Patient Safety Newsletter - May 2024


Compare and Provider Data Catalog Updated

Care Compare.png​The Centers for Medicare & Medicaid Services (CMS) Care Compare website provides consumers with information on over 100 quality measures for over 4,000 hospitals nationwide, including Veterans Administration (VA) medical centers and Department of Defense (DoD) military h​​ospitals.  

With the Provider Data Catalog, users can explore and download hospital data, as well as data on ambulatory surgical centers, inpatient psychiatric facilities, and some cancer hospitals. Publicly displaying quality information encourages hospitals and other health care facilities to make continued improvements in care.  

CMS updates the data on Care Compare and the Provider Data Catalog websites quarterly, though not all data are updated each quarter.  

Data Updates 
On April 24, 2024, CMS has updated data for hospitals on the Care Compare and Provider Data Catalog website.  

CMS updated data for the following measures, measure groups, quality reporting programs and payment programs:  
  • Healthcare-associated infections (HAI) 
  • Maternal health 
  • Timely and effective care 
  • Ambulatory Surgical Center Quality Reporting (ASCQR) 
  • Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey (includes data on Medicare-certified hospitals, PCH hospitals, VA medical centers, and Department of Defense [DoD] hospitals) 
  • Inpatient Psychiatric Facility Quality Reporting (IPFQR) 
  • Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) Survey for ambulatory surgical centers and hospital outpatient departments 
  • Prospective Payment System -Exempt Cancer Hospital (PCH) Quality Reporting Program 
CMS will no longer publicly report the following measures: 
  • OP-2; Percentage of outpatients with chest pain or possible heart attack who got drugs to break up blood clots within 30 minutes of arrival 
  • OP-3b; Average (median) number of minutes before outpatients with chest pain or possible heart attack who needed specialized care were transferred to another hospital 
CMS intends to release the Overall Hospital Quality Star Ratings in July 2024 release. Measure data from the January 2024 release will be used for the calculations.  July 2024 release will include the Veterans Health Administration (VHA) hospitals measure data along with subsection (d) hospitals and Critical Access Hospitals. 


Patient Safety Newsletter - April 2024

Resources for Mental Health Awareness Month

square.pngDid you know, according to Mental Health America’s screening platform, Indiana is the third worst state for rates of depression per 100,000, at 52.4? We can change that statistic by addressing the mental health and social determinants of health needs of our health care workforce and the patients that come into our organizations. For resources around improving the well-being of our health care workforce, please look at the IHA Safe and Sound digital toolkit here​. Consider utilizing the American Hospital Association’s People Matter, Words Matter resources to ensure adoption of patient-centered, respectful language around mental health. There are many steps, big and small, we can take to normalize and improve mental health. 

For health and behavioral health providers and organizations, the Indiana Division of Mental Health and Addiction invites you to apply to attend a Zero Suicide Academy on May 15 – 16, 2024. The Zero Suicide Academy will be virtual and free to attendees.  

Zero Suicide Academies are designed for behavioral health and health care organizations to learn to implement evidence-based best practices for preventing suicide among their patients. Team members from participating organizations will learn skills to lead system-wide culture change, develop their workforce, assess for suicide risk, treat individuals who are at risk for suicide, and critically evaluate and improve their organization's current processes. Learn more: About | Zero Suicide ( 

Any behavioral health and health care organization in Indiana is eligible to apply. Interested organizations can apply here.

​The registration deadline is April 30, 2024. Please contact Caitlyn Short​  with any questions. 

Depression Map.png


Notice.Talk.Act.® at Work​

Notice Talk Act.pngNotice.Talk.Act.® at Work, the virtual mental health training for managers and people leaders is available thru the American Psychiatric Association Foundation at a discounted price for IHA members.  

Because of the overall positive response from our vetting process, IHA and the American Psychiatric Association Foundation (APAF - creators of this training) have agreed to work together to provide IHA members with a discounted offering.  Pricing is tiered based on the number of FTEs in your organization.  The APAF is ready to offer a flat 15% discount with a potential for additional funding support by IHA based on your tier level.  For example, our pilot offering was for 50 courses and the cost was $500.  

The course can be integrated into your electronic learning platforms for ease of distribution and access.  If you are interested in pursuing this opportunity, please email Laurie Gerdt and we will work together with APAF to get your specific pricing based on your FTEs.
Please note that the IHA funds are limited so this is a first-come, first-served offering.  We hope to expend these funds by June 2024.

  • Overall rating of 4.36/5
  • “This is a good module with very helpful tips on “how to.. I feel we see a lot of managers that are not comfortable with "conflict", so with all the information given, they continue to struggle with the applicability part of addressing difficult situations and not so much the knowledge”. 
  • ​“I feel this would be beneficial to provide this training to Directors and Managers within our hospital system.”   

CAH CHEST Training

CHEST.png The State Office of Rural Health (SORH) & IHA, through the Medicare Beneficiary Quality Improvement Project (MBQIP) conducted a Certified Health Care Environmental Services Technician (CHEST) Train the Trainer Workshop on April 9 - 11, 2024, for Critical Assess Hospitals (CAHs). Twelve Critical Access Hospital staff members completed the CHEST Train the Trainer Workshop.  The workshop is designed for trainers of health care Environmental Services (EVS) frontline staff who provide in-service and other education to the EVS department personnel (such as EVS directors or Infection Preventionist). The program uses a comprehensive nationwide job analysis of health care EVS technician responsibilities and covers all aspects of a frontline worker’s typical tasks and accountabilities.

The workshop covered ten modules:
  1. Infection Prevention
  2. Assignments with Supervisor and Other Staff
  3. Cart Set-Up and Handling Chemicals
  4. Occupied Patient Room #1
  5. Unoccupied Terminal Room
  6. Isolation Room
  7. Occupied Patient Room #2
  8. Common Areas
  9. Specialty Areas, Uncommon Situations
  10. CHEST Exam

For questions about the workshop, please reach out to Becky Royer at 


Patient Safety Newsletter - March 2024

​Convergence Health Hosting Professional Development and Improvement Programs ​

All IHA member organizations are invited to join the New Quality Director Mentorship Program. While it was developed to support quality leaders with less than three years of experience, everyone is welcome to join. The weekly series convenes every Wednesday, 12 – 12:30 p.m. ET March – May. Topics include Building an Effective QAPI Program, Emergency Preparedness, Science of Improvement, Rick Management and RCA/FMEA, among others.  Enroll here.

Reliability and Resilience Learning Action Series 

Resilience.pngThe HQIC Reliability and Resilience Learning Action Series is designed to educate and activate hospital leaders on the concepts and practices of resilience and high reliability in health care. Learning sessions will be focused across three concentrations: 1. Foundational knowledge about the concepts, theories, and activities related to resilience and reliability, 2. Examples of practical application of resilience and reliability activities at scale, and 3. Stories from the field: Hospital case studies of reliability and resilience in action at the local level. 

To learn more and register, visit​ here.


Workforce Safety, Wellbeing, and Violence Prevention Listening Series 

Wellbeing.png​Join two open listening sessions to better understand hospital approaches to workforce safety, wellbeing, and violence prevention. Join peers to learn from ex​periences to make hospitals safer places.  Learn more and register for these sessions here.

Patient Safety Newsletter - February 2024

​Guidelines for Child Sexual Assault Patients​

child.pngAn updated version of the Indiana Guidelines for Medical Forensic Examination of Pediatric Sexual Abuse Patients (2024) is now available. The guidelines aim to establish the best practices for trained pediatric medical forensic providers, but they are also a valuable resource for all service providers. The document provides comprehensive guidance on the role of service providers, necessary s​teps to take when a disclosure of sexual violence/abuse is made, essential care and treatment for pediatric survivors of sexual abuse, as well as Indiana statute regarding mandated reporting. We highly recommend that all healthcare and non-clinical pediatric service providers familiarize themselves with these guidelines to ensure they can better protect and care for children in Indiana.​​

​AHA launches 2024 DEI Benchmark Survey ​

Health Equity.pngThe AHA’s Institute for Diversity and Health Equity (IFDHE) recently launched their 2024 Diversity, Equity and Inclusion Survey. We are kindly asking for hospitals and health systems to participate in this biennial survey, which provides a snapshot of hospitals' and health systems' efforts, successes and challenges in diversity, equity and inclusion. To ensure the survey captures these critical variations and provides actionable insights, the AHA is asking that each hospital within your system completes the survey independently. This approach will allow them to understand the specific challenges and successes of DEI initiatives as they occur on the ground. You should have received a link to the survey on January 31 from this AHA email address –​. The survey will be open until March 29, 2024. If you have any questions, please reach out to​.  

Please note: The 2024 Health Equity, Diversity and Inclusion Survey differs from the Health Equity Transformation Assessment (HETA), an electronic tool within the Health Equity Roadmap initiative aimed at improving health care outcomes and advancing health equity, diversity, and inclusion. HETA assesses hospitals’ progress on their health equity journey. 

​IDOH Rape Prevention and Education

Rape.jpgThe Indiana Department of Health Maternal and Child Health Division announced a new funding opportunity: Rape Prevention and Education​. This opportunity is open through March 15, at 6 p.m. ET. The purpose of this opportunity is to fund organizations to implement sexual violence prevention programs, practices, and policies. 

If you have any questions, please reach out to Caitlin Seagraves​​.

Infant and Maternal Health Newsletter - Q4 2023

​HA hosts OB Summit in Partnership with IDOH​

OBSummit.pngOver the past eighteen months, we have seen a notable change in the availability of inpatient obstetrical (OB) services at Indiana hospitals. IHA is committed to advocating for all members as they make the best decisions for the communities they serve. In partnership with IDOH, IHA hosted an OB summit with representation from all levels of care throughout the state. Discussions were had about the need to support delivery hospitals and invest in prenatal/postnatal care models in other communities. Recommendations from the summit will be summarized in a consensus plan on how to move forward as a state. 


Patient Safety Newsletter - Dec. 2023

​Indiana Reportable Disease List Updated –Effective Jan. 1​

Reportable.jpgOn Jan. 1. 2024, updates to the Indiana Reportable Disease List for Healthcare Providers and Hospitals and the Indiana Reportable Result/Pathogen List for Laboratories will go into effect. Below you will find the updated reportable disease lists and a summary of the changes being made. If you have any questions, please contact Lunden Espinosa and Jim Sainsbury

​I​ndoor Air Pollution 

AirQuality.jpgThe American Lung Association is launching a nationwide survey of health care professionals to gain insights into their understanding and clinical experiences with indoor air pollution. Feedback will play a pivotal role in shaping the Lung Association’s indoor air quality programs, ultima​tely benefiting both providers and patients.   

Please take five minute to complete this online survey​.  Health ​care professionals who complete the survey will be entered for a chance to win a scholarship for an American Lung Association CME/CEU educational course. A summary of survey findings will also be shared with all survey respondents. 

If you have questions about this survey, you can reach out to​. ​


Patient Safety Newsletter - Nov. 2023

​Help IDOH Survey Hoosiers

QR code.pngIndiana Department of Health Maternal and Child Health Division & Children received their statewide needs assessment back and need your help! They want to hear from Hoosiers in every corner of the state.  

 Here are the details: 
  • ​The survey asks about the health and wellness of individuals, families, and their communities 
  • It is available in both English​ and Spanish 
  • Anyone older than 18 who lives in Indiana can take the survey 
  • It will remain open until Dec. 15 
  • Participants will have a chance to win gift cards for their participation 
We appreciate your help in distributing this survey. 
  • ​A flyer with the QR Code is attached. The link for the survey is:​ 
  • Distribute this widely with your network and community.  
  • Consider sharing this flyer at upcoming events, via newsletters, or post it to social media.  
This is the best way for Hoosiers to let us know their most important health needs. The Indiana Department of Health will use these deidentified findings to inform our work and priorities for the next Maternal and Child Health strategic plan. 


