From the President’s Desk
Submitted by Chelsey Davidson
Spring is here and I sincerely hope the sunshine, longer days, and warmer weather have made each of your days brighter after the past several months of challenges we’ve all faced in healthcare. In addition to the sunshine, Spring also brings with it the opportunity for us all to reset and spruce things up. Throughout the first part of this year, our Board has attempted to do just that. We are diligently working to ensure the benefits offered to our membership align with the ever-changing needs of both healthcare quality professionals and their respective healthcare institutions, which we recognize may look vastly different than it did prior to the start of the COVID-19 pandemic. Beginning in 2022, we welcomed several new members to our Board including Christie Whatley (CHI St. Vincent), Devin Terry (UAMS), Kristi Toblesky (American Data Network), and Tim Copeland (UAMS). These individuals replaced seats previously held by Lynette Jack, Pam Cochran, Patrice Moody, and Sharon Aureli. I would like to take this opportunity to thank Lynette, Pam, Patrice, and Sharon for their service. We will be forever grateful for the leadership and guidance provided by these individuals over the years (many years for some). AAHQ would not be what it is today without our Board members – both past and present – and without YOU, our members. If you are looking for ways to get involved, I encourage you to consider volunteering as a team member on one of our action teams. We have action teams focused on Finance, Membership, Professional Development, Protocols, Communication, and External Relations. We would love for you to join in on the fun, so feel free to reach out to any of us on the Board if you are interested! Finally, I’d like to mention the AAHQ Education Workshop we have coming up on June 24th. A Save-the-Date email was just sent out. As much as we’d like to meet in person, right now we are planning for this event to be virtual. Nursing contact and CPHQ credits are pending. We are looking forward to bringing you great content and hope you can join us for this event! As always, thank you for all that you do to advance healthcare quality throughout our state, and thank you for choosing to be a member of AAHQ.
Chelsey Davidson, CPHQ
2022 AAHQ Board President
From the Past President’s Desk
Submitted by Pam Blake
It was an honor and a privilege to serve as your 2021 President. I want to thank each of you for a rewarding experience. I could not have done it without the support of all of you: the members of AAHQ, the 2021 Board of Directors and the Arkansas Hospital Association. I appreciate your commitment and your perseverance to improving Healthcare Quality, Patient Safety as well as providing education for Leadership growth in our great state of Arkansas. I am looking forward to another great year while serving under our new President, Chelsey Davidson. The educational sessions and networking opportunities will be amazing. We all have so much to learn and share with each other.
Pam Blake, MHA, BSN, RN, CPHQ
Director of Case Management at Jefferson Regional.
Professional Development Roundup
Submitted by Justin Villines
2022 Arkansas Education Virtual Workshop:
AAHQ Education Virtual Workshop
June 24th, 2022 8:30 a.m. – 4:30 p.m.
AAHQ will hold its 2022 Education Virtual Workshop on Friday, June 24th, 2022 ! 6 CPHQ and CEU are pending.
Mark your calendars—you do not want to miss this event!
- Amanda Wyatt Hutto – Conversations to Prepare for Improvement, Promote Joy & Staff Wellbeing
- Justin Villines – Data Exchange in a Valued Based World
- Christy Whatley – Preventing Healthcare-associated Infections (HAI), Best Practices
- Erin Bolton – Team Building during Trying Times
- Tim Copeland – “How-to” on Quality Leadership
- Devin Terry – New Graduate RN Transition to Practice
For more information on this organization and quality news, visit the AAHQ website at www.arkahq.org.
Membership Services Update
Submitted by Devin Terry
Many of us have sat in Zoom meetings over the last two years wondering how we would ever get back to ‘normal.’ Now many of us have been challenged to ‘fix’ a process, measure whether we are successful or not, or even lead a new project, that you cannot
determine where to even begin. Healthcare practitioners are challenged more today than ever before to demonstrate a high level of patient care. Healthcare facilities’
reimbursement, ‘star ratings,’ and community reputation are contingent upon efficient, effective, and safe patient care with every patient episode. The good news about both
issues is that AAHQ is a great resource to help find the solutions to all these problems.
