Joint Commission Publishes new Monograph about CLABSIs

On May 16th, the Joint Commission released a new Monograph reviewing the most recent evidence and thoughts surrounding Central Line-Associated Bloodstream Infections.

The free monograph can be downloaded here: http://www.jointcommission.org/assets/1/18/CLABSI_Monograph.pdf

Below is an excerpt from the press release announcing the free monograph (emphasis added in red):


New Monograph Aims to Decrease Central Line-Associated Bloodstream Infections (CLABSIs)

The Joint Commission, in collaboration with Joint Commission Resources (JCR) and Joint Commission International (JCI), developed a new monograph containing the most current information, evidence-based guidance and resources to help health care organizations reduce the current risks and resulting harm associated with CLABSI. JCR and JCI are not-for-profit affiliates of The Joint Commission. The monograph was produced in partnership with infection prevention leaders from the Society for Hospital Epidemiology of America (SHEA), the Association for Professionals in Infection Control and Epidemiology, Inc. (APIC), the National Institutes of Health (NIH), the Infectious Diseases Society of America (IDSA), the Association for Vascular Access (AVA), and the International Nosocomial Infection Control Consortium (INICC). In addition, several other domestic and international infection prevention leaders from countries such as Argentina, Australia, Egypt, Switzerland, Thailand and Saudi Arabia have lent their expertise to the monograph.

“Recent patient safety initiatives have demonstrated how preventable CLABSIs can be when evidence-based guidelines are consistently put into practice at the bedside,” says Jerod M. Loeb, Ph.D., executive vice president, Division of Healthcare Quality Evaluation, The Joint Commission. “Our hope is that these resources will empower health care providers to implement practices that have been shown to not only improve patient safety, but also reduce costs.”

The project is supported by a research grant from Baxter Healthcare Corporation and focuses on the identification and broad dissemination of preferred practices and technological solutions to prevent CLABSI. 

Joint Commission Publishes Roadmap towards Patient Centered and Family Centered Care

Patient centeredness is probably the most difficult to define and thus difficult to improve dimension of healthcare quality (the other dimensions being safety, timeliness, effectiveness, efficiency, and equability). Nevertheless, sensitivity to the concepts surrounding patient centeredness is essential for a multitude of clinical and strategic reasons.

To help hospitals prepare for the Joint Commission's upcoming Patient-Centered Communication accreditation standards, the Joint Commission recently published a monograph titled Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals.

The monograph can be download here.

Joint Commission Posts Accountability Measures FAQ

On July 19th, the Joint Commission posted its FAQ concerning it's recently announced accountability measures. It can be found here. The following are excerpts from the FAQ:

Accountability Measures - Frequently Asked Questions

What are “Accountability Measures?”
Accountability measures are quality measures that meet four criteria that produce the greatest positive impact on patient outcomes when hospitals demonstrate improvement on them.

The criteria for classifying accountability measures include:

Research: Strong scientific evidence exists demonstrating that compliance with a given process of care improves health care outcomes (either directly or by reducing the risk of adverse outcomes).
Proximity: The process being measured is closely connected to the outcome it impacts; there are relatively few clinical processes that occur after the one that is measured and before the improved outcome occurs.
Accuracy: The measure accurately assesses whether the evidence-based process has actually been provided. That is, the measure should be capable of judging whether the process has been delivered with sufficient effectiveness to make improved outcomes likely. If it is not, then the measure is a poor measure of quality, likely to be subject to workarounds that induce unproductive work instead of work that directly improves quality of care.
Adverse Effects: The measure construct is designed to minimize or eliminate unintended adverse effects.
These criteria are based on The Joint Commission’s experience implementing and evaluating the outcomes of quality measures for more than a decade. The criteria provide a more rational approach to the process of collecting and reporting quality data.

Why is The Joint Commission reclassifying the core measures as accountability measures and how will this help hospitals?
The Joint Commission wants to help hospitals improve performance on accountability measures in an effort to promote excellence in the delivery of care and maximize health outcomes, and in anticipation of the Centers for Medicare & Medicaid Services incentive payments that become effective in 2013. The Joint Commission will eliminate measures that do not work well, include performance on accountability measures in accreditation standards and include only accountability measures in the ORYX program.

Why not remove non-accountability measures from use?
Measures that do not meet the accountability measures criteria can still prove to be a valuable source of information to hospitals. These measures are also currently used by other initiatives as standardized performance measures for assessing and reporting on hospital performance.

