Prepared for the Foundation of the American College of Healthcare Executives

Session S02AB

Building and Sustaining an Effective

Quality and Patient Safety Program

for Financial Health

Presented by:

Ann S. Blouin, PhD, RN, FACHE

1

Building and Sustaining an Effective Quality and Patient Safety Program for Financial Health

Disclosure of RelevantFinancial RelationshipsThe following faculty of this continuing education activity has no relevant financial relationships with commercial interests to disclose:

• Ann Scott Blouin

2

2

Presenter

• Ann Scott Blouin, RN, PhD, FACHE

Executive Vice President, Customer Relations

The Joint Commission

3

Learning Objectives

• To identify the relationship between quality and safety improvements and financial results

• To state two strategies leading healthcare organizations have deployed to achieve and sustain quality and safety improvements

4

3

Agenda• Introductory Framework: “Investing in Quality for

Financial Health”

• Current State of Quality & Safety

• Business Drivers for Improvement and The Role of Value-Based Care

• Costs of Serious Safety Events: Calculating the Impact

• Moving Past Quality Improvement to Quality Control

• IHI’s Six Elements of Quality Control

• Summary: Sustaining the Gains5

Systems & structure to

support Q&S measurement &

improvement

Track baselines & quantify

improvements

Communicate successes & “Hard Wire”

Strategic focus on quality &

SSE risk reduction

Top priority in strategic & operational

planning

Resource allocation sufficientfor Q&S Improvement

Learn from othersRisk Reduction

ReducedDirectCareCosts

ImprovedPatientSafety

IncreasedQualityOf Care

ImprovedWorkerSafety&Satisfaction

LowerLegalCosts

Evaluate & revise actions for continued efforts toward “Zero Harm”

Investing in Quality for Financial Health

Author: Blouin, 2013

6

4

Characteristics ofOptimal Organizations• Focus on quality and safety in patient care as “job one”

• Increase transparency to staff, patients, and the public

• Proactively manage potential risks (clinical, business, occupational, environmental)

• Continually focus on having a motivated, qualified and satisfied workforce

• Build capability for adoption of evidence-based leading practices

• Improve use of clinical information

• Improve all services continually; have standardized process improvement methodology

7

Perception of Quality

Added cost?

OR

Essential to overall performance of the organization

Companies that embrace quality as a way of running day-to-day operations tend to be more successful in

process performance and delivering customer satisfaction in comparison to those who merely seek having quality improvement because they “have to.”

8

5

Leadership SampleQuestion• Compared to all the strategic goals your

organization pursues, which of the following best describes the priority your organization gives to improving quality and safety? (choose one)

a) Quality is important but not among the top strategic priorities

b) Quality is one of many several priorities competing for attention and resources

c) Quality is one of our organization’s top 3 or 4 strategic priorities (e.g., volume growth, financial performance)

d) Quality is the highest priority strategic goal for our organization

9

Current State of Quality

• Routine safety processes fail routinely– Hand hygiene

– Medication administration

– Patient identification

– Communication in transitions of care

• Uncommon, preventable adverse events– Wrong surgery, retained foreign objects

– Fires in ORs

– Infant abductions, inpatient suicides

10

6

Source: SCHA Zero Harm PublicVideo, YouTube. https://www.youtube.com/watch?v=KRqQ1lPfy9U

11

3 Waves of Innovation in Patient SafetyTechnical and procedural improvements have made surgery safer, but future innovations will focus on reliably organizing the work of patient care.

Ghaferi AA, et al.  The Next Wave of Hospital Innovation to Make Patients Safer.  Harvard Business Review.  Aug. 8, 2016

12

7

© Copyright 2015 by the National Patient Safety Foundation.

