From the President’s Desk

Happy New Year to everyone!

I am extremely honored and still not quite believing that I am writing to you from the desk of the President!  Thank you all sincerely for your confidence in allowing me to hold this position!  I promise to do my very best to justify your confidence in me.   It’s going to be a privilege to work with you, but enough of what is beginning to sound like a post campaign address—and we have all likely heard enough campaigning in the recent months.

2016 seemed to fly by and the last 12 months as President-Elect have been a wonderful learning experience for me by being able to watch first-hand how the board carries out its work.  I am truly in awe of how much work this team does, from publishing the newsletter to maintaining the website, planning educational events to updating the bylaws to the election of new officers.  Phew, I honestly had no idea how much work these folks did, in addition to their regular day jobs!   Thank you to each and every board member for your very hard work!

Since I have set the tone to make supporting this organization sound like it is so easy—–I want to point out that we are actively looking for additional members to get involved with the teams we have set up.  If you are interested in helping in any capacity we would definitely like to hear from you!   I know there is a lot of talent out there – plus, board involvement looks great on a resume!

As a rank and file member, I recognized that the educational opportunities were always one of the most important assets of being an AAHQ member, especially since the educational conferences have helped me maintain my Certified Professional in Healthcare Quality certification.  But now, when able to see this from a different perspective, I want to assure you that the board understands the importance of continuing education to you, not only to maintain or pursue your certification, but also to improve your knowledge.  The board has already discussed the educational events planned for 2017 and we are working on facilitating improvements in the process, including credit card acceptance to make registration and silent auction purchases more customer friendly, as well as continuing to bring in high quality speakers.  The feedback you give in your post-conference evaluations helps us identify issues that are important to you such as this issue with credit cards, so thank you for that—–and please continue to communicate with us.

On the subject of the Silent Auction, I would like to say a very big THANK YOU for your generous donations at our November conference. The proceeds from this were donated to the National Association for Healthcare Quality’s Healthcare Quality Foundation.

Finally, I am excited to tell you about a couple of new team members who joined the board this month.  Beth Schooley, RN, BBA, CPHQ, CPPS is joining us as a Member at Large. Beth has been the Director of Performance Improvement/Risk Manager/Compliance Officer at Howard Memorial Hospital in Nashville, AR for the last 7 years and we are looking forward to adding her skill set to the team.  Additionally, David Vrudny, CPHQ, MPM, MPH(c) will be leading our newly developing External Relations Team. This team will begin to function as our liaison with sponsors and vendors for conferences and other endeavors.  David is joining us from the Arkansas Department of Health where he has been since 2011.  He is no stranger to start up, as he was on the team that started the Arkansas Stroke Registry.   Welcome Beth and David!

Also, I would like to extend my congratulations to Pam Cochran, who was elected our President Elect for 2017.

Teresa Jeffus, SRN, RN, CPHQ, CPPS
AAHQ President

Welcome New Board Members!

Beth M. Schooley, RN, BBA, CPHQ, CPPS
Member at Large

Beth is Director of Performance Improvement at Howard Memorial Hospital in Nashville, AR. Like many of us in a smaller hospital, she wears multiple hats, namely Risk Manager and Compliance Officer. She is one of our newest CPHQ Certified members, receiving that in 2016, and her CPPS Certification in 2014. She is also a member of the 2016 Rural Quality Advisory Council. She graduated from Deaconess School of Nursing in Minneapolis, Minnesota. In 2004, she received a Bachelor’s Degree in Business Administration from Washington State University, while living in Washington and Oregon.

Most of Beth’s nursing experience is in Med/Surg, orthopedics, and as a school nurse. She began working in Denial Management when first coming to Howard Memorial until 2008, when she began in quality as the Assistant Quality Director, moving into the Director Role in 2009. Past honors received by Beth and Howard Memorial include: Top 100 Critical Access Hospitals in 2012; AFMC Quality Excellence Award in 2013; and 2011- present – Avatar’s “Exceeding Patient Expectations for Patient Satisfaction.” A HEN/HRET Spotlight Video for their CAUTI project was completed in September 2016. She has been instrumental in HEN, MBQIP, pharmacy-led antibiotic stewardship, and many other quality projects.

