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This informative newsletter is a 12-page monthly resource that provides you with the hands-on advice, tools (including data collection forms), and best practices that you need to ensure your hospital scores high on its quality measures and receives all of the Medicare reimbursement it deserves!

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Quality Improvement Report

Issue 12, December 1, 2007 - VIEW THE FULL ISSUE

• New guideline empowers patients and families to call for rapid assistance

  Had Sorrel King been able to launch a rapid re-sponse team at the hospital where she watched her...

• Catheter removal key to infection prevention

  Editor's note: This is the third part in a series about how to prevent some of the conditions CMS...

• Prepare now for anticoagulation requirement

  Even though hospitals have all of 2008 to prepare for the new National Patient Safety Goal (NPSG...

• Confusion abounds about MM.4.10 standard

  Although The Joint Commission (formerly JCAHO) suspended its interim action requiring retrospective...

Issue 11, November 1, 2007 - VIEW THE FULL ISSUE

• How to present qualityinfo that will engage the board of directors

  If you want to really engage your board of directors, focus on two or three high-risk measures...

• Focus on staff is key to retaining quality professionals

  After 15 years in the quality and performance improvement field, Judy Perry-Ewald, BS, MPA, CPHQ...

• Creating a culture of safety takes time to develop

  The new standard calling on hospitals to create a culture of safety may not go into effect until...

• Hourly rounding, huddles help prevent patient falls

  Editor's note: This is the second part in a series looking at how to prevent some of the conditions...

Issue 10, October 1, 2007 - VIEW THE FULL ISSUE

• Pilot pressure ulcer prevention programs on one unit for success

  Editor's note: This is the first part in a series that details how to prevent hospital-acquired...

• How to score severity when conducting FMEAs

  Editor's note: This is the second in a series of stories about failure modes and effects analysis...

• High employee morale leads to high patient satisfaction

  For the past three years, Southwestern Vermont Medical Center (SVMC) in Bennington has ranked in...

• Focus on these six most-cited Patient Safety Goals

  Six patient safety goals are the source of many healthcare organizations' woes. The notorious six...

Issue 9, September 1, 2007 - VIEW THE FULL ISSUE

• Hospitals hustle to train staff to document conditions present on admission

  Hospitals should start training staff now to assess and document conditions present on admission to...

• Nonpunitive culture led to hundreds of near-miss reports

  Near-miss reporting can target potential mistakes before they become sentinel events, but...

• FMEAs identify risks before they become disasters

  Editor's note: This is the first in a series of stories about Failure Modes and Effects Analysis...

Issue 8, August 1, 2007 - VIEW THE FULL ISSUE

• New NPSG calls for a rapid response to patients' deteriorating conditions

  Kathy Duncan, RN, a faculty member of the Institute for Healthcare Improvement's (IHI) 5 Million...

• Education, clinician engagement led to rapid success

  Don't dive right into setting up a rapid response system without involving the frontline clinicians...

• Nurses need to feel free to call when anything looks awry

  Hospitals that want to set up successful rapid response systems need to ensure that all nurses feel...

Issue 7, July 1, 2007 - VIEW THE FULL ISSUE

• Present only pertinent data about dashboards for senior leaders, board members

  Quality improvement (QI) directors who want to build effective dashboards should present a few...

• How to master the basics of statistics and data

  Editor's note: The following is an excerpt from the book Statistics Basics: A Resource Guide for...

• AHRQ offers sample report cards on quality

  Hospitals struggling with growing demands for transparency may want to look at a new tool...

• Handwashing reminders impressed surveyors

  One of the main pieces of information Donna Stanley, RN, learned during her hospital's recent...

Issue 6, June 1, 2007 - VIEW THE FULL ISSUE

• Screen for substance abuse when assessing suicide risk

  Patients coming into the emergency department (ED) with substance abuse problems should go through...

• Validating registration, licensure, and traceability of records is critical

  Of the nine new FAQs The Joint Commission recently released about tissue storage, the one that's...

• Hospital's Universal Protocol form keeps it simple

  To standardize and simplify its Universal Protocol form, Blount Memorial Hospital formed a team to...

• Heed these measures to see your HCAHPS scores rise

  Quality improvement directors who want to make sure that their hospitals get glowing reviews when...

Issue 5, May 1, 2007 - VIEW THE FULL ISSUE

• Pennsylvania pioneers mandatory near-miss reporting for hospitals

  Near-miss reporting provides rich information that could potentially reduce adverse events, yet...

• AHRQ tools aim to get patients involved in their care

  The Agency for Healthcare Research and Quality (AHRQ) has developed two new tools to reach out to...

• Order sets, checklists help hospital in P4P success

  It's called pay for performance (P4P), but the incentive program has less to do with financial gain...

Issue 4, April 1, 2007 - VIEW THE FULL ISSUE

• Most stringent rules apply for new restraint regulations

  Hospitals that want to comply with CMS' new restraint and seclusion regulations that went into...

• Baystate pioneers successful surgical care strategies

  Baystate Medical Center in Springfield, MA, ranks in the top 10% in the country for both antibiotic...

• Compassion, 'calming rooms' lead to patient satisfaction

  Listening, showing compassion, and trying to turn waiting rooms into "calming rooms" stocked with...

• NPIs needed to apply for quality reporting bonuses

  CMS' Susan Nedza, MD, MBA, has two key pieces of advice for healthcare professionals who want take...

• Physician-hospital relations growing in importance

  Hospital administrators, like other business leaders, are concerned with protecting and growing...

Issue 3, March 1, 2007 - VIEW THE FULL ISSUE

• Communication, med rec among top compliance challenges in 2006

  Communication among clinicians and medication storage and reconciliation were among the top...

• Mystery shoppers keep tabs on patient satisfaction

  Long a staple in the retail industry, mystery shopping has made the leap to the hospital setting...

• Recognition paramount to hospital that got P4P bonus

  Bone and Joint Hospital in Oklahoma City recently received the second-largest single bonus...

Issue 2, February 1, 2007 - VIEW THE FULL ISSUE

• How to navigate the basics of the QI data terrain

  Vivian Chun, RN, CPHQ, learned in business school how to look at data, understand an Excel...

• System's reduction of pressure sores leads to award

  Quality improvement directors with ambitious plans to dramatically reduce hospital-acquired...

• Hospital reduces disparities, improves cardiac care

  Back in 2003, Del Sol Medical Center in El Paso, TX, decided it needed to do something about the...

• This hospital is a top patient satisfaction performer

  Sacred Heart Hospital in Eau Claire, WI, ranks in the 99th percentile for patient satisfaction...

• Experts: CMS verbal orders change adds to burden

  Although CMS' new Conditions of Participation (COP) rule changes are designed to ease the burden...

Issue 1, January 1, 2007 - VIEW THE FULL ISSUE

• As JCAHO eyes apnea as a goal, hospitals seeing more unexplained deaths

  Shelly Collins, PharmD, coordinator of clinical pharmacy services at Chesapeake (VA) General...

• Doctors detail good physician handoffs

  A quiet room that's free of interruptions, with just two people, face to face, conversing candidly...

• Hospitals still struggling with two patient identifiers

  The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has proposed adding a new...