2019 Spring Newsletter

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From the President’s Desk

Submitted by: Beth Schooley

Greetings AAHQ members!

Beth Schooley

I hope this newsletter finds you all enjoying the spring weather that is finally here. My family in the north woods of Wisconsin are jealous!

As you all probably know, National Patient Safety Week took place March 10th-16th. This was a good reminder for our organization to review and update our Top 10 Patient Safety List. If you have never created a top 10 list for patient safety, it can be an excellent tool to get your own organization’s top patient safety concerns in front of both leadership and staff. It is also a very good reminder about current patient safety issues that can be incorporated into your quality improvement plans and initiatives. Our team reviews this list at least yearly as a way to keep our top 10 patient safety issues current and relevant and make these items a priority for awareness and/or improvement.

According to Becker’s Hospital Review, “Using EHRs to communicate diagnoses and manage test results earned the number one spot on ECRI Institute’s list of the Top 10 Patient Safety Concerns for 2019”. EHR’s help aid in diagnosis, provide clinical alerts and reminders, coordinate care between departments, and a host of other great benefits to enhance patient care. The important reminder here is to close the loop making sure communication still takes place among caregivers, patients, and physicians. The “human element”, hand-off communication, clinical reasoning and decision-making, and feedback and follow-up in the diagnostic process are still important aspects of safe patient care when using our health IT products. https://www.beckershospitalreview.com/quality/10-top-patient-safety-concerns-for-2019-ranked-by-ecri-institute.html

Finally, I hope many of you will be participating in our April Educational Workshop, and remember to save the date for the AAHQ Fall Conference that will take place on October 18th. Have a wonderful spring!


Beth Schooley, RN, BBA, CPHQ, CPPS, CHC


From the Desk of the Past President

Submitted by: Pam Cochran

Today is April 15th and I am putting my finishing touches on the RCA presentation for our upcoming AAHQ Educational Workshop on the 26th of this month.  If you have not registered, I encourage you to do so.  The educational sessions, networking, and food will be great!  We will learn so much from the workshop and certainly from each other.

Pam Cochran

For those who can’t attend, I wanted to share information about running a Root Cause Analysis (RCA) within your organization.  There are so many resources available, but one particularly stands out as simple, easy to follow, and meaningful.  This information was pulled from the CMS website.  There are 7 key steps to consider.

  1. Identify the event to be investigated and gather preliminary information
  2. Charter and select the team facilitator and members
  3. Describe in detail what happened
  4. Identify the contributing factors
  5. Identify the root causes
  6. Design and implement changes to eliminate the root cause
  7. Measure the success of changes

As I reviewed The Joint Commission expectations, guidance from CMS, and other expert sources, I am reminded of critical considerations during each step that will make your work successful.  I look forward to discussing ideas about this important responsibility.

See you there and if not, reach out.  I can share my Power Point and we can talk about RCAs.




Pam Cochran RN, CPHQ

Professional Development Round-Up

Submitted by: Justin Villines

Principles That Help Healthcare Process Improvement

Justin Villines

Healthcare simply consists of thousands of interlinked processes that result in a very complex system. If we focus on the processes of care one at a time, we can fundamentally change the game and deal with the challenges facing healthcare. Meaningful quality improvement must be data-driven. This is particularly true for quality control in healthcare. You’re basically dead in the water if you try to work with healthcare providers and you don’t have good data. I think everybody recognizes that.

The right data in the right format, at the right time, in the right hands is crucial.  If clinician teams are going to manage care, they need data. They need the right data delivered in the right format, at the right time, and in the right place. And the data must be delivered into the right hands—the clinicians’ care team is involved in operating and improving any given process of care.

If quality improvement is going to work in healthcare—if we are going to realize value—it means, we must engage clinicians. Clinicians (nurses and providers’ care team) are the frontline workers who understand and own the processes of care. But we live in a pristine time. I once received from an email from a physician leader at a leading national delivery system. I’m going to withhold the name of the delivery system, but I can tell you that if you ask knowledgeable people to list of top 10 delivery systems in the country, almost everyone would put the same organization on their list. Despite that, this physician wrote to me lamenting how difficult it was for him to get his peer physicians to see a new future. And in his email, he succinctly described the problem by saying that his physicians were “historically encumbered and demoralized.” And I love the succinctness of his description because what he is basically saying is they’re clinging to the past and are demoralized because they don’t see a new future. And in that short phrase, this very excellent physician leader encapsulated the problem and points us towards the solution.

In short, quality and cost improvements require intelligent use of linked financial and clinical data coupled with education for multi-disciplinary teams who are driving process improvements.