On the personal side, her family is a blended “Brady Bunch”, consisting of Clint, her husband of 2 years, her 3 children and 3 stepchildren, (3 girls and 3 boys), whose ages range from 6-23. Being originally from Wisconsin, she is frequently called a “Yankee” by her husband and friends and her northern accent leads to a lot of teasing. She remains a Green Bay Packer fan. However, she feels she is adjusting quite well to being a “southern” girl, and has learned to hunt and fish (sort of) and has some camouflage garments in her closet. She also now knows what purple hull peas and hushpuppies are.

Beth joined AAHQ around 2009, and felt that affiliating with the top healthcare quality organization in the state would help her learn and grow in her role as Director of Quality at Howard Memorial. Membership in AAHQ, the workshops, knowledgeable speakers, and all the talented and experienced quality professionals she has been able to interact with and to learn from, have helped her to become a better leader in her own organization over the past several years. She states that she appreciates the willingness of everyone to share their knowledge with those new to the field of quality and feels that membership in AAHQ is very important for those reasons.

David Vrudny, CPHQ, MPM
External Relations

David joined the Arkansas Department of Health team in 2011 to start the Arkansas Stroke Registry (ASR) which aims to improve the quality of stroke patient care. It was the perfect way to combine his interest in public health with his background in computers (he previously worked for Acxiom Corporation). He will soon be moving into a new role at the Arkansas Department of Health (cannot share yet!) although will continue to be involved with the stroke registry.

He graduated with honors from Miami University (Ohio) with a business degree as a Management Information Systems (MIS) major, holds the Certified Professional in Healthcare Quality (CPHQ) and Master Project Manager (MPM) designations, a Certificate in Public Health from UAMS and is currently pursuing a Master of Public Health degree with UAMS.  David is a founding member and immediate past president of the Arkansas Department of Health’s Toastmasters club.

Professional Development Roundup

Submitted by Lynnette Jack

2016 Fall Education Conference

 

AAHQ’s Fall Education Conference returned with a great program on Friday, November 4, 2016, in Little Rock at the Baptist Health Barrow Road Center.  With a theme of, “Right Here, Right Now: Quality Projects in Arkansas,” the conference showcased quality professionals making an impact in our great state.  All of the speakers did a phenomenal job inspiring and informing attendees.  The new venue was a huge success and the networking opportunities and collegial atmosphere were amazing.

 

 

 

“Facility was excellent – Great program. Something for everyone. Brenda was so inspiring with her presentation. Jamey was outstanding. Dr. Sayyed – great info. Carol so inspiring at end of the day. Snacks, food, great!”

 “First conference! Fabulous speakers, facility, and amenities. Thank you!”

 “Excellent presentations! I really enjoyed having Arkansas presenters! Truly brings Quality “home” & allows Arkansans to share their good quality initiatives!”

 “The peer review presentation was FABULOUS! Please tell Dr. Sayyed, thank you. The venue was perfect & food wonderful. Great job to all who put this together. Loved Brenda Jacobs. So much heart & knowledge!”

 “Enjoyed all presentations. Food was awesome. Thank you for a very educational day.”

Great plans are being made for 2017!  We’ll let you know as soon as the details are finalized!

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 or have any suggestions, please contact Shannon Finley at sfinley55@gmail.com .

Membership Services Update

Submitted by Karen Donaldson

AAHQ Distinguished Members 2016

Louise Hickman, RN, MA, CLNC, was recognized at the Fall AAHQ Conference as a Distinguished Member of AAHQ for 2016.  The Distinguished Member Award recognizes members who have made an outstanding contribution to the quality profession in the state and/or nationally, demonstrating leadership in the field.  Louise has served as a Board Member for AAHQ for many years, first as the Member at Large, and then as Finance Team Leader.  She also currently serves on the board of the Arkansas Organization of Nurse Executives, the Jefferson County Single Parent Scholarship Board, and the Christian School Advisory Board as a secondary elected parent representative.  Louise obtained her Master of Art in Health Services Management in 1997 from Webster’s University, her BS in Nursing from ASU in 1980, and she is a Certified Legal Nurse Consultant.  Other professional affiliations include NAHQ, ANA, and The National League for Nursing, the American Heart Association, and Epsilon Sigma Alpha – Alpha Tau Sorority. She is also a member of the Greater Pine Bluff Chamber of Commerce.

