Fall Newsletter 2012

From the President’s Desk:

I hope that all of you are preparing to celebrate our profession during Healthcare Quality Week (October 14-20, 2012). The national theme this year is the “Face of Quality” which emphasizes the diversity of the disciplines that comprises our profession. I am hoping to present a photo array of the faces of Arkansas Quality at our Educational session December 6. Governor Mike Beebe has proclaimed this week as Healthcare Quality week in Arkansas and several of us will be meeting with the Governor to receive the proclamation. The goal of HQW is to recognize the efforts and celebrate the value of healthcare quality professionals.

AAHQ had great participation at NAHQ in Tampa, Florida this year. Susan Hapner, Stephanie Iorio-Minnes, and I participated in the second NAHQ leadership session. Sandra Bennett presented Many Paths, One Destination: Our Journey Toward Reducing Readmissions. Sandy was well received and led a lively discussion among the attendees.

The AAHQ booth and “little rocks” were a hit and we had a slide show of Arkansas scenes, our awards, and photos of our members (created by Lynnette Jack). We had many wonderful opportunities to network with our peers from around the country (and several from abroad). Many of us attended a CPHQ reception, a SIG (special interest groups), the NAHQ president’s reception and many wonderful thought-provoking educational offerings. We laughed and cried with Greg Risberg during a general session on “How to Stay Energized in a Changing World.” Dr. Carolyn Clancy from AARQ presented Patient-Centered System Transformation: New Opportunities for Quality Improvement”. The NAHQ Membership Meeting focused on what NAHQ can do to help meet the needs of the membership. Dr. Susan Mellott (one of our favorite CPHQ Review Course leaders) won the Claire Glover Award-the highest individual NAHQ award.

It has been a busy educational season, starting with our CPHQ Review Course (sponsored by ADN) in August. Plans for the December 6 AAHQ meeting are just about confirmed and the board, the Education Action Team and I are looking forward to presenting a well- balanced, informative program. Congratulations to AAHQ past-president Lana Williams, BSN, RN, CPHQ on her promotion to CNO at Arkansas Methodist Hospital in Paragould. We thank American Data Network and our other sponsors who enable us to present so many wonderful offerings at a reasonable cost to our membership. We welcome our new members who joined AAHQ at the CPHQ review.

This year we are sharing articles that have been written by our NAHQ colleagues (we are working smarter and not harder!). This opportunity allows us to share more of the content of the NAHQ sessions with our membership- one of the perks of networking on the national level.

Put a face on celebrating healthcare quality this month and send us your pictures!

Best regards,
Martha Clardy Chamness
MNSc., RN, CPHQ
President, AAHQ
University of Arkansas for Medical Sciences

CPHQ and Candy

AAHQ sponsored a CPHQ Review Course on August 27-28, 2012 led by Dr. Susan Mellott from Mellot & Associates. Thirty-seven attendees participated in Dr. Mellot’s interactive approach to content presentation.

The two day course provided an overview of concepts that are addressed in the current CPHQ exam including: total quality management, patient safety, elimination of medical errors, effective information management, statistical analysis and data interpretation tools used in performance improvement, strategic management process, change management, FMEA and continuous readiness programs. Attendees enjoyed a data analysis exercise using M&M candies. Attendees were especially effusive in their praise of Dr. Mellott and the course:

“Unbelievable value! One of the best workshops I have ever attended. Speaker informative, captivating and inspiring.”

“The entire course was extremely informative & helpful, but the information management chapter was especially helpful & you made it very easy to understand. Thank you very much!”

“I really enjoyed your statistics review. It made all of those key concepts much easier to understand. Thank you!”

“The entire class was so excellent – I can honestly say I cannot think of one thing to make it more effective & please, please, do not close the M& Ms. That is the first time I’ve ever used M & Ms as data – how fun as well as making a great point! Thank you!”
Pareto Diagram

AAHQ is proud to bring high quality educational opportunities to healthcare quality professionals in Arkansas. The CPHQ Review Course was made possible through the generous support of American Data Network.