SAVE THE DATE: AAHQ Fall Education Conference

The AAHQ Education Conference–Outcomes of Data: What is the ROI?–is scheduled for Friday, October 18, 2019 at the J.A. Gilbreth Conference Center on the Baptist Health Main Campus (9601 Lile Drive, Little Rock, AR 72205). To give a little further guidance on the premise of the conference. Achieving outcomes is important, but the process by which health systems/organizations achieve outcomes is equally important. Process measures or data outcomes capture providers, nurses, quality analyst/directors, IT directors outcomes of data and measurements actually prove productivity and adherence to standards of recommended care and produce better health outcomes.

Membership Services Spotlight

Submitted By: Pam Blake

Pam Blake

“I am thrilled to obtain my CPHQ,” said Mary Daggett, Service Line Director at Jefferson Regional Medical Center. “It feels like the icing on the cake after serving the Quality department officially and through an unfathomable amount of quality initiatives over the last 20 years. This has been on my things to do list for at least three years.  I love making that list smaller.  I look forward to continuing my work, serving as a resource and making process improvements that leave a footprint that fosters safe patient care and improved patient outcomes.”

Mary Daggett

Mary has been employed at Jefferson Regional Medical Center since 1995.  She was recruited to Arkansas from San Antonio, Texas, straight out of school, where she received her Bachelors’ and Masters’ Degree in Communication Disorders with special emphasis on Neurogenic communication disorders (strokes and traumatic brain injury).  She practiced as a Speech Language Pathologist for one year on the Inpatient Rehabilitation unit, before being promoted into her first management position.  She moved from manager to Service Line Director assuming operational oversight of the Inpatient Rehabilitation Unit, Transitional Care Unit, Inpatient Psychiatric Unit and the Home Health Unit.  She then assumed oversite of the Clinical Informatics department where she lead the team that deployed the Electronic Health Record, from configuration to implementation.  Mary obtained her Master’s in Business Administration from the University of Arkansas, Little Rock and was promoted to Assistant Vice President of Patient Care Services.  She assumed additional departments from Nursing Administration, Medical Surgical Departments, Maternal Child Departments and Critical Care.  In 2015 Mary was assigned oversight of the Quality Department, Case Management and Emergency Services.            

Mary’s professional affiliations/certifications are the American College of HealthCare Executives, Arkansas Hospital Association, American Case Management Association, Arkansas Association of Healthcare Quality, and Arkansas Speech & Hearing Association. 

Mary recently attended the CPHQ review course sponsored by AAHQ in December 2018 and passed the exam in February 2019. 

Mary is pursuing a Fellowship with the American College of Healthcare Executives (FACHE).  She indicates that this has also been on her things to do list for several years.  The FACHE credential signals a Fellow’s high competency, commitment to service and recognition as an esteemed leader.  She has completed all her pre-requisites and looks forward to testing soon.  Mary is a member of NAHQ and has been a member of AAHQ for the past 9 years.  When not working, Mary enjoys being with her family.  Mary met her husband on her first day of work at JRMC.  They have been married for 22 years and have three children, two in college and one in elementary school.   Mary enjoys traveling all over the world, reading, watching movies, cooking and anything that involves water from swimming, sailing, snorkeling, kayaking, floating, sunning and fishing.  She loves animals and has a special attachment to her Bull Terrier, Mr. Biggs.

External Relations Update

Submitted by: Steve Chasteen

Steve Chasteen

Virtual medical services are breaking down barriers to accessibility thanks to advances in smartphone and computer applications, which is why mobile health is changing the way healthcare is delivered. This increase in mobility can significantly lower cost, and many health care organizations are investing in virtual platforms. The challenge in this evolving virtual world is to continue delivering a personalized, and hopefully excellent, patient experience. To do this, health care organizations must transform how it develops leaders, and how its leaders build relationships with staff in remote or virtual locations.

Staff location does not change the fact that an accountable culture and staff alignment starts with the top. An organization’s responsibility to develop leadership competencies is not negated just because leaders and their team members are not face-to-face every day. Nor does the location change the need for engaging staff in providing the best possible care. Checking in with your staff or team members should always be an intentional activity that is done consistently. It builds relationships, which is a tenet of successful external relations, and it reduces turnover. While technology can make virtual care and services accessible to more people, it can also allow leaders to make themselves more accessible to their teams.

Finance Action Team Report

Submitted by: Lynnette Jack

Lynnette Jack

AAHQ’s financial stability is based on three revenue streams: membership dues, meeting registration fees, and sponsorships.  Meeting and speaker expenses make up the bulk of expenses with additional financial support given for member scholarships, elected board member attendance at NAHQ Next, and association management fees.  AAHQ has maintained a solid financial footing and careful planning will ensure that we have the resources available to continue making a positive impact for our members and healthcare quality in Arkansas.

