The Quality Quarterly

HQI is excited to announce a partnership with BETA Healthcare Group to offer California hospitals a proven, comprehensive program that will guide them toward unprecedented progress in patient safety. 

HQI’s Perinatal Mental Health (PMH) Learning Community, funded by the California Health Care Foundation, is continuing to provide vital programming and resources to more than 148 California hospitals, aligned with the requirements of Assembly Bill 3032 (Frazier).

It has often been referred to as the “silence of shame.” Mental health conditions, substance use, and workplace events have been documented as contributing antecedents to nurse suicides. When a nurse is at risk for losing or loses his/her license, the psychological impact can be devastating. The experience of isolation, feelings of failure, public humiliation, and the stigma of losing his or her career can result in cascading events, potentially leading to a lethal outcome.

The 2021 wave of ransomware attacks has washed over every major business sector — including health care. Moreover, a Wall Street Journal article dated June 10 pointed out that one group of ransomware criminals is specifically targeting hospitals. This unfortunate reality strongly suggests that everyone in the CHA/HQI community should be working to avoid becoming a ransomware victim. This article will discuss high-priority items for organizations to pursue in that effort and identify some important strategies that sometimes get overlooked. Together, this information will hopefully help bolster your barriers against ransomware. 

Among all the patient safety reports that CHPSO receives from members, about 50% end up classified in the catch-all event type of “Other” rather than in a specific clinical or other meaningful event type category (e.g., healthcare-associated infection, fall, medication error, etc.). Sometimes the reports are categorized into the “Other” category because the facts of the safety event do not fit into one of the existing Agency for Healthcare Research and Quality’s (AHRQ) Common Formats specific event type categories. The broad nature of this “Other” category, diversity of events that it contains, and large size relative to the more specific event type categories renders it not particularly useful for identifying emerging patient safety issues or tracking trends over time.

HQI, in cooperation with the Patient Safety Movement Foundation and the California Hospital Association (CHA), creates and distributes quarterly dashboards of publicly available quality data for each CHA acute care member hospital. These model dashboards currently provide information on eight measures. 

Earlier this month, California reached a milestone that at many times throughout the course of the past year might have seemed unattainable. The state has now “reopened” for business, retiring the color-coded tier system and relaxing social distancing and capacity restrictions. After more than 15 months of numerous public health orders, three surges of cases, countless mask and gown changes along with many sleepless nights, the COVID-19 pandemic has finally given us a little bit of breathing room.  

For the past year, while much of the state has been locked down — working remotely and enjoying perhaps a slower pace of life — it’s been quite the opposite for our front-line health care workers. They stepped up, answered the call, working round the clock to care for patients, both COVID-19 and non-COVID-19.   

HQI, in cooperation with the Patient Safety Movement Foundation and the California Hospital Association (CHA), creates and distributes quarterly dashboards of publicly available quality data for each CHA acute care member hospital. These model dashboards currently provide information on eight measures.

Assembly Bill 3032, which was signed into law in 2019 and took effect in 2020, has two specific requirements for all California hospitals:  

1. Provide education and information for postpartum women and families about maternal mental health conditions, post-hospital treatment options, and community resources.  
2. Provide education and information for hospital employees regularly assigned to work in the perinatal unit, including, as appropriate, registered nurses and social workers, about maternal mental health conditions.  

At the Feb. 10 meeting, the HQI Board of Directors elected four new board members and extended the term for two members.  

As we wrap up a pandemic year and work through2021 with COVID-19 still at large, the arrival of the vaccine leaves most of us cautiously optimistic at best. While there is light on the horizon, many are still, and will continue to be impacted by delays in care during this epic time. HQI kicked off its first Safe Table of the year with this topic. 

This month, HQI is launching its first report of findings from the sentinel signal detection system, which automatically detects abnormal changes (i.e., signals) in the incidence of diagnosis codes from hospital discharge records in the Hospital Quality Improvement Platform, as well as term frequencies from the Collaborative Healthcare Patient Safety Organization safety reports.  

With the recent resurgence of COVID-19 and hospitals stretched to capacity, it’s more important than ever to be diligent about infection prevention. While so much more is known now about the disease than it was nine months ago, one thing that we have known since the start is how to minimize the spread of COVID-19.  

Now, more than ever, we must do what we can to limit the spread of COVID-19 locally and throughout the state.

HQI added two team members to its roster in October. In her role as a data analyst for HQI, Candice Cam will manage the data intake, system integrity, and performance enhancement of the Hospital Quality Improvement Platform. Specifically, she’ll be working to help our hospitals ingest discharge records into the platform so they have timelier analytics, ensure that the analytics presented are correctly calculated, and work with our vendor to create new reports and make improvements to the platform.  

In November, HQI was pleased to welcome Admiral Thad Allen, U.S. Coast Guard (Retired) to a webinar on Critical Leadership Situations: Dealing with the Added Pressures of the COVID-19 Pandemic.  

Our partners at the Pennsylvania Patient Safety Authority have produced a short video — Knock Out the Flu — that explains why everyone should get the flu shot every year, and why it’s more important now than ever to help protect you and your loved ones. It’s a helpful resource to share with your patients and community. 

Every quarter, HQI receives a large volume of discharge records (as part of the Hospital Quality Improvement Platform) and safety reports (as part of the Collaborative Healthcare Patient Safety Organization, or CHPSO) from hospitals.