SPONSOR

ARKANSAS FOUNDATION FOR MEDICAL CARE
Julie Kettlewell, RNP, AVP of Quality Programs
1020 West 4th Street, Suite 300
Little Rock, AR 72201
Phone 501-212-8740
E-Mail jkettlewell@afmc.org
Website www.afmc.org

The Arkansas Foundation for Medical Care (AFMC) was incorporated in 1972 as a private, nonprofit educational organization dedicated to the evaluation and improvement of health care. We are the federally designated quality improvement organization (QIO) for Arkansas. Our staff includes physicians, nurses, statisticians, educators, communicators – professionals with widely varied expertise, at various stages of life and career, who have been on both sides of the health care system. We work with staff in every health care setting and offer free tools and resources, such as educational materials for patients and providers and help with Medicare and Medicaid issues. We review certain types of health care paid for by Medicare and Medicaid to ensure high-quality, cost-effective care and to resolve beneficiary concerns. We help find evidence-based ways to improve preventive care as well as treatment and management of specific illnesses and conditions. We are also a health information technology regional extension center (HITREC), federally funded to provide technical assistance to health care providers as they make the transition to electronic health records. Our roles and responsibilities are constantly evolving, but they all serve the purpose of building support systems and partnerships, and helping focus the efforts of the health care community, agencies and organizations toward common goals. Together, we’re working to make health care safer, more effective and more efficient.

Member Spotlight…

Dottie Gann
MSN, RN, CRRN, CPHQ

Dottie Gann, is the Performance Improvement Nurse Manager for Central Arkansas Veterans Healthcare System (CAVHS). Dottie graduated as a non-traditional student in 1996 from Henderson State University at the age of 36. She began working at CAVHS as a VALOR student (Veterans Affairs Learning Opportunities Residency) the summer of her senior year and became employed full time as a Registered Nurse on the dementia unit directly after graduation. Dottie became an assistant nurse manager in 1998 and a Nurse Manager on a rehabilitation unit in 1999. During her time on the rehab unit she became a certified rehabilitation nurse.

Dottie became interested in quality during the 7 years she spent as a Nurse Manager but
admits she never really understood data or the concepts relating to quality management and Performance Improvement. She did not know where data came from or how graphs were made. In 2006 because of her experience as a Nurse Manager and her work ethic, Dottie became the facility’s nurse recruiter supervisor. It was now imperative that she used graphs, spreadsheets, and databases. Most of her early data experiences were trial and error but she did learn enough basic applications to track, trend, and report simple data.

Dottie states she really became serious about data and quality management when she was asked to assume the responsibility of performance improvement nurse manager (until a new PI nurse manager could be hired). She learned everything she could about quality concepts and
decided there was so much to learn that she would just have to apply for the PI NM position because she saw the potential of teaching healthcare quality to other nurses. During this time, Dottie also completed her MSN and has become a certified green belt in lean management principles. Dottie is also a mentor and is an active participant in a data analytics certificate program pilot for the facility.

Dottie currently manages a staff of eight experts who compose the PI team and are truly outstanding nurses. She was determined to develop her healthcare quality expertise in her role as PI Nurse Manager (to feel effective in her position). She studied for the CPHQ examination and became certified in July 2012. She reports it was one of the most challenging things she has ever done as a nurse, but definitely worth the journey. She was also the gracious recipient of the AAHQ reimbursement grant for new CPHQ certified nurses. Dottie is very proud to be a member of AAHQ which is an organization dedicated to quality and safety.

Sandra J. Grinder, MSN, RN, CPHQ, NE-BC
Membership Team Leader
Central Arkansas Veterans Healthcare System

Many Paths, One Destination: Our Journey Towards Reducing Readmission

Sandra S. Bennett, RN, BSN, CPHQ, and Director of the Quality Management Department (QMD) of the University of Arkansas for Medical Sciences presented this timely topic on the final day of NAHQ in Tampa, Florida. As readmissions may become a money pit, UAMS, like all institutions, have been on a journey to find what works and what doesn’t. Ms. Bennett reported the beginnings of the journey which included Project Red, a QMD and Care management team, hiring of a QA Coordinator for Readmissions, A CMS “fee for service” application and restructuring of the Care Management Team.

