Your Resource for HQIC Highlights and Learning Opportunities | June 2021
Preventing Falls
Falls are the number one reported adverse event for adults in the inpatient setting. It is estimated that more than 700,000 to 1 million individuals fall each year in the hospital, and up to one-third of these falls are preventable.1 In older adults, aged 65 or greater, falls are the leading cause of injury-related death, non-fatal injuries, and hospital admissions for trauma.

Falls are associated with increased length of stay, increased healthcare utilization, poorer health outcomes, and increased costs.2 The Centers for Disease Control and Prevention (CDC) notes that about 2.8 million older adults are treated in emergency departments (EDs) each year for injuries caused by falling, and more than 800,000 are hospitalized because of the injury.

Use the tools below to help your organization's fall prevention program.
The Flash: Resources
HSAG HQIC Roadmap to Success: Falls With Injury
This document includes evidence-based tools and resources for each step of your hospital's fall-prevention journey, including instructions to:
  1. Create the right environment. Implement universal fall precautions and engage staff and patients.
  2. Determine a patient’s risk for falls using a standardized assessment tool.
  3. Use identified risk factors to implement your fall prevention program. Individualize the care plan by tailoring interventions to target patient-specific risk factors.
  4. Conduct post-fall management.
  5. Assess your progress. Aggregate and analyze the contributing factors on an ongoing basis.  
  6. Hardwire fall safety culture/patient and family engagement (PFE).
HSAG HQIC Zone Tools: Total Hip or Knee Replacement
These tools were created to assist patients in managing their condition after discharge.
To view all the Zone Tools for a variety of conditions, available in English and Spanish, go to
Fall TIPS (Tailoring Interventions for Patient Safety)
From the Fall TIPS Collaborative, this patient-centered, fall-prevention toolkit offers steps to ensure success with fall-prevention implementation, as well as hospital success stories.
CDC: STEADI (Stop Elderly Accidents, Deaths and Injuries) 
This fall-prevention toolkit offers clinical resources and training for healthcare providers, as well as patient and caregiver resource.
Emergency Preparedness
Thanks to your efforts and support at the federal, state, and local level, the rates of COVID-19 infection continue to decrease across the country. It remains vitally important that healthcare facilities maintain a heightened state of awareness regarding their pandemic response and general emergency preparedness efforts. These tools from our partners at the Centers for Medicare & Medicaid Services (CMS) and the Federal Emergency Management Agency (FEMA) will help to ensure that your facility evaluates its pandemic response efforts and implements improvement efforts based upon identified areas of opportunity.  
CMS Resources
These CMS resources detail the conditions of participation expectations regarding emergency preparedness.
FEMA Resources
This toolkit provides a standardized format for facilities to review and evaluate their emergency response plans.
Critical Communication
HSAG HQIC Culture of Safety and the IHI National Action Plan to Advance Patient Safety Assessment
The Culture of Safety Assessment was developed by the Institute for Healthcare Improvement (IHI) to establish a baseline for the culture of safety infrastructure in your hospital. Implementing a culture of safety program can simultaneously reduce all-cause harm, incorporate Safety Across the Board and High Reliability, measure progress in overall safety, and identify potential correlations between a culture of safety and harm reduction.

The Culture of Safety Assessment contains four sections:
  1. Culture, leadership, and governance
  2. Patient and family engagement (PFE)
  3. Workforce safety
  4. Learning systems

HSAG HQIC is providing the Culture of Safety Assessment in an online format with the incorporation of the CMS PFE five focus measures. A short, how-to video on navigating the Safety Assessment is available at the button below. To access and complete the Safety Assessment, click the online assessment button and use the de-identified username provided to you by your Quality Advisor. 
It Figures
The Secure Data Portal Is Live! Do You Know How to View Your Data?
Your Quality Advisor will reach out regarding dashboard orientation. Reminder: To view your data in the dashboard you should have completed the following:
  • Data Use Agreement: Review, sign, and return. This document provides permission for HSAG HQIC to access and use specified data to measure and track hospital performance, provide data feedback reports, and populate the HSAG HQIC Quality Improvement and Innovation Portal (QIIP) secure data portal.
  • NHSN Confer Rights: This document contains detailed instructions to join the HSAG HQIC group and give HSAG HQIC permission to view your hospital's healthcare-associated infection (HAI) data.
  • Web Portal Data Administrator Form: Complete and return. This form designates specific people in your organization to access the QIIP to: view performance reports and dashboards, upload data, complete assessments, and manage users.
For questions or assistance with this process, please contact the HSAG HQIC team at
Best Practice Briefs
Dignity Health, now part of CommonSpirit Health, is one of the nation’s largest health systems and operates one of the most extensive hospital-based telehealth networks, Dignity Health Telemedicine Network (DHTN). Through this program, the hospital system was able to address barriers in access to care for behavioral health in the ED, which led to long wait times for patients requiring psychiatric consults. Implementation of telehealth behavioral health services resulted in:
  • A reduction in bedside response time to under 50 minutes.
  • A decrease in the average case time for a patient.
  • A discharge recommendation rate of approximately 40 percent.
  • A new focus on the standardization of behavioral health.
  1. Currie L. Fall and Injury Prevention. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (U.S.); 2008 Apr. Chapter 10.
  2. Cameron ID, Murray GR, Gillespie LD, et al. (2018). Cochrane Database of Systematic Reviews. Interventions for preventing falls in older people in nursing care facilities and hospitals.
This material was prepared by Health Services Advisory Group (HSAG) 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. The contents presented do not necessarily reflect CMS policy. Publication No. XS-HQIC-XT-06032021-01