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OHA Hospital Improvement Innovation Network: 2016-2018

Improving Health Care in Ohio
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The Centers for Medicare & Medicaid Services in 2016 announced plans to move forward with the next phase of the Partnership for Patients (PfP) initiative to improve patient outcomes and reduce preventable readmissions.

The Ohio Hospital Association is one of 16 national, regional or state hospital associations, Quality Improvement Organizations and health system organizations selected to continue efforts in reducing preventable hospital-acquired conditions and readmissions.

By collaborating with multiple partners to ensure sharing of best practices and education, OHA provides participating hospitals a unique experience for improving care. The Hospital Improvement Innovation Network, or HIIN, contract builds upon the collective momentum of the Hospital Engagement Networks and Quality Improvement Organizations to reduce patient harm and readmissions.

This announcement is part of a broader effort to transform the health care system into one that works better for the American people and for the Medicare program. Additionally, OHA has partnered with Battelle to include WayFinder, a predictive analytics software tool, into the HIIN contract. This allows allOHA HIIN hospitals to access and use the software at minimal or no cost, as well as use additional data analytic opportunities that are currently being designed specifically for the PfP initiative.

Through 2019, these Networks will work to achieve a 20 percent decrease in overall hospital-acquired conditions and a 12 percent reduction in 30-day hospital readmissions as a population-based measure (readmissions per 1,000 people) from the 2014 baseline. Efforts to address health equity for Medicare beneficiaries will be central to the Hospital Improvement Innovation Networks efforts. CMS will monitor and evaluate the activities of the Hospital Improvement Innovation Networks to ensure that they are generating results and improving patient safety.

Cross-topic Resources
Core Focus Topics
Adverse Drug Events (ADE)
Adverse drug events (ADEs) are injuries resulting from drug-related medical interventions. ADEs can occur in any health care setting.



Toolkits Links Recorded Webinars
  • Opioid Reduction Strategies (Recording | Slides)
    • Maria Foy, PharmD, BCPS, CPE, Clinical Pharmacy Specialist, Palliative Care, Abington Jefferson Health, Elkins Park, PA
  • Preventing Opioid ADEs...The past, present and future - Feb. 18, 2016
    • Slides: Kelly Besco, Pharm.D., FISMP, CPPS - Medication Safety Officer - OhioHealth Pharmacy Services
  • Glycemic Control: Hitting the Sweet Spot During Inpatient Care - July 1, 2016
    • Slides: Tim Brown, PharmD, BCACP, FASHP - Director of Clinical Pharmacotherapy, Family Medicine, Cleveland Clinic Akron General, Professor, Northeast Ohio Medical University
Clostridium Difficile (C. diff)

Clostridium difficile (C. difficile) is an important cause of infectious disease death in the United States. C. difficile was estimated to cause almost half a million infections in the United States in 2011. Approximately 83,000 of the patients who developed C. difficile experienced at least one recurrence and 29,000 died within 30 days of the initial diagnosis.

Poor prescribing practices put patients at risk for C. difficileinfections. More than half of all hospitalized patients will get an antibiotic at some point during their hospital stay, but studies have shown that 30-50% of antibiotics prescribed in hospitals are unnecessary or incorrect.

C. difficile infections can be prevented by using infection control recommendations and more careful antibiotic use.


Literature Toolkits Links Best Practices Webinars
Antibiotic Stewardship (ASP)
Misuse and overuse of antimicrobials is one of the world’s most pressing public health problems.  The Centers for Disease Control and Prevention (CDC) estimates that more than two million people contract antibiotic-resistant infections in the U.S. each year, with about 23,000 dying as a result.  Antimicrobial stewardship is a set of strategies that promotes the appropriate use of antimicrobials improves patient outcomes, reduces microbial resistance, while decreasing unnecessary costs and the spread of infections caused by multidrug-resistant organisms. 


Literature Toolkits Links Webinars
Catheter-Associated Urinary Tract Infections (CAUTI)
A urinary tract infection (UTI) is an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney. 


Toolkits Links Recorded Webinars
Central Line-Associated Blood Stream Infections (CLABSI)
CLABSI is a primary bloodstream infection that develops in a patient with a central line in place within the 48-hour period before onset of the bloodstream infection that is not related to infection at another site.


