Hospital Resources

Resources to support Hospital Quality Improvement Contractor (HQIC) partners. For additional tools, visit our Resource Library.

Hospital Resources

Resources to support Hospital Quality Improvement Contractor (HQIC) partners. For additional tools, visit our Resource Library.

Topic-Specific Patient Safety Resources for Quality Improvement

Antibiotic Stewardship

Antibiotic Stewardship: Quick Wins for Improving Duration of Therapy Change Pathway

Change Pathway: Antibiotic Stewardship

The Core Elements for Antibiotic Stewardship in Action Change Pathway

The change pathway tool is a topic-specific, step-by-step guide to quality improvement. The change pathway is created using evidence-based practice resources and guidelines. Key quality improvement activities such as formulating an aim statement, conducting a root cause analysis and identifying interventions are included in each guide. Interventions are outlined as beginner, intermediate and expert so that you may explore opportunities for improvement that meet your needs. Download to get started!

Antibiotic Stewardship Change Pathway

Anticoagulation ADEs

Thromboprophylaxis of Hospitalized COVID-19 Patients Change Pathway

The change pathway tool is a topic-specific, step-by-step guide to quality improvement. The change pathway is created using evidence-based practice resources and guidelines. Key quality improvement activities such as formulating an aim statement, conducting a root cause analysis and identifying interventions are included in each guide. Interventions are outlined as beginner, intermediate and expert so that you may explore opportunities for improvement that meet your needs. Download to get started!

The use of “triggers,” or clues, to identify adverse drug events (ADEs) is an effective method for measuring the overall level of harm from medications in a healthcare organization. The Trigger Tool for Measuring Adverse Drug Events and the Adapted Trigger Tools provide instructions for conducting a retrospective review of patient records using a known list of ADE triggers and instructions for measuring the degree of harmful medication events to guide quality improvement efforts. Download the Adapted IHI Trigger Tool for Measuring Anticoagulant Related Adverse Drug Events.

Antidiabetic ADEs

The use of “triggers,” or clues, to identify adverse drug events (ADEs) is an effective method for measuring the overall level of harm from medications in a healthcare organization. The Trigger Tool for Measuring Adverse Drug Events and the Adapted Trigger Tools provide instructions for conducting a retrospective review of patient records using a known list of ADE triggers and instructions for measuring the degree of harmful medication events to guide quality improvement efforts.

Download the Adapted IHI Trigger Tool for Measuring Antidiabetic Related Adverse Drug Events.

 

Falls

The Fall Prevention Organizational Assessment will assist you in conducting a gap assessment of your organization’s fall prevention policies and processes. This tool helps you determine the implementation status of several evidence-based practice interventions in your facility.

Hypoglycemia

Exploring Strategies to Prevent Hypoglycemic Events in Hospitalized Patients Change Pathway

The change pathway tool is a topic-specific, step-by-step guide to quality improvement. The change pathway is created using evidence-based practice resources and guidelines. Key quality improvement activities such as formulating an aim statement, conducting a root cause analysis and identifying interventions are included in each guide. Interventions are outlined as beginner, intermediate and expert so that you may explore opportunities for improvement that meet your needs. Download to get started!

Medication Reconciliation

Meaningful Medication Reconciliation to Prevent Adverse Drug Events Change Pathway

The change pathway tool is a topic-specific, step-by-step guide to quality improvement. The change pathway is created using evidence-based practice resources and guidelines. Key quality improvement activities such as formulating an aim statement, conducting a root cause analysis and identifying interventions are included in each guide. Interventions are outlined as beginner, intermediate and expert so that you may explore opportunities for improvement that meet your needs. Download to get started!

Opioid Mortality Prevention

Exploring Strategies to Prevent Opioid Morbidity and Mortality Change Pathway

The change pathway tool is a topic-specific, step-by-step guide to quality improvement. The change pathway is created using evidence-based practice resources and guidelines. Key quality improvement activities such as formulating an aim statement, conducting a root cause analysis and identifying interventions are included in each guide. Interventions are outlined as beginner, intermediate and expert so that you may explore opportunities for improvement that meet your needs. Download to get started!

The use of “triggers,” or clues, to identify adverse drug events (ADEs) is an effective method for measuring the overall level of harm from medications in a healthcare organization. The Trigger Tool for Measuring Adverse Drug Events and the Adapted Trigger Tools provide instructions for conducting a retrospective review of patient records using a known list of ADE triggers and instructions for measuring the degree of harmful medication events to guide quality improvement efforts. Download the Adapted IHI Trigger Tool for Measuring Opioid Related Adverse Drug Events.

