SNF patient safety, Alzheimer’s and Dementia Conversation Starter Kit
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This Week at the Institute for Healthcare Improvement
May 23, 2016
Improving Patient Safety
in Skilled Nursing Facilities

Just like hospital patients, skilled nursing facility (SNF) patients don't expect to suffer harms such as falls, infections, or pressure ulcers. But many do. A federal study indicated that 33 percent of Medicare beneficiaries experience an adverse event during their SNF stays. Of those events, 59 percent were preventable. An interview with Lee Adler, DO, Adventist Health System Senior Advisor for Safety, Quality, and Innovation, describes how this alarming data led to the development of the IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events. Dr. Adler is one of the tool’s co-creators and faculty for the IHI Virtual Expedition: SNF Trigger Tool – Measuring Patient Harm in Skilled Nursing Facilities.

New Alzheimer’s and Dementia Conversation Starter Kit

It’s not easy to talk about how you want the end of your life to be. And when you or someone you love has Alzheimer’s disease or another form of dementia, that conversation can be all the more difficult — and that much more important. The Alzheimer's Disease and Other Forms of Dementia Conversation Starter Kit is the latest resource developed by IHI and The Conversation Project. This new Starter Kit provides guidance for starting conversations about end-of-life care in the early stages of decline, and for using the Kit to speak on your loved one’s behalf when advanced illness occurs.

Health Care in Motion: WIHI, May 26

IHI Chief Medical and Scientific Officer Don Goldmann has been thinking a lot about the current state of quality improvement and new value-driven initiatives that have health care organizations undertaking unprecedented levels of financial risk and undergoing rapid transformation. On the next WIHI (Thursday, May 26, 2-3pm ET), Don will discuss these and other provocative topics: Why is it so hard for the US health care system to measure patient-reported outcomes? Are radical redesign of measures and lessening the associated burden on providers possible? Are we learning fast enough from demonstration projects to transform US health care? Will MACRA better align reimbursements with quality of care?

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IHI faculty Dr. Carolyn Gould from the Centers for Disease Control and Prevention helps us understand how hospitals can successfully tackle C. difficile

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The Journal of Oncology Practice reports that “Managing the Clues in Cancer Care,” co-authored by IHI Senior Fellow Len Berry, was their most-accessed editorial in April

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The National Quality Forum is hosting a free webinar on Wednesday, May 25 (1:30-3:00pm ET) to launch “Antibiotic Stewardship in Acute Care: A Practical Playbook” and discuss how hospitals can use the Playbook to support their efforts


In memoriam: Nancy Ridley, IHI colleague and patient safety pioneer from the perspective of regulatory agencies, recently passed away. For 33 years she served in various roles at the Massachusetts Department of Public Health, working to make the state's health care system among the best and safest in the US.

Who's at IHI?
Health professionals from 20 countries are at IHI this week for the IHI and Harvard T.H. Chan School of Public Health’s International Leadership Development Program for Physicians.
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