Fall 2018 Newsletter

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From the President’s Desk

Submitted by: Pam Cochran

Pam Cochran

I hope this finds you well and right in the middle of National Healthcare Quality week celebrations. As I shared at the recent AAHQ Educational Conference in September, the week of October 21-27 has been proclaimed Healthcare Quality Week in Arkansas by the honorable Governor of the Great State of Arkansas, Asa Hutchinson. In planning for this week’s activities at our hospital, I was reminded of Liz Jazwiec’s writings where she shared that making staff feel valued and appreciated does not need to include spending large amounts of money and planning grand revelries. Simple recognitions such as informal Shout-Outs, small inexpensive gifts, and making someone feel valued and appreciated goes a long way.

As I write this on the week before Healthcare Quality Week, I wanted to share what our office is doing to promote quality and safety. Each day during the week, we will send a global email to our staff speaking to a “friend” of quality. This will include a short, simple email about the person’s contribution to our quality improvement work. Then, our leader will acknowledge the contribution and in person, present a small lapel button acknowledging the staff as a Shout-Out Recipient. Lapel buttons are inexpensive and inclusive and I find staff wear and value them when accompanied with sincere thanks of gratitude. Secondly, our office has provided a fall basket full of goodies to eat and neat little gifts. Staff are eligible for entry into the drawing by sending an email with “Yeah Quality” in the subject line and stating all required assigned trainings are complete and up-to-date. We have been pleasantly surprised by the staff who have returned our email and wanted to participate. Finally, we are mandated through recent behavioral standards to fully implement the practice of Measurement Based Care (MBC). The practice of MBC might be unfamiliar to those who practice quality outside of behavioral health, but the concept is the same. An educational blitz will take place where multiple times during the day, staff can come and learn more about MBC practice expectations. The sessions are quick and well developed. During this time, an emphasis on quality and the importance of our work to improve is threaded during our time with employees.

Regardless of how you are celebrating or celebrated Healthcare Quality Week, I hope you continue to spread the word about the importance of what we do. Every effort you take brings value and pride to the role performed by Quality Professionals!

Congratulations to our newly elected officers. Clay Leigh will be our President-Elect for 2019 and Dalana Pittman will serve for 2019-2020 as the AAHQ Secretary. We are a better and stronger association because of your willingness to serve.

Professional Development Round-up

Submitted by: Justin Villines

Health Care Quality Week is October 21-27th, 2018: We were honored to meet Arkansas Governor Asa Hutchinson on the proclamation of this year’s Healthcare Quality Week celebration. Healthcare quality professionals are invaluable to the success of an organization, as they are continually looking for the next improvement opportunity. In the fast-moving and complex healthcare environment that we work in, it’s essential to have trained and qualified professionals, specifically focused on systems and processes and methods of measuring, analyzing, and improving them to achieve best outcomes.

2018 CPHQ Review Course Reminder: The interactive two-day workshop is designed to support those planning to take the Certified Professional in Healthcare Quality© (CPHQ) Certification Examination. Based on the current exam content outline, this course engages participants in a review of the exam material and offers them valuable tips on how to best prepare for test day. The workshop fee includes electronic access to handout materials for 1 year. Earn 15 CPHQ CE credits upon completion and evaluation of the course. CPHQ CE is available only to current CPHQs. Space is limited to 60 attendees, so register early! The course materials are being licensed from the National Association for Healthcare Quality. AAHQ will provide continental breakfast, snacks, and lunches on both days. Come experience AAHQ’s legendary hospitality while you learn!

• Thursday, December 6, 2018 8:00 AM to 5:00 PM
• Friday, December 7, 2018 8:00 AM to 5:00 PM

Instructor: Joyce Hall, RN, CPHQ, CHC

Host Facility: Arkansas Hospital Association
419 Natural Resources Drive
AHA Classroom
Little Rock, AR 72205
Register Today: http://www.arkahq.org/2018/08/2018-cphq-review-course-announced/

Words of Advice: Maintain the focus after Healthcare Quality Week. Set goals based on NAHQ recommendations:
• Build and maintain a strong culture to continuously improve quality of care and optimize patient safety.
• Establish accountability for integrity of quality and safety programs.
• Create systems to continuously improve.
• Report quality and safety data accurately.
• Remove barriers to success.
• Communication, Communication, Communication.

Membership Services Update

Submitted by: Lynette Jack

Lynnette Jack

Welcome! AAHQ added nineteen new members who took the opportunity to “Register and Join” in conjunction with the Annual Conference in September. We are excited to have new members and want to remind all members of some of the benefits of membership.
AAHQ seeks to provide:
· Networking opportunities
· Continuing education through national and state speakers
· Reasonable membership dues
· A medium for the exchange of ideas
· Resources for those everyday questions
· Scholarships for healthcare quality events

We would love to hear your thoughts on AAHQ and membership. Email me at ljack@mqrs.net.