Patient Safety Newsletter - Oct. 2023

Notice. Talk. Act. Well-Being Training

Notice Talk Act.pngIHA is looking for individuals to pilot a 35-minute, on-line, well-being training course called Notice. Talk. Act., an e-Learning training module that supports leaders, managers, and supervisors to

  • Understand the impact of mental health on employees and the organization. 
  • NOTICE what may be signs of potential mental health concerns. 
  • Know how to TALK with a person they may be concerned about. 
  • Be better equipped to ACT by connecting a person with services and supports.  
If you are interested and willing to participate, please email Laurie Gerdt​ and she will provide you with a link to the actual training for your review, critique, and feedback. There are a limited number of links available so please email soon. View the introductory video here: Workplace Mental Health - Notice.Talk.Act. at Work 


​​​Patient Safety Newsletter - Aug. 2023

September is Suicide Prevention Month

988.jpg988 is a mental health crisis hotline that operates in Indiana 24/7. Indiana calls are answered by five Indiana crisis call centers manned by trained mental health crisis professionals. Indiana has some of the highest answer rates in the country, yet many are not familiar with this valuable resource.   

What can Indiana hospitals do to increase awareness of this service? 

For additional resources regarding suicide prevention all year round, please access IHA’s  suicide prevention toolkit as part of the IHA Patient Safety Awareness Toolkit here.

IHA Safe and Sound Campaign Training Opportunity

RISE Training Overview

 ​​Training Overview
The R.I.S.E. (Resilience in Stressful Events) program was developed at The Johns Hopkins Hospital to provide peer support to health care workers who are second victims and/or encounter stressful, patient and work-related events. In partnership with their local Patient Safety Center, Johns Hopkins Medicine now delivers the “Caring for the Caregiver: Implementing RISE” training program to hospitals throughout the world.

This 2-day VIRTUAL workshop focuses on creating a structured and sustainable peer support program to fit each hospital’s unique culture and trains the inaugural peer responder team to provide timely confidential support to colleagues in distress.
  • Day 1: Implementation Training — This is a full training day for the LEADERSHIP TEAM. Please consider including HR, quality/safety, EAP, chaplain, marketing, and risk management leaders.  Topics include: strategies for leadership buy-in and to navigate operational challenges, guidance on recruiting and retaining peer responders, strategies for rolling out and sustaining Caring for the Caregiver.
  • Day 2: Peer Responder Training — This training occurs 2 to 4 months after implementation training and is designed for the peer responder team. Day 2 consists of skill-building activities or the “how-to” provide a RISE response.



Patient Safety Newsletter - July 2023

​IHA Call For Blood Culture Contamination Data 

Blood Culture.pngFalse-positive blood cultures due to contamination increase risk to patients. In June, the Council on Quality & Patient Safety endorsed a goal for IHA member organizations to achieve a 1% blood culture contamination rate. To aid our assessment of the state of the state, voluntary reporting is available by following steps found HERE. At a minimum, report monthly data for Q4 2022 but we welcome continued reporting of 2023. In addition, a learning community will be launched in the coming months and will include insight from national and state subject matter experts. We will also spotlight best practice innovations across the state. For questions regarding the blood culture contamination priority and to share your challenges and successes, contact Annette Handy.

Infection Prevention – A Team Sport 

Baseball.pngThrough the generosity of the Indiana State Office of Rural Health’s FLEX funding, IHA is excited to advance building the infection prevention bench of Indiana hospitals. Recognizing the important role of environmental services, laboratory, microbiology, and pharmacy professionals to infection prevention, a series has been developed spotlighting these disciplines and the important role they have in protecting patients and staff from harm. The series flyer with session registration is found HERE. Becky Royer​  and Annette Handy will join national subject matter expert and coach, Barb DeBaun MSN, RN, CIC as we play ball! 

Indiana Medical Error Reporting Changes 

Med Error.pngOn July 1, the roster of reportable events through the Indiana Department of Health (IDOH) Medical Errors Reporting System changed with the adoption of the 2011 National Quality Forum’s (NQF) serious reportable events. To lend aid with interpretation, IHA will be co-hosting an event with NQF and the Indiana Department of Health on Aug. 3 at 3 p.m. ET.  Register HERE after which you will receive confirmation with joining detail. 

AHRQ Releases TeamSTEPPS 3.0 

TeamStepps.pngThe Agency for Healthcare Research and Quality (AHRQ) has updated its TeamSTEPPS® training program, an evidence-based resource designed to improve patient safety by optimizing the performance of healthcare teams. To access the refreshed curriculum, visit TeamSTEPPS 3.0​

Start Planning for September Sepsis Awareness Month 2023​
Sepsis.jpgIt is time to begin planning for Sepsis Awareness Month activities. The IHA 2023 Sepsis Toolkit will be published early Aug. IHA will host the Indiana Sepsis: State of the State webinar on Sep. 6, 3 p.m. ET. Register Here. Our request is to continue focus on improving bundle compliance, hospital onset sepsis care improvements, and community education to improve time to treatment. Social media messages, billboards, signage with QR codes for patient education, oral hygiene to prevent pneumonia are available resources. Please send pictures using “I Am a Sepsis Champion” from the 2022 toolkit to Casey Hutchens for inclusion in the 2023 toolkit. Consider attending the Sepsis Alliance Summit Sept. 28 & 29 and IHA’s American Lung Association Resources webinar on Sept. 27, 3 p.m. ET. Registere HERE​. Share your plans with Rebecca Hancock​.

CAH Staff Completes Swing Bed Management Program

Swing Bed.pngMany critical access hospitals (CAHs) are focused on building their swing bed programs to strengthen relationships with tertiary hospitals and increase patient volume and revenue. Most importantly, Swing Bed programs allow patients to stay close to home while receiving the skilled care services required to safely return home. Comprehensive education and training are needed to address rural swing bed issues, provide the necessary tools for compliance, efficiency, and quality, and support population health, wellness, and other services. Hospital leadership must understand the specific guidelines related to caring for swing bed patients to get the most out of their program. Therefore, the State Office of Rural Health provided funding to support CAH staff attending a Swing Bed Management Certificate program through the MBQIP FLEX grant. Participants completing the certificate program in 2023 include the following.

Brandi Richardson           Ascension St. Vincent Southwest Indiana, Ascension St. Vincent Critical Access Hospitals
Jama Cox                                 Discharge Planner Ascension St Vincent Dunn, Jennings, Salem, and Williamsport
Pam Erickson                      Community Hospital of Bremen
April Shewmaker                      Harrison County Hospital
Cyndy Kern                                 Indiana University Health Jay
Sue Dee Horton                      Perry County Memorial
Dusti Simmons                      Perry County Memorial
Brantley Purcell                      Pulaski Memorial 
Linda Powers                      Pulaski Memorial 
Dodie Vick                                Scott Memorial Hospital
Jamee Beard                                Sullivan County Community Hospital
Whitney Bell                                Sullivan County Community Hospital
Mandie Hawkins                     Union Hospital Clinton
Josh Morgan                                Union Hospital Clinton
Brittany Bonomo                      Union Hospital Clinton
Terri McCollom                      Union Hospital Clinton

Congratulations to all for completing the Swing Bed Management Certificate Program.


Patient Safety Newsletter - June 2023

 Harm Prevention​

​​CMS Randomly Selects Hospitals for FY 2026 Validation ​

Data.pngCMS randomly selected the sample of hospitals for data validation of measures within the Hospital IQR Program and the Hospital-Acquired Condition Reduction Program for the FY 2026 payment determination/program year. The list of hospitals and validation resources are available on QualityNet. Selected hospitals will receive a direct email from the CMS Value, Incentives and Quality Reporting Validation Support Contractor. 


CDC NHSN Updates  

CDC.pngOn Friday, June 16, Centers for Disease Control and Prevention Director, Dr. Rochelle P. Walensky responded to President Biden’s announcement that he intends to appoint Dr. Mandy Cohen to be the next CDC director. Read Dr. Walensky’s statement HERE.  

The 2023 Q2 newsletter is now available on the NHSN website​. This issue of the NHSN newsletter announces and introduces CDC’s plans for the next HAI Rebaseline within the Patient Safety Component. Please refer to page 3 of the newsletter for more information. Inside this issue – 2022 HAI Rebaseline Information, AUR Module Updates, NHSN Education and Training Highlights, NHSN Dialysis Component Q1 2023 QIP Deadline, NHSN Data Quality and Vendor Corner Information and other General NHSN Updates. ​

​CMS Readmissions & Mortality Metric Update ​

CMS.pngIn the 2023 Methodology Report on CMS Readmission & Mortality metrics, CMS added specific COVID-19 codes that affect risk adjustment and acuity levels for expected readmissions and mortalities. Please share this information with your Clinical Documentation Integrity Teams. 

The following ICD-10 codes affect the (risk adjustment) methodology for calculating Case Mix Index and also affect 2023 Condition-Specific Readmission and Mortality Measures: 

Code Excluding patient from readmission/mortality cohort
​•  U07.1    COVID-19  
Codes Affecting Risk Adjustment 
​•  U09.9    Post COVID-19 condition, unspecified.  
​•  Z86.16 Personal history of COVID-19  
​•  ​J12.892 Pneumonia due to coronavirus disease 2019  

Patient Safety Newsletter - May 2023

Harm Prevention

​​​​CMS Issues Proposed FFY24 PPS Rules 

CMS.pngThe Centers for Medicare & Medicaid Services (CMS) issued proposed rules in April that affect acute care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, long-term care hospitals, and PPS-exempt cancer hospitals. IHA has updated the quality measures table​ to reflect the proposed chang​es to quality measurement requirements announced in the rules.

Additionally, the Healthcare Association of New York State (HANYS) has created a payment rule briefing​ outlining key components of the proposed Medicare inpatient payment rule for federal fiscal year 2024. The document focuses on the key proposed provisions covering inpatient rates, changes to the rural wage index and rural floor calculation, Medicare Disproportionate Share Hospital, Graduate Medical Education, pay-for-performance, inpatient quality reporting provisions, and interoperability.


Patient Safety Newsletter - April 2023

Harm Prevention

​​IHA Launches Voluntary Blood Culture Contamination Reporting ​

Blood Culture.pngBlood culture contamination (BCC) influences clinical decision-making and a cascade of actions that may lead to unintended consequences. There is a national movement to a new blood culture contamination benchmark of 1%.  

To evaluate Indiana hospitals’ current state of BCC, on April 7, IHA opened voluntary reporting utilizing the December 2022 approved National Quality Forum (NQF) measure definition. To learn more, including how your organization can participate, contact Annette Handy​

World Hand Hygiene Day  ​

Handwashing.pngMay 5 is World Hand Hygiene Day! The World Health Organization (WHO) 2023 campaign is Accelerate action together. SAVE LIVES – Clean Your Hands. Access WHO resources here. IHA’s 2023 Patient Safety Awareness Toolkit also includes hand hygiene resources including social media images and text. ​

Patient Safety Newsletter - March 2023

Harm Prevention

​​​Indiana Communicable Disease Rule Updated – Changes effective April 1 

IDOH.pngThe Indiana Department of Health (IDOH) has announced upcoming changes to Indiana’s Communicable Disease (CD) Rule (410 IAC 1), including streamlined timeframes for reporting and updates to reportable diseases. Indiana Code Title 16 (Health 16-41-2-1) was amended in 2019. This amendment allows the IDOH to publish and update the list of reportable communicable diseases and control measures on the IDOH website.  