13

Eight Recommendations forAchieving Total Systems Safety

14

8

Eight Recommendations forAchieving Total Systems Safety

15

Quality and Safety ImprovementKey Business Drivers

Business Drivers

Regulatory and Accreditation Requirements

Public Reporting

Financial Imperatives

• Pay for Performance/VBP• Malpractice Costs• Competitive Managed Care Contracting• Medicare Reimbursement• Bundled Payments

• HospitalCompare• Joint Commission Quality Check

• Joint Commission• AHRQ• CMS• City and State Requirements

Leadership Imperatives

Beyond the desire to provide high quality & safe care, health care leaders must balance decisions around three areas

16

9

ACA Strategy Map

Source: Healthcare Executive. May/June 2014, Vol. 29, No. 3.

Rewards and penalties

17

Competing on Outcomes Improves Performance by Providers

Source: E Hansson, B Spencer, J Kent, J Clawson, H Meerkatt, and S Larsson, BCG Perspectives. Sept. 9, 2014.

18

10

19

20

11

21

The Link Between Quality andFinancial Health

Credit rating services, such as Moody’s, expect specific quality-focused strategies and efforts to demonstrate long term financial health.

Source: Moody’s Investors Service; Improving Clinical Quality and Patient Safety of Greater Importance to Not-for-Profit Hospitals; May 2006a

Long-Term Positive ImpactsLong-Term Positive Impacts

Increased Investments in

Quality

Improved Clinical Outcomes

Enhanced Competitive Advantage

Superior Financial Performance

Higher Bond Rating

• Improved market share and volumes• Better ability to recruit and retain

physicians• Lower nursing vacancy/turnover rates• Improved financial performance• Better credit position

Moody’s Four Key Enablers of a Quality-Focused Strategy

Moody’s Four Key Enablers of a Quality-Focused Strategy

1. Organizational Commitment to Quality

2. Hospital-Physician Partnerships Integral to Executing Quality

3. Information Technology and Quality are Highly Correlated

4. Individual Quality Goals to Drive Strategy, Irrespective of National Benchmarks

22

12

Rating AgenciesHospitals providing a high-quality level of care are likely to be more profitable, have stronger balance sheets than their average peers, invest more in technology and take a long-term view for results• Moody’s Investors Service – Introduced six new indicators in 2013 to

more accurately capture the changing payment and care models. It uses the following to measure demand:– Unique patients: the number of people who received care at the hospital in a 12-mo.

period, both inpatient and outpatient– Covered lives: number of people within the community for which hospital is responsible

along the continuum of care – either through exclusive contract, hospital-owned insurance plan, an ACO contract or through an ACO-like structure provided by Medicare, Medicaid or other commercial payers

– Employed physicians: This figure serves as a predictor of referrals. (Hospital doctors better utilize electronic medical records and coordinate care, which the rating agency recognizes as a credit positive.)

Source: Becker’s Hospital Review. June 30, 2014. 23

Rating Agencies (continued)

• For reimbursement risk, Moody’s now focuses on the following indicators:

– Medicare reimbursement rate: Since Oct. 1, 2012, CMS started penalizing hospitals with high Medicare readmission rates for congestive heart failure, heart attack and pneumonia

– “All-payer” readmission rate: This measurement of patients covered by other insurers will include readmissions within 30 days of discharge, no matter the diagnosis, unless it is part of the plan of care

– Risk-based revenues: Hospitals currently with or in the process of obtaining a Moody’s credit rating will need to annually provide data on the type of reimbursement methodology used in its contracts. Risk-based revenues will include new reimbursement models, such as bundled payment and pay-for-performance. Moody’s will use this metric along with traditional forms of payment, such as DRGs, per diems and capitation in its evaluation

Source: Becker’s Hospital Review. June 30, 2014.

24

13

A Business Casefor Quality…A business case for health care improvementintervention exists if the entity that invests in theintervention realizes a financial return on its investmentin a reasonable time frame, using a reasonable rate ofdiscounting. This may be realized as “bankable dollars”(profit), a reduction in losses for a given program orpopulation, or other types of cost avoidance. Inaddition a business case may exist if the investingentity believes that a positive indirect effect onorganizational function and sustainability will accruewithin a reasonable time frame.