AAHQ 2019 Officers & 2018 Distinguished Member of the Year

Clay Leigh

President Elect Clayton R. Leigh, MSN, RN, CPHQ
During his 12-year tenure as a licensed Registered Nurse (RN), Mr. Leigh has been blessed to care for patients at Arkansas Children’s Hospital (ACH), Conway Regional Health System (CRHS), and the Central Arkansas Veterans’ Healthcare System (CAVHS). Through these experiences, he has been responsible for patient and staff care in the roles of charge nurse, nurse manager, house supervisor, facility performance improvement coordinator, patient safety coordinator, acting associate nurse executive of operations, and accreditation coordinator. Mr. Leigh has participated as a member of the Arkansas Nurses’ Association (ARNA), Arkansas Association for Healthcare Quality (AAHQ), and Arkansas Hospital Association (AHA). He obtained the national certification as Certified Professional of Healthcare Quality (CPHQ) in 2015 and completed a Master of Science in Nursing (MSN) degree in 2017.

Dalana Pittman

Secretary Dalana Pittman, BSN RN CPHQ
Mrs. Pittman is the Manager of Client Services for American Data Network in Little Rock, AR. She graduated from Henderson State University with her Bachelor of Science in Nursing in 1998. She began her career in ICU and quickly transitioned to the Emergency Room where she worked for 10 years. In 2010, she moved to the Quality Department and began her work in Core Measures and Process Improvement. She accepted her position at American Data Network in 2012. Dalana has been a member of NAHQ and AAHQ since 2012 and earned her CPHQ in 2013. She then joined the AAHQ Board in 2014. Dalana has served as a Member at Large, Communications Team Lead, and most recently as Secretary this past year.

Lynnette Jack

2018 Distinguished Member of the Year Lynnette Jack. In a surprise to the honored recipient, Ms. Jack received the Distinguished Member of the Year award during the AAHQ Education Conference in September. Ms. Jack stated, “My years of service to the organization have been filled with camaraderie and joy! Thank you for the honor!” She has provided countless hours of work as a board member and assists new members as needed. “She’s a great role model,” said Clay Leigh, Communication Team Lead and new board member. “Along with the other board members, Lynnette sets the tone for excellence.”

External Relations Update

Submitted by: David Vrudny

David Vrudny

Federal Rule has Negative Impact on Arkansas Hospitals (article source: Ms. Jodiane Tritt, Arkansas Hospital Association)

Hospitals in Arkansas will be negatively impacted by the CY 2019 Hospital Outpatient PPS/ASC Proposed Rule. The Arkansas Hospital Association sent a comment letter on September 24, 2018, on behalf of its members to Secretary Azar and Administrator Verma detailing how Arkansas hospitals will be adversely impacted if the Outpatient Prospective Payment System and Ambulatory Surgery Center Rule is implemented. Senators Rob Portman (R-Ohio) and Debbie Stabenow (D-Mich.) asked their Senate colleagues and Representatives Peter Roskam (R-Ill.), chair of the Ways and Means Health Subcommittee, and Mike Thompson (D-Calif.) asked their House colleagues to sign on to a letter urging the Centers for Medicare and Medicaid Services (CMS) to withdraw proposals to expand certain site-neutral payment policies to grandfathered off-campus hospital provider-based departments (PBDs).

It its OPPS proposed rule, CMS proposes (1) to pay for clinic visit services in excepted PBDs at 40% of the OPPS payment amount, and (2) if an excepted off-campus PBD begins to provide a “new” service from a clinical family for which it did not previously furnish and bill for during a baseline period (generally from November 1, 2014 through November 1, 2015), the new service would no longer be a covered outpatient department service and would be reimbursed at the reduced rate. Across the country, that equates to an estimated $760 million in hospital cuts in calendar year 2019. In Arkansas, our hospitals are expected to shoulder a reimbursement reduction of $7,209,178.

For many rural areas, hospitals are the sole available provider of care for all patients. As the backbone of the Arkansas healthcare system, it is crucial that hospitals are appropriately reimbursed for all services that a community needs – emergency care, inpatient care, and outpatient services. Add to that, a new study conducted for the America Hospital Association by KNG Health Consulting LLC found that Medicare patients who receive care in a hospital outpatient department are more likely to be poorer and have more severe chronic conditions than Medicare patients treated in an independent physician office. The study also specifically examined the characteristics of Medicare cancer patients seen in HOPDs and IPOs and found similar results. The study, which was unveiled September 25, 2018, at a Capitol Hill briefing, highlights why proposals under consideration by Congress and the administration to reimburse hospitals the same amount as physician offices could threaten access to care for the most vulnerable patients and communities.

