Your Resource for HQIC Highlights and Learning Opportunities | Feb. 2022
Cultivating Person/Patient and Family Engagement
Patients and families are valuable resources to the quality improvement process. Research shows that a commitment to person/patient and family engagement (PFE) contributes to a positive patient and family experience, as well as measurable improvements in quality and safety.1

PFE is a priority for the Centers for Medicare & Medicaid Services (CMS); in 2020 CMS released five updated PFE metrics for hospitals.2 These metrics challenge hospitals to develop a culture that incorporates patient and family input into care decision-making, with the ultimate goal of improving the patient/family experience and outcomes.3

While PFE is an important component to quality care, many hospitals have found it challenging to maintain robust PFE programs during the ongoing COVID-19 pandemic. Your HSAG HQIC team is dedicated to support your PFE efforts, even during these challenging times. Contact your quality advisor if you would like to develop, implement, and/or reactivate PFE strategies and interventions in your facility.
It Figures—Data and Performance
HSAG HQIC integrates PFE into strategies and interventions for each area of harm. HSAG HQIC also works with hospitals to integrate PFE activities into existing corporate patient and family advisory committees (PFACs) to ensure the needs of Medicare beneficiaries are incorporated into all interventions. The table below displays the percentage of reporting HSAG HQIC hospitals that have implemented each of the PFE metrics.
Source: HSAG HQIC Culture of Safety Survey Data. For additional details on measure specifications, please reference the HSAG HQIC Compendium of Measures.
The Flash: Resources
PFE Measures Checklist
To assist hospitals in meeting the PFE metrics, HSAG has put together a checklist for the five CMS PFE metrics and details on what components must be in place to be in compliance.
PFE—Hospital Coaching Package
The HSAG HQIC Hospital Coaching Package for PFE assists hospitals in achieving a shared vision of PFE and meeting the five PFE metrics. This package describes the five PFE metrics and includes an organizational assessment, tools, and resources for each metric.
PFAC Roadmap to Success
One component of PFE is to have a PFAC in place at your hospital. To assist hospitals with implementing a PFAC, HSAG HQIC has developed a roadmap to success, which provides a step-by-step process of how to implement and maintain a PFAC.
Critical Communication
CMS Quality Reporting Program Submission Due
NHSN analysis reports use data from the most recently completed annual survey. This is important to consider for the upcoming CMS Quality Reporting Program Submission of 2021 Q3 data, due February 15, 2022. Facilities that do not complete the 2021 annual survey prior to the deadline will have their data risk-adjusted using 2020 survey data.
Vaccine Monitoring—Accept Rights for New Template
CMS has incorporated healthcare personnel vaccination monitoring as part of the HQIC initiative. To reduce any duplicative reporting, since you are already a part of the HSAG HQIC NHSN Group ID 83573, you will simply have to accept the rights for the new template. 

When you log into the NHSN Healthcare Personnel Safety component for your facility, you will receive a message asking you to accept the new template. Simply scroll to the bottom of the template and click the “accept” button. For questions, email HSAG HQIC infection preventionists Eli DeLille or Geoff Granseth.
Health Equity Change Package
To align with the CMS focus of improving health equity, HSAG HQIC has designed a change package to assist your hospital in the journey to identifying and addressing disparities in care. This change package will be launched during a webinar on March 9, 2022. Part of the change package includes a health equity organizational assessment for HSAG HQIC hospitals to assist in identifying areas of focus around health equity. Your quality advisor will be in contact soon with more details.
Events and Education
KNOW Sepsis. Save a Life Today!
Thursday, February 24, 2022, 2–3 p.m. ET
Sepsis is a complicated condition. This webinar highlights an institutional sepsis response that is consistent, punctual, and organized for early detection and treatment.

  • Differentiate patient demographics to determine top contributors and give examples of right care, right time, right place.
  • Assess for systemic inflammatory response syndrome (SIRS) criteria.
  • Duplicate sepsis screening prior to discharge and recognize post-sepsis syndrome.

Kathy Madlem, BSN, RN
Santa Clara Valley Medical Center Sepsis Quality Improvement (QI) Coordinator
Continuing Education (CE): Health Services Advisory Group, Inc., is the CE provider for this event. Provider approved by the California Board of Registered Nursing, Provider Number 16578, for 1 contact hour. There is no charge to attend this event. You must attend the live event to earn CE credit.
Upcoming Education Quickinars
HSAG HQIC Quality and Safety Series
The Quality and Safety Series will assist your organization in its QI journey, from planning and preparation to sustaining gains.

The series, scheduled through July 2022, takes place the 2nd and 4th Tuesdays of the month. These 30-minute-or-less "quickinars" are bite-size learning presentations that review key QI skills necessary for you to function in the QI role or for other staff members who are participating in a QI initiative. Recordings from past presentations are available at:
Quality and Safety Series 13: Prioritization Matrix
Tuesday, February 8, 2022, 2–2:30 p.m. ET
Quality and Safety Series 14: Data Plan
Tuesday, February 22, 2022, 2–2:30 p.m. ET
NEW! HSAG Care Coordination Series
Join HSAG in an action-based quickinar series to provide tactics, strategies, and information needed for managing avoidable hospital readmissions.

The 11 quickinars are short, 30-minute webinar presentations that began in January and run through August 2022. They are offered on the 1st and 3rd Tuesdays of the month.
Session 2. Care Transitions Assessment Overview
Tuesday, February 1, 2:00–2:30 p.m. ET

Session 3. Care Coordination Gap Root-Cause Analysis
Tuesday, February 15, 2:00–2:30 p.m. ET

Session 4. Care Coordination Strategy Tree Development and Implementation
Tuesday, March 1, 2:00–2:30 p.m. ET
HSAG Opioid Stewardship Program
Join HSAG in an action-based quickinar series for information on implementing a successful opioid stewardship program.

The 11 opioid stewardship quickinars are short, 30-minute webinar presentations that began on October 21 and run through May 2022. Recordings from past presentations are available when you click the registration button.
Partnering With Pharmacists
Thursday, February 10, 2022, 1:30–2 p.m. ET
1. New York State (NYS) Health Foundation—Strategically Advancing PFACs in NYS Hospitals:
2. American Institute for Research®. PfP Strategic Vision Roadmap for Person and Family Engagement: Achieving the PFE Metrics to Improve Patient Safety and Health Equity. Available at: . Accessed on Sept. 2, 2021.
3. Centers for Medicare and Medicaid Services (CMS). Person and Family Engagement Strategy: Sharing with our Partners. Available at: . Accessed on Sept. 2, 2021.
This material was prepared by Health Services Advisory Group (HSAG), a Hospital Quality Improvement Contractor (HQIC) under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. Publication No XS-HQIC-XT-01312022-01