Toolkits Links Webinars
Surgical Site Infections (SSI)
A surgical site infection is an infection that occurs after surgery in the part of the body where the surgery took place. 


Resources Toolkits Links Recorded Webinars
Ventilator-Associated Events (VAE)
Ventilator-associated events are comprised of ventilator-associated conditions (VAC), infection-related ventilator-associated complications (IVAC), and ventilator-associated pneumonia (VAP).


Literature Toolkits Links Recorded Webinars
Injuries from falls and immobility
Patient falls are unplanned descents to the floor with or without injury to the patient.


Literature Toolkits Links Webinars
Pressure Ulcers
A pressure ulcer is an area of skin that breaks down when something keeps rubbing or pressing against the skin.



Toolkits Links Webinars
  • Effective Practices for Assessment and Documentation of Pressure Ulcer Prevention - June 27, 2018
    • Lisa Stepp, BSN, RN, Quality Patient Safety Manager, Holzer Health System (Slides)
    • Donn Wolfe, MBA, Clinical Data Center Manager, Quality Management Services, The Christ Health Network, Cincinnati, Ohio (Slides)
  • Pressure Injury Prevention Strategies - September 27, 2017 (Recording)
    • Kathy L. Gray, RN, ON, CWS, Wound/Ostomy Nurse, Adena Regional Medical Center, Inpatient Wound Care & Education/Staff and Patient Education (Slides)
    • Wendy Greathouse, RN, BSN, Quality & Risk Coordinator for Southern Lorain County, Mercy Health (Slides
Venous Thromboembolism (VTE)
Venous thromboembolism (VTE) is a disease that includes both deep vein thrombosis (DVT) and pulmonary embolism (PE). It is a common, lethal disorder that affects hospitalized and nonhospitalized patients, recurs frequently, is often overlooked, and results in long-term complications including chronic thromboembolic pulmonary hypertension (CTPH) and the post-thrombotic syndrome (PTS).


Toolkits Links Articles
Hospitalizations account for nearly one-third of the total $2 trillion spent on health care in the United States. In the majority of cases, hospitalization is necessary and appropriate. However, a substantial fraction of all hospitalizations are patients returning to the hospital soon after their previous stay. These rehospitalizations are costly, potentially harmful, and often avoidable.


Toolkits Links Best Practice Recorded Webinars
Severe Sepsis and Septic Shock
Sepsis, a deadly blood infection, impacts thousands of Ohioans every year (estimated 34,000 patients). Many of these patients continue to require additional health care services after surviving sepsis due to the complications of the disease. Early recognition and treatment can reduce the morbidity and mortality of sepsis.


For Resources and Links related to sepsis, please visit the OHA Statewide Sepsis Initiative here.


For access information on previous webinars, please visit the OHA Statewide Sepsis Initiative Education Resource page.

Additional Topics
Hospital Culture of Safety
The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization’s health and safety management.


Literature Toolkits Links Best Practices Webinars
Iatrogenic Delirium

Delirium may be the single most common acute disorder affecting adults in general hospitals. It affects 10-20 percent of all hospitalized adults, 30-40 percent of elderly hospitalized patients and up to 80 percent of ICU patients. In addition, delirium increases length of hospital stays, contributes to higher cost of care, leads to long-term cognitive impairment and increases mortality rates.


Calendar of upcoming sessions: click here (Partnership with Minnesota HEN)

Literature Toolkits Links OPSI Education Series

Diagnostic Error and the Diagnostic Process Conference Series is being offered throughout 2018 and 2019.  To access the recordings and slides of the series visit the Ohio Patient Safety Institute Website.