For more information on this, please visit the American Hospital Association’s website at www.aha.org

Effective Jan. 1, 2019: Revisions to 5 EPs for deeming in hospitals, critical access hospitals (article source: The Joint Commission web page, October 2018)

The Joint Commission is revising five elements of performance (EPs) for deeming in hospitals and critical access hospitals to more closely align with language found in the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs). These revisions will go into effect Jan. 1, 2019.

The affected EPs are:
• EC.02.03.01 EP 9
• LD.01.03.01 EP 13 (hospitals only)
• LD.04.03.01 EP 2
• LS.01.01.01 EP 1
• PC.02.02.03 EP 7 (critical access hospitals only)
• PC.03.01.01 EPs 5 and 8

The changes resulted from CMS’ review of The Joint Commission’s EP Review Project for the Leadership (LD) chapter, and as part of the deeming application review for psychiatric hospitals.

View the prepublication standards.

Finance Action Team Report

Submitted by: Lynnette Jack

Lynnette Jack

The income and expenses for the AAHQ Conference have not been finalized; however, we were able to increase our sponsorships and increased our attendance from previous years. The strong financial foundation of AAHQ allowed us to bring in Liz Jazwiec, a national speaker who electrified the meeting. The next financial event for AAHQ is the CPHQ Review Course on December 6-7, 2018, in Little Rock. Two scholarships were awarded at the conference with another being awarded for Healthcare Quality Week October 21-27.
Reimbursement for the 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.

The financial standing of the organization remains strong. Our financial balance as of August 30, 2018 was $24,815.26. Thank you for all the member support that makes the work of AAHQ possible!

Quality Submission Articles

People and Technology: The Right Pairing for Data Automation in Healthcare Quality

Submitted by: Patrick Herguth, Chief Operating Officer, Q-Centrix

Patrick Herguth

Amid the ongoing transformational shift to value-based care, hospitals must decide whether to direct more resources toward quality reporting or find new innovative approaches to meeting their demands. As it has in other industries, Artificial Intelligence (AI) provides a new set of tools for improvement in healthcare quality.

A form of AI-driven machine learning, Natural Language Processing (NLP), is designed to understand human language and unstructured information. Because up to 80% of data in electronic medical records (EMRs) can be in unstructured formats, leveraging NLP for quality data automation not only makes sense, but sets the stage for previously unattainable efficiencies.

For example, recent NLP deployment by Q-Centrix has shown that data-abstraction-time improvements of up to five-minutes per case are possible – an immense improvement for hospitals that do thousands of these transactions a month.

While this technology is amazing, success is only achieved when it is properly paired with people. In other words, technology designed to behave like a human must be guided like one.

Many hospitals have large, diverse and unique sets of information systems in use, so their workflows and documentation practices are also unique. For NLP to work in these settings, it must be guided by clinical experts familiar with each institution’s combination of technology and workflow. Continuous performance audits and tuning are critical to ensuring the desired output. You could say, quality experts are the key to driving this new era of automation.

When properly deployed, NLP in healthcare quality sets the stage for numerous benefits, including:
• Speedier and more-accurate reporting, which can help hospitals work toward achieving maximum reimbursement and minimal payment penalties.
• Minimal disruption to staff – clinicians do not have to drastically change how they enter information into EMRs and instead can focus on delivering and improving care.
• Fewer staff hours needed for manual data abstraction.
• Improved patient-reported outcomes and satisfaction due to adherence to quality measures.

What truly brings efficiency advancements like effective NLP deployment full circle is not just the cost- and time-savings, but redirecting recouped resources to new quality initiatives or to strengthen existing ones. For example, this could mean putting in place the recommended number of infection preventionists or participating in clinical registries, to further positively impact patient care – a result we all want to see.

Compelling Results from Good Catch Survey Set Stage for Launch of ADNPSO Specimen Study

Submitted by: Susan Allen, American Data Network

ADNPSO made several key discoveries after checking in with facilities that participated in the 2017 Good Catch Campaign. We surveyed participants with the goal of learning what successes and/or barriers the hospitals may have experienced since the campaign wrapped six months ago.

The survey results provided compelling evidence, demonstrating Near Miss reporting as an impetus for building trust among teams, strengthening culture, and ultimately a catalyst for decreasing adverse events.

1. 100% of facilities that responded to ADNPSO’s survey confirmed their organization continues to view Near Miss reporting as a priority. Reporting and analysis of Near Miss events are seen as an improvement strategy that works!