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 amazing benefit. The financial standing of the organization remains strong.  Our financial balance as of March 31, 2019 was $33,946.55.  Thank you for all the member support that makes the work of AAHQ possible!

2018 Governor’s Quality Award: Unity Health—White County Medical Center

Submitted by Debbie Hare; Unity Health—White County Medical Center

Unity Health–White County Medical Center

The Governor’s Quality Award Program encourages Arkansas organizations to engage in continuous quality improvement, which leads to performance excellence, and to provide recognition to those organizations that participate in the program. The Governor’s Quality Award (GQA) was founded by Arkansas business leaders who understood the need to recognize companies reaching for the highest standards in their products, services and processes. They 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.

Unity Health – White County Medical Center received the Governors Quality Award in 2018.  However, our journey with GQA began in 2002 with our first application. The GQA program utilizes the Baldridge Excellence Framework to evaluate the applicants. The purpose of the framework is to help your organization improve – no matter its size or types of services it offers.   Simply put, using the criteria will help you answer three questions: Is your organization doing as well as it could? How do you know? What and how should your organization improve or change? The criteria is divided up into six interrelated categories and a results category.  By challenging your organization with the questions it helps you to improve, get sustainable results and become more competitive.  The seven categories: 1) Leadership 2) Strategy 3) Customers 4) Measurement, analysis, and knowledge management 5) Workforce 6) Operations and 7) Results.  All are key aspects of performing and managing your organization.

Leadership wanted something beyond the accreditation and survey process to help us improve our organization and the GQA program and Baldridge criteria was selected.  The set of questions allows you to assess your organization and help you identify goals for improvement in the process.  You are analyzing your organization in a systems perspective – managing all the components of your organization as a whole to achieve sustained improvement and achieve performance excellence.

I know how the Baldridge Excellence Framework helps you achieve your goals, improve results and helps your organization become more competitive.  Our organization went from a 124-bed facility to 438 beds today. We now have three facilities (two in Searcy and one in Newport) and 20 clinics. We have the second largest Graduate Medical Education in the state and are the first Arkansas Hospital to become a member of the Mayo Care Network.

I have been involved in the GQA program since 2002 with the application process. Then I served as an examiner for 7 years. After each application process you receive a feedback report to improve. Even when you are recognized with the Governors Quality Award you get feedback on how to improve. We have also applied and received the Governors Quality Aware in 2002 and again in 2012. I would encourage you to take advantage of this program. They offer excellent training as an examiner and seminars that showcase past recipients as well as the Malcolm Baldridge winners.

The 2019 Governors Quality Award Healthcare Seminar will be held on June 18th in Little Rock.  This is a great opportunity to learn more about this excellent program in our state.  


Unity Health is the only organization in Arkansas to receive the Governor’s Quality Award three times; the hospital also received the prestigious Governor’s Quality Award in 2002 and 2012 and 2018. 

As the leading healthcare provider in an eight-county area, Unity Health and its associates strive to improve the quality of health and well-being for the communities it serves through compassionate care. Unity Health is the largest employer in an eight-county area with more than 2,000 associates. The Searcy facility has a combined total of 438 licensed beds and a medical staff of 150 physicians that specialize in various areas of healthcare.

Governor’s Quality Award: Washington Regional Medical Center

Submitted by Terri Church; Unity Health—Washington Regional Medical Center

Unity Health–Washington Regional Medical Center

There is a quote attributed to Aristotle that says “We are what we repeatedly do. Excellence, then, is not an act but a habit.” Washington Regional Medical Center (WRMC) is a community-owned, locally governed, not-for-profit hospital serving Northwest Arkansas and surrounding areas. Since 1950, WRMC’s mission has been to improve the health of people in the communities we serve through compassionate, high-quality care, prevention and wellness education. Upon partnering with the Arkansas Institute for Performance Excellence to receive training and apply for the Governor’s Quality Award for Performance Excellence, we already demonstrated habits that resulted in excellence in care, customer service, and quality, but we were still seeking continuous improvement opportunities.

The Governor’s Quality Award Program utilizes the Baldrige Excellence Framework, a set of questions that represent the leading edge of validated best practice in leadership and management. While we took our journey with a definite destination in mind- receiving the top award in the program- the journey itself was immensely rewarding.         