Recorded Webinars
  • September 27, 2018 - Sleep Hygiene Considerations with Iatrogenic Delirium (Recording | Slides)
    • Yoanna Skrobik, MD, FRCP(c), MSc, FCCM, Internist and Intensivist and Clinician Scientist, L'Universite De Montreal A L'Hospital Maisonneuve-Rosemont, Montreal, Quebec and Faculty of Medicine, McGill University, Montreal, Canada
  • July 26, 2018 - Incorporating Champions/Volunteers into a Delirium Prevention Program
    • Jan Dionne, MSN, CNS-BC, CEN, Delirium Prevention Specialist/Program Manager, Regions Hospital, St. Paul, MN (Slides | Recording
  • May 31, 2018 - Person and Family Engagement Considerations with Iatrogenic Delirium
    • Judith Ann Tate, PhD., RN, Assistant Professor, Center of Excellence in Critical and Complex Care, The Ohio State University College of Nursing, Columbus (Slides | Recording
  • March 22, 2018 - Early Mobility: Beyound the ICU (Slides | Recording)
    • Cynthia J. Brown, MD, MSPH, Professor of Medicine and Director, Division of Gerontology, Geriatrics and Palliative Care, University of Alabama at Birmingham
  • January 25, 2018 - The Role of the Clinical Pharmacist in Management of Iatrogenic Delirium (Slides | Recording)
    • Anthony Gerlach, PharmD, FCCM, FCCP, Specialty Pharmacist, Surgical ICU, The Ohio State University Wexner Medical Center;  Clinical Associate Professor, The Ohio State University College of Pharmacy
  • November 16, 2017 - Leveraging the Electronic Medical Record to Prevent Iatrogenic Delirium (Slides | Recording)
    • Aminata Cham, RN, MSN, APRN, ACNS-BC, Medical/Surgical Clinical Nurse Specialist, HealthEast Care System
  • September 28, 2017 - Executive Sponsorship of Iatrogenic Delirium Initiatives (Slides | Recording)
  • July 27, 2017:  ICU Liberation ABCDEF Bundle Implementation: Focus on Delirium
    • Diane Byrum, MSN, RN, CCRN-K, CCNS, FCCM, Quality Implementation Consultant, Innovative Solutions for Healthcare Education, LLC (Slides | Recording
  • 10th Annual Quality Summit: Impact of Iatrogenic Delirium - June 14, 2017
    • Moderator: James V. Guliano, MSN, RN-BC, FACHE, vice president, Quality Programs, OHA
    • Keynote: Nathan Brummel, MD, MSCI, assisant professor, Center for Quality Aging, Center for Health Services Research, Vanderbilt University Medical Center
    • Panelist:  Michele Balas, PhD, RN, Ohio State University College of Nursing
    • Panelist:  Crystal Hollon, BSN, RN-BC, CMSRN, NICHE coordinator, TriHeatlh Bethesda North Hospital
  • May 25, 2017: ICU Delirium Prevention and Treatment: Medication-Associated Implications
    • John W. Devlin, PharmD, BCCCP, FCCM, FCCP, Professor of Pharmacy, Northeastern University and Member of Scientific Staff in the Division of Pulmonary, Critical Care and Sleep Medicine at Tufts Medical Center, Boston, MA (Slides, Recorded Session)
  • March 23, 2017:  Physical Therapy Intervention in Delirium: Prevention, Identification, and Treatment
    • Amanda LaLonde, PT, DPT, Director of Clinical Education, Assistant Professor, Division of Physical Therapy (Slides, Recorded Session)
  • Jan. 26, 2017: Delirium: How We Can Make A Difference
    • Denis Kresevic, RN, PhD., APN, Clinical Nurse Specialist III, University Hospital Case Medical Center (Slides)
  • Dec. 1, 2016: Road Map to a Delirium Detection, Preention, Management Program
  • July 27, 2016: Non-Pharmacologic Management of Delirium: An ABCDEF Approach - recorded session
    • slides: Michelle Balas PhD, RN, APRN-NP, CCRN-K, FCCM - Discusses research findings to identify clinical education opportunities and clinical practice implementation.
  • June 22, 2016: System Wide Delirium Prevention Program at HealthPartners Facilities in Minnesota and Wisconsin - Engaging Patients and Families - recorded session
    • slides: Jan Dionne, MSN, CNS-BC, CEN; Susan Schumacher, MS, APRN, GCNS
  • April 27, 2016: Iatrogenic Delirium & Dementia/Delirium Related Behaviors - recorded session
    • slides: Heather Carey, PharmD, BCPP - UH Richmond Medical Center
    • slides: Sue Bikkie, DNP, GNP, APRN, BC - Orr & Associates
  • Feb. 24, 2016: Delirium Assessment & ICU Delirium - recorded session
    • slides: Susan Schumacher, MS, APRN-BC - Park Nicollet Methodist Hospital
    • slides: Denise Kresevic, RN, Ph.D, APN - UH Case Medical Center
Integration of Worker & Patient Safety
Health care professionals whose focus is on patient safety are very familiar with these alarming and frequently cited statistics from the Institute of Medicine: medical errors result in the death of between 44,000 and 98,000 patients every year. Health care professionals whose focus is on occupational health and safety, however, are likely aware of additional statistics that are less well known: health care workers experience some of the highest rates of nonfatal occupational illness and injury—exceeding even construction and manufacturing industries.