How will The Joint Commission utilize accountability measures in future accreditation activities?
The Joint Commission currently is considering a variety of innovative approaches to integrating hospital performance on the accountability measures into its survey and accreditation activities. To promote improved performance on accountability measures, and help hospitals prepare for the increasing reliance on attaining high performance on quality measures. The Joint Commission will be engaging accredited hospitals through focus groups and online surveys over the next few months.

Where can I locate additional information on accountability measures?
Additional information on accountability measures can be found in the June 23, 2010 special issue of Joint Commission Online and the June 23, 2010 on-line issue of the New England Journal of Medicine, “Accountability Measures: Using Measurement to Promote Quality Improvement.” Additional information will be posted on The Joint Commission’s Web site and in the August 2010 issue of Joint Commission Perspectives.

Will The Joint Commission continue to categorize measures as accountable and non-accountable measures?
In the future, The Joint Commission will only adopt accountability measures for use in its ORYX initiative.

Eight Recommendations for Policies for Communicating Abnormal Test Results

The Joint Commission recently published this article in its Joint Commission Journal on Quality and Patient Safety (May 2010, Volume 36 No 5).

The article can be downloaded free from AHRQ here: http://psnet.ahrq.gov/public/Singh-JCJQPS-2010_PSNetID18026.pdf

The eight recommendations are:

1. Policies should be introduced with clear definitions of key terms.
2. Policies should clearly outline provider responsibilities.
3. Policies should specify procedures for fail-safe communication of abnormal test results.
4. Policies must define verbal and/or electronic reporting procedures for both critical and significantly abnormal laboratory, imaging, and other test values.
5. Policies should specify "Critical Tests" and acceptable length of time between their ordering and reporting.
6. Policies should define time lines between the availability of test results and patient notification, and institutions should specify preferred mechanisms for patient notification.
7. Policies must be of "real world" value and written with feedback from key stakeholders.
8. Policies should establish responsibilities for monitoring and evaluating communication procedures.

The following is the text of the Article-at-a-Glance:

Background: Health care organizations continue to struggle to ensure that critical findings are communicated and acted on in a timely and appropriate manner. Recent research highlights the risks of communication breakdowns along the entire spectrum of test-result abnormality, including
significantly abnormal but nonemergent findings. Evidence-based and practical institutional policies must uphold effective processes to guide communication of abnormal test results. Eight recommendations for effective policies on communication of abnormal diagnostic test results were developed based on policy refinement at the Michael E. DeBakey Veterans Affairs Medical Center
(Houston), institutional experience with test result management, and findings from research performed locally and elsewhere.

Key Facets of Effective Policies: Research findings on vulnerabilities in existing policies and procedures were taken into consideration. The eight recommendations are based on important refinements to the policy which clarified staff roles and responsibilities for test ordering, follow-up, and communication; defined categories of abnormal test results to guide appropriate follow-up action; and elaborated procedures for monitoring the effectiveness of test result communication
and follow-up. Participation of key stakeholders is recommended to enhance buy-in from personnel and to help ensure the policies feasibility and sustainability.

Conclusions: The proposed recommendations for ensuring safe test-result communication may be potentially useful to a wide variety of institutions and health care settings. These practical suggestions, based on research findings and experiences with a previous policy, may be a useful
guide for designing or amending policies for safe test-result communication in both inpatient and outpatient settings.

Joint Commission Updates Sentinel Event Statistics

The Joint Commission reported today that it has updated its sentinel event statistics through December 31, 2009.

The updated statistics can be found here: http://www.jointcommission.org/NR/rdonlyres/377FF7E7-F565-4D61-9FD2-593CA688135B/0/SE_Stats_31_Dec_2009.pdf

The sentinel events data webpage is here: http://www.jointcommission.org/SentinelEvents/Statistics/

Wrong site surgery is still the leading sentinel event.

Leadership in Healthcare Organizations

Yesterday the Joint Commission posted this monograph from the Governance Institute regarding healthcare organization leadership. You can download the 44 page white paper here.

The paper is divided into the following chapters:
Part 1 - Introduction and Background
Chapter 1: Leaders and Systems
Chapter 2: What Leaders Do

Part 2 - Joint Commission Leadership Standards
Chapter 3: Leadership Structure
Chapter 4. Leadership Relationships
Chapter 5. Hospital Culture and System Performance
Chapter 6. Leadership Operations

Every quarter, along with updating the hospital compare website, CMS also makes the flat files available for download. With the flat files, anyone can compare any combination of CMS performance measures. Below is the performance of HF-1 for all Indiana hospitals that submitted data.

