July 2023 | Issue 28


Community Health Resource Guide Template

Has your facility addressed health care disparities as a quality and safety priority? Effective July 1, The Joint Commission (TJC) elevated the standard addressing health care disparities to a new National Patient Safety Goal (NPSG) – NPSG #16. Putting a standard as a NPSG means it is always surveyed during an accreditation visit. 

Here is a report from TJC with all of the information: r3-report_npsg_16.pdf (jointcommission.org)

The second element of performance in NPSG #16 outlines important, health-related social needs (HRSNs) to assess and document. It also speaks to providing information about community resources and support services. The Partnership to Advance Tribal Health (PATH) team has created a generic community resource guide (CRG) template you can use to build a comprehensive guide to use across your organization. Please reach out to your PATH quality improvement advisor for support in creating or improving your CRG.

Advance Care Planning Scripting Resources

Talking with patients about advance care planning promotes patient-centered care by ensuring

patients’ personal preferences and wishes are met. This one-page handout provides tools for

proactively discussing advance care planning with patients.

PATH Partnership with IHS HOPE Committee Featured Nationally

Earlier this month, the Centers for Medicare & Medicaid Services (CMS) highlighted an article about how PATH and the Indian Health Service (IHS) National Committee on Heroin Opioids and Pain Efforts (HOPE Committee) are working together to amplify our reach and impact on opioid use disorder in Tribal communities.

  • Read the article to learn more about the tools and resources this collaboration has developed.
  • Learn more about the IHS HOPE Committee.


Collaboration and Discussion Advance a Solution

for a Long-Standing Social Driver of Health

Transportation proves to be a critical social driver in many communities, having a substantial impact on people’s ability to access physical and mental health care and other essential services. This fact has been proven true in one of our partnering Tribal communities.

Learn how PATH QIAs helped facilitate a bigger discussion to collaboratively uncover a solution with different associated entities.


Identifying and Reducing All-Cause Harm

What is all-cause harm?

Adverse events are also called all-cause harm. The Office of Inspector General (OIG) defines all-cause harm as patient harm, regardless of preventability or cause. All-cause harm is a composite or sum of harms from patient care. According to an OIG report, adverse events in hospitals lead to more than a quarter of Medicare patients experiencing harms.

What is all-cause harm's effect on IHS facilities?

A recent OIG report on the Incidence of Adverse Events in IHS found that 13% of patients in IHS facilities experienced harm.

Most of the harm was reported in smaller hospitals (19%), while larger hospitals accounted for 9% of harm cases. Patient harms were more prevalent in older adults (30%) and labor and delivery patients (21%). Medication-related events were the most common, representing more than half of the events.

What are all-cause harm measures?

The all-cause harm measures assess the patient safety indicators that may be preventable complications during a patient’s procedure or hospital stay. These measures are divided into categories such as healthcare-associated infection, medication-related, patient care related, surgery care related and perinatal harm. Additionally, the Centers for Medicaid & Medicaid Services (CMS) monitors this list of Patient Safety Indicators (PSI).


PATH provides technical assistance and support for the identification and reduction of all-cause harm, with a specific focus on the following:

  • Healthcare-associated adverse drug events for anticoagulants
  • Hypoglycemic agents and opioids
  • Catheter-associated urinary tract infections
  • Central line infections
  • Clostridioides difficile (C. diff) infections
  • Methicillin-resistant Staphylococcus aureus (MRSA)
  • Pressure ulcers
  • Sepsis mortality and sepsis shock

How is all-cause harm measured?

All-cause harm is measured nationally by CMS for Medicare recipients from specified hospital claims diagnoses and procedure codes. Infection data is submitted by hospitals to the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN). Additionally, health care facilities and other providers measure and report harm internally and externally (e.g., insurance health plans, hospital associations, patient safety organizations).

How can patient harm be detected and prevented?

Internally, facilities use incident reporting systems, trigger tools and diagnosis and procedure code reports to identify and record harm. OIG has recommended that IHS prioritize patient harm monitoring and reduction.


Strategies for reducing and identifying harm:

Risk and harm reduction and prevention must be an intentional and ongoing effort. Check out these ways to reduce patient harm:

  • Create checklists to offload repetitious tasks performed in a sequence
  • Share learning and improvements from harm events
  • Incorporate evidenced-based and promising practices
  • Examine electronic health record (EHR)- and Resource and Patient Management System (RPMS)-automated reports and chart reviews
  • Review of self-reported data (ISTAR, complaints grievances, survey, tracer results)
  • Conduct debriefings to analyze events and maximize quality improvement
  • Conduct daily huddles, rounding by staff and shift change handoff between nurses
  • Use quality improvement tools (e.g., failure mode and effects analysis [FMEA], root cause analysis [RCA], plan-do-study-act [PDSA], fishbone diagram) to identify and improve system issues


Health care workers need to have a strong understanding of all-cause harm to improve patient care and safety. Ask yourself these three important questions regarding all-cause harm:

  1. Do you know how your facility defines harm?
  2. What education does your staff receive on what constitutes an event that should be reported?
  3. What other methods does your facility use to detect harm?


  • OIG Clinical Guidance for Identifying Harm - The adverse event toolkits are technical resources to assist the health care community, government agencies and researchers in identifying and measuring adverse events in hospitals or other inpatient settings
  • Preemptive & Proactive: Anticipating and Addressing Risk to Prevent Patient Harm - PATH hosted a six-session huddle series to support health care teams in their efforts to provide safe and high-quality care. The sessions covered various harm topics, including healthcare-associated infections (HAIs), sepsis, hospital-acquired pressure injuries, vaccination administration mistakes and ensuring the safe usage of prescription medications. Please view the recordings and key takeaways for each session.
  • Preventing Healthcare Associated Infections - The CDC provides infection control assessment tools, prevention toolkits, information on protecting health care personnel and more.
  • Project Firstline: Infection Control Training - CDC’s Project Firstline is a collaborative of diverse health care and public health partners that aims to provide engaging, innovative and effective infection control training for millions of frontline health care workers and members of the public health workforce.

