2022 Summer Newsletter

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From the President’s Desk
Submitted by Chelsey Davidson


Chelsey Davidson


Greetings AAHQ Members!

With the end of Summer approaching, I know we all are gearing up to get back into a normal routine both at home with our families and at work. As a Board, we’re working to move back to a more normal, pre-pandemic way of operating as well! As described later in this newsletter, as of right now we are planning to meet IN-PERSON for our upcoming 2022 Fall Conference. This will be the first time since the beginning of the pandemic that we’ll get to see you all face-to-face and further our healthcare quality knowledge together. I can’t tell you how excited I am for this to happen and hope you all are too! Be on the lookout for more information about this event coming soon. And speaking of healthcare quality knowledge, I want to thank those of you who were able to attend our 2022 AAHQ Virtual Educational Workshop. All in all, we had over 60 attendees at this event where our speakers delivered content that was so relevant to the challenges we all are facing as a healthcare community. Also of note, we have an election underway for the President-Elect position on the AAHQ Board of Directors. Please make sure to cast your ballots, as the individual filling this position will serve at the helm of AAHQ beginning next year. As mentioned in our last newsletter, we would love to have more of you involved in our board action teams. These teams include Finance, Membership, Professional Development, Protocols, Communication, and External Relations. Please don’t hesitate to reach out to any of our Board members if you would like to join in on the fun. Lastly, I want to thank you all for your continued dedication to the high-quality healthcare our patients receive throughout the state – you are all difference makers and our communities would not be the same without you!


Chelsey Davidson, CPHQ
2022 AAHQ Board President

Professional Development Roundup
Submitted by Justin Villines

Justin Villines

Thank you all for a successful workshop this spring, it was well attended, and congrats to the winners who will attend our fall conference Free!

SAVE THE DATE! AAHQ will hold its 2022 Education Conference at CHI St. Vincent Infirmary (North Auditorium) and hope you can attend.




2022 Arkansas Quality Conference: AAHQ Education Conference

Location: CHI St. Vincent Infirmary (North Auditorium), Little Rock, Arkansas

Friday, October 14th, 2022, 8:30 AM – 4:15 PM

Mark your calendars—you do not want to miss this event! For more information on this organization and quality news, visit the AAHQ website at www.arkahq.org.


Membership Services Update
Submitted by Devin Terry

Devin Terry


Please enjoy our Membership Spotlight below!





Membership Highlight
Amanda Wyatt Hutto, PCMH CCE

Amanda Wyatt Hutto

Amanda works for TMF Health Quality Institute (tmf.org). TMF helps provide high-
quality health care through federal, state, and local contracting. Here expert healthcare
professionals support clinicians and practices in quality improvement efforts through
leadership and development opportunities, peer–to–peer learning, the monitoring and
evaluation of data, and training assistance. Amanda has worked on special projects,
including Comprehensive Primary Care Plus (CPC+), ECHO National Nursing Home
COVID-19 Action Network, Primary Care First (PCF), and Stakeholder Engagement &
Awareness. Amanda identifies priorities and solution-focused improvement solutions,
data analysis, and integrity in her role, providing training, technical assistance, and
mentorship. Amanda has been in various healthcare roles for over twenty years!
Amanda has been a member of AAHQ since 2019 and has participated in all
educational and professional development opportunities. Through her AAHQ
membership, she has ‘obtained CEUs, scholarships that covered event registration
feeds and experienced exceptional networking opportunities.’

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 | Arkansas
Association for Healthcare Quality (arkahq.org) or call AAHQ at 501-224-7878.


Communications Update
Submitted by Dalana Pittman

AAHQ Communications team is looking for any member interested in serving on our Executive Board Communications Team. There is so much to learn and there are always great networking opportunities. Are you a self-motivated learner and interested in technology like websites and social media? If so, then this is the team for you! Please reach out to me for more information, I’m happy to share the knowledge I’ve obtained over the years while I’ve been so fortunate to be part of this amazing group of individuals!

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!

Dalana Pittman
2022 Communications Team Lead

Finance Action Team Update
Submitted by Clay Leigh

Financial Update—July 1, 2022
The Arkansas Association for Healthcare Quality has $25,863.76 of available cash on April 30, 2022. Fiscal year-to-date, $5,415 has been generated from membership dues, $3,060 from meeting
attendance, and $1,500 from sponsorship. Revenue and expenses generated from the 2022 Arkansas Quality Workshop: AAHQ Education Virtual Event on June 24, 2022, is not reflected in this report. Since
July 1, 2021, $4,758.32 has been spent on meetings, and $4,511.00 on national meetings. There have been $363.20 for bank fees and $94.92 for supplies. The AAHQ fiscal year ends 6/30/2022 and will be reflected in a future newsletter when reports are available. Full disclosure of bank statements is available by request, please contact Arkansas Hospital Association at 501-224-7878.