To access resources related to these updates, visit IDEPD website. Questions regarding the Communicable Disease Rule reporting should be directed to Kelly White​, MPH CPH.  ​​


​Diversity, Equity, & Inclusion

​CMS Framework for Health Equity 2022-2023 ​

CMS Framework.pngThe CMS Framework for Health Equity was developed with particular attention to disparities in chronic and infectious diseases such as diabetes, chronic kidney disease, cancer, dementia, cardiovascular disease, maternal and infant health, behavioral health, as well as HIV/AIDS, and COVID-19, which disproportionately impact members of underserved communities due to prevalence, complexity, and social risk factors. This plan focuses on people who experience or serve those who experience high burdens of disease, worse care outcomes and barriers to care access.


​Healthcare Partnerships

​Long Term Care PASRR I and II Approvals Resume ​

PASRR.pngThe Pre-Admission Screening and Resident Review (PASRR) Trainings online for new staff will resume at the end of the Public Health Emergency planned May 11.  The trainings will be announced through an e-newsletter you can sign up for here. Information on PASRR Reviews can be found here​.​


Leading in Tough Times: Applying Cross-Sector Lessons on Resilience to Health Care​

Resilance.pngWe invite you to join Cynosure Health on April 20 for a conversation with experts from across the globe about how to apply ideas about resilience—the process and outcome of successfully adapting to difficult circumstances—to the ever-changing health care landscape. 

Leading in Tough Times: Applying Cross-Sector Lessons on Resilience to Health Care 
April 20 | 10 a.m. – 1 p.m. ET 
Register (for free!) here
Read more about the event and our panel of experts here​

Speakers include: 
•  ​Charles Vincent, Professor of Psychology at Oxford University 
• Amy Edmondson, Professor of Leadership and Management at Harvard Business School 
• David Gaba, Associate Dean for Immersive and Simulation-based Learning at Stanford School of Medicine 
• And many more! 


Patient Safety Newsletter - February 2023

​Harm Prevention

C. auris Toolkit Available  ​

C auris.pngThe Indiana Department of Health (IDOH) has created a Candida auris (C. auris) resource page  to guide organizations in the identification and care for individuals with this drug-resistant fungus which can spread in healthcare facilities. A toolkit has been developed to guide the implementation of current best practices. Included are steps for case reporting and an inter-facility infection control transfer form. The IDOH lead for C. auris inquiries is Caleb Cox​, MPH.

Patient Safety Newsletter  - January 2023

Mark Your Calendars For The 2023 IHA Patient Safety Summit

Summit Save the Date.jpg

Harm Prevention

​Senate Bill 1 to Address Mental Health

988.jpgSenate Bill 1 will require the Division of Mental Health and Addiction to maintain the 988 help line. 988 is an emergency response option specifically for anyone experiencing mental health-related distress. Call 911 for police, fire, and medical emergencies. Call 988 for thoughts of suicide, mental health, substance use crises, or any other kind of emotional distress. Use of 988 provides immediate response to patient needs and can divert patients from emergency departments if no medical intervention is needed. For more information and to support funding click Senate Bill 1 - Behavioral health matters - Indiana General Assembly. For more information on 988 click ​FSSA: DMHA: 988 Indiana.

Hospitals participating in the SHIP Improving Practices Around Mental Health cohort are including this new service within their discharge instructions and/or their patient education materials. A demonstration was provided to these hospitals that included a recording of the automated phone tree messaging individuals hear when they call 988. ​They were also provided  resouces including these  cards in English and Spanish.

Diversity, Equity, & Inclusion

HumanTrafficking.jpgJanuary is Human Trafficking Prevention Month​


January is National Human Trafficking Prevention Month. Since 2010, January has been dedicated to raise awareness about human trafficking and to educate the public about how to identify and prevent this crime. This month, we celebrate the efforts around the world to raise awareness and increase education about human trafficking.

Human Trafficking Resources

Healthcare Partners

​​IHA Names Larry Tracy Council on Quality & Patient S​afety Chair

Larry Tracy.jpgLarry Tracy, President of Memorial Hospital of South Bend, has been named the Chair of the IHA Council on Quality and Patient Safety for 2023. The IHA team is appreciative of Brian Herwig, President and CEO of Perry County Memorial Hospital, serving as the Chair for several years and providing statewide leadership for quality and patient safety initiatives.

Events & Webinars

​​January is Birth Defects Prevention Month

Birth Defects Large.jpg

IHA Maternal Infant Safety Newsletter  - Q4

Safe Sleep for Babies Act in Effect Nov. 12​

Safe Sleep.jpgThe Safe Sleep for Babies Act of 2021 was signed into law in May of 2022. The law is in effect beginning November 12, 2022. The law bans crib bumpers and inclined sleepers. Regardless of manufacture date, these are now considered banned, hazardous products. The law makes it unlawful to sell, offer for sale, manufacture for sale, distribute in commerce, or import into the United States crib bumpers or inclined sleepers. Manufacturers, importers, distributors, and retailers failing to comply will face enforceme​nt action and civil penalties. If you see a violation of this new act, report it to the CPSC: 
  • Submit online via​,
  • ​​​Call CPSC’s toll-free Hotline at (800) 638-2772, or (301) 595-7054 for the hearing and speech impaired.
More Info on the CPSC & Infant Safe Sleep:​

​Indianapolis Coalition for Patient Safety Hero Awards Winner

JMH.jpgThe Johnson Memorial Health Maternity Services Team, based on the goals of AIM, created a “Hypertensive Emergency Task Force” in June 2021, with the goal of improving the care provided to pregnant women experiencing hypertensive disorders of pregnancy. This task force was multi-disciplinary in nature, including clinicians from the inpatient, emergency and clinic sites of care.  Providers, nursing, lab, information technology, and pharmacy met routinely to change the way care was provided to pregnant women affected by hypertensive disorders of pregnancy, from their initial office visit through to delivery. Care pathways were created, including a pathway for pregnant women presenting at intake with chronic hypertension, and order sets were created to ensure every patient was treated according to evidence-based standards.  Manual blood pressure competencies were also created and completed for all clinic and maternity staff. The maternity staff remains engaged in this important safety topic, committing all nursing staff to annual professional education on hypertensive emergency, either by webinar or article review. 

Data collection began in August 2021. Treatment of severe hypertension was monitored by tracking blood pressure and medication administration actual performance, compared to the treatment algorithm from ACOG. The group’s 1st data point showed 75% compliance with the treatment algorithm.  In order to continue to improve that performance, 100% of cases are debriefed, using a debriefing tool and in those cases where an opportunity is identified, either the physician champion or the maternity manager follow-up accordingly, directly with the person involved.

Despite an organization-wide cyber-attack that impacted electronic order sets and data-analysis (no usable data available for October through December 2021), the team remained focused and 2022 YTD data shows 100% bundle compliance in 5:8 months, with 100% compliance for the last 3 months.

This team, led by an outstanding nurse manager, with strong physician leadership, continues to improve care for the women we serve while also being awarded the PRC “FIVE STAR” award for patient experience, ranking in the top 10 percent nationally for 2021.  Many of the patients cared for by this team in 2021, included babies and moms from Camp Atterbury’s “Operation Allies Welcome”.

Patient Safety Newsletter - December 2022

Prevent Patient Harm

​INspire Recognition Held During Labor of Love

INspire.jpgThe Indiana Hospital Association, in partnership with Governor Eric Holcomb and State Health Commissioner Kris Box, recently held the third annual INspire Hospital of Distinction recognition program during the Labor of Love Summit. 
INspire, funded by the Indiana Department of Health’s Safety PIN grant, was developed to encourage the implementation of best practice care for Hoosier moms and babies and recognize hospitals for excellence in addressing key drivers of maternal and infant health. 

Recognition is based on six key areas, including infant safe sleep, breastfeeding, tobacco prevention and cessation, perinatal substance use, obstetric hemorrhage, and maternal hypertension.  

In 2018, the state of Indiana received a challenge from Governor Eric Holcomb to reduce Indiana's infant mortality rate and become the best in the Midwest by 2024. 

Also during Labor of Love, in partnership with the Indiana Department of Health, IHA distributed nearly 1,500 blood pressure cuff kits from the Preeclampsia Foundation to Indiana’s delivering facilities. Hospitals were allocated kits based on their size and admission rates for severe preeclampsia & eclampsia. These kits provide women with the tools and support to monitor their blood pressure at home. It includes a quality blood pressure monitor, education on the importance and proper way to check their blood pressure, and warning signs on when to call their provider. 

Improve Community Health & Equity

Mental Health America of Indiana Held Annual Mental Health Symposium 

Mental Health America.pngFrom left to right: 
Steve McCaffrey, President and CEO of MHAI 
Jay Chaudhary, Director of the Indiana Division of Mental Health and Addiction 
Mike Nielsen, Sheriff – Boone County Sheriff’s Office 
State Senator J.D. Ford 
State Representative Ann Vermilion 
State Senator Mike Crider 
Zoe Frantz, President & CEO Indiana Council of Community Mental Health Centers 
State Representative Greg Steuerwald  
Carrie Cadwell, CEO of 4C 

On Dec. 9, Mental Health America of Indiana held their annual mental health symposium. Members of the Indiana Behavioral Health Commission joined in a panel to discuss and answer questions regarding the commission report that addresses the safety and care of Hoosiers with psychiatric needs. Several IHA members attended the symposium. To review the commission report, please click here:  Indiana Behavioral Health Commission Report​


Patient Safety Newsletter - November 2022

Prevent Patient Harm

​ED QI Collaborative: The State of Emergency in Children's Mental Health ​​

kids.jpgThe Emergency Medical Services for Children Innovation and Improvement Center (EIIC) is providing the Emergency Department (ED) Screening and Treatment Options for Pediatric (STOP) Suicide Quality Improvement (QI) Collaborative to address the ongoing state of emergency in children’s mental health, specifically acute suicidality. The purpose of this collaborative is to bring together ED-based teams from across the nation with experts in pediatric mental health to exchange evidence-based best practices and optimize the care and follow-up of children and adolescents presenting with acute suicidality. 

This QI collaborative will provide an opportunity for ED-based teams to collaborate with other diverse teams across the country. Participants will have access to evidenced-based best practices, collaborative educational sessions, resources, coaching by pediatric mental health experts, and networking opportunities to improve the care of children and adolescents in their community – at no cost. Continuing education credits are offered.

Improve Community Health & Equity

​Rural Award Winners Announced ​

Joyce.jpgDuring the Critical Access Hospital Convening meeting held on October 25 many rural health awards were announced.   

1.  The National Organization of State Office of Rural Health (NOSORH) selects award winners each year.  This year, Joyce Fillenwarth, Indiana Department of Health (IDOH), State Office of Rural Health (SORH) Manager, received the national NOSORH Advocate Award. 

2.  NOSORH each year offers an opportunity for rural communities from each state to nominate their ‘Community Star’, which represents individuals  who are making a difference and positively impacting their communities in several vital health-related areas.   

Those nominated this year include: 
  • Chris Butler, MHA, BSN Adams Health Network 
  • Jessica Clifton, Adams Memorial Hospital 
  • Brittany Kelley, C-CHW, Sullivan County Community Hospital 
  • ​Brian Herwig, CEO Perry County Memorial Hospital 
​​​This year’s Community Star award winner for Indiana is Brian Herwig!   Brian cultivates a vital, innovative rural health landscape and infrastructure and develops leadership capacity to grow rural population health and health equity. He strives to build capacity for rural data-driven program planning and decision making. And, finally, Brian was nominated for this award for his contributions to rural health innovation, education, collaboration, and communication.