Adapted IHI Trigger Tool

Pressure Injury

Watch the HQIC Pressure Injury webinar recording to hear from subject matter experts, explore helpful resources and learn best practices. Read more about why this matters, review data and access tools to utilize in your facility.

Pressure Injury

Readmissions

Download the Readmission & Multi-Admission Patient Reduction Learning Collaborative Workbook to develop an individualized, multidisciplinary program with goals, process and outcome measures aimed at preventing hospital readmissions and reducing multi-admission patient utilization.

Readmissions Workbook

Vaccination Resources

Telligen’s Vax Hub provides on-demand tools, resources, and learning modules related to the COVID-19 vaccine and bivalent booster.

Download Telligen’s Vaccination Toolkit for a guide to assist hospitals and healthcare organizations with routine vaccination assessment for influenza, pneumonia, COVID-19 and RSV in an effort to vaccinate more adults according to the recommendations.

 

Infection Prevention Tools and Templates

Catheter-Associated Urinary Tract Infections (CAUTI)

Keep Calm and Prevent CAUTI and CLABSI Change Path

The change pathway tool is a topic-specific, step-by-step guide to quality improvement. The change pathway is created using evidence-based practice resources and guidelines. Key quality improvement activities such as formulating an aim statement, conducting a root cause analysis and identifying interventions are included in each guide. Interventions are outlined as beginner, intermediate and expert so that you may explore opportunities for improvement that meet your needs. Download to get started!

Central Line-Associated Bloodstream Infection (CLABSI)

Change Pathway: Central Line-Associated Bloodstream Infections

Moving Forward Using Lessons Learned to Prevent Central Line-Associated Bloodstream Infections and webinar recording.

The change pathway tool is a topic-specific, step-by-step guide to quality improvement. The change pathway is created using evidence-based practice resources and guidelines. Key quality improvement activities such as formulating an aim statement, conducting a root cause analysis and identifying interventions are included in each guide. Interventions are outlined as beginner, intermediate and expert so that you may explore opportunities for improvement that meet your needs. Download to get started!

CLABSI

Clostridioides Difficile Infection (CDI)

Clostridioides Difficile Infection (CDI) Root Cause Analysis Tool

Use this tool to complete a root-cause analysis (RCA) of a recent CDI case on your unit or in your facility. Answer the questions using information from chart review, discussions with staff, and infection prevention rounds. Review your responses with your team and/or staff to identify opportunities for preventing future CDI cases. Consider performing an RCA on each CDI case moving forward so that you may identify trends in infection prevention practices.

CDI Drill Down Template

Infection Prevention Orientation Checklist

This checklist has been developed for hospital infection preventionists. Download here.

 

Infection Prevention Trainings

Learn more about the Centers for Disease Control and Prevention’s Project Firstline National Training Collaborative for Healthcare Infection Control.

Project Firstline

Infection Prevention Words of Wisdom

Watch the Infection Prevention: Words of Wisdom recording.

IP Words of Wisdom

Multi-Drug Resistant Organisms (MDROs)

Infection Prevention Back to Basics: Multi-Drug Resistant Organisms (MDROs) Change Path

The change pathway tool is a topic-specific, step-by-step guide to quality improvement. The change pathway is created using evidence-based practice resources and guidelines. Key quality improvement activities such as formulating an aim statement, conducting a root cause analysis and identifying interventions are included in each guide. Interventions are outlined as beginner, intermediate and expert so that you may explore opportunities for improvement that meet your needs. Download to get started!

Use this Excel line list template to track MDROs.

National Healthcare Safety Network (NHSN)

Download the Centers for Disease Control and Prevention’s NHSN Patient Safety Component Manual which includes five modules that focus on events associated with medical devices, surgical procedures, antimicrobial agents used during healthcare, and multidrug resistant organisms.

Learn more about the Targeted Assessment for Prevention (TAP) Strategy framework for quality improvement developed by the CDC to use data for action to prevent healthcare-associated infections (HAIs).

NHSN PSC Manual

Personal Protective Equipment (PPE)

Use this tool to conduct observation audits of donning and doffing PPE and track compliance. The tool includes a compliance calculator to get a compliance rate. PPE compliance is critical for infection prevention, consider developing a PPE quality improvement plan and use this tool to measure compliance rates over time, to track if your quality improvement activity is working.

PPE Audit Tool

Sepsis

Sepsis Care in 2022: Identification + Management Strategies to Optimized Patient Outcomes

Transitions in Care: Preventing Sepsis-Related Readmissions

The change pathway tool is a topic-specific, step-by-step guide to quality improvement. The change pathway is created using evidence-based practice resources and guidelines. Key quality improvement activities such as formulating an aim statement, conducting a root cause analysis and identifying interventions are included in each guide. Interventions are outlined as beginner, intermediate and expert so that you may explore opportunities for improvement that meet your needs. Download to get started!