Note the following:

• Caution when looking at Hospitals with n<=25
• National Top 10% of hospitals submitting data was 99%
• Indiana Average of hospitals submitting data was 77%
• National Average of hospitals submitting data was 76%
• This is based on data submitted to CMS from Jan 08 to Dec 08
• Some hospitals sampled. Other Hospitals reported on all eligible patients

HF-1 n Hospital Name
100 303 PORTER, VALPARAISO HOSPITAL
100 60 MORGAN HOSPITAL AND MEDICAL CENTER
100 41 BLUFFTON REGIONAL MEDICAL CENTER
100 22 DUPONT HOSPITAL LLC
100 9 COMMUNITY HOSPITAL OF BREMEN INC
100 38 ST VINCENT WILLIAMSPORT HOSPITAL INC
100 33 TIPTON HOSPITAL
100 27 JASPER COUNTY HOSPITAL
100 25 ST MARY'S WARRICK HOSPITAL INC
99 250 ST MARGARET MERCY HEALTHCARE CENTERS
99 327 ST CATHERINE HOSPITAL INC
99 169 ST JOSEPH HOSPITAL
99 101 RIVERVIEW HOSPITAL
99 296 INDIANA HEART HOSPITAL, THE
98 102 HOWARD REGIONAL HEALTH SYSTEM
97 252 ST MARY MEDICAL CENTER INC
96 251 CLARK MEMORIAL HOSPITAL
96 49 MEMORIAL HOSPITAL
96 191 COMMUNITY HOSPITAL OF ANDERSON AND MADISON COUNTY
95 751 CLARIAN HEALTH PARTNERS INC D/B/A METHODIST IUU
95 111 KING'S DAUGHTERS' HOSPITAL AND HEALTH SERVICES,THE
95 188 ST MARGARET MERCY HEALTHCARE CENTERS
95 42 DUNN MEMORIAL HOSPITAL
94 80 JOHNSON MEMORIAL HOSPITAL
94 358 WILLIAM N WISHARD MEMORIAL HOSPITAL
94 98 GOSHEN GENERAL HOSPITAL
94 49 HENRY COUNTY MEMORIAL HOSPITAL
94 291 REID HOSPITAL & HEALTH CARE SERVICES INC
94 363 BALL MEMORIAL HOSPITAL INC
92 218 GOOD SAMARITAN HOSPITAL
92 64 GREENE COUNTY GENERAL HOSPITAL
91 180 ST ANTHONY MEMORIAL HEALTH CENTERS
91 264 COMMUNITY HOSPITAL
91 91 CLARIAN WEST MEDICAL CENTER
91 23 MONROE HOSPITAL
90 331 ST MARY'S MEDICAL CENTER OF EVANSVILLE INC
90 52 KOSCIUSKO COMMUNITY HOSPITAL
90 10 WABASH COUNTY HOSPITAL
89 160 MARION GENERAL HOSPITAL
89 55 DECATUR COUNTY MEMORIAL HOSPITAL
88 267 FLOYD MEMORIAL HOSPITAL AND HEALTH SERVICES
88 319 MEMORIAL HOSPITAL OF SOUTH BEND
88 56 WITHAM HEALTH SERVICES
88 26 ST VINCENT FRANKFORT HOSPITAL INC
87 231 METHODIST HOSPITALS, INC
87 223 TERRE HAUTE REGIONAL HOSPITAL
87 45 PARKVIEW HUNTINGTON HOSPITAL
87 54 MAJOR HOSPITAL
85 119 HENDRICKS REGIONAL HEALTH
