Improving Patient Care

Massachusetts healthcare providers are continually working to provide the safest possible care, and place a high priority on making performance measures transparent. These measures include patient falls, pressure ulcers, and healthcare acquired infections. Healthcare providers create innovations and “best practices” that enhance excellence in patient care.

Summary:

Hospitals and other healthcare interests are performing very targeted interventions in specific areas to improve the health of the patients and communities they serve. By clicking on each item under the "Improving Patient Care"  shaded column to the left, you can learn about some of the many programs now underway in Massachusetts.


Much of the patient care improvement work now underway at Massachusetts hospitals is coordinated through the Hospital Improvement Innovation Network (HIIN), as part of the Centers for Medicare and Medicaid Services (CMS) Partnership for Patients (PfP) Campaign.

The Centers for Medicare & Medicaid Services awarded the Health Research & Educational Trust (HRET) a two-year HIIN contract (with an optional third year based on performance), to continue efforts to reduce all-cause inpatient harm by 20 percent and readmissions by 12 percent by 2018. An American Journal of Medical Quality article, written by HRET staff, explores the relationship between engagement in improvement activities and affected quality measures ...>Full Article

 


Definition of Safety Culture 

 Safety culture is the sum of what an organization is and does in the pursuit of safety.  The Patient Safety Systems (PS) chapter of The Joint Commission accreditation manuals defines safety culture as the product of individual and group beliefs, values, attitudes, perceptions, competencies, and patterns of behavior that determine the organization’s commitment to quality and patient safety.

Healthcare Acquired Infections

Healthcare acquired infections (HAIs), also known as nosocomial infections, are infections that patients get while receiving treatment for medical or surgical conditions. HAIs occur in all settings of care, including hospitals, surgical centers, ambulatory clinics, and long-term care facilities such as nursing homes and rehabilitation facilities.


Readmissions

"Readmission" occurs when patients who have had a recent stay in the hospital go back into a hospital again. Patients may have been readmitted back to the same hospital or to a different hospital or acute care facility. They may have been readmitted for the same condition as their recent hospital stay, or for a different reason. Often referred to as "rehospitalization."


Pressure Ulcers

A pressure ulcer or bedsore is an injury to the skin or underlying tissue usually over a bony protruding area of the body. Pressure ulcers can range in severity from minor skin reddening to deep wounds. Factors that cause pressure ulcers are unrelieved pressure on the skin, or slight rubbing or friction on the skin.


Patient Falls

The National Quality Forum (NQF) defines a fall as an unplanned descent to the floor (or extension of the floor e.g., trash can or other equipment) with or without injury to the patient.


Hospitals in Pursuit of Excellence (HPOE)

HPOE provides field-tested practices, tools, education and other networking resources to accelerate performance improvement in the nation's hospitals. HPOE's fundamental principles support the Institute of Medicine's Six Aims for Improvement- care that is safe, timely, effective, efficient, equitable, and patient-centered (STEEEP).

  • ICU Harm

    ICU Harm Related TopicsThe critical care unit can be the location where a patient harm event occurs or it can be the unit where patients are transferred following an event elsewhere. With this in mind, we have grouped the following Patnership for Patients (PfP) option year (or Leading Edge Advanced Practive Topics - LEAPT) topics together under "ICU Harm Related Topics": Failure to Rescue, Hospit...» Full Article
  • AHRQ’s Preventing Hospital Associated VTE Guide

    Hospital-associated venous thromboembolism (HA-VTE) is a common source of morbidity and mortality. While VTE sometimes occurs despite the best available prophylaxis, there are many lost opportunities to optimize prophylaxis and reduce VTE risk factors in virtually every hospital. This guide targets these failure modes in the process of preventing VTE in the inpatient setting and provides improveme...» Full Article
  • Massachusetts STAAR Learning Session February 2011 (with Presentations)

    One of MHA's Strategic Improvement Performance Agenda priorities made advances in February as more than 400 care providers attended the State Action on Avoidable Readmissions (STAAR) project's second learning session in Framingham, Massachusetts. The STAAR project is focused on improving care transitions to reduce readmissions. A total of 49 cross-continuum teams attended the session. Twenty-two...» Full Article
  • Massachusetts STAAR Learning Session October 2011 (with Presentations)

    Massachusetts STAAR Learning Session October 11-12, 2011 Working Across the Continuum to Drive for Results! Learner Objectives: Learn about work underway by peers in the four key changes for improving care transitions Engage a cross continuum team with active participation by all Share promising work with faculty and peers and obtain input and new ideas for achieving results Form...» Full Article
  • Venous Thromboembolism (VTE)