She currently serves as Vice President for Patient Care Services/Chief Nursing Officer, at Jefferson Regional Medical Center in Pine Bluff, having previously been their Compliance Officer.  Congratulations, Louise!

A 2^nd Distinguished Member Award was given to Connie Taylor, RN, who moved out of state early in 2016, but had served as President, Past President, and as several other Board and Team Leader positions.  Connie was unable to attend, but asked Debbie Hare to accept the award for her.  Debbie read the following acceptance letter from Connie:

“Good Afternoon!  I would like to thank AAHQ for the huge honor of being selected as the distinguished member for AAHQ 2016.  Those that have been selected in the past were mentors that I hold in very high regard.  I know for a fact there are many more qualified candidates in AAHQ.

I love AR, being a member, and a board member of AAHQ was such a pleasure.  The ladies (and gentlemen), who serve you on the board put a great deal of thought into offering educational, thought provoking events for you each and every year to help you achieve success in your role, whether it is quality, case management, or risk management.  Just look how far we have come in the healthcare quality field in AR in the last 10 years!  Give yourself a pat on the back because each of you make a difference every day in the quality of care your organization provides. 

I am humbled and honored to accept this award.  I miss my home state of Arkansas and will always be a Razorback at heart.  Thank you, Connie. “

Member of the Year 2016

The annual AAHQ Member of the Year Award is given out to provide recognition for exemplary performance in the service of the quality professions and in service to the AAHQ organization, which Dalana Pittman demonstrates in spades.  Dalana has worked diligently over the past year to transform our website, our newsletter, our social media, and our whole communications network.

She has been a healthcare leader from the beginning of her career, serving as President for the Student Nurse’s Association.  After graduation from college, she went into direct patient care but transitioned into Quality and Process Improvement over 6 years ago.  Dalana earned her CPHQ in 2013 and served as an Examiner for the Governor’s Quality Award.  She is a member of NAHQ and has been on the AAHQ board for two years.  She has a fountain of ideas on communications improvement!  She is integral to the American Data Network management team where she is the Manager for Client Services.

Dalana is the proud mother of three beautiful daughters and a King Charles Cavalier, and is a huge Star Wars aficionado.  Congratulations, Dalana!

Member Spotlight: Kristi Toblesky

Kristi is the Products/Services Specialist for American Data Network, managing the Data Analytics Team.  Before getting involved in quality, she was in the accounting field.  Her love for data and numbers combined with the desire to help others make this a natural next step.  Kristi thinks quality is more than just about the numbers, though – it’s about using our abilities to help others while we use evidence-based practice to guide our way.

Kristi attained her CPHQ in 2015 and has various certifications in data analytics, statistics, and R programming as they relate to data science.  She has been in the quality field for almost 15 years, with the early years at Baptist and now at ADN. She has been a member of AAHQ since 2011 and considers it a great source of periodic quality check-ups, and enjoys the various content from speakers from diverse professional backgrounds.  Since everyone is so busy and wears many different hats, she considers AAHQ as helping highlight some of those “need to know” items as well as offering terrific networking opportunities.

Outside work, Kristi has been married to her handsome husband (see picture) Kevin for 13 years and they have 2 wonderful boys, Zack (7) and Zane (2).  They keep them moving!  She also enjoys beach vacations, cake decorating and her son’s activities.  To keep busy, she also teaches 2^nd graders on Wednesday nights and enjoys following the Razorback football team games.  AAHQ is proud to have Kristi as a member.

Communications Update

Submitted by Dalana Pittman

The Communications Action Team laid the groundwork in 2016 to update our media storage processes and become more visible in the quality community through social media and website activities. This leads directly into our 2017 goal to investigate other social media apps and to enhance our use of Google apps to store organizational documents and to archive all historical documents for future reference.

In order to move forward, it was determined additional team members would be helpful in completing the necessary tasks. We called for assistance and our members responded! I am pleased to announce not one, but two new Communication Action Team members, Andrea Harrison and Josh Tennant. We welcome both of you to the team and look forward to your added skill sets to enhance our organizational efforts!