The criteria have the interesting ability to make you look closely at all systems, from those that are assumed to be sound and well regulated, to those that prove to be fragmented.  This analysis creates the big picture for organizational performance success and ultimately provides a fresh look at your organization. 

We learned so much about ourselves before we even completed the application – areas where we had opportunity for improvement and areas where we excel. If we had never received the award, the application journey and the momentum toward improvement it provided would have been a worthwhile effort. However, now that we have been identified as a role model for quality in the state, our goal is to continue to identify, create and implement best practice and to share these findings in an effort to improve quality across the state of Arkansas.

While the Baldrige Criteria and the Governor’s Quality Award Program bridge sectors- manufacturing, healthcare, business, and education- healthcare is at a tipping point where innovation and excellence is the key to sustainable change. For that reason, the systems approach to performance improvement is a key factor in the success of those who utilize this framework. For us at WRMC, telling our story in the application and to the examiners during the site visit renewed our passion for healthcare and reminded us poignantly that we are striving successfully toward our vision of being the best place to receive care and the best place to give care. If you want to get to know your organization better than you ever have and see its opportunities and glorious successes, this is a journey you want to take. If you want to rejuvenate your organizational pride, as you watch your culture shift and mature, and develop new habits that create excellence, this pathway of self-assessment is for you.  It isn’t a simple process, quite the contrary. It is, however, a worthwhile process. And as Lao Tzu once said, “A journey of a thousand miles begins with a single step.”

Quality Submission Articles

American Data Network Abstraction Expert Shares Key Insights from ACC Registry Conference

Submitted by Susan Allen, American Data Network

In concert with the shift toward value-based care, participation in quality-focused registries is on the rise. But managing these intricate data sets and leveraging findings to improve patient care is challenging. Success is highly dependent on knowledgeable, attuned staff, especially skilled abstractors who know the registries inside and out and are committed to keeping up with ever-changing guidelines.

In March, Tammy Holton, RN, a Data Abstraction Specialist and Registry Lead with American Data Network, attended the American College of Cardiology’s first-ever mega Quality Summit in New Orleans. Holton had the opportunity to engage with a diverse assembly of cardiovascular thought leaders, administrators, clinicians, and data experts who explored the harmonization of registry participation, quality campaigns, and accreditation, examining their collective impact on improvement in quality and patient safety. Holton picked up on several underlying themes that defined the event.

One area of focus was on the significant role that abstractors play in improving patient care. Keynote speaker, Zubin Damania, MD, aka ZDoggMD, known across social media circles for his relatable, healthcare-themed videos, advised his audience never to underestimate an abstractor’s ability to pinpoint opportunities for improvement. They know that data, he explained. Abstractors’ observations and insights can drive decisions that translate into winning strategies.

The primary aim of most registries is to provide feedback to staff that supports the implementation of the most current, evidence-based treatments and therapies for specific diseases and conditions. However, another common theme centered on the intent to expand these tools to incorporate more data that hospitals can use to track and prevent readmissions of cardiovascular patients.   

“Right now, most follow-up data that could be helpful in curbing readmissions is being collected voluntarily, but speculation is that these data elements may soon be mandatory,” Holton said.

Additionally, heightened expectations surrounding transparency have prompted some registries to incorporate public reporting functionalities, which offer hospitals another way to demonstrate their commitment to providing high-quality patient care. 

The bottom line is that quality-focused registries are here to stay, and the ongoing evolution of these valuable tools is exciting for teams eager to put their data to work. While participation can be arduous, the benefits outweigh any hindrance. Organizations like the ACC and American Heart Association (AHA) offer ample resources to help staff maximize registry participation, but it’s important that staff take a proactive approach to the review of available materials. It’s a good idea for team members to share the responsibilities of monitoring and scouring these resources so nothing is overlooked. In some situations, especially when a facility participates in multiple registries, a hospital may opt to expand its reach by outsourcing some of its abstraction work to a trusted partner.

2019 Board Members

Beth Schooley
870-845-4178 fax
Pam Cochran
501-257-3110 fax autocontrols@att.net
Clay Leigh
501-548-4693 clayleigh.pi@gmail.com
Dalana Pittman
501-225-5539 fax dpittman@americandatanetwork.com

Action Team Leaders

Professional Development Justin Villines
501-978-3940 fax justin.villines@hit.arkansas.gov
Pam Blake
External Relations
Steve Chasteen
501-804-2432 schasteen@afmc.org
Lynnette Jack
501-407-9288 fax mqrs@comcast.net
Clay Leigh
501-548-4693 clayleigh.pi@gmail.com
Sharon Aureli
501-202-6435 Sharon.Aureli@baptist-health.org
Amanda Wyatt Hutto

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