    VTE Summary:Pulmonary embolus resulting from VTE is the most common cause of preventable hospital death. The risk for developing VTE varies between 10-85 percent by reason for admission. VTE Top Ten, Evidenced Based Interventions  HRET's VTE Change Package - Reduce Harm from VTE-Related Events - 2016   Eliminate Harm Across the Board HRET's Days Since Last VTE...» Full Article
  • Ventilator Associated Event (VAE)

      VAE Summary: Mechanically ventilated patients are at high risk for complications. These risks include VAE, peptic ulcer disease (PUD), gastrointestinal bleeding, aspiration, venous thromboembolic events (VTE), and problems with secretion management. Evidence-based interventions can reduce the risk of these complications and reduce the occurrence of VAE. Implementing the ventilator bundle ...» Full Article
  • AHRQ’s Effective Health Care Program

    AHRQ's Effective Health Care Program funds individual researchers, research centers, and academic organizations to work together with the Agency for Healthcare Research and Quality (AHRQ) to produce effectiveness and comparative effectiveness research for clinicians, consumers, and policymakers. AHRQ is the lead Federal agency charged with improving the quality, safety, efficiency, and effectivene...» Full Article
  • Massachusetts Alliance for Communication and Resolution following Medical Injury (MACRMI)

    The Massachusetts Hospital Association is a founding participant of the Massachusetts Alliance for Communication and Resolution following Medical Injury (MACRMI). Click here to learn more. Alan Woodward, MD from the Massachusetts Medical Society and Kenneth Sands, MD from Beth Israel Deaconess Medical Center provided MHA member hospitals with a briefing on December 3, 2012 on the Massachusetts...» Full Article
  • November 6, 2014 – Readmissions Summit

    November 6, 2014 - Readmissions Summit - Focused on Care across the Continuum - The MA Hospital Engagement Network sponsored a free learning event focusing on the partnerships to improve care management and coordination being developed between hospitals, SNFs, home care/hospice, primary care and community organizations. Presentations: Keynote Presentations All Breakout Sessions...» Full Article
  • MA Hospital Improvement Innovation Network (HIIN)

    What is the MA Hospital Improvement Innovation Network (HIIN)The Massachusetts Health & Hospital Association (MHA) once again, is serving a Hospital Improvement Innovation Network (HIIN), as part of the Centers for Medicare and Medicaid Services (CMS) Partnership for Patients (PfP) Campaign.The Centers for Medicare & Medicaid Services awarded the Health Research & Educational Trust (...» Full Article
  • Massachusetts STAAR Learning Session April 23, 2012 (with Presentations)

    Learner Objectives Describe successful approaches that have been implemented to improve care transitions Develop necessary skills for driving improvement  Improve the coordination of care through greater engagement of the cross-continuum team   Agenda -with PPT Presentations (Agenda PDF here)Welcome and Set the Stage Presenter: Paula Griswold, MA Coalition for the Prevention...» Full Article
  • Massachusetts Care Transitions Forum and Care Transitions Seminar

    Patients in transition - those who are moving from one care setting to another - are at increased risk for hospital re-admission (also known as re-hospitalization). Massachusetts is currently participating in many projects to address and improve hospital readmission issues, and these efforts are largely coordinated state-wide by a collaborative called the Massachusetts Care Transitions Forum, whic...» Full Article
  • State Action on Avoidable Rehospitalizations Initiative (STAAR)

    A multi-state project involving 53 hospitals, STAAR was launched by the Institute of Healthcare Improvement (IHI) in May 2009 with grant funding from The Commonwealth Fund. 22 Massachusetts hospitals are enrolled in the initiative.  To date, participating hospitals have formed cross-continuum teams and submitted baseline 30-day readmission rates. Now they are busy determining how to improve the p...» Full Article
  • Airway Safety & Failure to Rescue (FTR)

    Airway SafetyApproximately 25,000 potentially life-threatening errors occur daily in hospital intensive care units (ICUs), and up to 10 percent of these adverse events involve unintended incidents in airway management; more than half of these errors have been deemed preventable (Needham, et al., 2004). Airway safety events refers to complications related to high-risk patients for airway compromis...» Full Article
  • M-LiNk: Mortality Learning-in-Network

    MORTALITY: LEARNING-in-NETWORK (M-LiNk)M-LiNk promoted a series of MHA and locally-sponsored educational offerings and related programs focused on reducing hospital mortality.  M-LiNk provided access to faculty experts, evidence-based interventions and local best practices to improve related structures, processes and outcomes.   M-LiNk was a  peer-based learning opportunity for hospitals to:...» Full Article