Source: Leatherman et al. Health Affairs. 2003

25

Justify Investment asCost Reduction

• Business case should include justification for investments that will lead to financial savings

– Reduce unreimbursed cost of care– Reduce total healthcare system costs– Reduce costs

Brilli, R. J., Sparling, K. W., Lake, M. R., Butcher, J., Myers, S. S., Clark, M. D., et al. (2008). The Business Case for Preventing Ventilator-Associated Pneumonia in Pediatric Intensive Care Unit Patients. Joint Commission Journal on Quality and Patient Safety, 34, 629-638.

26

14

Financial Calculations

• Assigning costs that goes in each bucket may be tricky– Clinical information and clinical data drives

financial figures

• Once each part is identified, calculation for business case is quite straightforward

27

Organizational Costs of Patient Safety Errors

Serious SafetyEvent

Net DirectCare Costs

LegalCosts

Accreditation Costs

Human CapitalCosts

MarketingCosts

DecreasedEfficiency

PersonnelRedirectedFrom PatientCare

Inability toGenerate NewBusiness

LowerProfitMargins

28

15

HAC and Estimated Financial Impact

*Sources: AHRQ | AHA | HRET 2013; Joint Commission Center for Transforming Healthcare, 2015

29

The Michigan Keystone ICU Project

• Focus: Change clinicians’ behaviors when inserting catheters to prevent bloodstream infections in the ICU

• Scope: More than 100 ICUs in the State of Michigan for 18 months

• Intervention: Following a standardized checklist

• Results: 66% reductions in catheter-associated infections– Saved >1,500 lives– Saved >$200 million in excess costs– For every $ invested, more than $200 saved

30

16

Ascension Health: Journey to Zero

MetricReduction Compared to

Estimated National Average*

Cumulative Reduction from

FY2007**

Birth Trauma 64% 30.8%

Neonatal Mortality 81% 27.8%

Facility-Acquired Pressure Ulcer

95% 23.3%

Falls with Serious Injury 57% (4.2%)

Central-line Blood Stream Infection

45% 32.6%

Ventilator Associated Pneumonia

84% 53.1%

*Calculations for national benchmarks abstracted from peer reviewed literature **Expected mortality based on 2011 CareScience Model Calibration

MetricReduction Compared to

**ExpectedCumulative

Reduction fromFY2004

Mortality 14% 40%

31

Citrus Valley:Process Excellence Results1. Care Continuum – Heart failure: all causes readmission rate

decreased from 23% to 16.7%

2. Emergency Room (ED) Flow – A reduction in leaving without being seen (LWBS) rate from 3.3% to 1.5%; a 50% decrease in patient wait times to 64 minutes

3. Nurse Handoff Communication – A decrease in defective rate from 38.3% to 24.2%

4. Medicare Denial Prevention – An increase in physician (2-midnight rule) documentation from 0% to 56%. Savings of $443,428 for 1 month

5. Meditech – An increase in the electronic submission rate of perinatal measures from 61% to 91%

6. Surgical Site Infection – A decrease in Surgical Site Infection (SSI) from 22 in 2013 to 11 in 2014; also, improvement in appropriate dosing of antibiotics by physicians Source: Choctaw WT. Transforming the Patient Experience. A New

Paradigm for Hospital and Physician Leadership. © Springer International Publishing 2016, p 69-70.

32

17

Source: Northwell Health Clinical Excellence and Quality Report 2016. Claims Data as of March 3, 2016.

33

Source: Northwell Health Clinical Excellence and Quality Report 2016. Northwell Health Pressure Ulcer Database, KQMI Table of Measures. Data as of February 19, 2016.

34

18

Source: Northwell Health Clinical Excellence and Quality Report 2016. National Healthcare Safety Network (NHSN). Data as of February 3, 2016.

35

High Reliability: Targeting CAUTI

Source:  Cooper MR, Hong A, et al.  Implementing High Reliability for Patient Safety. Journal of Nursing Regulation. April 2016; 7(1).

