. As a result, some hospital PFACs are even better and stronger than ever before. Wills Memorial Hospital, a 25-bed critical access hospital (CAH) located in Washington, GA will present on the rebuilding and reenergizing of their PFAC, identifying and prioritizing several key areas of concern, and implementing projects based on greatest need.


  • Explain the five Patient and Family Engagement metrics and other key measures of the Hospital Quality Improvement Contractor (HQIC) program.
  • Discuss the PFAC infrastructure and the importance of listening to the patient’s voice to improve patient care.
  • Illustrate how one hospital implemented training for the patient care team based on PFAC discussions and how the training has improved quality outcomes.

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Patient Stories Collection: Infectious Diseases

Compiled by IPRO HQIC

The following are websites where you can find patient stories related to infectious diseases:

1. Infectious Diseases Society of America (IDSA). IDSA Home [Internet]. Patient Stories: The Faces of Antimicrobial Resistance; [cited 2023 Aug 8]. Available from:

2. Pew Charitable Trusts. The Pew Charitable Trusts | The Pew Charitable Trusts [Internet]. True Stories of Antibiotic Resistance; 2017 Nov 13 [cited 2023 Aug 8]. Available from:

3. National Foundation for Infectious Diseases (NFID). NFID [Internet]. Real Stories, Real People – NFID; [cited 2023 Aug 8]. Available from:

4. Sepsis Alliance [Internet]. Faces of Sepsis; [cited 2023 Aug 11]. Available from:

5. Summa Health | Nonprofit Healthcare System in Akron, Ohio [Internet]. Infectious Disease Patient Stories | Summa Health; [cited 2023 Aug 11]. Available from:

6. Cleveland Clinic [Internet]. Infectious Disease Patient Stories | Cleveland Clinic; [cited 2023 Aug 11]. Available from:

7. St. Jude Children’s Research Hospital [Internet]. Infectious Diseases Treatment Patient Stories; [cited 2023 Aug 11]. Available from:

8. Patient Stories and Patient Safety [Internet] CDC. Published September 13, 2023. [Cited September 18, 2023]. Available from:

9. COVID-19 Patient Stories. [Internet] [Cited September 18, 2023]. Available from:

10. HQIC Antibiotic Stewardship Workgroup: Clostridioides difficile Module. [Internet] IPRO NQIIC. [Cited September 18, 2023]. Available from:

IPRO Fall and Injury Prevention: A 6-Part Webinar Series

Prepared by IPRO NQIIC in collaboration with Dr. Pat Quigley

Falls represent a major public health problem around the world and continue to be the most common adverse event in healthcare settings. The IPRO Hospital Quality Improvement Contractor (HQIC), in collaboration with Dr. Pat Quigley, Nurse Consultant, invites you to participate in a patient safety webinar program beginning May 3, 2023.

The Fall and Injury Prevention webinar series features six monthly webinars, each followed by open forum/coaching sessions from May through October 2023.

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.