Is this you and you are wondering whom to turn to for help, education, or even
interpretation of this new language that is Healthcare quality? If you can relate to this, I
want to encourage you to become a member of AAHQ today.
Becoming a member of AAHQ allows you to connect with other professionals that are
facing the same issues as you, are familiar with the language, and have valuable and
pertinent experience that you may not have. Once you become a member of AAHQ you
have access to networking opportunities from across the whole state of Arkansas,
educational offerings related to moving healthcare quality forward, and quality leaders in
all areas of healthcare. Areas include, but are not limited to, acute care hospitals, skilled
nursing, ambulatory, etc. Today’s AAHQ membership is a strong representation of all
regions of the state. However, something is missing… YOU!
If you are not a member of AAHQ today, please honestly consider joining RIGHT NOW!
Why are you waiting? To join visit our website Membership | Arkansas Association for
Healthcare Quality (arkahq.org) and sign up online or print the paper form and mail it in
with payment. Then connect with other healthcare professionals across the state to
provide higher quality direct patient care to all Arkansans.
If you have questions or need help, please submit an online question at Contact |
Arkansas Association for Healthcare Quality (arkahq.org) or call AAHQ at 501-224-
Submitted by Dalana Pittman
AAHQ Communications team has been hard at work. We have been updating social media, our website, and working on the new process for our newsletters! It is our goal to bring you educational material on quality topics throughout the year. In order to participate and interact with AAHQ, please follow us on Facebook and LinkedIn. Our website is up and running and can provide you with much information on our organization and educational events. Please bookmark the website and visit often!
The communications team is also looking for anyone in our organization who is interested in learning more about our team and participating in our social media and website updates. If interested, please reach out to me directly at dpittman@americandatanetwork or 501.554.0723. I would love to have you join this team!
Finance Action Team Update
Submitted by Clay Leigh
AAHQ, The Arkansas Association for Healthcare Quality, has $27,004.28 of available cash as of February 28, 2022. Fiscal year-to-date, $4,700 has been generated from membership dues, $3,060 from meeting attendance, and $1,500 from sponsorship. The board-sponsored, 2022 Arkansas Quality Workshop: AAHQ Education Virtual Event on June 24, 2022, is expected to increase available cash as well. Since July 1, 2021, $4,758.32 has been spent on meetings and $4,511.00 on national meetings (to include scholarships for AAHQ members for Virtual NAHQ Next in September 2021). There have been $332.58 for bank fees and $94.92 for supplies. Projected upcoming expenditures in the coming months will include the annual fall conference, which will vary depending on the platform—live or virtual and keynote speakers. Full disclosure of bank statements is available by request, please contact Arkansas Hospital Association at 501-224-7878.
Submitted by Erin Bolton
Good afternoon! As I am writing this, the sun is beaming through my window, spring has arrived, and the Razorbacks have made it to the elite 8 in the NCAA tournament! It’s a good day! It’s also a great time to join the protocol team! My name is Erin Bolton and I am the Protocol Team Lead. Pam Blake, Past-President of AAHQ, also serves on the team. The protocol team is responsible for updating the by-laws, nomination and election of officers, policy review and revision, and revising and distributing job descriptions. We recently updated the by-laws Article X—Meetings, section 1, to allow the Association to hold the annual business meeting virtually in the event of a national emergency, state of emergency, or major disaster. Pam and I would love to have you join our team. Please feel free to contact me at firstname.lastname@example.org if you are interested in joining us, have questions about the by-laws, or would like to make suggestions for changes. I look forward to seeing you all virtually at the Spring Conference in June!
Digital health care records and infrastructure provides many benefits over paper systems. But just like paper charts, electronic health records are stored within a clinic or hospital system and are rarely shared with other providers. As a result, patient health information remains siloed across other modicum of care teams. To bridge the patient information compartmentalization issue, the State of Arkansas related a “single connection approach”, called Arkansas State Health Alliance for Records Exchange (SHARE), a statewide health information exchange (HIE). SHARE provides health information in a standardized electronic format and enables medical data to follow patients rather than being housed in separate physician’s offices or within a single hospital system. SHARE can greatly improve the completeness of patient records, which can have a major effect on care as medical history, current medications, and other information is reviewed during visits.