36

19

• In 2013, The South Carolina Hospital Association Board established the Certified Zero Harm Award to recognize hospitals that achieve 12 consecutive months or longer without certain infections

• In 2016, 110 awards were give to 37 hospitals

Source: SCHA Zero Harm PublicVideo, YouTube. https://www.youtube.com/watch?v=KRqQ1lPfy9U

37

Source: SCHA Zero Harm PublicVideo, YouTube. https://www.youtube.com/watch?v=KRqQ1lPfy9U

38

20

This totals to a projected savings of $5 MillionSource: SCHA Zero Harm PublicVideo, YouTube. https://www.youtube.com/watch?v=KRqQ1lPfy9U

39

Determining “Hard” vs. “Soft” Financial Impact: Mayo’s Quality Measurement• Hard Impact has these general attributes:

‒ Effect on “cash flow” is definite‒ Effect on “cash flow” is readily quantifiable‒ Timing tends to be “near term” (i.e., months, maybe even a year or

two depending on project scope, duration)‒ Items tend to have transaction-based evidence

• Soft Impact has these general attributes:‒ Effect on operations is identifiable; however, cash flow is indirectly

impacted‒ Effect on “cash flow” is indefinite or not quantifiable‒ Timing tends to be “long term” (i.e., may require a year or two, or

more, before cash flow impact is realized)‒ Long-term impact is likely realizable. If not realizable, ignore.

Source: Swensen et al. J Patient Safety 9(1), March 2013, p. 44-52 40

21

Determining “Hard” vs. “Soft” Financial Impact: Mayo’s Quality MeasurementSome Examples: Hard Soft Neither

Infrastructure (usually multiple years of service)‒ Equipment to be acquired (capital $) x‒ Equipment presently in place but not needed x

in future (to be sold on market)‒ Software and related costs (i.e., to make operational) x‒ Space (additional or reduced square footage) x‒ Remodeling (e.g., to tailor space to its x

intended usage)‒ Defer capital expenditure (impact is the x

investment opportunity)

Capacity (productivity)‒ Free up additional capacity (potential x

increased patient volume and related revenue)

Source: Swensen et al. J Patient Safety 9(1), March 2013, p. 44-52

41

Determining “Hard” vs. “Soft” Financial Impact: Mayo’s Quality Measurement

Some Examples: Hard Soft Neither

• Revenue‒ Direct increase/decrease in reimbursement x‒ Increased revenue because of increased x

capacity without adversely impacting margin

• Contractual Services‒ Increase or decrease in contract programmers, x

consultants, others not on Mayo “payroll”‒ Increase or decrease in maintenance contracts x‒ Malpractice cost avoidance (includes legal,

settlements, etc.) x

• Supplies (usually consumed in days, weeks or months)

‒ Increase or decrease in equipment x(expensed, minor $ each)

‒ Increase or decrease in supplies x(used in “day-to-day” operations

Source: Swensen et al. J Patient Safety 9(1), March 2013, p. 44-52 42

22

Determining “Hard” vs. “Soft” Financial Impact: Mayo’s Quality MeasurementSome Examples: Hard Soft Neither

• Staffing/human resources‒ FTE increase or decrease from existing levels, x

with firm commitment to increase or decrease FTE‒ FTE reduction from existing levels with x

“redeployment” to other activities‒ FTE avoidance (future) x‒ Effort savings across multiple jobs/persons, x

with no FTE reduction‒ Employee days away from work x‒ Project effort (existing staff, x

“quality is everybody’s job”)

Source: Swensen et al. J Patient Safety 9(1), March 2013, p. 44-52

43

Determining “Hard” vs. “Soft” Financial Impact: Mayo’s Quality Measurement

Some Examples: Hard Soft Neither

• Hospital inpatient impacts‒ LOS increase or decrease with clear impact x

(variable expense)‒ LOS increase or decrease with unclear x

impact‒ Readmissions – revenue impact x‒ Readmissions – expense impact (variable $) x

Source: Swensen et al. J Patient Safety 9(1), March 2013, p. 44-52

44

23

1. Consumer’s inability to perceive quality differences

2. Displaced payoffs in time and place

3. Disconnect between consumers and payers via administrative pricing

4. Failure to pay for quality, while paying for defects

5. Uneven access to information among cliniciansSource: Leatherman S, Berwick DM, Iles D, et al. The business case for quality case studies and an analysis. Health Affairs(Millwood). 2003;22: 17-30.