Medication reconciliation issues on discharge were identified as a major factor in readmissions. The pharmacy chair of the Medication Reconciliation is a very active member of the team who has initiated Project Red on a pilot unit, piloted a medication reconciliation project by pharmacy, and has formed a medication history consult service.

The QMD has been reviewing all (CHF, AMI, PN) readmissions within the thirty day window and has developed a data base. To date the problems identified have been medication reconciliation, patient discharge instructions, and follow-up appointments. A peer review process has been developed to address outliers with physicians. QMD has also partnered with the patient education department to initiate and utilize the Teach Back principles.

Care Transitions is also on the road map. UAMS is participating in the HEN (health engagement network), a Care Link commitment (contracting with UAMS, this group makes an initial patient contact in the hospital and then follows up with a home visit after discharge with the goal of a 20% reduction in readmission by 2013). The committee is also formulating a plan to foster stronger alliances with area post- acute care facilities.

After presenting the UAMS journey, Ms. Bennett directed a lively discussion with the session attendees. The participation of the group added good value to the discussion and clearly pointed out that we are all on the same road. There are many interventions that will reduce readmissions but there is no one yellow brick road to follow.
My thanks to Sandy Bennett for presenting this timely and informative topic at NAHQ. She represented AAHQ and UAMS well.

Martha Clardy Chamness
MNSc., RN, CPHQ
President, AAHQ
University of Arkansas for Medical Sciences

GET THE FACTS!

COST of Patient-Handling Injuries

53%: Percentage of injuries responsible for compensation costs among patient-care staff.
72%: Percentage responsible for musculoskeletal injuries among patient-care staff.
$578: Cost per claim for full-time (full-time equivalent) physical and occupational therapy aides.
$347: Cost per claim for full-time (full-time equivalent) nursing aides.
$185: Cost per claim for full-time (full-time equivalent) patient transporters.
Source: Division of Occupational and Environmental Medicine study, Duke University Medical Center- 2011.
To get the complete article emailed to you or for further information about Guldmann Lift Products contact mark.ruble@att.net, (501) 951-1776.

RESULT from Reducing Injuries

One hospital shares its success story. (From Susie Haseloff, CRRN, Employee Health Nurse and Safe Patient Handling Champion at Methodist Rehab Center in Alabama) This four-year evidence based data shows a drastic decrease of employee injuries and a reduction in lost work days and reduced days worked with restrictions after implementing a Safe Patient Handling Initiative. They determined Lift Systems are a Great Employee Benefit!

Celebrate Healthcare Quality Week

Celebrate the dedication of healthcare quality and patient safety professionals during National Healthcare Quality Week (HQW), October 14-20, 2012. HQW highlights the work of healthcare quality and patient safety professionals and their influence on improved patient care outcomes and healthcare delivery systems.

NAHQ members are encouraged to alert administrators, allied health professionals and the
public about the impact of healthcare quality through special events during the week of October 14-20, 2012.

Celebrate quality with activities, education, and planning tips from NAHQ!

HQW Planning Materials
HQW Promotional Products – coming soon!
HQW Logo & Poster

HORCHER LIFTING SYSTEMS, INC.
Tom Fitzgerald, Director of Sales
1620 S.W. 17th Street
Ocala, FL 34471
Phone 918-629-2043
Email: tom.fitzgerald@horcher.com
Website: www.horcher.com

Since 1986 Horcher has been designing, manufacturing and distributing aids such as patient lifts, lifting slings, bathing systems and bedpan cleaning systems for the elderly and disabled. Thank you for letting us serve you for more than 25 years!

WCMC Receives Arkansas Governor’s Quality Award

(top row) WCMC President/CEO Ray Montgomery; A VP/DON Peggy Turner; AVP of Ancillary Services Scotty Parker; Director of Marketing Brooke Pryor; Administrative Secretary Kim Ezell; and, AVP of Fiscal Services B.J. Roberts; (bottom row) AVP of Surgical Services Tisa Carlisle; Director of Case Management and Performance Improvement Connie Taylor; VP of Patient Care Services LaDonna Johnston; Director of Quality, Risk & Regulatory Compliance Debbie Hare; and, AVP of Specialty Services Ramona Staton.

