August 2023 | Issue 29


Centers for Medicare & Medicaid Services (CMS)

New Safety Guidance | Review CMS memo 

CMS released updated guidance for state surveyors assessing ligature risk in hospitals, which pertains to environmental safeguards for patients at risk of harm to self or others. The guidance clarifies that hospitals can demonstrate compliance with certain patient safety standards by conducting appropriate patient assessments, adequately staffing and monitoring units and mitigating environmental risks through risk assessments. 


CMS Memo Regarding Inconsistencies in Survey Processes | Review CMS memo

As many of you have inquired, The Joint Commission received a transmittal on June 16 from CMS,

which addresses changes to survey processes. CMS has asked all accrediting organizations to evaluate and change processes for pre-survey notifications, avoid dates and complaint investigations. These changes

would apply to all deemed programs (excluding Laboratory) and to all accreditors. 


CAH Revisions from CMS Review Go into Effect August 27 | Learn more

Effective this Sunday, Aug. 27, the Joint Commission is making several changes to the elements of

performance (EPs) for critical access hospitals (CAHs) to better align with CMS Conditions of Participation.


The Joint Commission Eliminates Additional Standards across all Accreditation Programs

Get the details

The Joint Commission recently announced it will eliminate and consolidate a second section of standards, following the first major reduction announced late last year. The more than 200 eliminated and

consolidated standards, also effective this Sunday, Aug. 27, will streamline requirements and make them

as efficient and impactful on patient safety and quality as possible. 


PATH Training Inspires Support among Non-hospital Service Units

The Partnership to Advance Tribal Health (PATH) can extend its training and resources beyond Indian Health Service (IHS) hospitals when it comes to improving patient safety and reporting.


Learn how one IHS Area Office used a discussion around a PATH training to support a non-hospital service unit.


Detecting Harm with Trigger Tools

Research shows only 10-20% of errors are ever reported in voluntary event reporting systems. Lack of reporting can be due to system culture, fear of blame or staff not knowing what should be reported. Trigger tools are an additional resource to identify harm in your facility and address safety concerns.  

Triggers are specific occurrences that signal the need for a more intensive record review to determine if harm occurred. Trigger tools are not standalone solutions. They are part of a comprehensive patient safety program. When harm is identified, the health care team can take appropriate actions to improve patient safety and quality and prevent harm. 

Various types of trigger tools are available from The Institute for Healthcare Improvement (IHI), including the IHI Global Trigger Tool for Measuring Adverse Events. These tools are used to enhance measurement of the overall level of harm within an organization. 

Follow these steps to implement trigger tools: 

  1. Determine the type of trigger tools to use (general, specialty or location-specific). 
  2. Review records and gather data according to trigger tool criteria and instructions.  
  3. When a trigger is identified, a multidisciplinary team should review the record to confirm an event occurred. Once an event is confirmed, conduct a root-cause analysis (RCA) to determine reasons for the event. 
  4. Develop and implement strategies to address the identified safety concerns and prevent future occurrences.  
  5. Provide ongoing education and training to health care staff regarding patient safety best practices, the use of trigger tools and the importance of reporting safety events and concerns.  
  6. Continuously measure and monitor the effectiveness of the implemented corrective actions. 
  7. Foster a culture of safety, which includes open communication, non-punitive reporting of safety concerns, and a focus on continuous improvement. 
  8. Collaborate with other health care institutions and organizations to share best practices and lessons learned in using trigger tools effectively for patient safety. 




IHS Opioid Surveillance Dashboard Office Hours | Register Now

Every third Wednesday September through November

2-3 PM ET | 1-2 PM CT | 1-12 PM MT | 11 AM-12 PM PT

Join the IHS National Committee on Heroin Opioids and Pain Efforts (HOPE Committee) and PATH for open office hours sessions on the use of IHS Opioid Surveillance Dashboards (OSD). This call will support IHS users of the IHS OSD through

  • discussing dashboard functionality and use cases;
  • responding to dashboard questions;
  • providing a forum to discuss requests, recommendations or enhancements;
  • highlighting techniques to get the most out of this dashboard.

(This event is free and open to IHS staff only.

Registration is required to receive the call-in information.)