Five impediments to realizingthe business case for quality in health care:

45

• Help translate your everyday knowledge of what prevents patient harm into financial impacts (revenues and costs)

• Identify high risk areas (“latent conditions”) which if ignored, could lead to patient harm and financial outlays

• Understand how to express quality and safety concerns in both qualitative and quantitative measurements

• Work with the entire team and finance to track revenue/cost impact of your quality and safety efforts

• Sustain quality improvements through quality control

Implications for Staffand Leaders

46

24

The Relationship of Quality Improvement and Quality Control

Scoville r, Little K, Rakover J, Luther K, Mate K.  Sustaining Improvement. IHI White Paper.  Cambridge, MA: Institute for Healthcare Improvement; 2016.

47

What Drives Quality Control?• Standardization: Processes exist to help define and disseminate

standard work (what to do and how to do it)

• Accountability: A process is in place to review execution of standard work

• Visual Management: Process performance information is continuously available to synchronize staff attention and guide current activities

• Problem Solving: Methods are available for surfacing and addressing problems that are solvable at the front line, and for developing improvement capability

• Escalation: Frontline staff scope issues and escalate those that require management action to resolve

• Integration: Goals, standard work, and QI project aims are integrated across organizational levels and coordinated among units and departments

Scoville R, Little K, Rakover J, Luther K, Mate K.  Sustaining Improvement. IHI White Paper.  Cambridge, MA: Institute for Healthcare Improvement; 2016.

48

25

Why Standardization Matters

• Improves quality

• Reduces variation and risk of error

• Improves consistency of training

• Enables accurate measurement

• Reduces costs and improves productivity

• Simplifies processes, procedures and policies

• Avoids data “noise”

• Enables mobile workforce (regardless of location, do the same thing)

49

Barriers to Standardization

• Philosophy of “more than one way to skin a cat”

• Claims around professional autonomy

• Resistance to change

• Past success: “It’s always worked before.”

• Arguing the science around the change

• “We’re different; that won’t work here.”

• “This is just an excuse for staff reductions.”

• Continued upheaval with mergers & acquisitions

• Lack of intentional, well-orchestrated plans

• Lack of leadership commitment

• Trying to standardize too much (not strategic)

50

26

Sustaining Improvements

Intentionally

Designed &

Implemented

Changes

Professional

Accountability

To Follow

New Process

Source:  Hickson G.  NPSF, May 2016.

51

Monitor Progress

• How will you know you’ve been successful?

– Establish measurable milestones for sustaining

– Identify who is accountable for sustaining each activity

• How will you know you have actually made and sustained an improvement, not just a change?

• How will you communicate and show continued progress?

52

27

Sustain the GainsForcefield Analysis

Helping Hindering

Curren

t state

Desired

 state

53

Understand deeply what the new improvement should look like when fully implemented, so sustaining is possible

Use dashboards to focus on the “critical few” vs. the many; consider developing cultural expectations where sustaining prior improvements is as important as beginning new initiatives

Develop leadership incentives to maintain the gains, evaluate further improvements

Be clear around accountability for maintenance (once past implementation)

Sustaining Improvements Over Time: Core Concepts

54

28

Define standard work/standardized processes to evaluate and reduce future variation

Measure against standardized improved processes

Once reaching improvement target, keep monitoring but decrease the frequency

Use concepts and tools of “Control” phase from Six Sigma’s DMAIC

Sustaining Improvements Over Time: Core Concepts(continued)