3.  The Indiana Department of Health (IDOH), State Office of Rural Health (SORH) aspires to honor the Indiana Critical Access Hospitals (CAH) for their performance and acknowledge high-performing CAH and their leaders. This year’s recipients include the following: 

  • NOSORH Advocate Award – Joyce Fillenwarth 
  • CAH Hero – Jared Sterrett, Franciscan Health Rensselaer 
  • Patient and Family Experience – Zach Beiswanger, Cameron Memorial Hospital 
  • Outstanding Rural Health Provider – Dr. Lisa Clunie, Harrison County Hospital 
  • Community Impact – Indiana University Health Bedford Hospital 
  • Community Impact – Union Hospital Clinton 
  • NOSORH Community Star Award Winner – Brian Herwig 
  • Outstanding CAH Leadership – Chris Butler, Adams Memorial Hospital 
  • CAH Community Partner – Dukes Memorial Hospital & United Way 
  • Innovation in Quality Improvement – Indiana University Health Paoli Hospital 
Congratulations to all of the Indiana rural health award winners!​

World COPD Day 2022

Your-Lungs-For-Life_Final-scaled.jpgWorld COPD Day is organized by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) on Nov. 16 in collaboration with health care professionals and COPD patient groups throughout the world. Its aim is to raise awareness, share knowledge, and discuss ways to reduce the burden of COPD worldwide. To learn more, visit the Global Initiative for Chronic Obstructive Lung Disease site here

If you go here​, you can download the graphic they have for sharing.  

​Lead A Culture of Safety

​Transition of COVID-19 Hospital Reporting Date is Nearing

Data.jpgIn August, HHS announced transition planning for COVID-19 data collection away from the federal portal TeleTracking to NHSN and will be in effect, Dec. 15. IHA has been working with state and federal partners to ensure that planned migration from TeleTracking to the NHSN platform goes smoothly. As such, IHA can confirm that Juvare, the vendor of the IDOH platform EMResource, is in active testing with the NHSN​ platform and is working to close any data gaps that would prevent a successful transition.  

Given this daily reporting is subject to a CMS Condition of Participation, IHA highly recommends that its members develop and become familiar with direct data entry into NHSN for back up purposes. We have and continue to strongly encourage hospitals and their reporting teams to frequently visit, Transition of COVID-19 Hospital Reporting | NHSN | CDC​ to stay current with updates and to access related training.  

For questions related to this transition, your IHA contacts are Annette Handy and Matt Browning. ​

Workforce Wellbeing

Stress Meter.pngCheck in on your mental wellbeing using the American Hospital Association’s Stress Meter:  Your Stress Meter™ | AHA.  The Stress Meter™ application (Stress Meter™) is a self-assessment tool intended to offer general feedback to the user. It does not substitute or replace in any way a formal diagnosis from a qualified medical professional. Resources and suggestions are prov​ided for each level of stress.

​Events and Webinars

​​Rural Health Clinical Congress Fall 2022 

Fall.jpgNOSORH is partnering again with RME Collaborative for Rural Health Clinical Congress Fall 2022, a FREE virtual CME/CE conference for clinicians who serve rural and underserved communities! This multi-topic event will be broadcast live on Saturday, Nov. 19 starting at 8 a.m. CT. 

Click here to learn more about this unique continuing education event and help us spread the word by inviting clinicians in your area to participate. Questions? Contact RME Collaborative at


SHIP Newsletter - Quarter 2 - 2022

​​Critical Access Hospital Convening 

​You are invited to a virtual convening of your Indiana Critical Access Hospital (CAH) peers on Tuesday, October 25, 2022, from 9:00 a.m. – 3:45 p.m. ET, sponsored by:
  • The Indiana Department of Health (IDOH) State Office of Rural Health
  • IDOH Epidemiology Resource Center
  • Indiana Hospital Association 
  • Indiana Rural Health Association
  • Qsource
Given the public health emergency challenges around health, safety, and workforce issues, the CAH Convening meeting will be virtual.

The primary target audience includes Senior Leadership, Quality Leaders, and Management Leaders.
The agenda has a variety of topics that will be of interest (see attached for more details).  Please share the agenda with others. If you or other staff members are interested in just one session during the day, please register and feel free to join for the individual session. There is no limit to the number of hospital attendees.

Overview of the agenda: 
  • State Office of Rural Health Critical Access Hospital Award Presentations
  • Key Indiana Department of Health Updates and Agency Initiatives
  • Eliminating Health Disparities in Your Community through Z Codes
  • Improving Patient Care through Chronic Care Management Remote Monitoring
  • Recruitment and Retention of Providers and CAH Staff
  • LifeLine Pilots
  • Addressing Current Behavioral Health Concerns; One Behavioral Health Hospital’s Approach
Please register no later than October 11, 2022, via this link: CAH Convening Registration 


Patient Safety Newsletter - October 2022

Prevent Patient Harm

​​​Join IDOH & IHA for IP Bootcamp 

IP Bootcamp Header.jpgJoin us Nov. 9 & 10 for two days of engaging activities as we strengthen infection prevention programs across Indiana. This FREE program is open to ALL whether novice or expert.  

Bootcamp is limited to the first 100 registrants and each hospital may register up to two individuals by visiting HERE.​

The Bootcamp flyer is available HERE​

If you have more than two individuals from your organization who wish to attend, please contact Becky Royer to be placed on a wait list. On Nov. 1, if space remains, those on the wait list will be notified.  

Questions regarding this professional development opportunity should be sent to Becky Royer​ or Annette Handy.  

Honoring Quality & Infection Prevention Professionals  

Healthcare Professionals.jpgOct. 16 – 22 is a week to celebrate Health Care Quality and Infection Prevention professionals and IHA sends our hearty gratitude to teams dedicated to ensuring the delivery of quality care.  

Healthcare Quality Week The National Association for Healthcare Quality (NAHQ)has created a planning Guide with associated webinars found HQW Planning Guide 2022 ( To learn more about the Indiana Association for Healthcare Quality (InAHQ), click here.

International Infection Prevention Week (IIPW). IHA joins the Association for Professionals in Infection Control and Epidemiology (APIC​) in celebrating this year’s theme: The Future is Infection Prevention: 50 Years of Infection Prevention.” When visiting this site, you may also learn how to engage with the APIC Indiana Chapter 

Improve Community Health & Equity

​​​Applications Open for Second Round of Grant Program 

Challenge Grant.jpgOn Oct. 7, the Indiana Department of Health announced $7.5 million in grants will be available as part of a second round of funding through the Indiana Health Issues and Challenges Grant program, which was established by the Indiana General Assembly and supported by IHA in 2021 with funding from the American Rescue Plan Act. 
Entities are eligible to apply for funding for programs to help improve health outcomes related to one or more of the following priority areas: tobacco cessation, food insecurity/obesity, lead exposure, chronic disease, and public health prevention programs, including community paramedicine and community health workers. Priority will be given to organizations that can demonstrate a high need and high impact in their grant proposals. 
Applications must be submitted by Nov. 18, and application and grant guidance can be found here. Award notifications are expected in early 2023. 
More than $35 million was previously awarded through the first round of funding in June for programs addressing issues such as asthma, cancer prevention, heart disease, diabetes, lead prevention, food insecurity and obesity, community health workers, and community paramedicine. The list of previous recipients can be found here​. All funds must be spent by Dec. 31, 2026.

​Lead a Culture of Safety

​SMART Medical Stability Guidelines​SMART.jpg

In August, IHA’s Council on Behavioral Health presented the SMART medical stability guidelines​ to help standardize the process for patients needing inpatient mental health treatment. One of the goals in using the SMART guideline model is to reduce ED boarding and provide more effective and efficient coordination between EDs, psych units, and law enforcement.  

Four County Counseling Center(4C), located in Logansport, ​ implemented the SMART model about 6 months ago. 4C’s Medical Director, Dr Neff, implemented this new approach and they are now at 8% of admissions needing medical "clearance", a reduction from 75% which means time back to ER and Law Enforcement staff and no long delays in triage. If you would like to learn more about medical stability and the SMART form, please view the presentation here. 

Events & Webinars

​9th Annual Suicide Prevention Mini Conference

Suicide flyer.jpgLocation: Marriott East, 7202 East 21st St, Indianapolis, IN 46219 

Cost: $30 (online, main room only) or $75 in-person; scholarships are available on a limited basis 

Hotel rooms: A block of rooms are being held for conference attendees for $127 

Questions? Contact Kelby Gaw, ​

IHA Maternal Infant Safety Newsletter  - Q3 2022

​​​​New Federal Infant Sleep Products Safety Standard Takes Effect 

On June 23, 2022, TheSafety Standard for Infant Sleep Products took effect. This federal rule ensures products marketed or intended for infant sleep provide a safe sleep environment for babies up to 5 months old. The new Safety Standard for Infant Sleep Products makes it unlawful to sell non-compliant infant sleep products and applies to products manufactured on or after June 23rd. The new rule applies to inclined sleepers because infant sleep products must have a sleep surface angle of 10 degrees or lower. It also applies to any flat sleeping products that do not comply with the mandatory Safety Standard for Bassinets and Cradles. The new rule eliminates potentially hazardous sleep products such as inclined sleepers, travel and compact bassinets, and in-bed sleepers that don't meet a CPSC mandatory safety standard for infant sleep. ​


Patient Safety Newsletter - August 2022


​​​​​2022 Patient Safety Summit ​

Join colleagues at IHA’s Patient Safety Summit, the premier event for Indiana’s hospital and health system leaders. We’ve missed hosting our annual event in-person. It’s time to gather and reimagine, reengage, and rebuild. This year’s Summit will take place on Sept. 20 at the Embassy Suites in Plainfield. We hope to see you there. You’ll have the opportunity to re-connect with your peers and meet new ones.  
Through the lens of COVID-19, the robust sessions will explore post-pandemic health care and the hospital community’s renewed commitment to inclusivity and health equity. Influencing restoration of safety practices and outcomes using the key tenets of high reliability and strategies to achieve a culture of zero violence are two other areas of focus for the day.  
Patient safety and quality leaders will come together to learn effective strategies and share best practices that will improve patient safety statewide. Anyone responsible for patient safety and leading change for improvement will find the Patient Safety Summit an informative and inspiring experience. Please share and encourage others to attend.   

Improve Community Health & Equity ​

Mental Health is as Important as Physical Health 

English Version.jpgSeptember is suicide prevention month. Not only do we want to reduce the number of Hoosiers that die by suicide, but we also want to prevent anyone from feeling suicidal in the first place. Connecting with others and asking for help are two ways to help prevent feelings of suicide from occurring. Please consider adding your logo to this flyer and promoting connection and help-seeking behaviors. #BeThe1 To SAVE A LIFE and it is okay to not be okay. Access the IHA Suicide Prevention Toolkit here.​


Events & Webinars

​I-HOPE Program Participants: Please Join Us for Our First Educational Session

​​​Inhaler.jpgIt may be difficult to tell the difference between the two chronic lung diseases, Asthma and COPD, especially as people living with these chronic conditions get older or smoke. Asthma COPD overlap syndrome (ACOS) is an umbrella term that doctors use when a person has both asthma and chronic obstructive pulmonary disease (COPD). These lung diseases share some similarities, but they are separate conditions. People with a diagnosis of Asthma-COPD Over-lap Syndrome (ACOS) tend to have more symptoms than people with either asthma or COPD alone and have more severe attacks, leading to more emergency room visits and hospitalizations. 

Courtney Stewart, MPH, from the Indiana Joint Asthma Coalition (InJAC) will review the work being done to increase public awareness of asthma as a serious chronic disease, in addition to improving the knowledge and skills of patients regarding the detection, treatment, and control of asthma, particularly among high-risk patients. Courtney will also discuss the work on tobacco prevention and cessation, the Indiana Quit Line, and introduce you to the CDC’s EXHALE strategies.  