2. 63% of facilities reported a decrease in overall patient safety incidents, and they attribute improvement to corrections and initiatives established in response to lessons learned through Near Miss reporting.

3. 84% of facilities described their current organizational Culture of Safety as either Engaged or Empowered. These hospitals have moved beyond perceptions of patient safety as a regulatory obligation and have adopted a more proactive, “because we want to make sure this doesn’t happen again,” approach.

Survey results, which can be reviewed here in full, revealed that prioritizing Near Miss reporting means implementing ongoing efforts to educate staff, providing feedback and rewarding good catches. When leaders embrace Just Culture and leverage opportunities to turn vulnerabilities into improvements, the hospital staff responds. Seventy-five percent of the hospitals reported continued support from senior leaders with progress being shared in leadership and board meetings. This finding is especially significant because engagement from senior leaders is essential if culture change across the organization is the overarching goal. ADNPSO was encouraged by the fact that 79% of the hospitals providing feedback reported improvement in overall culture, positioning these organizations for continued success.

The Good Catch Campaign focused on increasing event reports; and together, participating facilities reported 9,445 Near Misses — a 47% increase over baseline. The campaign helped hospitals shift their mindset regarding event reporting, strengthen safety culture, and improve care. Building on that momentum, ADNPSO is set to launch a new initiative, on November 1, designed to help hospitals sharpen their focus and dive deeper into data surrounding Specimen events. These are prevalent, costly and can lead to serious medical mistakes including diagnostic errors and inappropriate treatments.

“Laboratory testing is essential to medical decision-making. Unfortunately, mix-ups and mishaps happen — inside and outside of the lab,” said Phyllis Ragland, RN, CPHQ, CPPS and Clinical Patient Safety Advisor for ADNPSO. “In fact, the literature suggests incidents like mislabeling and inaccurate patient identification, which are carried out before specimens even get to the lab, make up the majority of specimen events. The good news is these are highly preventable.”

Arkansas hospitals signed on to participate in ADNPSO’s Specimen Focused Study include: Ashley County Medical Center, Baptist Health System (Arkadelphia, Conway, Heber Springs, Hot Springs County, Little Rock, North Little Rock, and Stuttgart), Baxter Regional Medical Center, Conway Regional Medical Center, CrossRidge Community Hospital, Howard Memorial Hospital, St. Bernards Medical Center, and Unity Health (Harris Hospital and White County Medical Center). These organizations will gain a better understanding of why specimen events happen and will collaborate to decrease errors across the testing process.

Our Sponsors

Julie Kettlewell, RNP, Director of Quality, 1020 West 4th Street, Suite 300
Little Rock, AR 72201 Phone 501-212-8740
E-Mail jkettlewell@afmc.org Website www.afmc.org

AFMC’s purpose is solid: to help health care providers deliver the best quality of care at the lowest cost and to empower patients to take control of their own health and that of their families.
AFMC is a nonprofit organization headquartered in Little Rock, Ark., with an additional office in Fort Smith, Ark. We are dedicated to working with beneficiaries and health care providers in all settings to improve overall health and consumers’ experience of care, while reducing health care costs. We accomplish this through education, outreach, data analysis, information technology, medical case utilization and review, and marketing/ communications services provided by a staff of 270 employees. At the forefront of health care reform and practice transformation, AFMC is an established, trusted partner in private, state and federally led payment innovations by Medicare, Medicaid and commercial payers.

Susan Allen, 10809 Executive Center Dr., Searcy Building Suite 300 Little Rock, AR 72211
Phone 501-537-7941
E-mail sallen@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.

Q-Centrix aims to measurably improve the quality and safety of patient care through its market-leading technology platform, Q-Apps, coupled with the industry’s largest and broadest team of nurse-educated, quality information specialists. Q-Centrix is a comprehensive quality partner with more than 450 hospitals, providing quality data management solutions, including quality data abstraction, surveillance, reporting, and analysis. Learn more about Q-Centrix at https://www.q-centrix.com/.


2018 Board of Directors

Pam Cochran
501-257-3110 fax


Teresa Jeffus
501-686-8175 fax


President – Elect
Beth Schooley
870-845-4178 fax


Dalana Pittman
501-225-5539 fax


Action Team Leaders

Pam Blake



Professional Development
Justin Villines
501-978-3940 fax


Membership Services
Lynnette Jack
501-407-9288 fax


Lynnette Jack
501-407-9288 fax


Clay Leigh


External Relations
David Vrudny
501-280-4207 fax


Member at Large
Steve Chasteen


AHA Liaison
Cindy Harris
501-224-0519 fax

Editor: Clayton Leigh, MSN, CPHQ
Central Arkansas Veterans Healthcare System
Little Rock, AR

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