55

Control Phase Strategy

• Consider anything and everything to sustain the gains

• Implement solutions with controls to guarantee performance

• Control guides the team to:– Think how the improvements may fail– Act on these potential failure modes before

they occur– Control/avoid performance deterioration

despite variables impacting the system

Purpose

56

29

Control Plan

• Ideally, a process should be mistake-proofed and cannot fail

• For those that are not mistake-proofed, monitoring is essential

• By definition, variation is not controlled so alerts are necessary when the process is becoming unstable

– Visual management– Statistical Process Control charts

Monitoring the Improved Process

57

Examples of How Selected Organizations Execute Drivers for Quality Control

Scoville, R, Little, K, Rakover, J, Luther, K, Mate, K.  Sustaining Improvement. IHI White Paper.  Cambridge, MA: Institute for Healthcare Improvement; 2016.0 58

30

Scoville, R, Little, K, Rakover, J, Luther, K, Mate, K.  Sustaining Improvement. IHI White Paper.  Cambridge, MA: Institute for Healthcare Improvement; 2016.

Examples of How Selected Organizations Execute Drivers for Quality Control (continued)

59

Scoville, R, Little, K, Rakover, J, Luther, K, Mate, K.  Sustaining Improvement. IHI White Paper.  Cambridge, MA: Institute for Healthcare Improvement; 2016.

Examples of How Selected Organizations Execute Drivers for Quality Control (continued)

60

31

SummarySustain the Gains

• Create opportunities for short-term successes as this:- Encourages the team - Supports early adopters- Displays credibility - Energizes other key stakeholders- Builds momentum - Takes power away from the cynics- Generates buy-in

• Don’t let up! Don’t assume that a few successes or a few areas being on board means everyone is supportive

• Remember where you started and celebrate how far you’ve come

• Empower staff to function freely in the new state without going back to the old ways of doing things

• Continue to monitor the metrics• Be transparent with successes and challenges

61

Ann Scott Blouin, RN, PhD, FACHEExecutive Vice President, Customer Relations

ablouin@jointcommission.org / 630-792-5750

Ann Scott Blouin, RN, PhD, FACHE, is the Executive Vice President of Customer Relations at The Joint Commission. In this position, Ann focuses on building and strengthening external customer and stakeholder relationships, primarily in hospitals and health systems.

From 2008 to 2012, Dr. Blouin held the position of Executive Vice President for the Division of Accreditation and Certification Operations at The Joint Commission. Her responsibilities included executive leadership of accreditation and certification for more than 19,000 health care organizations and programs.

Dr. Blouin has over 35 years of health care administration, consulting and nursing experience, including senior leadership positions. She has also published and taught at nursing and medical schools and currently serves as Vice Chair of the National Patient Safety Foundation Board of Directors, America’s Essential Hospitals Institute Board, and as an editorial advisor for the Journal of Nursing Administration and American Nurse Today. Ann is a Certified Lean Six Sigma Green Belt.

Dr. Blouin earned her PhD and MBA from the University of Illinois, her MSN from Loyola University, and BSN from Lewis University. She is a Fellow of the American College of Health Care Executives.

62

32

Appendix A – ResourcesTo Help Improve Qualityand Safety

Available at www.jointcommission.org

63

64

33

65

66

34

67

68

35

69

70

36

The Physical Environment Portal

71

72

37

73

Safe Health IT

74

38

Appendix B - References

75

References• Brilli RJ, Sparling KW, Lake MR, Butcher J, Myers SS, Clark MD, et al. “The Business

Case for Preventing Ventilator-Associated Pneumonia in Pediatric Intensive Care Unit Patients.” Joint Commission Journal on Quality and Patient Safety. 2008, 629-638.

• Byrnes J, Fifer J. “Moving Quality and Cost To The Top of The Hospital Agenda.” Healthc Financ Manage. 2010 Aug;64(8):64-9.