Andrea Harrison:

I have been a registered nurse for 11 years.  I currently work in the quality department as the process improvement coordinator for Conway Regional Health System.   I am an avid Razorback football fan; enjoy traveling, and spending time with my family.

 

 

 

 

 

 

Josh Tennant:

I am passionate about healthcare and began my career working in direct patient care and found myself slowly transitioning towards the business and operations area. I recently accepted the position of Quality Analyst this past October at Conway Regional Medical Center, and have loved it. Since taking on the role, we’ve made numerous improvements I believe have been felt system wide. I’m eager to bring this same passion to the AAHQ Communications team!

 

 

 

Finance Action Team Update

Submitted by Louise Hickman

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

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.

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 December 31, 2016 ending with a balance of $36,992.94.  This positive trend has been demonstrated several years with the AAHQ board and member efforts.

 

 

Calculator Tool Can Help Estimate Financial Impact of Adverse Events

Susan Allen

 

 

Long has been the assumption that adverse patient safety events lead to increased resource utilization and greater intensity of services, resulting in additional costs and days of hospitalization, but the identities of those events, which are most costly to patients and healthcare facilities, often remain unspecified. After conducting an impact study on the financial costs and increased length of stay (LOS) associated with certain adverse events that occur in hospitals across the country, American Data Network (ADN) has made available an easy-to-use tool for calculating the total excess cost of specific patient safety indicators in any facility.

Using the Agency for Healthcare Research and Quality’s (AHRQ’s) Patient Safety Indicators (PSIs), which are widely accepted for identifying complications or adverse events, ADN analysts evaluated excess cost and Length of Stay (LOS) for 10 types of events including pressure ulcers, catheter related bloodstream infections, respiratory failure and sepsis. Analysts benchmarked data against the HCUP All Payer database (4+ million records representing 484 facilities) and CMS MEDPAR database (13+ million records representing 3,378 facilities). An ADN infographic illustrates some of the study’s most significant findings which include:  

 

Based on a review of HCUP All Payer Data:

• A patient with a Central Venous Catheter Related Bloodstream Infection is estimated to cost $28,336 more (73% more) than a patient without.

• Total avoidable costs when applying excess cost percentages to the patients affected by the top 3 PSIs equal $94 million.

• A patient with Post-Op Respiratory Failure is estimated to stay in the hospital 7.8 days longer (68% longer) than a patient without.

• Total avoidable LOS when applying excess LOS percentages to the patients affected by the top 3 PSIs equals 28,407 days.

Based on a review of CMS MEDPAR data:

• A patient who experiences an Accidental Puncture or Laceration is estimated to cost $24,358 more (68% more) than a patient who does not.

• Total avoidable costs when applying excess cost percentages to the patients affected by the top 3 PSIs equal $1.7 billion.

• A patient with Post-Op Sepsis is estimated to stay in the hospital 12.27 days longer (65% longer) than a patient without.
• Total avoidable LOS when applying excess LOS percentages to the patients affected by the top 3 PSIs equals 375,611 days.

ADN has created a free online calculator that you can use to quantify your facility’s excess cost and LOS for selected PSIs simply by entering a few figures depicting your organization’s unique volumes, costs and LOS. With this data in hand, your organization will be better equipped to target patient safety efforts where they can have the most significant financial impact.

Successful Implementation of Performance Improvement Initiatives in an Ambulatory Care Setting

Devin Terry, MSN, RN, ACNS-BC, CPHQ
Joe Jimmerson, MSNc, RN, CPHQ

Healthcare is currently changing on a daily basis.  In order to maintain pace, one must not only be diligent in continuing education in his/her specialty but also in healthcare quality.  For many professionals, healthcare quality is a new, unexplored world where language, culture, and ideologies are unfamiliar. In my experience, I have found this to be even truer in the ambulatory setting where I work. The incorporation of healthcare quality in ambulatory settings has been challenging on multiple levels, but in this article, we will discuss successful implementation strategies.