SHARE allows participating doctors, nurses, specialists, health services professionals and public health authorities to access and securely exchange with each other real-time, electronic patient information that is protected by federal and state privacy and security laws. However, the majority of providers sharing data, bidirectional or unidirectional, are in the medical field – hospitals, FQHC, doctor’s offices, not specialty behavioral health and intellectual developmental disability providers.
Brief Project Description
Connecting the electronic health records (EHRs) of the provider practices, long-term post-acute care facilities, hospitals, and specialists to the HIE that are not contributing data is key to the long-term success of the Behavioral Health Community and their patients. Connecting all these EHRs through SHARE creates a “single connection approach”, where all the clinical data needed to manage the BH/DD patient populations can be achieved through one connection to SHARE. One connection, numerous benefits.
SHARE’s single connection to each provider’s EMR system gives all integrated providers and the
BH facilities and payers several benefits:
- Access and exchange clinical patient information in an efficient, timely, and cost-effective manner
- Connect to hospitals, physicians, nurses, labs, long-term care entities, and others involved in a patient’s care
- Coordinate patients’ care with their other providers in an efficient and secure way.
- Make better-informed care decisions through immediate access to patient health information from all points of care
- Connect to the Arkansas Department of Health local health units
- Bridge the communication gap across acute and ambulatory settings
- Avoid duplicate testing and procedures through records sharing
- Reduce administrative costs associated with data management.
In fact, the opportunity to collect and close gaps in care and seamlessly update respective EHR with real-time data proves to lower costs and provide better patient outcomes. As the healthcare landscape continues to transform, HIEs, such as SHARE, play a key role in providing data that fuels innovation. SHARE and the behavioral health providers and payers together contribute to these innovation efforts such as population health initiatives, identifying potential social determinants of health, and assisting with payer relations, among other efforts. Connecting health (BH) and intellectually disabled / developmentally delayed (ID/DD) provider EHR systems -with an understanding of how to apply the data- the results can change the lives of members in the community as well as reduce the overall cost of health care in Arkansas.
The Office of Health Information Technology, a division of the Arkansas Department of Health is encouraging COVID vaccines across the state using SHARE Health Information Exchange COVID-19 Notifications.
Submitted by Justin Villines
The HIE first started alerting PCPs statewide on COVID 19 positives in 2020. SHARE COVID-19 Laboratory Notifications service brings alerts of positive test results of attributed patients to providers, accountable care organizations (ACO), clinically integrated networks (CIN), and payers. The qualified participants that are already receiving the SHARE 24-hour daily reports of ED and Inpatient Discharges will also get the COVID-19 Laboratory Notifications. Through direct secure messaging, we can notify you when patients have tested positive for COVID-19.
How Can This Information Be Used?
Access to this timely information can be used to:
- Improve disease management during the COVID-19 pandemic
- Improve care management and coordination for patients or members
- Prevent hospital admission and readmissions
- Inform quality improvement
- Help healthcare providers pinpoint areas for improving outcomes
COVID-19 Notification Example
Secondly, The Arkansas Department of Health/SHARE COVID-19 Vaccine Notifications service brings alerts of patients/members that have received dose (1), dose (2), dose (3), and dose (4) of the COVID-19 Vaccine. The report includes manufacturer, date, and vaccine given location. The qualified participants that are currently receiving the SHARE 24-hour daily reports of ED and Inpatient Discharges will also get the COVID-19 Vaccine Notifications. Through direct secure messaging, the HIE can also notify you when patients have tested positive for COVID-19.
How Can This Information Be Used?
Access to this timely information can be used to:
- Improve disease management during the COVID-19 pandemic
- Improve care management and coordination for patients or members of given Vaccine
- Inform quality improvement and vaccinated patient groups
- Help healthcare providers pinpoint areas for improving outcomes
ADH/SHARE COVID-19 Vaccine Notification Example
Learn more about Arkansas’ statewide HIE here: https://www.healthy.arkansas.gov/programs-services/topics/state-health-alliance-for-records-exchange-share or www.SHAREarkansas.com .
