From the President’s Desk

 

Happy Summer AAHQ Team,

We ARE a Team, you know.  According to the dictionary, a team is a group that comes together to achieve a common goal.  We may not work in the same facility, come together but twice a year, or even communicate regularly, but we do have a common goal, which is “…to promote and improve the healthcare quality and patient safety in Arkansas…..”  This action-oriented phrase comes from the AAHQ mission statement.  I believe each one of you lives this mission in your daily work.

The remaining phrase of the mission statement speaks to encouraging professional growth of our members. The Board chose this as part of the mission statement because we want each member to reach their highest potential and want the organization to support that pursuit.  Professional growth of individuals strengthens the team as a whole for promotion of improved quality and safety for patients.

Summer is vacation time and I hope each of you are having a fun and safe summer!  Your Board has been busy this summer working on membership, financial, governance and educational activities.  The Communication Team is on the ball getting this newsletter to you and is working on the website and many other activities that will be rolling out soon. Please visit the website if you have not done so lately.  You will get more details from the Education Team in this newsletter.  You will also learn about our financially stability.  Be proud in the fact that our membership is strong.  ALL of this is made possible by YOU, the AAHQ Team! If you have colleagues that are not members of AAHQ, please tell them about membership.

I encourage you to get involved in one or more of the action teams.  It is very rewarding to be an active part of a team.  The AAHQ Board members are all volunteers and many of us have “grown up” on the Board with our beginning as a team member.  Additionally some of the Board members are active at the national level on National Association for Healthcare Quality or Healthcare Quality Foundation teams, which is also professionally gratifying.

I hope all this has given each of you a nudge to think about participation in your professional organization and how your career may be enriched!

See you all soon!

Phyllis Dorrough, MA, RNP, CPHQ
President

Professional Development Round-up!

CPHQ Review Course

Back by popular demand, AAHQ is teaming up with NAHQ to offer a CPHQ Review Course on September 15-16, 2016, in Little Rock.  This is great opportunity for Quality Professionals seeking the certification to further their professional development and for current CPHQs to brush up the most current issues facing the profession.  The cost is only $329 for NAHQ/AAHQ members and 15 CPHQ CE are available for current CPHQs.  AAHQ will provide our legendary refreshments and meals.  Registration is open at CPHQ Review Course Registration.

Fall Education Conference

Returning to our traditional Educational Conference, AAHQ is proud to present “Right Here, Right Now: Quality Projects in Arkansas” on Friday, November 4, 2016, in Little Rock at the Baptist Health Barrow Road Center at 900 John Barrow Rd., Little Rock, AR  72205.   The speaker list is shaping up to be a fantastic day of learning about what is happening in our great state.  Poster sessions and the Silent Auction will help make a great event.  The brochure and more details should be here soon, so SAVE THE DATE!

Call for Volunteers

Professional Development Team needs YOU!  AAHQ’s Educational Conferences are one of the most visible services to the members and central to our mission as an organization.  If you would like to serve on the Professional Development Team, please contact Lynnette Jack mailto:ljack@mqrs.net or 501-379-8980.

NAHQ Virtual Watch Party

All Quality Professionals deal with change on a daily basis and understand that sometimes the rewards of change are great and sometimes the change doesn’t work out the way we hoped.  The NAHQ Virtual Watch Party was a major change from the Spring Educational Conference and didn’t quite live up to our hopes and expectations.   With only a few members registering using the AAHQ discount code, the party wasn’t looking bright.  Wonderfully, Quality Professionals are always able to make the best of situations and AAHQ was invited to join our colleagues and fellow association members from UAMS at their watch party.  AAHQ provided the food and drink and the party was on a roll!  Over twenty Quality Professionals participated in the joint watch party for great education and networking.  We might not do another Virtual Watch Party, but the attendees will have fond memories of the one we had.

 

 

 

 

 

 

Membership Services Update

Member of the Year and Distinguished Member -2016

Usually AAHQ recognizes a Member of the Year at the Spring Conference and the Distinguished Member at the Fall Conference. This year, 2016, both will be recognized at the Fall Conference. Member of the Year is selected from nominations by AAHQ members and based on level of participation in the organization, including team member volunteer, speaking or helping at conferences, writing articles for the newsletter, recruitment of new members, serving as an Officer or Board member, and other involvement in healthcare quality at the state and national level.
The AAHQ Distinguished Member is selected by the Board, based on applications from individuals. This award recognizes a member who has made an outstanding contribution to the quality profession, by contributing to the body of knowledge about quality, publications, educational leadership, poster or other presentations locally, in the state, or nationally. Other requirements include CPHQ certification and membership in AAHQ for at least 5 years. Members of the Board are not eligible for this recognition.
Be thinking about who you might want to nominate for the Member of the Year. A request for nominations will be sent out in September. Also, be thinking about your own contributions to the field of quality and if you might qualify for the Distinguished member award. It is a short application form.