White County Medical Center is pleased to announce that it has received the prestigious Governor’s Quality Award. The honor was given to hospital representatives at the recent Governor’s Quality Award banquet, in which Arkansas Gov. Mike Beebe recognized WCMC with the award.

“We know that the future of healthcare rests in our ability to provide superior care for our patients,” said WCMC President/CEO Ray Montgomery. “We do not want to be merely average or good; we want to be ‘world class.’”

The Arkansas Governor’s Quality Award is the highest level of recognition presented to state organizations that have demonstrated the highest level of performance excellence through their practices and achievements.

“It is an enormous honor to accept this award and we are so humbled to be the only hospital that has won this honor twice,” said Vice President of Patient Services LaDonna Johnston. “We hope this truly paints a picture of our commitment to utilizing this process and our recognition of the processes value to our organization and to our customers. It is the quest for excellence that we all strive for in healthcare.”

“The Governor’s Quality Award allows organizations like ours to look at various areas of our hospital, from a leadership and strategic planning perspective, as well as human resources and processes in order to measure our overall results,” Johnston said. “It is a transparent and objective way of looking at our level of achievement and how we arrived here, much like a road map guides your journey to a specific destination; we want to continue on this route to achieve even higher levels of success in providing quality patient care and creating a healthy community.”

WCMC is the only hospital in Arkansas to receive the Governor’s Quality Award twice; the hospital also received the prestigious Governor’s Quality Award in 2002.

The goal of the Governor’s Quality Award Program is to encourage Arkansas organizations to engage in continuous quality improvement, which leads to performance excellence, and to provide significant recognition to those organizations. The Governor’s Quality Award was founded by Arkansas business leaders who understood the need to recognize companies reaching for the highest standards in their products, services and processes and who understood the need for organizations to have the tools and training to improve and to strive for performance excellence. The Governor’s Quality Award Program, a private non-profit 501(c)(3) corporation, was established in 1994 for the purpose of supporting the broad based use of quality principles throughout Arkansas to drive performance improvement.

ABOUT WHITE COUNTY MEDICAL CENTER
As the leading healthcare provider in a six-county area, White County Medical Center associates strive to create a healthy community by providing quality patient care and participating in community health events. White County Medical Center is the second-largest employer in a six-county area with more than 1,600 associates. The facility has a combined total of 438 licensed beds and a medical staff of 150 physicians that specialize in various areas of healthcare.
Press Release from WCMC 9/27/2012

Quality: Fourth leg of the health care delivery stool

Reflecting more than 200 years description of ‘three legged stool’ (hospital concept of Benjamin Franklin), a model of a hospital is organized with the board, administration, and the medical staff as the three legs of the stool supporting a platform for patient care delivery.

As we enter a new era of thinking on quality and patient safety, numerous new measures of health care quality are becoming public on an ongoing basis. Regulatory agencies, State governments, payors and others are requiring reporting with focus on outcomes pursuant to such measures. Pay-for-performance programs are here to stay along with new generation of “gainsharing” proposals.

This heightened spotlight given to health care quality measurement and reporting obligations and how quality of care affects matters of cost controls, efficiency, reimbursement, collaboration between organizational providers and practitioners sparks a renewed interest for hospital board, administration, and the medical staff. Especially board members who have the organization oversight function are increasingly expected to assess organizational performance on emerging quality of care concepts with focus on patient safety, appropriate levels of care maintaining high standards of quality health care delivery.

‘Corporate Responsibility and Health Care Quality’ article released by the American Health Lawyers Association and the Office of the Inspector General of the United States Department of Health and Human Services sums up the present health care system, “The U.S. health care system is at a challenging point in its history. It is extraordinarily advanced, yet is inefficient, uneven and too often unsafe. A consensus is forming that improvement in the system will require better collaboration and cooperation among independent providers, payors and purchasers, more integrated care and better aligned incentives.” A scorecard on the U.S. health care system developed by the Commonwealth Fund in 2006 recommended – The U.S. should expand health insurance coverage; implement major quality and safety improvements; work toward a more organized delivery system that emphasizes primary and preventive care that is patient-centered; increase transparency and reporting on quality and costs; reward performance for quality and efficiency; expand the use of interoperable information technology; and encourage collaboration among stakeholders.