Please feel free to share this invite with all folks at your facility who may have interest in this topic.  

Please register in advance for this meeting: 
​After registering, you will receive a confirmation email containing information about joining the meeting. 

Medical Stability of Patients with Acute Mental Health Needs in the Emergency Department

Med Stability.jpgPresented by the IHA Council on Behavioral Health 
Aug. 25, 2 – 3 p.m. ET 

Please register in advance for this meeting: 
After registering, you will receive a confirmation email containing information about joining the meeting 
 Please forward this meeting invitation to additional pertinent staff 

During this webinar, we will: 
  • Discuss the definition of medical stability 
  • Understand the varying medical capabilities of psychiatric facilities and how that impacts the disposition of the patient 
  • ​Hear about emergency department physician use of a medical stability SMART tool 

2022 Perinatal Substance Use Virtual Conference

Implementation of a Standardized Clinical Definition of Opioid Withdrawal in the Neonate
Dr. Shahla M. Jilani
Office of the Assistant Secretary for Health
US Department of Health and Human Services
Disproportionality in Testing and Treatment
Dr. Caitlin Bernard
Assistant Professor of Clinical Obstetrics & Gynecology,
Indiana University School of Medicine

Engaging Community Stakeholders into Family Care Plans
Kathy Detweiler, MHL, BSN, RN
Director, Perinatal Center and Nurse Navigation Women's & Children's Services
Parkview Regional Medical Center

Register in advance for this meeting: 


Patient Safety Newsletter - July 2022

​​​H​​QIC Quality Improvement Fellowship

HQIC Map.jpg​​On July 13, hospitals participating in the Hospital Quality Improvement Collaborative (HQIC) joined IHA in celebrating the work of peers who completed a Back-to-Basics Quality Improvement (QI) Fellowship. Over six months, teams were coached in quality improvement principles and chose a topic that is a priority to their organization. IHA President, Brian Tabor, recognized ALL Indiana hospitals that remain steadfast in our joint mission to make Indiana the safest place to receive health care. Join us in congratulating our 2022 HQIC QI Fellows! 

  • ​Greene County General Hospital – Adverse Drug Events – Hypoglycemia, Megan Brust, Jill Raines, Kyla Nichols, Jennifer Crody & Stacy Street  
  • Logansport Memorial Hospital – Antibiotic Stewardship, Sheila Briner                                                                 
  • Margaret Mary Health – Readmissions ,   Laurie Mustin 
  • Norton King’s Daughters’ Health – Sepsis Readmissions, Cortney Chowning & Natalie Thornsberry 
  • Pulaski Memorial Hospital – Readmissions, Linda Webb 
  • Reid Health – Sepsis, Amanda Sudhoff 
  • Rush Memorial Hospital – Readmissions (R) & Sepsis (S), Jane Gentry (R) & Shelbi Heger (S) 
  • Witham Health – Sepsis, Abbie Morgan 

Quality Improvement Fellowship Pearls and Reflections from national Improvement Advisor

Jackie Conrad, Cynosure Health Improvement Advisor walked alongside Indiana HQIC hospitals with IHA throughout the 2022 Quality Improvement Fellowship and she shares the following reflections: 

A few lessons learned as shared from Fellows:
  • Improvement is a team sport. Don’t try to do this alone!
  • The Discovery Tool helped hospitals identify a specific target for their work.
  • The messenger matters. If providers need to be influenced, send a provider champion who speaks their language.
  • Involve staff early on in deciding what change will lead to an improvement and how to test a change idea. 
  • Listen to the nay-sayers. They will tell you what barriers you will need to plan for.​
  • New behaviors, like escalating a suspected sepsis case, require rewards to keep staff motivated and know they are appreciated.
From the lend of an improvement coach:
  • Don’t assume you know what’s broke. Use data to identify which care processes are failing and contributing to harm. The Discovery Tools will point you in the right direction.  
  • Working on a very small change and following the small test of change (STOC) concept, running quick Plan-Do-Study-Act (PDSA) cycles, hospitals were able to see results and get excited. Working the kinks out by testing a new process with a few key champions made spreading a new process easier with quicker adoption.
  • Sustainability is always a concern. When you use STOC and PDSA cycles, your changes are more likely to stick because they were designed and tested by staff before being implemented.
  • Quality improvement is both an art and science. Use the rules of engagement to engage many in your improvement work to spread the joy of success!

Prevent Patient Harm

​​September is Sepsis Awareness Month: Back to the Future with Sepsis! 

Survive It.jpgPlan your local awareness campaign for staff, visitors and your community. Use updated 2022 social media messages, updated table tents and posters with QR codes for sepsis education, and World Sepsis Day Sept 13 local governmental proclamation. Please send “I am a Sepsis Champion” selfies from the 2021 Toolkit to Casey Hutchens​ on social media on Sept. 13. Send now for cameos in the 2022 Toolkit!  The updated 2022 toolkit will be published early August. Share your creative plans with Becky Hancock

Webinar Series Sept. 1 - Oct. 6, Thursdays, 3 p.m. 
Sept. 1: IHA’s Sepsis State of the State, Rebeccca Hancock 
Sept. 8: Sepsis Back to the Bascis: Pathophysiology and Bundles, Tom Ahrens 
Sept. 15: Sepsis Future: Culture Diagnostics Device,  Sandy Estrada 
Sept. 22: Maternal Sepsis, Brittany Waggoner 
Sept. 29: Sepsis Future: Fluid Management System 
​​​Oct. 6: Sepsis Future: Dental Health Month—Oral Hygiene & Sepsis

Joint Guidance to Prevent Healthcare Associated Infections Released 

vent.jpgThe Society for Healthcare Epidemiology (SHEA), the Infectious Disease Society of America (IDSA), and the Association for Professionals in Infection Control and Epidemiology (APIC) have joined with other stakeholders to release the following updates:  

​​Lead a Culture of Safety

You Got to Refresh to Be Fresh - Refreshed IHA Toolkit for Health Care Worker Resilience and Well-Being

Health-Care-Customizable.jpgTrying to tackle improving workforce well-being while coming out of the Covid-19 coma and in the midst of a workforce crisis is a daunting task. Please consider reviewing this refreshed IHA Resiliency Toolkit​ for strategies and quick tools that health care leaders and workers can use across practice settings to take action toward decreasing burnout and improving clinician well-being.  ​

Events & Webinars

​​2022 Perinatal Substance Use Virtual Conference

PSU.jpgSave the Date!
Wednesday, Aug. 31
10a.m. - 1 p.m. ET

Speakers: ​
Dr. Shahla M Jilani
Office of the Assistant Secretary for Health US Department of Health and Human Services

Dr. Caitlin Bernard
Assistant Professor of Clinical Obstetrics & Gynecology, Indiana University School of Medicine
Kathy Detweiler
Parkview Regional Medical Center

​Midwest Injury Prevention Alliance Virtual Summit


Content conveyed at, or in conjunction with, this event does not constitute the opinion or views of IHA. 



Patient Safety Newsletter  - June 2022

IN the Spotlight​

Collage.jpgAfter more than two years of limited visits to Indiana hospitals and attending conferences, the IHA team is back on the road again. We look forward to seeing you at upcoming events and meetings. Here is a recap of a few events from last week:

Clockwise from upper left:  
IHA’s Annette Handy and Becky Hancock attended the APIC Annual Conference held in Indianapolis. A photobooth at APIC provided a fun opportunity at the end of the environmental/construction simulation tour. Pictured are Anna Roe from Saint Joseph Plymouth, Becky Hancock from IHA, Annette Handy from IHA, and Rhonda Neal from Memorial Hospital of South Bend. 

IHA’s Brian Tabor traveled to Ft. Wayne and was pleasantly surprised to see Parkview Health promoting its involvement with IHA’s INspire program. INspire, funded by the Indiana Department of Health's Safety PIN grant, was developed to implement the delivery of best practice care for Hoosier moms and babies and recognize hospitals for excellence in addressing key drivers of infant and maternal health.

The Indiana Rural Health Association (IRHA) conference was a wonderful opportunity to learn and network. When Billy Riggs appeared as the keynote speaker during day one of the afternoon’s session, things on stage disappeared, time flew by, and no one left the room. IHA’s Chairman of the Board and CEO of Rush Memorial Hospital Brad Smith and IHA’s Kristin Schwartz a part of the Riggs’ presentation. Everyone in attendance is still wondering how Riggs read the minds of Brad and Kristin. 

IHA’s Karin Kennedy joined the psychologist masquerading as a comedian and magician and participated in one of Riggs’ magic tricks. 

IHA’s Brittany Waggoner learned from Union Health’s Melissa Barker, Dan Hardesty, Kristen Moore, and Sarah Wessel at the IRHA conference on how they are transforming rural prenatal care experiences by bridging access and transportation gaps through the offering of continuity clinical services closer to home, as well as within the patients’ homes

​​Prevent Patient Harm

​​Has Your Organization Seen Increases in HAI?​

HAI.jpgYou are invited to join IHA for a 2-part conversation as we discuss diagnostic and antibiotic stewardship, mitigating HAIs, false-positive blood cultures, and emerging technologies. Series detail and registration links are found here. NOTE: You must register for each session separately.  

Part 1: July 6    3 – 4 p.m. ET  Register HERE  

Part 2: July 19 3 – 4 p.m. ET  Register HERE​ 

The target audience includes quality, infection prevention, pharmacy, antimicrobial stewardship, laboratory and microbiology teams so please share with your teammates. For more information, contact IHA’s clinical director Annette Handy.  

​​How Can We Layer Protection to Prevent Harm? ​

Layer.jpgPrevention of health care-associated harm requires layers of protection. Cynosure Health has released Summer is Coming, a compilation of practical, tactical advice from subject matter experts and frontline providers across U.S. hospitals to help you layer protections to avoid harm and engage patients and caregivers.  ​

​Improve Community Health & Equity

​IDOH Announces Probable First Case of Monkeypox in Indiana ​

NHS-MonkeyPox-collage.jpgOn June 18, the Indiana Department of Health (IDOH) announced the first probably case of monkeypox in Indiana. Prior to this announcement, IDOH released an Indiana Health Alert Network Advisory (IHAN) for monkeypox which included several resources including IDOH contacts for guidance if a hospital has a suspected case.  

​Zero Suicide Academy - a virtual training opportunity ​

ZeroSuicide.jpgThe Zero Suicide Academy is a best practice approach to improving the care provided to those individuals struggling with suicidal ideations and behaviors. According to U.S.A. Suicide: 2020 Official Final Data, Indiana lost 1,024 Hoosiers in 2020 to suicide. That is more than the number of deaths by homicide in 2020 (718). 

The Division of Mental Health and Addiction and MHAI Stanley W. DeKemper Training Institute are offering a virtual Zero Suicide Academy on August 11 - 12 to healthcare and behavioral health organizations in the state of Indiana. 

Zero Suicide Academy is a two-day virtual training opportunity for leaders of healthcare and behavioral health organizations and their Zero Suicide implementation teams that seek to reduce suicides among individuals in their care. This event provides the opportunity to learn from Zero Suicide experts, receive implementation consultation, and begin strategic planning for their own Zero Suicide implementation, strategies to maximize success, and provide individual consultation for teams participating in the Academy while introducing the framework and its seven core components: 

  • Lead system-wide culture change committed to reducing suicides 
  • Train a competent, confident, and care workforce 
  • Identify individuals with suicide risk via comprehensive screening and assessment 
  • Engage all individuals at-risk of suicide using a suicide care management plan 
  • Treat suicidal thoughts and behaviors using evidence-based treatments 
  • Transition individuals through care with warm hand-offs and supportive contacts 
  • Improve policies and procedures through continuous quality improvement 

Teams should consist of four individuals who champion Zero Suicide with passion and those who influence systemic change. Recommended team composition includes: 
  • Person responsible and with authority for implementation decisions (e.g. Medical Doctor, CIO, ED, Director, or IT). 
  • At least one person who manages your electronic health records system, quality improvement, or risk management 
  • At least one person who provides care to individuals daily (e.g. case manager, psychologist, social worker, or nurse). 