85 13 GIBSON GENERAL HOSPITAL
85 33 ADAMS MEMORIAL HOSPITAL
84 318 ST VINCENT HEART CENTER OF INDIANA LLC
84 38 DUKES MEMORIAL HOSPITAL
82 131 COLUMBUS REGIONAL HOSPITAL
82 55 WESTVIEW HOSPITAL
81 412 UNION HOSPITAL, INC
81 37 DEKALB MEMORIAL HOSPITAL INC
81 42 SCOTT COUNTY MEMORIAL HOSPITAL AKA SCOTT MEMORIAL
80 185 BLOOMINGTON HOSPITAL
80 258 SAINT JOSEPH REGIONAL MEDICAL CENTER - SOUTH BEND
80 465 LUTHERAN HOSPITAL OF INDIANA
80 25 CAMERON MEMORIAL COMMUNITY HOSPITAL INC
79 19 WHITE COUNTY MEMORIAL HOSPITAL
78 153 LAPORTE HOSPITAL AND HEALTH SERVICES
78 67 SCHNECK MEDICAL CENTER
76 46 SAINT JOSEPH'S REGIONAL MEDICAL CENTER - PLYMOUTH
76 144 SAINT JOHN'S HEALTH SYSTEM
74 563 DEACONESS HOSPITAL INC
74 31 ST VINCENT CARMEL HOSPITAL INC
73 210 ST ELIZABETH CENTRAL
73 56 ST CLARE MEDICAL CENTER
73 33 PERRY COUNTY MEMORIAL HOSPITAL
72 576 ST VINCENT HOSPITAL & HEALTH SERVICES
72 18 PARKVIEW WHITLEY HOSPITAL
72 36 SAINT CATHERINE REGIONAL HOSPITAL
72 40 BEDFORD REGIONAL MEDICAL CENTER
71 245 COMMUNITY HOSPITALS OF INDIANA INC (EAST)
70 80 ST JOSEPH HOSPITAL & HEALTH CENTER INC
70 100 ST FRANCIS HOSPITAL AND HEALTH CENTERS
70 47 CLARIAN NORTH MEDICAL CENTER
69 227 PARKVIEW HOSPITAL
69 32 MARGARET MARY COMMUNITY HOSPITAL INC
68 44 PARKVIEW LAGRANGE HOSPITAL
67 420 ST FRANCIS HOSPITAL AND HEALTH CENTERS-INDIANAPOLI
66 228 ST ANTHONY MEDICAL CENTER OF CROWN POINT
64 164 COMMUNITY HOSPITAL SOUTH
63 27 DAVIESS COMMUNITY HOSPITAL
60 53 LAFAYETTE HOME HOSPITAL
60 65 COMMUNITY HOSPITAL NORTH
59 29 SULLIVAN COUNTY COMMUNITY HOSPITAL
59 27 HARRISON COUNTY HOSPITAL
56 27 STARKE MEMORIAL HOSPITAL
52 98 DEARBORN COUNTY HOSPITAL
52 149 MEMORIAL HOSPITAL AND HEALTH CARE CENTER
50 36 WEST CENTRAL COMMUNITY HOSPITAL
50 12 PUTNAM COUNTY HOSPITAL
48 62 FRANCISCAN PHYSICIANS HOSPITAL LLC
48 21 ST VINCENT CLAY HOSPITAL INC
45 304 ELKHART GENERAL HOSPITAL
42 86 HANCOCK REGIONAL HOSPITAL
41 46 PARKVIEW NOBLE HOSPITAL
41 44 ST VINCENT RANDOLPH HOSPITAL INC
34 90 FAYETTE REGIONAL HEALTH SYSTEM
33 21 PINNACLE HOSPITAL
25 4 ST FRANCIS HOSPITAL MOORESVILLE
23 13 JAY COUNTY HOSPITAL
11 9 ST VINCENT MERCY HOSPITAL
10 10 ST VINCENT JENNINGS HOSPITAL INC