Understanding Indigenous Drivers of Health

PATH and IHS leaders, Dr. Phillipe Champagne, MD, MPH, IHS Physician Senior Advisor, and CAPT Jana Towne, RN, BSN, MHS, Director, IHS Office of Quality (Acting), hosted a timely event last month. The session highlighted The Joint Commission (TJC) requirements to reduce health care disparities, provided guidance on implementing a health equity program, shared creative ways to use electronic medical records (EMRs) to assess and document social drivers of heath and more. If you missed the session or would like a refresher, you can listen to the event recording and view the Indigenous Drivers of Health PowerPoint slides.


Check out these resources:

Did You Know?

We know life happens, and though you may have wanted to attend a live event, a time conflict or any other many possible reasons kept you from it. Many of our past event recordings, key takeaways, flyers and resources can be found on our event page on our website. 


Please feel free to check out our PATH Events page if you missed an event or would like a refresher. While you are there, check out some of our other postings and materials available to you.


AHRQ Releases TeamSTEPPS 3.0 Training Curriculum

to Improve Safety

The Agency for Healthcare Research and Quality (AHRQ) updated its TeamSTEPPS® training program, an evidence-based resource designed to improve patient safety by optimizing the performance of health care teams. The update incorporated consultation with experts, patients and family caregivers and addresses changes in health care delivery and learning methods, emphasizing patient engagement. It also allows for virtual training. Explore the TeamSTEPPS 3.0 curriculum.

New NIHCM Infographics on Combination Drug Use Overdoses

Earlier this week, the National Institute for Health Care Management (NIHCM) released excellent infographics on the Latest Data: Combination Drug Use Increases Overdoses. Data are provided by the Centers for Disease Control and Prevention (CDC).

The majority of methamphetamine and cocaine deaths involve a synthetic opioid. Deaths involving opioids and meth are highest among American Indians or Alaska Natives.


Yet another reason to provide your community with naloxone access and training.


HOPE and PATH have developed several tools and resources for you to use. Access them on the IHS website:

HOPE and PATH offer many more resources on this critical issue. Please reach out to us for tailored tools and trainings at

Chapter 3-33: Infection Control and Prevention

IHS is very pleased to announce the agency published IHM Chapter 3-33, Infection Control and Prevention. This marks an important step in standardizing infection control and prevention (ICP) programs agency-wide to meet nationally recognized standards and ensure the health and safety of our patients. This chapter establishes the program policies, procedures and responsibilities required for ensuring a comprehensive ICP program exists in all IHS health care facilities and service units.


Sepsis Awareness Month

Anyone can get an infection that can lead to sepsis. In fact, sepsis kills more than 350,000 people

every year, but only about 65% of people have know the term. That is why it is important for

all community members, not just health care professionals, to know what sepsis is and recognize symptoms. September is Sepsis Awareness Month. Here are a variety of tools to make sure

both your community and your staff know about sepsis and its life-threatening risks.

Community awareness:

Staff awareness:

  • Check staff knowledge for Sepsis Awareness Month by sharing these quizzes with your staff via email: CDC sepsis e-quiz and/or Sepsis Alliance quiz.
  • Have you implemented a "code sepsis" protocol? Code sepsis saves lives and improves bundle adherence. According to the results of a study published in the American Journal of Emergency Medicine, rapid deployment of a Code Sepsis Response Team significantly increased adherence to the SEP-1 bundle, improved times to empiric antimicrobial therapy, time to effective antimicrobial therapy and decreased mortality.
  • Several patient demographics have been associated with readmissions among sepsis survivors, including American Indian/Alaska Natives, low-income and Medicare or Medicaid beneficiaries. Be sure to review your sepsis survivors for readmission risk. Learn more with this study: Readmissions among Sepsis Survivors: Risk Factors and Preventions


National Suicide Prevention Month/Week (Sept. 10-16)

As a leading cause of death in the U.S., suicide is a public health issue that claims thousands of lives every year. It is always important to raise awareness about suicide prevention and remove stigma, but September offers the opportunity to shine a light of hope with community awareness and education. Here are some suicide prevention resources for Native American/Alaska Natives:

Other resources:


This material was prepared by Comagine Health for the American Indian Alaska Native Healthcare Quality Initiative under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. 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. NQIIC-AIHQI-413-08/21/2023