Interested applicants please include the following information in your application: 

  1. A cover sheet. The lead applicant will receive all correspondence and must be one of the team members. 
  2. A narrative that, in two to four pages, description including:  
      • The members of your team and relevant skills, knowledge, and experience they bring to the Zero Suicide Academy 
      • ​​A response to the following question: What are your team’s goals for participating in the Zero Suicide Academy and what does the team hope to learn during the training? ​
  3. ​A Zero Suicide Organization Self-Study completed by your implementation team members 

Apply for the Zero Suicide Academy here by July 15 at 5 p.m. ET. Please direct any questions you may have about this opportunity to Justin Beattey,  or Michelle Bulington.  

Content conveyed at, or in conjunction with, this event does not constitute the opinion or views of IHA. 

​Increase Patient & Family Engagement

Tactile Training Tool Improves Patient S​afety​

Adams training pfe.jpgFor the past year, Adams Memorial Hospital has been participating in the Small Rural Hospital Improvement Project (SHIP) focusing on patient and family engagement. One of the main tenets of patient and family experience is ensuring patients understand their discharge instructions. An important component for a patient to demonstrate a clear understanding is using visual aids so patients and families can share the medical information communicated to them and hospital staff assess understanding and ability to better self-manage their care.  

Adams Memorial Hospital recently purchased an Anatomical Apron by Joy. This apron is designed as an educational tool to demonstrate a variety of different surgical procedures such as colostomies, ileostomies, and much more. After being trained themselves on how to use the anatomical apron tool to improve their teach back skills, the wound care team at Adams has used the Anatomical Apron to educate patients and families as a visual aid regarding physical and psychological expectations prior to and after surgery and how to confidently manage them. Individuals appreciate that it is a tactile tool that makes ostomy education easier to understand. 

​Events & Webinars

Live Sepsis Alliance Webinar 

Sepsis.jpgAs you are making plans to provide education for the upcoming September Sepsis Awareness Month 2022, the IHA team is encouraging Indiana hospital leaders to include oral hygiene process improvements to prevent pneumonia and sepsis. Plan to attend this week’s The Sepsis Alliance is offering a webinar, Oral Hygiene as Prevention: Discovering the Links Between Oral Health, Respiratory Infection, and Sepsis. 1.20 registered nurse continuing education contact are available to participants.  

Wednesday, June 22 
 2 — 3 p.m. ET 

Content conveyed at, or in conjunction with, this event does not constitute the opinion or views of IHA. ​

Infant and Maternal Safety Newsletter - June 2022

​T​​obacco Prevention & Cessation - 3 Minutes or Less Can Save Lives

Ask Advis Refer.jpgEvery Patient/Every Visit/Non-Judgmental

  • Ask if your patient uses tobacco.
  • Ask what kind of tobacco is used and how often.
  • Ask when was the last time the patient smoked or used any type of tobacco.​
Be Clear/Be Strong/Be Personal
  • Advise every tobacco user to quit. Quitting is the best decision.
  • Advise those who weren’t successful with their previous quit attempts to try again.
  • Employ a teachable moment: link health findings with advice. Quitting will help the patient and the health of their family.
Fax Referral/OnlineReferral/E-Referral


  • Refer patients to 1.800.Quit.Now.
  • Fax referral form.
  • Web-based online referral portal.
  • E-referral if your health system is setup.

​​​​​Breathe: Healthy Stephs to Living Tobacco Free

Breathe.jpgMcMillen Health received funding support from the Indiana State Department of Health to develop a comprehensive ​tobacco curriculum, training, and resources to be used with Head Starts and other early childhood education centers.
Resources include:
  • An interactive teaching flip chart for one-on-one or group education with parents
  • Parent handouts (13 different topic areas)
  • Children’s activity book
  • Parent activity book
  • 7 videos for parents
For more information, call: (888) 240-7268 or email

​Social Determinants of Health Screening​

CAH.jpgThank you to all the hospitals who actively participated in Cohort 1’s Social Determinants of Health Quality Improvement Screening call. 
  • Parkview DeKalb 
  • Parkview Randallia
  • Parkview Huntington Hospital
  • Parkview LaGrange Hospital
  • Parkview Noble 
  • Parkview Regional Medical Center
  • Parkview Wabash 
  • Parkview Whitley Hospital
  • Adams Memorial Hospital
  • Cameron Memorial
  • Dukes Memorial Hospital
  • Dupont Hospital 
  • Lutheran Hospital 
  • Marion General
We look forward to working with the rest of our cohorts in the near future and you for prioritizing health equity by screening for social determinants of health in the maternal/infant health population by capturing Z:Codes. If you have any questions regarding this work, please reach out to Brittany Waggoner  or Madeline Wilson​.

​​​​My Healthy Baby ​

Healthy Baby.jpgMy Healthy Baby connects pregnant women to family support providers in their own community. A family support provider offers free, personalized guidance and support to the woman during her pregnancy and for at least the first 12 months after her baby’s birth.

My Healthy Baby is a collaboration between the Indiana Department of Health, the Indiana Family and Social Services Administration (FSSA), and the Indiana Department of Child Services (DCS). This initiative is building a network of services and support to wrap our arms around moms and babies to create healthier outcomes for both. It was established by House Enrolled Act 1007, which was signed into law by Gov. Eric Holcomb in 2019.

Visit this page​ for a breakdown of where My Healthy Baby currently is and where it will be going through 2023.


Updated Newborn Screening Toolkit Available​

Newborn Screening.jpgThe Genomics and Newborn Screening (GNBS) program has spent months updating the previous newborn screening toolkit to include information helpful to our partners, providers, and birthing facilities. This program manual serves as a reference for professionals who have a role in Indiana's state-mandated Newborn Screening Programs and its best practices and procedures. Please view the Newborn Screening Program Manual for information regarding each of the three required screens, proper documentation, requesting materials, and more.





Patient Safety Newsletter  - May 2022

​May is Mental Health Awareness Months

Rush.jpgNot too long ago, people with mental illness in our country were literally locked up in chains.  

Today, there have been vast improvements relating to the care and services provided related to mental health and well-being. But there is still much work to be done to break down the stigma, fear, and neglect that surrounds mental health issues.  

To that end, Mental Health America is working hard, every single day, to overcome the silent stigma surrounding mental illnesses and shorten the gap between the first signs of mental health problems and getting help—well before the Stage 4 crisis point.  

Learn more about MHA and our B4Stage4 philosophy   
Learn what else you can do to help advocate for improvements for those living with mental health concerns  

Rush Memorial Hospital has taken on the task of shortening that care gap between first signs of mental health problems and accessing care by implementing UNIVERSAL mental health screenings (Patient Health Questionnaire (PHQ-9 & PHQ-2​) ( across their organization. Universal screening refers to screening the entire patient population without regard to individual risk factors (versus selective screening of  patient subgroups determined to be at risk). And to take it one step further, Rush Memorial Hospital has created a new Behavioral  and Mental Health Services Department that will employ seven various mental health professionals to provide the care and treatment of those patients with mental health related needs. These improvements to care were made during   Rush Memorial Hospital’s team participation in the IHA’s Small Rural Hospital Improvement Program’s Improving Practices Around Mental Health project, which is funded through the Indiana State Department of Health’s Office of Rural Health. For more information on how this was accomplished at Rush Memorial Hospital or about the SHIP projects, you can email Laurie Gerdt. ​

Improve Community Health & Equity

​​CDC Health Advisory: Acute Hepatitis in Children

Peds.jpgOn April 21, the CDC released a health advisory, Recommendations for Adenovirus Testing and Reporting of Children with Acute Hepatitis of Unknown Etiology in response to a cluster of children identified with hepatitis and adenovirus infection. The full CDC Health Alert Network summary is found here.  

For consultation or to report suspected cases to the Indiana Department of Health (IDOH) Epidemiology Resource Center, please contact Nicole Stone, Senior Enteric Epidemiologist, at 317-234-2898 or​.  

CDC Health Advisory: Avian Influenza A (H5N1)

Bird flu.jpgThe full CDC Health Alert Network summary for Highly Pathogenic Avian Influenza A(H5N1) Virus: Recommendations for Human Health Investigations and Response was released April 29 and is available here​. Recommendations include clinicians, state health departments, and public including recommendations for flock owners and worker protection.  

For a confirmed case who is hospitalized, facilities should follow standard contact and airborne precautions, which is higher level than seasonal infuenza. Questions regarding H5N1 should be directed to the IDOH Epidemiology Resource Center at 317-233-1325. 

2022 Indiana Asthma Summit

​​Asthma.jpgThe Indiana ​Asthma Coalition will be hosting a free virtual Asthma Summit on August 25 from 10am-2pm. This event will have a clinical track and a public track for all of those who are interested in learning how to reduce the burden of asthma in our state. Use the QR code below to register for the event.

Content conveyed at, or in conjunction with, this event does not constitute the opinion or views of IHA.​

Events & Webinars

​​​​NHSN.jpgChanges Coming in May to Vaccination Data Reporting

What are the main changes?  


  1. COVID-19 vaccination data will no longer be reported by vaccine manufacturer for questions on primary vaccine series and additional/booster doses.  
  2. Questions on vaccine supply will be removed.  
  3. Completing a monthly reporting plan for the COVID-19 Vaccination Module in the Healthcare Personnel Safety Component will no longer be required. Instead, upon saving or uploading data, users will agree to the following:  
    • The data reported are consistent with definitions outlined in NHSN surveillance protocols (including tables of instructions and frequently asked questions).  
    • ​The data will be sent to the Centers for Medicare & Medicaid Services (CMS) to fulfill CMS quality reporting requirements (when applicable).


    4. Adding a question for facilities to report the cumulative number of individuals who are up to date with COVID-19 vaccination.  


How should I prepare?  

Facilities should develop or update data tracking mechanisms to collect weekly COVID-19 vaccination data on healthcare personnel for the additional questions. 

Tip: Using the event-level COVID-19 vaccination form (coming soon!) in NHSN can simplify the tracking and reporting of data on multiple booster doses and up to date vaccination status.  

How can I learn more?  

CDC will conduct a training webinar to review these changes for the Healthcare Personnel Safety Component on May 25 at 2 p.m. ET  ​  

Facilities can register for this webinar using this link:  
​After registering, you will receive a confirmation e-mail containing information about joining the webinar.  
If you have questions, please send an e-mail to with ‘COVID-19 Vaccination Data Reporting’ in the subject line. 



Patient Safety Newsletter - April 2022

​​IHA Provides Tools to Promote Workforce Wellbeing​


Prevent Patient Harm

​​Pediatric Sepsis Week April 17 - 23

Peds.jpgDid you know that sepsis affects 75,000 children every year in the U.S. alone? 6,800 of these children die, more than from pediatric cancers.​​

In tandem with Pediatric Sepsis Week, Sepsis Alliance is sharing educational activities and resources to support health care providers in diagnosing and treating sepsis in the pediatric population, as well as information about life after sepsis in young children. 