Member Spotlight:

From the front lines to the C-Suite – what an opportunity to spread a culture of quality throughout an organization!

Ashley Gibson, BSN, has been a member of AAHQ for only a couple of years, but has been involved in quality care in one way or another for over 10 years. Ashley received her BSN from the University of Arkansas in Monticello in 2005 and has worked as a nurse in all areas of the hospital, from surgery to OB to ER. In 2012, she became a Case Manager at Delta Memorial Hospital in Dumas. After a stint with AFMC, she returned to Delta Memorial in 2015 as the Director of Quality and Risk Management. While at AFMC, Ashley worked in Care Transitions, the Quality Measures, and PQRS, gaining a wealth of insight about quality from the QIO side. Most recently, she was selected as the new CEO of Delta Memorial Hospital, taking the reins in June of this year. She took the CPHQ preparatory class last year, and still plans to take the certification exam in the near future, as well as remain a member of AAHQ. She values her AAHQ membership for the networking opportunities with other quality professionals as well as the educational programs offered.

Ashley has had a passion for quality for a long time and understands the importance of it. With all the changes coming about in measures, payment, and other regulatory impacts, commitment to quality and maintaining excellence becomes more and more important. Quality will continue to be a priority with Ashley in her new executive leadership role. She has a unique understanding and insight into the overall impact of the processes of quality measurement and improvement on the overall organization and indeed into the whole model of healthcare in the US.

On the personal side, she is a little busy too, with 2 sons, planning a wedding in August, and building a new house. With her marriage, she not only gains a husband, but she will gain a stepson and a stepdaughter. She likes to travel, to do outdoor activities, and to spend time with family.

Finance Action Team Report

 

 

 

 

 

 

 

June 30, 2016

The goal of the Finance Team is to manage funds to support the mission, vision, goals and objectives of AAHQ.  Some of the objectives include:

• Establish corporate sponsorship to alleviate expenses of each education conference.
• Raise funds to submit a minimum of $1000.00 donation to Healthcare Quality Foundation (HQF) annually and sponsor silent auction items at selected conferences each year.
• Provide stipends for delegates/alternates to NAHQ annual meetings or State Leadership Summit,  if funds are available
• Oversee the availability of funds to support day-to-day operations of AAHQ (such as printing, AAHQ pins, postage, conference costs, etc.).
• Secure sponsor for development and maintenance of AAHQ website.

The value of strategic collaborations has truly proven to be an investment in the Arkansas Community. Partnerships have proven to be beneficial to the organization as demonstrated by provision of supplies and AV equipment, donations for door prizes, and representation on AAHQ Board by both American Data Network (ADN) and Arkansas Foundation Medical Care (AFMC).

Reimbursement for CPHQ examination may be considered for members applying for this assistance if funds are available.  If you are interested, you may contact any board member who will be able to respond to any questions you may have about this benefit.

Stipends and/or grants may also be provided to a minimum number of members who apply and are approved (pending availability of funds).   Virtual conferences are now being considered as a part of this application process. If you are interested, you may contact any board member who will be able to respond to any questions you may have about this benefit.

Our huge profits are generally seen from our educational conferences offered each year.    These profits are spent for future conferences and for membership recognition and to assist in support of the mission, vision, goals and objectives of AAHQ. Please thank the Professional Development Team for their great work in generating profits from these conferences.

The financial viability of the AAHQ is strong as evidenced with April 30, 2016 ending with a balance of $33,329.44.  The AAHQ financial year begins in July and ends in June.   The final yearend financial statements will be completed in the next couple of months based on AHA auditing processes.

Submitted by:
Louise Hickman
Finance Team Leader

Sentinel Event Alert (SEA) 53 – Managing risk during transition to new ISO tubing connector standards

Shannon Finley, MSN, RN
Teresa Jeffus, SRN, RN, CPHQ

Abstract:  Joint Commission’s Sentinel Event Alert 53, Managing risk during transition to new International Organization for Standardization (ISO) tubing connector standards, was released in August 2014.  This article gives a brief overview of the University of Arkansas for Medical Science (UAMS) actions, thus far, and the responses to this Alert.  While complete change-over has been paused due to significant manufacturing delays on the national level surrounding production of the recommended connection tubing; UAMS and other healthcare settings remain ready to continue the transition to new tubing connections as products become available.