Literature Toolkits Links Best Practices Webinars/Recording
The Integration of Worker and Patient Safety: We Share 4 Safety 
  • August 3, 2018: Member Highlight: Safe Patient Handling Programs: Courtney Ulrich, MHSA; Deanna Danner, Salem Regional and Lisa Drouhard, Promedica (Recording)
  • July 6, 2018: Getting Results with SPHM Programs: Courtney Ulrich, MHSA and Margaret Arnold, PT, CEES, CSPHP (Recording)
  • May 11, 2018: Evaluating Safe Patient Handling Program Best Practices: Courtney Ulrich, MHSA and Dr. Jim Collins, PhD, MSME (Recording | Slides)
  • February 2, 2018: Building a Business Case: Integration of Worker and Patient Safety: Courtney Ulrich, MHSA and Kelly Austin, MHSA, RiskControl360 (Slides | Recording)
  • January 5, 2018: HRO/Integration of Worker and Patient Safety; Southern Ohio Medical Center Team: Christy Timberlake and Blake Howard; RiskControl360 Team: Brad Hunt and Courtney Ulrich (Slides | Recording)
  • December 8, 2017: HRO/Integration of Worker and Patient Safety, Brad Hunt, MBA, RiskControl360; Courtney Ulrich, MHSA, Risk Control360; Brian Swearingen and Laurie Clark w/Aultman Hospital; Mount Carmel Team (Recording | Slides)
  • Aug. 4, 2017: Aggressive Behavior Member Highlight w/Brad Hunt, MBA, RiskControl360; Courtney Ulrich, MHSA Risk Control360; Kelly Austin, PsyD, KLA Risk Consulting;  Deanna Danner, Salem Regional Hospital; and Jim Collins ProMedica (Slides)
  • July 7, 2017: Agressive Behavior Member Highlight w/Brad Hunt, MBA, RiskControl360; Courtney Ulrich, MHSA RiskControl360; Kelly Austin, PsyD, KLA Risk Consulting; Jenny Conn, Mercer Health; and Diane Darr, Bellevue Hospital  (Recording | Slides)
  • May 7, 2017: Aggressive Behavior Member Highlight  w/Brad Hunt, MBA, RiskControl360; Courtney Rulrich, MHSA, RiskConrol360; Kelly Austin, PsyD, KLA Risk Consulting, Sue Neumann, MS, RNC, WilsonHealth; aned Christy Timberlake, SOMC (Recording |  Slides)
  • April 7, 2017: Aggressive Behavior w/Brad Hunt, MBA, RiskControl360; Courtney Ulrich, MHSA, RiskConrol360 and Kelly Austin, PsyD, KLA Risk Consulting (Recording | Slides)
Crosscutting Topics
Patient and Family Engagement
Engaging patients and families in improving health care safety means creating effective partnerships between those who provide care and those who receive it—at every level, including individual clinical encounters, safety committees, executive suites, boardrooms, research teams, and national policy-setting bodies. Increasing engagement through effective partnerships can yield many benefits, both in the form of improved health and outcomes for individuals and in safer and more productive work environments for health
care professionals.