Live Webinar - Register Here​
1.20 RN CE Contact Hours Available
After the Hospital: Longer-Term Impacts of Pediatric Sepsis 
Wednesday, April 20 
2 – 3 p.m. ET 

Speaker: Erin Fitzgerald Carlton, MD 
Clinical Assistant Professor, University of Michigan​

Improve Community Health & Equity​

​​IDOH and SORH Seek Nominations for Critical Access Hospital Awards​

Award.jpgThe Indiana Department of Health (IDOH), State Office of Rural Health (SORH), continues to aspire to honor the Indiana Critical Access Hospitals (CAH) for their performance and acknowledge the best of the best! The IDOH SORH acknowledges and greatly appreciates the hard work and dedication of each CAH. These esteemed awards are provided annually to honor those who have made notable contributions to the health care delivery systems in rural Indiana.

Please see the award nomination form for the details of each category. We encourage innovative applications, such as developing a short video clip to provide the nomination details. The deadline for nominations is 5 p.m. ET on Friday, July 1. Nominations should be submitted to David Conrad​, FLEX Coordinator. For questions, please contact David by email or by phone at 317.234.2885. Awards will be presented during the Fall CAH Convening meeting, currently anticipated for October 2022.

​​​National Organization of SORH Community Star Award​

star.jpgThe National Organization of State Office of Rural Health offers an opportunity for rural communities from each state to nominate their ‘Community Star’; those who are making a difference and positively impacting their communities in several vital health-related areas.

Please see the award nomination document for the Community Star award eligibility. Nominations should be submitted to Joyce Fillenwarth​, State Office of Rural Health Manager. The deadline is also 5 p.m. ET on Friday, July 1. For questions, please contact Joyce by email or by phone at 317-450-9953.

QPR Instructors Certified in Suicide Prevention Training​

Zoom.pngOn March 10, IHA’s Small Hospital Improvement Program (SHIP) hosted a Question, Persuade, Refer (QPR) Instructor course for hospitals participating in the SHIP project. Led by Master Instructor Whitney Nixon, 12 individuals representing six hospitals received their certification as QPR Instructors. They are now able to teach the QPR suicide prevention training to their communities and organizational staff. Thank you for being agents of hope!  Those receiving certification are:

  • Amanda King, Cameron Memorial Hospital 

  • Ryan Sheets, Cameron Memorial Hospital 

  • Kara Moyer, Deaconess Gibson Hospital 

  • Natalie Teeters, Deaconess Gibson Hospital 

  • Brad Law, IU Health, Frankfort Hospital 

  • Gail Poe, IU Health Frankfort Hospital 

  • Cherish German, Parkview LaGrange Hospital 

  • Jayme Bley, Parkview LaGrange Hospital 

  • Tara Speicher, Parkview LaGrange Hospital 

  • Drew Hahn, Rush Memorial Hospital 

  • Lisa Field, Woodlawn Hospital 

  • Becky Royer, IHA consultant ​

​Lead A Culture of Safety

​A Just Culture is Needed in Health Care 

Court.jpgIHA has been closely watching and discussing the recent trial of RaDonda Vaught, a nurse who was charged and convicted of two felonies following a drug error at Vanderbilt University Medical Center, and we want to acknowledge its impact on the health care industry. 

We understand the trial has likely been a topic of discussion among your teams who continue to function in challenging environments heightened by the pandemic response.  For some, the case has increased concern regarding professional practice and liability. Kaiser Health News has covered various reactions found here.  We encourage you to engage all staff and reinforce your commitment to always maintaining a culture of patient safety. Emphasizing the importance of reporting medical errors and near misses supports a just culture.​​   

For more background on the trial, the Institute for Healthcare Improvement’s recent Community Roundtable, “Responding to Medical Errors with Care, Not Criminalization,” is now available to view here. The slides are available here as well, and slides 21-22 include several recommendations rooted in the concept of just culture. 

We also wanted to take a moment to emphasize IHA’s current support and services.  IHA’s Quality & Patient Safety Team is available to aid your teams in conducting the AHRQ Culture of Patient Safety Surveys.  Insights gleaned from survey analysis may identify opportunities around hesitancy to report medical errors and near misses.  To learn more about the process to administer a survey, please contact Madeline Wilson​.  

Going forward, IHA intends to convene leaders from the Council on Quality and Patient Safety, as well as leaders in compliance and risk management, to determine how IHA can best support our members.  Finally, should you receive media inquiries regarding this case, the AHA statement can be found here.   

Events & Webinars

​​​Get to Know the New Indiana 211​

211-logo-square.jpgIndiana 211 is a free service that connects Hoosiers with help and answers from thousands of health and human service agencies and resources right in their local communities - quickly, easily, and confidentially.

Join IHA for a members-only webinar on Tuesday, May 3,  3 p.m. ET. Register here​. 

Target Audience:  ALL disciplines that work with and refer patients to resources, including those that address social determinants of health.

Learn more about Indiana 211 here.




SHIP Newsletter - March 2022

​​​​Patient and Family Experience - Patient Stories Matter!

Story.jpgStories have been used since the beginning of time and are used​ to pass along knowledge and share meaning from life experien​ces. The SHIP Patient and Family Experience teams are focused on developing powerful patient stories that bring vision to the patient and family experience and motivate others toward implementing improvement activities to transform care at the hospital. Patient stories provide valuable insights that go way beyond data. Stories inspire, humanize, and spark the passion to ensure improvement opportunities are maximized. The Cohort is working with Tanya Lord, Director, Patient and family Engagement at the Foundation for Health Communities and subject matter expert. Tanya provided the guidance in developing an impactful story.​​​​

​​​​​Reminder: SHIP 2021-2022 Stipend Expenditures

dollar.jpgFor those projects that have an allowable $2000 stipend, these dollars must be spent and turned in to Laurie Gerdt for reimbursement by May 1, 2022. Included projects are:  Improving Practices Around Mental Health, Patient and Family Experience, and the Special Innovation Project.  ​

​​​Improving Practices Around Mental Health

ProQOL.jpgImproving practices around mental health includes improving practices around taking care of our own staff. Woodlawn Hospital has made employee mental health and well-being a priority. From increasing marketing of their employee assistance program to distributing the Professional Quality of Life survey, Woodlawn has increased their efforts and improved practices around the mental health of their staff.​

Special Innovation Project

AHA Rural Conf.jpgKaren Bartrom, director of clinical integration & documentation, from Cameron Memorial Community Hospital and Madeline Wilson, quality & patient safety advisor, from the Indiana Hospital Association co-presented during the American Hospital Association’s 2022 Rural Health Care Leadership Conference on Feb. 9 in Phoenix. The session, Eliminating Health Disparities in Your Community through Z Codes, described a journey of improving health equity, which has always been a component of quality work; however, has been illuminated further by COVID-19.

​Using Simulation to Promote Patient Safety​

Decatur Co.jpgThe Rural Health Innovation Center met with leadership from Decatur Memorial Hospital and developed a specialized training and evaluation event for their clinical team. This event would center around an unannounced simulation that would start in the hospital’s Emergency Department and transition to the Obstetrical Unit and Nursery and would focus on the use of high-fidelity simulation-based methodologies for both evaluating and educating the staff. The simulation lasted for close to 50 minutes and included health professionals from Nursing, Medicine, Respiratory Therapy, Administration, and Quality and Safety. After completing the simulation, the clinical team was asked to come together for post-simulation debriefing in an adjacent conference area. 

The debriefing session was nothing short of remarkable. the staff described that the simulation provided a means of dealing with their emotional turmoil from a real-life event and that the post-simulation debriefing allowed for some emotional catharsis. In addition, the clinical team and leadership from the hospital were able to identify over 30 areas where they felt they had an opportunity for improvement!

​Maximizing Reimbursement in the Outpatient Setting​

RHC conf.jpgOn March 3rd, over 50 attendees participated in a half day rural health clinic training. Topics addressed included:  preparing for a rural health clinic site review with Kate Hill from The Compliance Team, preparing for the Indiana state rural health clinic visits with Bridget Boston of the Indiana Department of Health, and maintaining your HPSA/MUA designation and provider recruitment opportunities with Lacy Foy of the Indiana Department of Health. For access to the recordings, please email Laurie Gerdt​.

Upcoming events.gif

​The Indiana Critical Access Hospital (CAH) Convening 

CAH.jpgThe Indiana Critical Access Hospital (CAH) convening is on Thursday, April 28 from 9:30 a.m. – 3:15 p.m. ET, sponsored by: The Indiana Department of Health (IDOH) State Office of Rural Health, IDOH Epidemiology Resource Center, Indiana Hospital Association, Indiana Rural Health Association, Qsource.

Given the public health emergency challenges around health, safety, and workforce issues, the CAH Convening meeting will be virtual. Please register no later than April 21 via this link:

​Indiana Rural Health Conference​

IRH Conf.jpgIRHA's premier event will once again be held in French Lick, Indiana on June 14 and 15. Exhibitor and attendee registration is open now. Exhibitor space fills up quickly, so please register soon to reserve your spot! Hotel reservations can also be made now.

Find all of the information you need here:

Patient Safety Newsletter - March 2022

​​​IHA Releases Patient Safety Awareness Toolkit PSAW Video.jpg​​​​​​​​​​​​​

IHA Releases Patient Safety Awareness Toolkit ​​​​​​​​​​​​​
As we welcome the spring season, our team is encouraged by the promise of renewal that accompanies. As our members continue to walk through and emerge from the cloud of the COVID pandemic, we pause to celebrate the many lessons learned and resulting growth. Cultivating new relationships and strengthening existing partnerships is the foundation whereby all blossom and flourish. 

Each year, Patient Safety Awareness Week is recognized however we know that patient safety is a 24/7/365 priority for our members. To support, IHA has released the 2022 Patient Safety Awareness Toolkit. This resource stresses that patient safety is a team sport, and all voices are needed as we march toward a healthier Indiana. The toolkit addresses many topics and includes resource and communication tools which include social media messaging and images.  

We are inspired by you all! Please share your patient safety awareness activities with our team by sending a description and photos to Casey Hutchens

Prevent Patient Harm​

​​​AHRQ Celebrates Patient Safety Awareness Week 

AHRQ.jpgIn recognition of Patient Safety Awareness Week 2022, AHRQ and colleagues from the U.S. Department of Health and Human Services, the Health Resources and Services Administration, and the Institute for Healthcare Improvement are collaborating to observe Patient Safety Awareness Week.  Jeff Brady, M.D., M.P.H., Director of the Center for Quality Improvement and Patient Safety, welcomes participants to Patient Safety Awareness Week 2022. 

​Improve Community Health​

Together We Will Mini-Grants Available 

equity.jpgThe Indiana Department of Health (IDOH) has received funding from the Centers for Disease Control and Prevention (CDC) to help reduce the burden of the COVID-19 pandemic among racial and ethnic populations that have been disproportionately affected. As part of this effort, IDOH is implementing through its Office of Minority Health Together We Will, a grant program investing over $5 million during 2021 – 2023 in community initiatives that address health inequities for disparate and marginalized populations of color and indigenous people. Applications for the Together We Will grant program will be accepted by the Office of Minority Health on a rolling basis, with awards ranging in amounts from $1,000 to $75,000. 

Together We Will is a mini-grants and technical assistance program focused on funding community projects impacting eight (8) public health priority areas of infant & maternal mortality, environmental justice, substance use disorder, mental health, COVID-19 hesitancy, access, violence, and structural & systemic barriers. 

Starting December 2021 through June 2023, $5 million dollars is available to fund community driven projects. The application process is a rolling process; applications will be accepted until funding is exhausted or by close of program on June 30, 2023. 