With the above premise, it opens a great opportunity for the best performers in the industry to initiate profound change—and then open up these best practices through transparency of data and the promotion of collaboration to spread change. Health care organizations generally view themselves as mission-driven providing a nurturing environment that supports the health and well- being of patients and their families. As hospitals must be responsive to the changing needs and values of patients, families and the community, health care ‘quality’ assumes a vital role in the accomplishment of health care organizations mission. The board along with administration and the medical staff are in a unique position to take the lead in implementing quality systems that will advance their organizations’ respective missions contributing towards the nation’s health.

Apparently, as there is not a one size fits all mantra for the integration of Quality with the work of Board, Administration and the Medical staff, below are a few basic essentials that would help them examine the scope and operations of the organization’s quality and safety initiatives:
‘Quality Concept’ for Board, Administration and Medical Staff

To understand the evolving realities of ‘Quality’ focus and if it has not already been done, should elevate quality to the same level of priority as is financial viability and regulatory compliance.
To develop an understanding of the quality and patient safety issues and then focus on performance goals that drives the organization to provide the best quality and most efficient care.
Board, Administration and the Medical staff should have an explicit expectation of the organization’s quality improvement program and its goals. The various metrics and benchmarks are to be understood to measure progress towards achieving the performance goals.
To make sure the performance goals are directed towards improvement of quality of patient care and integrated with the mission and strategic objectives of the organization and identify leaders responsible for implementation of such programs.
To provide required resources to have the appropriate systems and processes in place to support patient safety and clinical quality.
To have organization’s credentialing, privileging, competency assessment and training, peer review process adequately recognize the necessary focus on clinical quality and patient safety.
Effective leadership has been described as a means to achieve competitive advantage (Day, 2000). With declining reimbursements, heightened competition, informational and medical technologies development, staff turnover and shortages, etc. ‘Quality’ can provide the competitive advantage to administration.

Quality improvement and safety initiatives success depends on culture, leadership and staff engagement. Quality professionals’ key question – how to integrate and engage leadership and staff in a multitude of quality, safety and other priorities and create a culture of safety and quality improvement so that it becomes a fabric of the organization is directly related to Board, Administration and Medical Staff. The three legs in Board, Administration and Medical staff and the quality professionals’ (fourth leg) work in tandem to lay out a broader vision and strategy will define the new era of healthcare organizations survival and growth.

References:
The Commonwealth Fund Commission on a High Performance Health System, “Why Not the Best? Results from a National Scorecard on U.S. Health System Performance,” The Commonwealth Fund, September 2006.

Arianne N. Callender, Douglas A. Hastings, Michael C. Hemsley, Lewis Morris, Michael W. Peregrine (2010).
Corporate Responsibility and Health Care Quality: A Resource for Health Care Boards of Directors

Day, D.V. 2000. “Leadership Development: A Review in Context.” Leadership Quarterly 11 (4): 581-613

Sujay Kola, MBBS, MHSA, CPHQ, HA
St. Vincent Health

BANCORPSOUTH INSURANCE SERVICES, INC.
Tom Hesselbein, CPCU, Executive VP, Healthcare
(Ramsey, Krug, Farrell & Lensing)
8315 Cantrell Road, Suite 300
Little Rock, AR 72227
Phone 501-614-1134
Email Tom_Hesselbein@rkfl.com

News

From the President’s Desk:

CPHQ and Candy

SPONSOR

Member Spotlight…

Many Paths, One Destination: Our Journey Towards Reducing Readmission

GET THE FACTS!

Sponsors

Celebrate Healthcare Quality Week

WCMC Receives Arkansas Governor’s Quality Award

Quality: Fourth leg of the health care delivery stool

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