Justin Villines, MBA, BSM
Health Information Technology Policy Director
Arkansas Department of Health – Office of Health Information Technology
State Health Alliance for Records Exchange (SHARE)
O: 501.537.8924| C: 870.688.0445| F:501.978.3940 | E: email@example.com
1501 North University Avenue, Suite 420, Little Rock, AR 72207
|What is NCDR?
NCDR (National Cardiovascular Data Registry) is a collection of data registries developed by the American College of Cardiology to help hospitals and health systems manage and improve cardiovascular care. Among the hospital-specific registries are CathPCI, Chest Pain-MI, EP Device Implant, STS/ACC TVT, LAAO, Afib Ablation, and IMPACT. Among the outpatient, registries are PINNACLE and Diabetes Collaborative.
Through the American College of Cardiology’s National Cardiovascular Data Registry (NCDR), facilities can obtain a wealth of clinical data that can help them measure performance, improve healthcare quality, and demonstrate success in the process.
Developing a comprehensive program involves more than just collecting data. Supporting these registries is essential for achieving the goal of increasing evidence-based care and improving outcomes. However, not every facility’s NCDR program is the same. The quality and quantity of data produced through participating in the NCDR registry can differ dramatically from one facility to another, as can the success of using the data to drive improvements.
Having spent a decade working in specialized registry abstraction, Tammy Holton, ADN’s top NCDR expert, shared 5 best practices for managing your facility’s NCDR program based on 10 years of experience, both as hospital staff and as an Assistant Manager for ADN’s Core Measures & Registry Data Abstraction Outsourcing Service.
#1: Keep your knowledge up to date
Knowing the latest trends and staying up-to-date is key to maintaining an outstanding NCDR program. Because registries like NCDR undergo constant changes, maintaining an updated knowledge base is critical. Without it, a program will almost certainly fail. Moreover, many of the other best practices require the Registry Manager to demonstrate expertise on the topic, so they’re easier to implement. There are several areas in the knowledge base that require constant attention, including program requirements, evidence-based guidelines, abstract specifications, transmission standards and deadlines, dashboard updates, reporting and benchmarking options, and validation, as well as important announcements.
Additionally, it is important to stay up-to-date on all the educational offerings available on the NCDR website. There is an array of on-demand courses available at the QII Learning Center, from very basic registry overviews to more in-depth topics such as risk-adjusted metrics. On the NCDR website, you can also find frequently updated FAQs, the Monthly Case Scenarios, and the Registry Calls that are held every two months on the NCDR home page for the selected registries. In the event that you are unable to attend, the registry call is usually posted online a few days after the conference call. “One of my favorite features is the ‘Questions From Your Peers’ section of the calls,” Holton said. “Typically if you have lingering uncertainties, you’ll find you are not alone and there are others out there with the same questions.”
#2: Establish rapport with stakeholders and gain their buy-in
An NCDR program’s success depends on establishing a rapport and gaining the buy-in of stakeholders. Consequently, it is essential to choose the right strategy to achieve these critical components. In order to maximize patient satisfaction, making the effort to explain to physicians (the primary stakeholder group) why your hospital is participating in the NCDR program and how their efforts will contribute to improving overall care quality will pay dividends. “If you can get physician buy-in, you’re going to be golden,” Holton said.
“A lot of times we find the problem isn’t that something wasn’t done, but rather it wasn’t documented.” It is not uncommon for physicians to be extremely busy, and without the right elicitation of buy-in, it may be difficult to constantly have quality or cardiovascular team members approach them about lack of documentation. However, if the groundwork has been laid properly to communicate the “why” behind your efforts, these interactions will be much more fruitful. As healthcare places a greater emphasis on quality, physicians are used to receiving feedback and show most interest when they’re able to understand how their clinical documentation relates to the improvements. “Driving home the ‘why’ and making a compelling case with real-world examples can make things much easier,” Holton said.