Each project must be completed within 12 months. Interested applicants should review the How To Apply section of the website for further details. ​

Rural Clinic Opens After Disaster 

Rural Clinic.jpgThe impact of natural disasters can have long-lasting and unforeseen consequences. Unfortunately, the community of Brook, IN understands these effects firsthand. After a flood left Franciscan Health Rensselaer’s certified rural health clinic unusable, leaving the community of Brook with nowhere to go for health care, the rebuilding process began. The Rural Health Clinic team at the hospital moved and found an interim site at the hospital. In working with IHA’s Small Rural Hospital Improvement Project consultant, Elizabeth Burrows, they were able to set up a new shop that meets regulations and accreditations where Brook​ patients can now go for local health care. To learn more about meeting regulation standards click Preparing for the Indiana Sate RHC Visits – Bridget Boston, Area Supervisor in Home & Community Based Care. ​


Critical Access Hospitals Certify Staff to Provide Suicide Prevention Training 

Suicide awareness.jpgThe fundamental premise of Question, Persuade, Refer's (QPR) effectiveness is based on the belief, and growing research, that those most at-risk for suicide do not self-refer. To locate these individuals, identify their suicidal communications and get them to needed services is at the heart of the QPR approach to suicide prevention. Cameron Memorial Hospital, Deaconess Gibson Hospital, IU Health Frankfort Hospital, Parkview LaGrange Hospital, Rush Memorial Hospital, and Woodlawn Hospital had staff participate in QPR’s Instructor training so that these individuals can train staff and community members in QPR. QPR increases awareness and competence in having discussions around mental health and suicide prevention. Mental health is health! ​

​Events & Webinars

​2022 NHSN Training​

NHSN.jpgReistration is open for the 2022 National Heistration is open for the 2022 National Healthcare Safety Network (NHSN) Virtual training event hosted by the Centers for Disease Control and Prevention (CDC)  

The virtual training will be held March 22 – 24. Training details are available within the Agenda and you may register here​.


Join the Critical Access Hospital Convening Meeting  

CAH.jpgAll Indiana critical access hospitals (CAH) are invited to join the next CAH convening meeting on Thursday, April 28, from 9:30 a.m. – 3:15 p.m. ET.  This meeting is being hosted virtually in collaboration with the following organizations: 

-The Indiana Department of Health (IDOH) State Office of Rural Health 
-IDOH Epidemiology Resource Center 
-Indiana Hospital Association  
-Indiana Rural Health Association

The primary target audience includes senior leadership, quality leaders, and management leaders. 

The agenda​​ has a variety of topics that will be of interest.  Please share the agenda with others, particularly information technology teams, human resources professionals, and infection preventionists. If you or other staff members are interested in just one session during the day, please register and feel free to join for the individual session. There is no limit to the number of hospital attendees. 

Below is an overview of the agenda:  
  • Key Indiana Department of Health Updates and Agency Initiatives 
    • Pam Pontones, Deputy Health Commissioner and State Epidemiologist, Indiana Department of Health 
  • Recruitment and Retention: Utilizing Federal and State Loan Repayment Programs 
    • Lacy Foy, Office of Primary Care Manager, Division of Chronic Disease, Primary Care and Rural Health, Indiana Department of Health 
  • Increasing Access to Care Through Community Paramedicine – The Future of EMS 
    • ​Brittany Fortinberry, Mobile Integrated Health Coordinator, Office of the State Fire Marshal, Indiana Department of Homeland Security 
    • Shane Hardwick, Community Paramedic, Indianapolis Emergency Medical Service  
    • Nathaniel Metz, Phoenix Paramedics 
    • Jason Padgett, Phoenix Paramedics 
    • Paul Miller, Division Chief of EMS, Crawfordsville Fire Department  
  • Cyber Security Trends and Risk Assessment – Protecting Your Hospital and Patients 
    • Jim Boyer, Chief Information Officer at Rush Memorial Hospital 
    • Mark Hicks, Manager – Virtualization and Software Infrastructure, CISSP, VCA, MCP, NSE4, WD-CIDE at Van Ausdall & Farrar  
  • The Telehealth Journey – What you need to know! 
    • Cameron Hilt, Project Director for the Indiana Rural Health and manages the Upper Midwest Telehealth Resource Center 
    • John Henry, Vice President, Client Services at Access Physicians, a Division of SOC Telemed 
Please register here​​ no later than April 21.


Patient Safety Newsletter - February 2022

Bartrom​​ and Wilson Present at AHA Conference

Z code.jpg​​Karen Bartrom, director of clinical integration & documentation, from Cameron Memorial Community Hospital and Madeline Wilson, quality & patient safety advisor, from the Indiana Hospital Association co-presented during the American Hospital Association’s 2022 Rural Health Care Leadership Conference on Feb. 9 in Phoenix. The session, Eliminating Health Disparities in Your Community through Z Codes, described a journey of improving health equity, which has always been a component of quality work; however, has been illuminated further by COVD-19. Bartom shared how Cameron Memorial Hospital was able to develop a program to address these societal factors through IHA’s special innovation project (SIP), which is funded through the Health Research & Services Administration’s Small Rural Hospital Improvement Grant Program (SHIP) and Indiana’s Office of Rural Health. Both presenters gave valuable insights on how to leverage partnerships and cross-sector collaboratives to advance health equity through the understanding of history and future expectations of CMS and acquire strategies to engage leaders in support of health equity activities and multidisciplinary team participation. The presentation provided resources about how to identify a system baseline for social determinants of health through Z code tracking. Additionally, Bartom and Wilson helped the audience understand why processes that impact hospital performance and support reducing health inequalities in local communities by targeting specific Z codes are important.  ​

​Prevent Patient Harm​

Guidance on Transfer Patients with Candida auris 

chart.jpgThe Indiana Department of Health has created a Candida auris guidance sheet to address questions about placement of patients with clinical and colonized C. auris to de-mystify this condition and to reduce hesitancy among facility regarding accepting these individuals. 

CMS Vaccine Mandate for Health Facilities​

Vax.pngAs a reminder, on Jan. 14, CMS issued QSO 22-09 and Attachment D regarding hospitals to provide guidance on compliance with the CMS Interim Final Rule (IFR) following the U.S. Supreme Court’s reinstatement of the rule for Indiana and other states. QSO 22-09 and Attachment D specifically apply to Indiana, and with the first compliance date approaching we wanted to provide a reminder that QSO 22-09 states health facilities will be in compliance with the CMS IFR if:  

  • Within 30 days after issuance of the memorandum (Feb. 14, 2022) a facility demonstrates that:  
    • Policies and procedures are developed and implemented for ensuring all facility staff, regardless of clinical responsibility or patient or resident contact are vaccinated for COVID-19; and 
    • ​​100% of staff have received at least one dose of COVID-19 vaccine, or have a pending request for, or have been granted qualifying exemption, or identified as having a temporary delay as recommended by the CDC. 
  • Within 60 days after the issuance of the memorandum (Mar. 15, 2022) the facility demonstrates that:  
    • ​100% of staff have received the necessary doses to complete the vaccine series (i.e., one dose of a single-dose vaccine or all doses of a multiple-dose vaccine series), or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the CDC.  
​QSO 22-09 and Attachment D also outline instances of non-compliance and the thresholds for not being subjected to enforcement action if compliance is not demonstrated by the above timelines. Surveyors will begin surveying for compliance 30 days after the issuance of the memorandum. Attachment D includes important information on how compliance with the CMS IFR will be surveyed in particular.  
 An overview of the CMS IFR from our partners at Hall Render can be found here​

​​Improve Community Health

​​2022 INspire Letter of Intent Due 

INspire Roadmap.jpgThe deadline to submit a letter of intent for the 2022 INspire Hospital of Distinction Recognition Program was Feb. 11. If your hospital has not submitted its intent, please reach out immediately to Brittany Waggoner​. The IHA partners with hospitals to create a highly reliable health care system for mothers and infants throughout the state of Indiana. In 2020, IHA launched the inaugural INspire recognition for Indiana birthing hospitals to voluntarily pursue a recognition program.

Indiana Extends Public Health Emergency Through Mar. 4 

Holcomb.pngGovernor Holcomb has issued Executive Order 22-01 to extend Indiana’s public health emergency declaration through March 4. Governor Holcomb also issued Executive Order 22-02​, continuing the provisions that allow for the COVID-19 Temporary Healthcare Provider Registry, the flexibilities for administering COVID-19 vaccinations, and the ability for APRNs to practice in multiple locations. 

IDOH Launches Grant Program to Address Health Issues ​​

Public Health.jpgOn Jan. 27, the Indiana Department of Health (IDOH) announced it is seeking applications for the Indiana Health Issues and Challenges Grant, a $50 million program established by the Indiana General Assembly to address health issues that impact Indiana.  
 These funds must be used to develop and implement services focused on improving health outcomes related to one or more of the following  areas: 

  • Chronic disease (diabetes, cardiovascular disease, asthma, and cancer); 
  • Tobacco use; 
  • Food insecurity/obesity; 
  • Elevated blood lead level reduction; or 
  • Disease prevention programs (community health workers/patient navigators and community paramedicine for chronic disease, immunizations, and substance use disorder).  
Each proposal must include:  

  • A proposed measurable and specific improvement in one or more critical health metrics within a defined cohort; 
  • A timeframe to achieve the proposed measurable improvement; 
  • A description of how the proposal will address/impact health equity; and 
  • An explanation of how the proposed activities will be sustained past the funding period.  
Applications are due by Mar. 31, and award notices will be issued by July 1. For more information, please click here​

Lead a Culture of Safety

​​IHA Launches 2022 Patient Safety Awareness Week Toolkit 

PSAW.jpgJoin IHA’s quality and patient safety team as we celebrate Patient Safety Awareness Week, March 13 - 19 by following and sharing our posts on Facebook and Twitter​, downloading our updated Patient Safety Awareness Toolkit available on our Patient Safety Awareness webpage​, and sending pictures of our Patient Safety Awareness Week activities to Casey Hutchens​

​IHA Quality and Patient Safety Survey Due Feb. 18 

PriorityFocus Survey_QR_code_MS7LGY7.pngTo better understand what the future educational and training needs are for our members, the IHA team is asking you to take a few minutes of your time to complete this brief survey. The purpose of the survey is to help us to plan IHA quality and patient safety educational and training programs in 2022. Learning more about your hospital’s priorities will allow us to plan accordingly.  

 There are three options for completing the survey: 
  1. You can access Survey Monkey using this link  
  2. You can use your phone by scanning the​ QR code 
  3. You can also complete and scan the survey and return it to Casey Hutches 
 We are seeking one response per hospital by Feb. 18. If you have already completed the survey, thank you. We look forward to hearing from as many IHA members as possible. 

​Events & Webinars

​​​Beryl Institutes Offers IHA Members Discounted Registration  

Elevate.jpgOver the last decade, The Beryl Institute has worked to establish a global community of practice on improving the patient experience and offers a variety of learning programs. March 28 – 30, the Institute is hosting its ELEVATE PX​ conference in Indianapolis. An in-person and virtual 20% registration discount is being offered to IHA members. ELEVATE PX is an interactive event connecting communities in learning, supporting, and sharing of ideas to positively impact the experience in healthcare organizations around the world. Use code Indiana_2022 to register. 

​IDOH Hosts 2022 World TB Day Event - Registration Open ​

TB day.jpgThe Indiana Department of Health is hosting a free educational forum focused on tuberculosis (TB) in Indiana. Featured topics included the FiberCell investigation, TB treatment regimen updates, cases at Camp Atterbury, TB in long-term care, IDOH lab updates, TB survivor stories, and an epidemiology update.  

Breakfast and lunch will be provided. Register here​ for the March 30 event. 

Information and materials conveyed at non-IHA hosted programs do not constitute the advice or opinion of IHA.   ​​​​​​​​​​​