Cross Cutting Resources – Patient and Family Engagement, Health Equity & More

Culture of Health Equity

I Want To, I Just Don’t Know How: A Practical Guide for Advancing Health Equity

The change pathway tool is a topic-specific, step-by-step guide to quality improvement. The change pathway is created using evidence-based practice resources and guidelines. Key quality improvement activities such as formulating an aim statement, conducting a root cause analysis and identifying interventions are included in each guide. Interventions are outlined as beginner, intermediate and expert so that you may explore opportunities for improvement that meet your needs. Download to get started!

Addressing Health Disparities Resource Guide

Health disparities are differences in health outcomes closely linked with social, economic and environmental disadvantage. These are often driven by the social conditions in which individuals live, learn, work and play. These disparities negatively impact the individual goal of achieving and maintaining good health, as well as the collective goal of providing quality care and achieving optimal population health. Learn about recommendations to increase understanding and awareness of disparities. Download to get started!

 

Patient and Family Engagement (PFE)

Patient and Family Engagement Implementation Resource Guide

This resource provides you with evidence-based resources, implementation strategies and general guidance to assist your organization’s efforts in establishing a successful PFE committee and meeting all five of the PFE measures.

 

  • PFE 1 – Implementation of a planning checklist for patients known to have a planned admission to the hospital (e.g., for elective surgery), and PFE 2 – Implementation of a discharge planning checklist.
  • PFE3 – Conducting shift change huddles and bedside reporting with patients and families.
  • PFE4 – Designation of an accountable leader in the hospital who is responsible for patient and family engagement.
  • PFE5 – Hospitals having an active Patient & Family Engagement Committee/Advisory Council (PFAC) or other committees where patients are represented and report to the board.
  • PFE and Sepsis
Rural Health Information

Find rural-specific healthcare statistics, data, evidence-based interventions, case studies and toolkits that support rural and critical access hospitals in quality improvement efforts from the Centers for Medicare & Medicaid Services here.

Social Determinants of Health

Check out the Centers for Medicare & Medicaid Services Z-Codes Infographic.

Using Z Codes

Quality Improvement Tools and Templates

IHI Quality Improvement Essentials

Check out IHI’s QI Essentials Toolkit which includes the tools and templates you need to launch a successful quality improvement project and manage performance improvement. 

Plan-Do-Study-Act (PDSA) Tools

Pan View Working Tool Template

PDSA Pathway Guide

  • This PDSA Guide outlines the steps to navigate this structured improvement process.

PDSA Worksheet

  • A tool to guide you through the steps to conduct a Plan-Do-Study-Act process or cycle.

Turtle Diagram and Process Approach

 

Sepsis Data Sharing Checklist

Use this checklist while preparing to share data at your quality improvement committee meetings, board meetings or during other opportunities to communicate about data. The aim of this checklist is to empower you to share your data with your teams, support you in feeling more comfortable discussing data and help you engage your staff in identifying opportunities for improvement. Download here.

Root Cause Analysis Tools

Brainstorming, Affinity Grouping and Multi-Voting Tool

  • A PDF tool that helps with using the Affinity Group method for uncovering root cause analysis (RCA) that was released by the Centers for Medicare & Medicaid Services (CMS).

Facilitators Guide for the Root Cause Analysis Method

  • The purpose of a Root Cause Analysis (RCA) is to find out what happened, why it happened and determine what changes need to be made. The steps in the resource below outline the process for conducting an RCA.

Fishbone Diagram Worksheet

  • A tool to walk you through a root cause analysis.

Five Whys Worksheet

  • A root cause analysis tool (RCA) using the Five Whys method.

Root Cause Analysis Pathway

  • Use this interactive step-by-step guide for completing a root cause analysis (RCA).

Root Cause Analysis Tool Selection Guide

  • This tool helps with selecting which RCA tool to use between Affinity Group, Five Whys or Fishbone.

When to Use Root Cause Analysis

  • Root cause analysis (RCA) is a problem solving method. It is a process to investigate an incident, failure, actual or potential problem or concern that indicates a need for deeper understanding of the reasons why the event occurred. However, not every incident, failure or problem will need a RCA completed. This tool will help teams determine when and for what events a thorough RCA should be completed.

 

Telligen's Quality Improvement Workbook

In this workbook, you will find valuable resources to support your team’s quality improvement efforts. We have created a timeline to follow and ways to track progress during your organization’s quality improvement journey.

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