Once an organization decides what it wants to do, what it should do, and what it can do, strategic goals and objectives are developed. The organization will typically roll down the creation of specific implementation plans, targets, process review, etc. to the department level.   All ideas, which make it through this process to become projects, have to begin with developing an effective team. Multiple team roles are important, but perhaps the most important are project champions; these individuals are opinion leaders who have credibility among the stakeholders of your project.    Many action plans are possible, but essentially you must choose the way that best fits your facility’s culture.  When trying to choose your performance improvement project team, it is vital to remember that the success of the project will lay at the feet of the dependability and strength of those on the team.  Once the team is in place, an agreement upon the scope of the assigned project must be determined and may require time to recalibrate your performance improvement project team.  From my experience, the fastest way to dismantle a project when frontline staff become involved is for the members of the leadership team to not have a clear understanding of the project and ability to articulate the scope and purpose of the project.  Familiarizing your team with new, important terminology is imperative, and may require collaborating with other departments of your facility. Once this relationship is built, training and collaboration will become more seamless and effective while simultaneously earning credibility from multiple areas of your facility.

Deciding as a group what you will use as the model to test for change is your next challenge.  One of the most popular models is the Plan Do Study Act cycle, PDSA.  This tool will help you gather data for each part of the process while ensuring that you analyze and evaluate every area.  An alternative approach would be to use Six Sigma.

The PDSA tool will help ensure the group stays on task and provides a concise way of reporting. During the Planning phase you will define the background/problem, identify key stakeholders, determine your project’s goals and root cause of your problem. Using tools designed to determine the root cause of your problem is essential to understand the cause and effect of your issue.

Once the group, has developed, implemented, and studied the results of the final action plan, the success of the performance improvement project will be determined.  Hopefully your project has shown positive results, and the group is ready to move into a time period where results are monitored and standardized while still making plans for future actions.

The process that has been described in this article can be utilized throughout an organization, but one must be aware of the nuances associated with ambulatory performance improvement projects. Specific resources can be utilize for ambulatory specific settings.   Fortunately, several experts in healthcare quality and ambulatory care have published resources that can aid to identify nuances. The following are a couple of these resources:

• American Association of Ambulatory Care Nurses. (AAACN) aaacn.org
  • Suggested use:
    • Education for front line staff in Primary Care centers, Medical Specialty clinics
    • Literature Reviews
    • Special Interest Groups
    • Continuing Education and professional certification for ambulatory nurses.
• Collaborative Alliance for Nursing Outcomes (CALNOC) calnoc.org
  • Suggested use:
    • Benchmark metrics for surgery and procedure centers, cancer centers, and urgent care centers
    • CALNOC: Advancing global patient care excellence. Pulled from aaacn.org January 10, 2017.
• Joint Commission (JC) jointcommission.org
  • Suggested use:
    • Ambulatory care facilities seeking accreditation guidelines
    • Education in ambulatory care eligibility requirements
    • Support through ambulatory care advisory councils
      • Resources: Using Performance Improvement Tools in Ambulatory Care.
• National Database of Nursing Quality Indicators (NDNQI) pressganey.com
  • Suggested use:
    • National benchmarks for nursing sensitive measures such as: CAUTI, CLABSI, Patient falls with injury.
    • Increased benefits for facilities that have longer patient stays or procedural areas.

 

 

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

 

 

 

 

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

 

 

 

 

 

 

President – Elect
Pam Cochran
501-257-3087
501-257-3110 fax
autocontrols@att.net

 

 

 

 

 

 

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

 

 

 

 

 

 

Action Team Leaders

Protocol
Pam Blake
870-718-1724
PBlake@hospicehomecare.com

 

 

 

 

 

 

 

Professional Dev.
Shannon Finley
501-296-1010
501-686-8175
Sfinley55@gmail.com

 

 

 

 

Membership Srv.
Karen Donaldson
870-382-7657
870-3382-6555 fax
kdonaldson@deltamem.net

 

 

 

 

 

 

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

 

 

 

 

 

 

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

 

 

 

 

 

 

External Relations
David Vrudny
501-661-2096
501-280-4207 fax
David.Vrudny@arkansas.gov

 

 

 

 

AHA Liaison

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

 

Member at Large
Beth Schooley
870-845-8014
870-845-4178  fax
beths@howardmemorial.com

 

 

 

 

 

 

Editor: Dalana Pittman
American Data Network
Little Rock, AR