In the fall of 2014 the University of Arkansas for Medical Sciences (UAMS) received notice of “Sentinel Event Alert (SEA) 53: Managing risk during transition to new ISO tubing connector standards”, (The Joint Commission, 2014). SEA 53 gives a history surrounding the problems encountered with tubing misconnections and outlines the mandated changes for the transition to new ISO tubing connector standards.  The worldwide transition, which started in 2011, is being phased in over six years with planned completion in 2017.  In this global effort, the world’s population has been divided up into three groups with each group having specific phases of implementation.  The United States and Canada are in Group 1; Europe, the Middle East, Africa, Australia and New Zealand are in Group 2; and the United Kingdom and Ireland make up Group 3. Specific timelines for implementation can be found at www.Stayconnected.org

Bedside clinicians are well aware of the battle of matching tubing to the correct pump – as well as the correct medication, and/or correct site. The so-called ‘Spaghetti Syndrome’ as seen with positioning similar looking tubing in close proximity to one another around a patient’s bed is common in intensive care unit environments. It is well documented in healthcare literature that, over the past several years, there have been a number of significant patient safety issues related to errors in tubing misconnections.  These have ranged from minor events with no harm to sentinel evens which resulted in patient death(s).

To implement the recommendations for the Sentinel Event Alert 53, UAMS formed a multidisciplinary team consisting of representatives from Nursing, Pharmacy, Value Analysis Director, Director of Supply Chain and Logistics, Nursing Education, Clinical Engineering, Director of Risk Management, Anesthesiology, Nutrition Services, Occupational Health and Safety, Patient Safety Officer, and Quality Management Department.    Initially the team members were tasked with reviewing the recommendations and brainstorming about ways to avoid connection-related injuries. The next suggested actions, by the Joint Commission in the SEA, were to complete a gap analysis to identify areas that stood compliance ready and look for opportunities for improvement. The UAMS team completed the gap analysis and set up corrective plans to address any identified weaknesses with tubing management at the bedside.

A campus-wide awareness campaign to educate staff about the upcoming changes and SEA recommendations was performed in January 2015.  For this initiative, information was disseminated throughout UAMS to raise awareness about the issues and concerns found as well as the changes that could be expected over the next several years.

UAMS Neonatal Intensive Care Unit trialed two neonatal enteral feeding systems and after deciding which one to use they had a successful “Go-Live” implementation in April 2015.  Since July 2015 UAMS has been using the adult set with the adapter included in the packaging, throughout the hospital without any difficulty. To better align with the changes to the industry standards and the multitude of national improvement efforts related to labeling of all tube connections, UAMS has been working to strengthen all plans for line and/or tube labeling. The ‘line labeling’ policy is currently under revision.

References

Global Enteral Device Supplier Association (GEDSA). (2014). Reducing the risk of medical device tubing misconnections. Retrieved from http://www.stayconnected.org/

Institute for Safe Medication Practices (ISMP). (2014, October 13). Plan now for upcoming changes inenteral feeding device connectors. Patient Safety and Quality Healthcare. Retrieved from http://psqh.com/september-october-2014/ismp-plan-for-upcoming-changes-in-enteral-feeding-device-connectors

The Joint Commission. (2014). New ISO Tubing Connector Standards: A Follow-up to the Sentinel Event Alert [PowerPoint Slides]. Retrieved from http://www.jointcommission.org/assets/1/6/New_ISO_Tubing_Connector_Standards_Webinar_Powerpoint.pdf

The Joint Commission. (2015). Sentinel Event Alert 53: Managing risk during transition to new ISO tubing connector standards. Retrieved from http://www.jointcommission.org/sentinel_event.aspx

The Joint Commission. (2014, August 20). Sentinel Event Alert 53: Managing risk during transition to new ISO tubing connector standards.

Understanding the Benefits of Working with a PSO to Meet the 2017 Mandate for Patient Safety

Susan Allen

The Centers for Medicare and Medicaid Services established new patient safety requirements  for hospitals with more than 50 beds when the agency finalized its Notice of Benefit and Payment Parameters for 2017. The Final Rule, published in the March 8, 2016, issue of the Federal Register, states in section 1311(h) that such hospitals may contract with a Qualified Health Plan only if they meet certain patient safety standards including utilization of a patient safety evaluation system, employment of a comprehensive hospital discharge program, and implementation of health care quality improvement initiatives. The new requirements go into effect January 1, 2017.

CMS’ 3 quality objectives to make patient care safer include: 1) Continued growth for a culture of safety; 2) Reducing unnecessary or inappropriate care; and 3) Preventing and minimizing harm in all settings. All of these objectives can be addressed through a Patient Safety Evaluation System (PSES) and a Patient Safety Organization (PSO).