• Corrigan JM, Wakeam E, Gandhi TK, Leape LL. “Improved Patient Safety with Value-Based Payment Models.” HFM Magazine August 2015. https://www.hfma.org/Content.aspx?id=32499

• “Designing the New Health Care System: The Need for CMO and CFO Collaboration.” A joint report form The American Assn. for Physician Leadership and Healthcare Financial Management Assn. 2015, 1-16.

• Ellison A. “Quality metrics hospital CFOs are tracking.” 13 Nov 2015. http://www.beckershospitalreview.com/finance/the-cfos-guide-to-healthcare-quality-key-metrics-to-track-trends-to-follow.html.

• Fleiszer et al. BMC Health Services Research, 2015.

• Gilbert WM, Nesbitt TS, Danielsen B. “The Cost of Prematurity: Quantification by Gestational Age and Birth Weight.” Obstes Gynecol. 2003 Sep; 102(3):488-92.

• Hickson G. NPSF Business Coalition, May 2016.

• Jones A, Nay T. “Healthcare Acquired Pressure Ulcers (HAPU).” Clinical Alert. Volume 6, No. 3. Maryland Department of Health and Mental Hygiene, 1 Dec 2009. Dec. 2012. dhmh.Maryland.gov/ohcq/HOS/Docs/Alerts/alert-v6-n3-winger2009.pdf

76

39

References• Leatherman S, Berwick DM, Iles D, et al. “The business case for quality case

studies and an analysis.” Health Affairs (Millwood). 2003;22:17-30.

• Mayer GS, Demehin AA, Liu X, Neuhauser D. “Two Hundred Years of Hospital Costs and Mortality – MGH and Four Eras of Value in Medicine.” N Eng J Med 7 June 2012. 366; 23.

• Maynard G, Stein J. “Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement.” Society of Hospital Medicine, Agency for Healthcare Research and Quality. US Dept. of Health & Human Services, Web. 5 Dec. 2012. http://www.ahrq.gov/qual/vtguide/vtguidepa.htm

• McClellan MB, Thompson TG. “FR Doc 04-4249.” US Food and Drug Administration. Volume 69, No. 38. Department of Health and Human Services, 26 Feb 2004. Web. 5 Dec. 2012.

• Parand A, Benn J, Burness A, Pinto A, Vincent C. Strategies for sustaining a quality improvement collaborative and its patient safety gains. International Journal for Quality in Health Care. 2012; pp. 1-11.

• Scott RD. “The Direct Medical Costs of Healthcare-Associated Infections in the U.S. Hospitals and the Benefits of Prevention.” Division of Healthcare Quality Promotion National Center for Preparedness, Detection, and Control of Infectious Diseases Coordinating Center for Infectious Diseases Centers for Disease Control and Prevention. Web. 4 Dec 2012. http://www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf

77

References• Scoville R, Little K, Rakover J, Luther K, Mate K. Sustaining Improvement. IHI White

Paper. Cambridge, MA: Institute for Healthcare Improvement, 2016.

• Shumway-Cook A, Ciol MA, Hoffman J, Dudgeon BJ, Yorston K, Chan, L. “Falls in the Medicare Population: incidence, associated factors, and impact on health care. Physical Therapy, 2009. 89(4):1-9.

• Swensen et al. J Patient Safety 9(1), March 2013. 44-52.

• Tablan OC, Anderson LJ, Besser R, et al. CDC Healthcare Infection Control Practices Advisory Committee. Guidelines for preventing health care-associated pneumonia, 2003: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004 Mar

• Tiongson J. “Solicitation for Applications Community-based Care Transitions Program.” Centers for Medicare and Medicaid Services, Web. 4 Dec 2012. www.cms.gov/Medicare/Demonstration-Projects/DemoProjectsEvalRpts/downloads/CCTP_Solicitation.pdf

• Yarbrough WG, et al. “A Tool to Determine Financial Impact of Adverse Events in Health Care: Healthcare Quality Calculator.” J Patient Saf, 10(4), December 2014.

78