The IHC Drumbeat is a monthly email featuring hospital success stories, recorded IHC webcasts, and local/national educational resources
December 7, 2016
Medical professional pointing to a group of medical icons
Season's greetings, wishing you and your family the best for the season and the year ahead, from your friends at the Iowa Healthcare Collaborative
Featured in this issue:
In the Spotlight logo. With a spotlight in the top left and top right corners of the picture shining light down onto the work "In the Spotlight".

Hospital Spotlight - 2016 IHC Patient Safety Award Winners

The Patient Safety Award aims to raise the standard of healthcare by promoting a culture of continuous improvement in quality, safety and value. 

This award honors patient safety champions that support the following initiatives:
  • Improve patient safety
  • Reduce the risk of harm
  • Keep patients at the center of care

The following highlights all winners of the 2016 Patient Safety Award!

Grand Prize Winner; Myrtue Medical Center in Harlan, Iowa
The passionate team developed a multi-angle approach to safety. Interventions ranged from simple changes to more involved changes. Interventions implemented included amending the medication administration policy by requiring documentation of practitioner notification date and time in the medical record; a tubing misconnection prevention labeling system; and reevaluation of “rights,” which were posted on the floors. Through these outstanding interventions and implementation by healthcare providers, the number of medication errors were reduced by 84% in eight months from November 14, 2014, to July 15, 2015.
Visit the Myrtue Medical Center website for more information.

Culture of Safety Categorical Winner; Mercy Medical Center - Sioux City
In January 2015, Mercy Medical Center Sioux City began an initiative to curb the increase in colleague injuries sustained at the clinic by forming the Serious on Safety (SOS) program. Actions were taken to address safety issues immediately after an incident occurred. Action was also taken to educate the workforce on safety. The main focus areas addressed were safety awareness; sharps, blood, and body fluid exposures; slips, trips, and falls; workplace violence, lifting, ergonomics, and supply movement; and patient movement. Mercy Medical Center Sioux City saw a systematic increase in colleague safety, reflected in an increase in OSHA recording to 95% of accident investigations completed within 48 hours of incident.
Visit the Mercy Medical Center - Sioux City website for more information.

Hospital Acquired Conditions Categorical Winner; Community Memorial Hospital
The year of 2015 brought on a new level of engagement and dedication to Community Memorial Hospital’s patient safety efforts. Community Memorial created a fall prevention committee and incorporated all aspects of the community. Staff were included in the prevention by increasing awareness of the fall risk by placing a yellow flag outside of a fall risk patient’s door, a yellow light outside of a fall risk patient’s room, and including fall risk on the patient’s whiteboard and ensuring it is reviewed at bedside. These actions, along with numerous other efforts, have resulted in a 38% reduction in falls since the start of 2015, with zero occurring after July of 2015.
Visit the Community Memorial Hospital website for more information.

Healthcare-Associated Infections Categorical Winner; Great River Medical Center
Great River Medical Center examined their care and identified a need for change on the protocols surrounding Clostridium difficile. A robust antimicrobial stewardship program was implemented, which had many layers. The medical center attacked the issue by the following means: reviewed and subsequently reduced their use of Levaquin for treatment of UTI’s, added probiotic use to their formulary, added a test for procalcitonin to reduce antibiotic usage, and deeply implemented interventions from their infectious disease physician (hired June 2013). Through these efforts, Great River Medical Center saw a 50% reduction in C. diff infections per 100 patient days and an 11% reduction in Levaquin use for UTI’s since 2014.
Visit the Great River Medical Center website for more information.

Person and Family Engagement Categorical Winner; CHI Health Mercy - Council Bluffs
After performing a Root Cause Analysis on a sentinel event, Mercy Council Bluffs discovered an opportunity for improvement for Capnography communication and monitoring. They noted that families of patients weren’t understanding the purpose of the monitoring equipment due to education that, in many cases, could have been performed in a more applicable or timely way. A new education platform was developed and implemented with great results. This dynamic shift resulted in a culture change that has seen Capnography compliance increase twofold, from 50 to 100% on audit. Mercy Council Bluffs has continued these efforts by pursuing updates in the content of information on patient whiteboards and identifying patient handoff inadequacies.
To learn more about the CHI Health Mercy - Council Bluffs Person and Family Engagement award, follow the link.