Joint Commission issues Sentinel Event Alert Regarding Leadership

On 8-27-09, the Joint Commission released a Sentinel Event Alert regarding leadership and its commitment to safety.

You can find the entire alert here.
The press release can be found here.

Within the alert are 14 recommendations for the governing body, CEO, and senior managers:

1. Define and establish an organization-wide safety culture that includes a code of conduct for all employees, including contract workers.
2. Institute an organization-wide policy of transparency that sheds light on all adverse events and patient safety issues within the organization, thereby creating an environment where it is safe for everyone to talk about real and potential organizational vulnerabilities and to support each other in an effort to report vulnerabilities and failures without fear of reprisal.
3. Make the organization’s overall safety performance a key, measurable part of the evaluation of the CEO and all leadership.
4. Ensure that caregivers involved in adverse events receive attention that is just, respectful, compassionate, supportive and timely. Also, make sure they have the opportunity to fully participate in the investigation, risk identification and mitigation activities that will prevent future adverse events.
5. Create and communicate a policy that defines behaviors that are to be referred for disciplinary action; include the timeframe that the disciplinary action should take place.
6. Regularly monitor and analyze adverse events and close calls quantitatively and communicate findings and recommendations to leadership, the board and staff. Conduct root cause analyses of adverse events. Look for patterns in root causes that identify latent hazards and weaknesses in the defenses against errors—the holes in the slices of cheese—and make sure they are addressed.
7. Regularly hold open discussions with risk management, performance improvement, physician, nursing and pharmacy leaders, and with physicians and staff caring for patients, to develop a true, unvarnished view of the safety risks and barriers to safety facing patients and staff. Patient safety rounds at the point of care could provide the ideal opportunity for these discussions, which should focus on learning and improvement, not blame or retribution.
8. Prioritize and address safety risks and barriers to safety according to a timeline, with the highest priority items getting immediate attention. Make a visible commitment of time and money to improve the systems and processes needed to defend against hazards and minimize unsafe acts. For example, some organizations create an emergency patient safety fund.
9. Establish partnerships with physicians and align their incentives to improving safety and using evidence-based medicine.
10. Add a human element and a sense of urgency to safety improvement by having patients communicate their experiences and perceptions to board members, executive leadership, medical staff, and other key leadership groups; also solicit patient input into safety design.
11. When planning and implementing safety improvements, use the expertise of front-line staff who understand the risks to patients and how processes really work.
12. Regularly measure leadership’s commitment to safety using climate surveys and upward appraisal techniques (in which staff review or appraise their managers and leaders).
13. When leaders assess managers during the annual performance review, make sure they ask about the safety issues the manager encountered, how they were handled, and the impact their actions had on reducing unsafe conditions.
14. Communicate to staff when their work improves safety. Reward and recognize those whose efforts contribute to safety.

Personal Opinion: Although senior leadership has the responsibility for creating a structure that is conducive to improving patient safety, senior leadership is also the least effective group to actually improve patient safety. It is the bedside staff that can impact patient safety the most - if allowed to by senior leadership. Maybe this list should have included more recommendations for senior leadership to empower the bedside staff to proactively assess and redesign their work flow to minimize risk factors?

TJC: Measuring Hand Hygiene Adherence: Making the What, Why and How Decisions

The Joint Commission issued a press release tonight about a monograph they have been working on. The full text of the press release follows.

WARNING: The monograph is 232 pages and weighs 4.46MB!
You can download the monograph here.

(OAKBROOK TERRACE, Ill. – April 14, 2009) Preventing infections is critical to patient safety. Effective hand hygiene practices have long been recognized as the most important way to reduce the transmission of potentially deadly germs in health care settings. To help health care organizations target their efforts in measuring hygiene performance, The Joint Commission is releasing “Measuring Hand Hygiene Adherence: Overcoming the Challenges.”

The monograph is the result of a two-year collaboration with major infection control leadership organizations in the United States and abroad to identify effective approaches for measuring adherence to hand hygiene guidelines in health care organizations. In addition to The Joint Commission, the participating organizations include the Association for Professionals in Infection Control and Epidemiology, Inc. (APIC), the Centers for Disease Control and Prevention (CDC), the Society for Healthcare Epidemiology of America (SHEA), the World Health Organization (WHO) World Alliance for Patient Safety, the Institute for Healthcare Improvement (IHI) and the National Foundation for Infectious Diseases (NFID).

Measuring compliance with hand hygiene practices has long been complicated because of the need to monitor the practices of many different care providers in numerous locations for sufficient periods of time. Without standardized approaches to measuring hand hygiene performance, it is impossible to determine whether overall performance is improving, deteriorating or unchanged as new strategic interventions are introduced. The Joint Commission’s National Patient Safety Goals require credited organizations to follow recognized hand hygiene guidelines; however, studies continue to show that adherence to these guidelines is lacking. This is due, in part, to the variation in approaches to measurement, which makes rates of adherence difficult to compare.

The monograph provides a framework to help health care workers make necessary decisions about when, why and how to measure compliance with hand hygiene. The monograph systematically reviews the strengths and weaknesses of commonly used approaches. Examples of measurement methods and tools in the monograph, which also includes references to evidence-based guidelines and published literature, were submitted by organizations through the Consensus Measurement in Hand Hygiene project. The project was supported by an unrestricted educational grant from GOJO Industries, Akron, Ohio.