Stay tuned next month as we further explore the use of trigger tools.


Have you listened to PATH new audiocast Candid Conversations?

View audiocast resource page | Listen to Episode 1  

PATH is excited to introduce its first audiocast series Candid Conversations. Throughout the series, the host and special guest co-hosts will share real-life examples and challenges experienced by both patients and staff in emergency care settings. Get answers and learn about important topics, including two-way communication between patient and care team, reasons why patients may leave the emergency department (ED) before seeing a provider, the importance of timely provider follow-up phone calls after ED visits and more!

In episode one, our expert hosts reflect on the patient’s decision to leave the ED before being seen by a provider and offer views and recommendations from both the patient and provider perspective.

Join us as we support systems, staff, patients and family members in understanding all our roles in improving the overall experience in these health care settings.


Bringing Patient Safety to Life

20th Annual Northwest Patient Safety Conference | Check it out

The Foundation for Healthcare Quality’s Washington Patient Safety Coalition is hosting the annual Northwest Patient Safety Conference - a virtual event! The conference will highlight

  • innovative patient safety methods, 
  • equitable and cultural approaches to patient relationships,
  • technological advances in health care systems,
  • extending beyond the four walls of the health care institutions.

The PATH team encourages joining this event to hear from leaders in thought and development of health care advances. One speaker will be the co-chair of the National Steering Committee for Patient Safety and collaborator from the Institute for Healthcare Improvement (IHI) that was part of the development of the Safer Together, National Action Plan to Advance Patient Safety. Other speakers include experts in building safety through Indigenous cultural and relationship-based approaches. 

Conference: Bringing Patient Safety to Life: What's Worked, What Hasn't, and What To Do About It

When: Tuesday, Oct. 17, and Wednesday, Oct. 18 | 8 AM to 1 PM PT

Where: Virtual!

Registration is now open! Learn more about the conference and get registered today, if you can!

Continuing education credits are available for a fee.

Addressing the Syphilis Epidemic

On Wednesday, July 19, IHS released a Dear Tribal Leader Letter on IHS plans to address the current syphilis epidemic impacting American Indian and Alaska Native (AI/AN) communities. Dr. Loretta Christensen, IHS Chief Medical Officer, recommended the following for all IHS, Tribal and Urban Indian Organizations to address this epidemic. Read the letter for additional information and resources.

  1. Annual syphilis testing for persons aged 13 to 64 to eliminate syphilis transmission by early case recognition.
  2. Turn on the annual electronic health record reminder at all sites to facilitate testing for two years or until incidence rates decrease locally to baseline.
  3. Three-point syphilis testing for all pregnant people at the first prenatal visit, beginning of the third trimester and delivery.
  4. Adoption of a sexually transmitted infection (STI)/human immunodeficiency virus (HIV)/Viral hepatitis testing bundle at all sites to screen broadly.
  5. Adoption of "Express STI Testing." Express STI services refer to triage-based STI testing without needing a full clinical exam.
  6. Enhance screening rates by screening outside of hospitals and clinics.
  7. Provide field treatment for syphilis for high-risk adults diagnosed with syphilis and their partners. Public health nurses (PHNs) could provide treatment with Benzathine Penicillin. The Express STI Services Toolkit includes policy examples.
  8. Presumptive treatment of syphilis for anyone having signs or symptoms of syphilis or with known exposure to syphilis.
  9. Create and build awareness and encourage people to get tested and treated.


There is a new AI/AN-specific national campaign called STOP SYPHILIS.


National Immunization Awareness Month

Many patients look to their health care provider for assurance vaccines are safe and effective.

National Immunization Awareness Month works to get ahead of the annual flu and

pneumonia season, promoting annual vaccines and encouraging people to get caught up

on any other vaccines they may need. The Centers for Disease Control and Prevention (CDC)

offers health care practices for professionals, including non-clinical staff, and a variety of

promotional materials. Other resources include:


International Overdose Awareness Day | Aug. 31

International Overdose Awareness Day (IOAD) is the world's largest annual campaign to

end overdose. PATH provides tools to help with screening, interventions and treatment

to make sure patients get the care and support they need, including for substance use disorder.

Opioid overdoses impact all walks of life and can happen to anyone.

Check out these PATH resources:

Check out these IHS HOPE Committee resources:

  • Naloxone resources
  • Naloxone Training Toolkit - Provide additional support to your community partners with these naloxone training materials for medical professionals, first responders and community members and for school settings.


National Breastfeeding Month/Indigenous Milk Medicine Week

National Breastfeeding Month brings partners together to focus on policy and practice changes

needed to support families and babies. This year's theme is "This Is Our Why."

Within this month, the Indigenous Milk Medicine Collective highlights

Indigenous Milk Medicine Week to shine a light on the diversity of experiences.

This year's theme, "From the Stars to a Sustainable Future," is already being talked about

on the collective's Facebook page.


Occupational Safety and Health Administration (OSHA) Safe + Sound Week | Aug. 7-13

Safe + Sound Week provides the opportunity to reflect on and recognize efforts

you and your teams have made to create a safe workplace environment.

OSHA has a webpage that focuses on safety in health care.

PATH facilitated a two-part Learning Circle that addressed workplace violence:


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-402-07/24/2023