Care Transitions Categorical Winner; Regional Medical Center
Regional Medical Center has taken great pride in their care transitions team since its inception in 2013. In 2015, more additions were made to ensure a proper transition out of the Center back to daily life. Regional Medical Center identified that there was a need in their communication with long-term care facilities. In partnership with Regional Family Health, a physician clinic within Regional Medical Center, an ARNP was hired to provide ongoing healthcare to patients discharged to one of the long-term care facilities. All of these changes have resulted in higher satisfaction scores and systematic improvement.
Visit the Regional Medical Center website for more information.
Welcome logo. Welcome spelled out with each individual letter in welcome hanging from a horizontal poll by black rings. There is a mistletoe on each end of the poll.
Head shot of Kate Carpenter smiling.
My name is Kate Carpenter. As your new IHC Improvement Advisor I am thrilled to join the work of Compass HIIN hospitals in patient safety and quality improvement efforts. It is exciting to be part of a network of hospitals that provides excellent patient care and embraces opportunities to make care the best it can be!

Kate joins the HIIN team after serving as an Improvement Advisor with the State Innovation Model. Prior to her roles at IHC she worked as Medical Imaging Quality Coordinator for a large hospital network. Kate has twelve years (12) of clinical experience in Medical Imaging and holds board certifications in three modalities including: General Radiography, Mammography and Computed Tomography. She has earned her Bachelor’s in Healthcare Administration and is also a Certified Professional in Healthcare Quality. Kate looks forward to serving the Compass HIIN Network and helping assist hospitals in achieving goals of the HIIN.
Head shot of Erin Hansman smiling.
My name is Erin Hansman. As your new IHC Improvement Advisor I am thrilled to join the work of Compass HIIN hospitals in patient safety and quality improvement efforts. It is exciting to be part of a network of hospitals that provides excellent patient care and embraces opportunities to make care the best it can be!

Erin joins the HIIN team after serving as an Improvement Advisor with the State Innovation Model.  Erin has five+ years of experience as a pediatric registered nurse. She received her Master’s in Public Health in Epidemiology from the University of Miami where she worked on infection control with the Miami-Dade County Department of Public Health. During her time in the clinical environment, Erin was part of multiple quality and improvement projects and is excited to share her experiences with the network.
Head shot of Jennifer Kok smiling.
Jennifer Kok will be joining our HIIN team as an Improvement Advisor, effective December 5, 2016. Jennifer comes to SDAHO with over thirteen years’ nursing experience working in hospitals and in quality and patient safety. In addition to her nursing degree, she holds a master’s degree in healthcare administration. Jennifer’s expertise as a clinician, along with her skills in quality measure interpretation, abstraction, improvement processes, documentation and quality reporting provides a great asset to
the association.

Head shot of Diane Trende smiling.
Diane R. Trende is a Senior Quality Improvement Facilitator at Telligen. Upon joining Telligen, Diane will be a Subject Matter Expert with efforts focused on reducing all-cause patient harm and 30 day readmissions. Diane has an extensive background and expertise in patient care, quality improvement, and management in multiple settings (i.e., hospital, clinic, home health, hospice, infection prevention). Prior to joining Telligen, Diane’s responsibilities included fostering a culture of safety specific to care coordination and infection prevention.

Weekly Focus

Dec. 5—Dec. 9: HIIN Data Series: Data Collection Overview

Dec. 12—Dec. 16: HIIN Data Series: Reporting Database Overview

Dec. 19—Dec. 23: HIIN Data Series: Run Charts/Goal Reports/CEO Dashboards Overview

Dec. 26—Dec. 30: Happy Holidays!

What's New?

Communities of Practice
Readmissions and Care Transitions Community of Practice

Beginning in December, we will be starting a Community of Practice (COP) for Readmissions and Care Transitions. The first COP will be Thursday, December 15 at 11:00 a.m., and moving forward (beginning in January) all Readmissions and Care Transitions COP will be the fourth Tuesday of every month.  The webinars will be between 30 minutes and an hour. During these webinars, we will go over the readmissions and care coordination measures, hear from various hospitals and other guest practices, and collaborate to share best practices to improve care transitions.

On December 15, we will provide an overview of the readmissions and care coordination measures and tips and tricks from the toolkit. We will also hear from Community Memorial Hospital in Sumner, Iowa, about their strategies to reduce readmissions, including bringing their readmissions and unplanned transfers to their Community Care Coalition meetings for discussion.
To join this webinar use the information below. If you would like this information sent out to you in a calendar invite, contact
Kolton Hewlett.
Topic: Readmissions and Care Transitions CoP
Time: Dec 15, 2016 11:00 AM (GMT-6:00) Central Time (US and Canada)
Join from PC, Mac, Linux, iOS or Android:
Or Telephone:
    Dial: +1 408 638 0968 (US Toll) or +1 646 558 8656 (US Toll)
    Meeting ID: 588 017 4267
For more information, contact Kolton Hewlett at

