Your Resource for HQIC Highlights and Learning Opportunities | May 2021
Preventing Healthcare-Associated Infections (HAIs)
HAIs remain a leading cause of patient harm in hospitals and experts agree that these events are preventable. To help combat these devastating harms, HSAG HQIC has worked with partners across the country to develop resources that focus on CDI, MRSA blood infections, CLABSI, CAUTI, VAE, and SSI.

Many of these resources use the CDC Targeted Assessment for Prevention (TAP) Strategy for HAI prevention. The TAP Strategy is an innovative approach that facilities can use to leverage the National Healthcare Safety Network (NHSN) to explore their HAI cases. The first step in the process is to use data to target specific departments with the most opportunity for improvement. 

The next step in the process is to assess the opportunities that could be contributing to increased incidence of HAI. HSAG HQIC has tools and resources that will help facilities explore these opportunities, and our experts will provide actionable insights on steps that can be taken to correct identified areas of concern.

The final component is to implement proven prevention strategies in the targeted areas to reduce the incidence of HAI. To learn more about the TAP Strategy and how to reduce HAIs within your facility, please see The Flash Resources section below, or reach out to your Quality Advisor.
The Flash: Resources
TAP Strategy: Using Data for Action
Use this simple handout to help your facility utilize the TAP Strategy and stay on target for HAI prevention and improvement. This handout includes links to CDC NHSN resources.
CDC: Strategies to Prevent CDI in Acute Care Facilities
This webpage provides an overview of CDI in acute care facilities with prevention strategies that hospitals can implement to reduce the incidence of CDI.
NHSN Acute Care Mapping and Leveraging the TAP Strategy—On-Demand Webinar Recording
Hear from CDC NHSN experts and discover how to leverage the TAP Strategy for your organization.

  • Utilize NHSN mapping guidance to determine appropriate unit acuity levels and make necessary changes within the application.
  • Analyze units within NHSN and identify those with the most opportunity for improvement.
  • Determine the cumulative attributable difference necessary to achieve goals.
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 IHI to establish a baseline for the culture of safety infrastructure in your hospital, 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 a online format with the incorporation of the Centers for Medicare & Medicaid Services (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. 
Events and Education
Culture of Safety Assessment Office Hours
Thursday, May 13 -and- May 27, 2021
2:00–2:30 p.m. ET (1:00 p.m. CT, 12 noon MT, 11:00 a.m. PT)

HSAG HQIC Quality Advisors are available to answer your Culture of Safety Assessment questions.
It Figures
The Secure Data Portal Is Live!
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 HAI data.
  • Web Portal Data Administrator Form: Complete and return. This form designates specific people (recommend a minimum of two) in your organization to access the QIIP to: view performance reports and dashboards, upload data, complete assessments, and manage users.
If you have questions or require assistance with this process, please contact the HSAG HQIC team at
  1. Clostridioides difficile infection (CDI), Methicillin-resistant Staphylococcus aureas (MRSA) blood infections, central-line associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), ventilator-associated event (VAE) and surgical site infection (SSI)
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-05042021-01