PFE Coaching Calls

  • July 19, 2018: Large Urban Hospitals regarding PFE 4 and 5 presented by Chrissie Blackburn and Jennifer Lastic, Supervisor, Patient Experience, MetroHealth (Recording | Slides)

  • July 12, 2018: Small and Rural Hospitals regarding PFE 4 and 5 presented by Chrissie Blackburn and Ryan Finch, Director, Organizational Experience, Holzer Health System (Recording | Slides)

Is your hospital considering developing a Patient and Family Advisory Council (PFAC) 3-Part Learning Event

  • June 4, 2018 - Part 3: The Path for Implementing a PFAC: Step 3: Building Infrastructure and sustainability (Recording)

  • May 10, 2018 - Part 2: The Path for Implementing a PFAC: Step 2. Recruiting and Selecting Advisors (Recording)

  • April 12, 2018 - Part 1: The Path for Implementing a PFAC: Step 1. Assessing Readiness & Building the Foundation (Recording

March 8, 2018 - A Designated Person and Family Engagement IPFE) Leader

  • Chrissie Blackburn, MHA, Principal Advisor, PFE, University Hospitals Cleveland Medical Center
    Lisa Morrise, MArts, Consultant, PFE, Salt Lake City Utah (Slides | Recording)

November 9, 2017 - The Relationship Between Patient and Family Engagement and Health Equity (Slides | Recording)

  • Knitasha V. Washington, DHA, MHA, FACHE, Executive Director of Consumers Advancing Patient Safety and Head of ATW Health Solutions

    Lee Thompson, MS, Senior Researcher, American Institutes for Research (PfP PFE Contractor)

October 12, 2017 - Achieving Patient and Family Engagement (PFE) Metrics

  • Melissa Henry, MPP, Research Associate, American Institutes for Research, Project Manager for the Patient and Family Engagement Contractor for Partnership for Patients 3.0 and

    Lee Thompson, MS, Senior Researcher, American Institutes for Research (PfP PFE Contractor) (Slides | Recording) (PFP Strategic Vision Roadmap for PFE)

Sept. 14, 2017 - Building the Business Case for PFE

  • Thomas Workman, Ph.D., Principal Researcher, American Institutes for Research (Slides | Recording)

July 13, 2017 - Patient & Family Engagement (PFE) Metrics

  • Susan Schultz, RN, BSN, MSN, FACHE, Vice President of Patient Care Servies and Chief Nursing Officer, Mount Carmel New Albany Surgical Hospital, Columbus, Ohio (Slides)

  • Jennifer Lastic, BS, PFAC Coordinator, Office of Patient Experience, The MetroHealth System, Cleveland, Ohio (Slides)

May 11, 2017 - Metric 3: Overside of PFE; Chrissie Blackburn, MHA

April 13, 2017 - 12-1pm - Activating Patient Family Engagement as a Strategy for Improvement

  • Slides: Libby Hoy, Founder/CEO PFCCpartners

March 9, 2017 - 12-1pm - Person & Family Engagement (PFE) as a Strategy to Improve Patient Safety

Feb. 9, 2017 - 12-1pm - Patient & Family Advisory Councils; Chrissie Blackburn, MHA


Toolkits Best Practices Links
Racial and socioeconomic inequity persists in health care quality. To meet the needs of their diverse populations, hospitals and health systems will need to bridge the gap between collecting meaningful patient data and reviewing the data to identify inequities in health care provision and utilization, and to implement simple yet effective interventions to improve care for patients.


Literature Toolkits Links Recordings
  • July 25, 2018: Disparities and the Opioid Epidemic
    • Mercy Health, Cincinnati: Larry Graham, MD, President, Behavioral Health and Navdeep S. Kang, Psy.D., Director of Operations, Behavioral Health (Slides)
    • Metro Health System: Margarita Diaz, Manager of Health Equity Initiatives and Karen Cook, MPH, LSW, Manager, Community Health Advocacy Initiative (Slides)
Leadership is a critical function in promoting high quality, safe health care. In health care organizations, leadership is provided by the governing body, the chief executive and senior managers, and the leaders of the clinical staff. When a sentinel event occurs in a health care organization, inadequate or ineffective leadership is often one of the contributing factors. In fact, inadequate leadership was a contributing factor in 50 percent of the sentinel events reported to The Joint Commission in 2006. Research shows that leadership makes a major difference in the quality and safety of patient care.



Toolkits Links



OHA HIIN (2016)

OHA HEN (2012-2014)


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