Person and Family Engagement Community of Practice

As we continue to strive towards providing the best quality care and patient safety, the role of the patient, their family, and/or caregivers cannot be understated.   The difference between having patients and families who are engaged in their care can be the difference between an event-free stay and a catastrophic fall or a readmission.
On January 12th, the Compass HIIN will convene its first Person and Family Engagement (PFE) Community of Practice (CoP). This CoP will offer the opportunity to connect with peer HIIN hospitals, content experts, and your HIIN team to explore the role of PFE in patient safety, share best practices, and highlight opportunities to continue to advance PFE in our hospitals.
Please join us on January 12th at 11 AM to learn more about how you can be a champion for PFE! The information to join is listed below.
Topic: PFE CoP Education Series
Time: Thursday at 11:00 AM (GMT-6:00) Central Time (US and Canada)
Join from PC, Mac, Linux, iOS or Android:
Or iPhone one-tap (US Toll):  +14086380968,591330493# or +16465588656,591330493#
Or Telephone:
    Dial: +1 408 638 0968 (US Toll) or +1 646 558 8656 (US Toll)
    Meeting ID: 591 330 493
If you would like additional information or to receive a calendar invite, please contact Kady Reese at

Medication Safety Community of Practice:
INR Greater Than 5 Quality Improvement Project

Your HIIN Team kicked off the INR greater than 5 Project on November 29th. This project includes 3 webinars provided by our faculty Pharmacist Dr. Brian Isetts. We will be giving valuable resources and assisting in Quality Improvement in this area. The webinars will be 30 minutes followed by coaching for a limited amount of hospitals.

The advantages to participating:
  • During this project we would like to provide you with evidence based best practice for managing patients on warfarin
  • Individual and group coaching with Dr. Brian Isetts, PhD
  • Opportunity to be part of a Pharmacist lead quality improvement project
We ask the following commitments to participate:
  • Participate in 2 Webinars, January 19th and February 23rd both at 11:00 AM CST
  • Implement process improvement techniques and best practices as recommended during the weeks between webinars
  • Monitor INR greater than 5 in your inpatient population and report data to the HIIN Database
  • Monitor and record INR greater than 5 that come into your ED
  • Have a team based work group participate in the webinar and improvement effort including your Pharmacist, Quality Lead, Bedside Best Practice Leader and Champion
  • Have one team member or more participate in IHC Patient Safety Conference on March 14, 2017
Please be ready to share successes and challenges with managing patients on warfarin therapy.

Preregistration is required! Use the information below to register for the meeting. You may create a calendar appointment by clicking the "Download To Your Calendar" tab upon registration.

Topic: INR Greater than 5
Time: Jan 19, 2017 11:00 AM (GMT-6:00) Central Time (US and Canada) 

Please register prior to the start date and time:
After registering, you will receive a confirmation email containing information about joining the meeting.

Please contact Jennifer Creekmur at if you are interested in this process improvement project.
"Join the Discussion" in red text with "HIINnovation" in blue text. HIINnovation is the social media platform for hospitals to share information and get resources.

IHC Save the Dates - 2017

Mark your calendars for our upcoming events! Hope to see you there!
SIM Learning Community - March 9, 2017
Patient Safety Conference - March 14, 2017
Compass PTN Learning Community - April 6, 2017
HIIN Learning Community - May 9, 2017
Care Coordination Conference - June 6, 2017
SIM Learning Community - July 12, 2017
14th Annual Conference - November 8, 2017
SIM Learning Community - November 14, 2017
HIINovation logo. This logo reads HIINovation.
Upcoming Calls and Events:
Weekly Office Hours -
Wednesday at 11:00 AM CST

What’s Up Call - 
December 13, 2016
at 10:00 AM CST

Readmissions and
Care Transitions
Community of Practice -
December 15, 2016
at 11:00 AM CST

Falls Prevention Community of Practice - 
December 20, 2016
at 11:00 AM CST

HAI Community of Practice -
January 3, 2017
at 11:00 AM CST

Person and Family
Engagement Community of
Practice -
January 12, 2017
at 11:00 AM CST

INR Greater Than
5 QI Project -
January 19, 2017
at 11:00 AM CST

HIIN Measure Set
Education Series
Part 1 -
January 26, 2017
at 11:00 AM CST

HIIN Measure Set
Education Series
Part 2 -
February 2, 2017
at 11:00 AM CST
Contact your Compass
HIIN Team!

IHC Website

 Want more resources? Check out our website at

Iowa Healthcare Collaborative logo. This logo reads Iowa Healthcare Collaborative.
Copyright © 2016 Iowa Healthcare Collaborative Drumbeat,
All rights reserved.

Our mailing address is:
100 E Grand Ave Suite 360
Des Moines, IA 50309
Want to change how you receive these emails?
You can update your preferences or unsubscribe from this list

The analyses upon which this publication is based were performed under Contract Number HHSM-500-2016-00070C, Entitled, "Hospital Improvement Innovation Network ", sponsored by the Centers for Medicare & Medicaid Services, Department of Health and Human Services.