PSOs are best suited to assist facilities with PSES development as they have a keen understanding of the framework under which hospitals can collect, analyze, manage and maintain information. A PSES allows providers to methodically evaluate systems and processes to determine what actually caused the systems to fail and prevent the reoccurrence. When reporting to a PSO, the evaluation of these failures is federally protected from litigation. While the PSES requirement infers that hospitals need to contract with a PSO, the Final Rule does go on to state that the Secretary of Health and Human Services can establish reasonable exceptions to that requirement

In a webinar conducted on May 3, 2016, CMS representatives made several clarifications regarding the requirements set forth in the Final Rule. According to CMS, QHP issuers are required to verify that contracting hospitals either have agreements with PSOs or are implementing an alternative evidence-based initiative to improve healthcare quality through the collection, management and analysis of patient safety events designed to reduce all cause preventable harm, prevent hospital readmission, or improve care coordination. So, documentation of a provider’s work within a Hospital Engagement Network or a Quality Improvement Organization could fulfill this requirement. However, CMS reiterated that the privilege and confidentiality protections provided by the Patient Safety Act only apply to PSO engagements and not to other evidence-based initiatives.

“The HEN and QIO programs are doing excellent work,” Phyllis Ragland, RN, CPHQ, CPPS, Clinical Patient Safety Advisor at American Data Network PSO, said. “And PSO participation can run parallel with these initiatives. Hospitals shouldn’t look at this as an either/or situation but an opportunity to cultivate an even more robust approach to patient safety.”  

Working with a PSO, hospitals can use a standardized event reporting tool to track all types of events, including near misses and unsafe conditions, as opposed to focusing on one or more specified events.    

“ADN PSO’s reporting tool incorporates AHRQ’s Common Formats, which CMS strongly recommends for tracking patient safety events,” Ragland said.

According to CMS, ample data, thorough analysis, and shared learning are essential to designing sound interventions to improve patient care. The integration of the Common Formats supports this objective and facilitates AHRQ’s charge to create a national Network of Patient Safety Databases that can be used to analyze and report on patient safety events and trends on a grand scale.

“Belonging to a PSO isn’t just about reporting patient safety incident, near miss and unsafe condition events. It provides the underpinning that promotes and supports a culture of safety through aggregate analytics and re-engineering in an expanded professional network of learning and sharing. This is the type of support your team gets that’s going to provide the return-on-investment that you need,” Ragland said.

Our Sponsors

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.

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

AMERICAN DATA NETWORK
Sherry Bird, Director, Business Development 10809 Executive Center Dr., Searcy Building Suite 300 Little Rock, AR 72211
Phone 501-225-5533
E-mail sbird@americandatanetwork.com
Website www.americandatanetwork.com

 

Founded in 1994, American Data Network provides clinical, quality, safety and financial data applications and services to healthcare executives, allowing them to better manage costs and care quality, influence physician practice patterns and meet demands for public accountability and disclosure.

2016 Board of Directors

President
Phyllis Dorrough
501-202-1276
501-202-1159 fax
phyllis.dorrough@baptist-health.org

 

 

 

 

 

President – Elect
Teresa Jeffus
501-296-1009
501686-8175 fax
JeffusTeresaM@uams.edu

 

 

Secretary
Margaret Corbett
501-5135735
501-513-5312 fax
mcorbett@conwayregional.org

 

 

 

 

Past President
Position Vacant

Action Team Leaders

Protocol
Pam Cochran
501-257-3087
501-257-3110 fax
autocontrols@att.net

 

 

 

 

 

Professional Dev.
Lynette Jack
501-379-8980
501-407-9288 fax
mqrs@comcast.net

 

 

 

 

 

 

Membership Srv.
Karen Donaldson
870-382-7657
870-460-3597 fax
kdonaldson@deltamem.net

 

 

 

 

Finance
Louise Hickman
870-541-7773
870-541-7204 fax
hickmanl@jrmc.org

 

 

 

 

Communication
Dalana Pittman
501-537-7944
501-225-5539 fax
dpittman@americandatanetwork.com

AHA Liaison

Cindy Harris
501-224-7878
501-224-0519 fax
charris@arkhospitals.org

Members at Large

Pam Blake
501-552-3844
PBlake@hospicehomecare.com

 

 

 

 

 

Shannon Finley
501-296-1010
501-686-8175
SFinley@uams.edu

 

 

 

 

 

Editor: Dalana Pittman
American Data Network
Little Rock, AR