“A not-so-successful strategy I’ve seen some facilities rely on is sending multiple emails requesting additional documentation, but not explaining why,” Holton said. She finds that holding monthly cardiovascular meetings creates an ideal environment for promoting your registry. “You want to help physicians understand the rationale behind your requests and show how their changes can make a difference in the performance metrics,” Holton says these meetings are often met with some resistance; however, in time, the providers begin to actively track their progress and ask for performance reports.
(For additional tactics on working effectively with your physician stakeholder group, see Best Practice #5 below.)
#3: Submit your data early and often
The ability to stay ahead of the game is a critical component of a first-class abstraction program, and it is typically only attainable with a lot of experience. “Seasoned Registry Managers, and some savvy abstractors, make a point to proactively identify risks before they become full-blown problems,” Holton said. A part of this involves raising the issue of trends observed during data abstraction and/or recognizing emerging patterns when reviewing specific types of outliers.
Holton recommends that submissions be made often and early. “One of my first questions, when we take on a new account, is ‘How often do you submit your data?’,” Holton said. “Unfortunately, a lot of facilities wait until shortly before the deadline to submit. You should never wait until the end of the quarter or harvest period to submit your data because this can result in major data quality issues, leaving no time for re-abstractions and corrections. Submitting unclean data not only impacts your internal reports but also affects the integrity of the NCDR database. That’s why I always prefer weekly data submissions and aim to complete them by the end of the day Friday. The way the NCDR system works is that it aggregates all new data once a week on Sundays. So, Monday morning your dashboard is fresh with all the data you’ve submitted from the week before.” The Registry Manager can then address any conflicts that are preventing case acceptance or re-abstract any elements that are flagged with informational errors based on the feedback reports. In addition, teams can initiate timely improvement plans by reviewing internal performance gaps. Dedicating time to this each week will make the workload much easier to manage.
Most facilities wait until the end of the harvest period not because they lack knowledge, but rather because of time and resource constraints. The majority of facilities lack the manpower to perform frequent and early data reviews, preventing them from identifying problems with submission and opportunities to improve care compliance in time. NCDR can take as long as six months after discharges and abstractions to release its Institutional Outcomes Report. As a result, you’re analyzing problems with little relevance to your stakeholders. “The only way to prevent this is to constantly work the data. And most facilities don’t have sufficient time or staff to do that,” Holton said. “If you want to ensure accurate data and identify trends early on, my advice is to submit your cases every week and immediately address any areas of concern. That way you can avoid a last-minute crisis.”
#4: Implement an IRR program that provides optimal abstraction accuracy
Having high-quality abstractions is crucial to a successful NCDR program. The best way to achieve this is to establish an Inter-Rater Reliability (IRR) program. In the IRR process, a team member is required to abstract a sample of the same cases that have already been abstracted by another abstractor and discuss any mismatches. Mismatches sometimes occur because the original abstractor did not know where a key piece of information was located in the documentation. In other cases, it could be a result of misunderstanding the abstraction definitions. “IRR is a worthwhile process because it prompts important discussions. It really is the best way to ensure reliable, consistent abstractions, which are the backbone of your clinical improvement efforts.”
#5: Clearly communicate the results after thoroughly analyzing the data
An important responsibility of a Registry Manager is to be able to understand the data, in particular, which elements impact outcomes and why. It is equally imperative that you are able to communicate your findings to your stakeholders effectively.
The first step in preparing to present any data is to ensure you understand it completely. It is important for the Registry Manager and team to describe how existing processes and practices affect registry performance. Start by analyzing the Executive Summary Report, which includes your facility’s metrics performance for the Rolling 4 Quarters (R4Q). Also, provide a three-year historical performance graph and a comparison group performance graph to compare your performance internally and against other NCDR participants.
Next, identify the physicians who are performing the best and the worst based on your data. It is also important to delve deeper into the case details to uncover the sources of variation. Holton says the Patient Level Detail Reports provided by ADN abstraction outsourcing clients are a valuable tool for identifying outliers. “A good Registry Manager will go into the chart to see why the case is an outlier in order to better understand where the breakdown occurred,” Holton said.