“Measuring hand hygiene adherence is not a simple matter,” says Jerod M. Loeb, Ph.D., executive vice president, Division of Quality Measurement and Research, The Joint Commission. “The monograph can help health care organizations more effectively measure compliance and strengthen improvement activities that save lives and money.”

“Monitoring hand hygiene is useful only if the methods are valid and reliable and the results are widely disseminated and used to improve practice,” says Elaine Larson, R.N., Ph.D., F.A.A.N., C.I.C., scientific advisor for the project and associate dean for research at the Columbia University School of Nursing, New York. “This Monograph will be an invaluable resource to institutions struggling to do it right.”

Electronic copies of the monograph are available on The Joint Commission’s Web site at http://www.jointcommission.org/PatientSafety/InfectionControl/hh_monograph.htm. A free printed copy is available by calling The Joint Commission’s Department of Customer Service Center at 630-790-5800, option 5, or sending an email to customerservice@jointcommission.org.

Joint Commission Changes its Changes

Posted on the Joint Commission website today:


Hospital deeming application: March 2009 Update
In January 2009, The Joint Commission posted 165 new and revised requirements as part of its hospital deeming application to the Centers for Medicare & Medicaid Services (CMS). Following discussions with CMS, a number of those requirements were considered equivalent to existing elements of performance or were already addressed in The Joint Commission survey process. As a result, the number of new and revised requirements has been reduced to 87.

Revised 2009 Accreditation Requirements as of March 26, 2009 - Hospital Accreditation Program

Changes to Accreditation Requirements between January 5, 2009 and March 26, 2009 documents - Hospital Accreditation Program

ISBAR?

The IHI posted a tool from Rhode Island Hospital that they call ISBAR.

At first glance, this appears to be the same as SBAR with I (Identify) inserted at the beginning of the process.

The full text as well as the tool itself can be downloaded from the IHI website at: http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/ISBARTripTick.htm

You will need to be logged into the IHI website to download the tool.

Joint Commission to review NPSG 8 - Medication Reconciliation

The Joint Commission posted on their website yesterday that, due to the difficulty hospitals are having with implementation, they will be reviewing NPSG 8 - Medication Reconciliation.

Specifically:

Today, The Joint Commission Accreditation Committee determined that effective January 1, 2009, survey findings on National Patient Safety Goal 8 (Accurately and completely reconcile medications across the continuum of care) will continue to be evaluated during the on-site survey. However, given the difficulties that many organizations are having in meeting the complex requirements of NPSG 8, the Accreditation Committee agreed that The Joint Commission should evaluate and refine the expectations for accredited organizations. While this evaluation is being conducted, survey findings from NPSG 8 will not be factored into the organization’s accreditation decision. In addition, survey findings on NPSG 8 will not generate Requirements for Improvement (RFIs) and will not appear on the accreditation report.

You can read the entire posting at the Joint Commission Website here.

Comment Period for Nursing Sensitive Care Measures

The NQF today announced a comment period for the Nursing Sensitive Care Performance Measure Set. The project summary can be found here. The deadline for public comments is Feb 26, 2009.

This project summary document provides a history of the development of this measure set and how it was tested nationally. Of interest to the acute care quality professional is the last paragraph that reads:

Following a detailed discussion of each individual measure, there was consensus among the members to recommend that each of the measures move forward. The NSC measure set is due to undergo a maintenance review by the National Quality Forum in early 2009. The Hospital Quality Alliance Principals adopted the measure set in December 2008, pending NQF endorsement. The Joint
Commission is currently in the process of considering the set as an additional core measure selection option.

Remember that NQF endorsed measures have a tendency to be selected by CMS for public reporting. If you are wondering what measures make up this set, they are listed here:

1. Death among surgical inpatients with treatable serious complications (failure to rescue).
2. Pressure ulcer prevalence
3. Falls prevalence
4. Falls with injury
5. Restraint prevalence
6. Urinary catheter-associated UTI for ICU patients
7. Central line catheter-associated blood stream infection for ICU and HRN patients
8. Ventilator-associated pneumonia for ICU and HRN patients
9. Smoking cessation counseling for AMI
10. Smoking cessation counseling for HF
11. Smoking cessation counseling for PN
12. Skill Mix (RN vs LPN vs unlicensed assistive personnel, vs contract)
13. Nursing care hours per patient day
14. Practice environment scale - Nursing work index
15. Voluntary turnover