Talking with your physician stakeholders using Patient-Level Detail Reports can be highly effective. “Having patient names and not just numbers facilitates a much more productive stakeholder conversation,” Holton said. Another valuable aspect of this strategy is that this type of report fosters healthy competition. “No one wants to be at the bottom of a drill-down report grouped by physicians,” Holton said.
Lastly, once you have a solid understanding of the data, it is crucial to present stakeholder reports in a visually appealing format that demonstrates clinically relevant information. “If you hand physicians a 10-page report with a list of names, they’re not going to take the time to try to decipher what it all means,” she said. “You have to figure out a way to make it digestible for them.”
Most NCDR programs are successful because of a strong communication system between registry managers, stakeholders, and abstractors. An information management system such as this is vital for communicating with stakeholders the overall facility performance, specific outliers, documentation needs, and negative and positive trends. The communication tree with abstractors is equally important, ensuring they know what you want them to concentrate on and encouraging them to speak up proactively regarding opportunities.
A Look at NCDR Abstraction “Smartsourcing”
The reality is that many Registry Managers have both the ability and the know-how to run a top-notch NCDR program but lack the time to do so, given all the other duties they have to perform. Therefore, most facilities are looking to “SmartSource” data abstraction and management so they can focus on quality improvement based on their NCDR and other abstraction data.
As opposed to spending their time constantly sifting through data among all their other responsibilities, an outsourced partner provides the key insights that warrant their attention. “We can point that out for them and make it easier,” Holton said.
Below are some of the tactical and strategic reasons facilities “SmartSource” their data abstraction, aside from saving time with routine data analysis and maintaining IRR programs.
CTA: Get more information about partnering with ADN for Data Abstraction Outsourcing
|Tactical Reasons||Strategic Reasons|
You can reduce costs by using per-chart pricing, reallocating abstraction staff to frontline positions or other roles, then outsourcing those positions to save budget dollars. You can further reduce costs by bundling with our Core Measures applications.
|IMPROVE BUSINESS FOCUS
Invest time and energy into the key objective leadership demands of quality directors and managers: creating a reliable organization. Delegate the time-consuming management of abstractions to experts.
Costs associated with insourcing go beyond salaries. Data indicates that the real cost per employee based on salary, benefits, taxes, and manager’s time is 125% – 140% of the salary. Download the Outsourcing Cost-Benefit Analysis Template.
Abstractions are complex, time-consuming, and strain your already stretched resources. Staff that is available and scarce should be reallocated to frontline care positions or to implement and monitor improvement tactics.
|SHIFT FROM GENERALISTS TO EXPERTS
It is typical for insourced teams to have a few abstraction generalists who may also wear many hats. Experts on ADN’s team are knowledgeable about many registries and measures and also stay current on ever-changing specifications.
|INCREASE AGILITY & FLEXIBILITY
The reduction of abstraction management will allow your department to implement improvement strategies or adapt to risks faster. Increase your confidence, reduce overhead, keep headcount low, and let the experts handle the data collection headache.
|ELIMINATE OPERATIONAL CHALLENGES OF TURNOVER AND LEAVE
Anxiety and frustration are often associated with vacancies. Partnering with an outsourcing company provides a safety net for the department. By extending your department with an outsourcing partner, absenteeism, vacations, and temporary or extended leaves are no longer an issue.
|PREPARE FOR FUTURE CHALLENGES
Plan ahead and weather future challenges by freeing up time and budget to better prepare for threats like the current pandemic.
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.
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.
2022 Board Members
President – Chelsey Davidson
Past-President – Pam Blake
Secretary – Kristi Toblesky
Protocol Team Lead – Erin Bolton
President-Elect – Shanda Guenther
Communications Team Lead – Dalana Pittman firstname.lastname@example.org
Professional Development – Justin Villines email@example.com
Membership Services – Devin Terry
External Relations – Christy Whatley
Finance Team Lead – Clay Leigh
Member at Large – Amanda Wyatt Hutto firstname.lastname@example.org
Member-at-large – Tim Copeland