Protocol Update
Submitted by Erin Bolton

Would you like to serve on the AAHQ Board? Do you know someone who would make a great AAHQ board member? We will be having elections this fall for Secretary and President-Elect to serve in 2023. The Secretary “shall be responsible for recording all meeting minutes and performing other duties as requested by the Board”. The Secretary will serve a two-year term. The President-elect “shall perform the duties of the President, in the absence of the President. He/She will also perform all duties assigned by the President and will become familiar with and prepare for the duties of the office.” The President-elect will serve one year as President-elect, one year as President, and one year as Past President. The nominee for President-Elect must hold a current Certificate as a Professional in Healthcare Quality (CPHQ) and maintain this certification throughout his/her three-year term.

If you have any questions about either of these positions, please feel free to reach out to me at boltone@jrmc.org and I can get you some additional information. Please watch your emails over the next few weeks as we start the nomination and election process!

“The Five Dysfunctions of a Team”, A Book Review
Submitted by Tim Copeland

“The Five Dysfunctions of a Team” by Patrick Lencioni was published in 2002.  So it’s been around for a while and many of you may have already read it.  But we are doing a “Book Club-style” review of it in our weekly staff meetings and our team is really enjoying our discussion about this “oldie but goodie.”

The subtitle of the book is, “A Leadership Fable.”  It tells the story of a fictional leadership team of a two-year-old Silicon Valley technology company.  Because the focus is not a healthcare provider, there is some translation necessary to make the principles in the book applicable.  But that’s not hard to do.  The CEO of the company has been removed from the role but continues to serve on the board and on the leadership team.  A new CEO has been brought in with years of leadership experience in manufacturing operations but almost no exposure to the tech industry.  To quote Lencioni’s descriptions of the leadership group, “Backstabbing among the executives had become an art.  There was no sense of unity or camaraderie on the team, which translated into a muted level of commitment.  Everything seemed to take too long to get done, and even then it never felt right.”

The new CEO takes a few weeks to observe and contemplate her first move.  That ends up being the scheduling of a two-day weekend off-site retreat where she takes them on a mental voyage of discovery where the team comes to understand the reality and the causes of their dysfunction.  The fictional CEO uses a model which portrays Lencioni’s model of the five dysfunctions of a team.  What follows is a graphical depiction of that model…

Upon completion of the retreat, there is apparent acceptance among the leadership team members that they have a lot of work to do.  But upon return to the office, things start to return to the status quo very quickly.  The remainder of the book is devoted to describing a second retreat and how the members of the team who remain on board are finally able to establish a productive, working relationship.  At the end, the author provides further elaboration on the model.  There is a self-evaluation tool that can be used to discover the dysfunctions that might exist in any team as well as a chapter on “Understanding and Overcoming the Five Dysfunctions.”

The use of fable is a very effective and entertaining vehicle to illustrate the model Lencioni presents.  I recommend the book for either a quick read for personal edification or for a team discussion in a “Book Club” type setting as we are doing at our facility…..

Tim Copeland, MHSA, BS(MT)
AAHQ Member-At-Large
Director of Quality Management

A Guide to Conducting a Survey on Patient Safety Culture (SOPS)
by Diana Giordani



All your attempts to build a “High-Reliability Organization” are in vain if a patient safety culture isn’t embraced at every level, from system to individual. The best way to measure your patient safety culture, and recognize trouble areas, is simply by asking.
One of the most reviewed assessment tools for this is the Survey on Patient Safety CultureTM (SOPS®) created by the Agency for Healthcare Research and Quality (AHRQ).
While the AHRQ survey has been available since 2004, lately it’s acquired considerable attention from accreditation associations like The Joint Commission (TJC) and public-scoring observers like Leapfrog.

Toward the end of 2018, TJC modified its survey process expectancies for Patient Safety Culture Assessment.

  • An organization will be expected to include its most recent Safety Culture Survey with the required documents listed in the Survey Activity Guide. The surveyors will want to review this prior to the opening conference (or as early in the survey process as possible).
  • Surveyors will be tracing safety culture as a part of other survey activities and asking questions to assess safety culture. See Table 2 for sample questions for assessing safety culture.

And more, the Leapfrog Hospital Safety Grade factors in whether or not a Patient Safety Culture Survey was administered.

  • “Hospitals can earn up to 120 points for measuring culture of safety, providing feedback to staff, and creating new plans to prevent errors.”

However, AHRQ’s survey is certainly not a one-size-fits-all process. The flexibility — how often to survey, how to survey, and how to manage the outcomes — comprehend the extensive variety in size and resources of patient-care organizations. Yet, it also implies a significant number of decisions that must be made in-house.

The following are 6 advised practices for your next SOPS to both satisfy accreditor and observer expectations and, more importantly, to make the process notable of an enhanced safety culture for your organization:

  1. Consider the Potential Benefits of Outsourcing Survey Administration and Analysis. Numerous organizations have kept on feeling the burdens of the healthcare staffing crisis since the pandemic. So regardless of whether you have taken care of the survey process in-house before, your ability to do so now may have changed. Furthermore, on the off chance that you haven’t managed a SOPS lately, you may be reluctant to add it to your plate given that AHRQ’s User Guide for Hospital SOPS Version 2.0 blueprints a 10-week timeline for arranging, building, conveying, and inspecting the survey.Most benefits of outsourcing are evident: The process doesn’t delay your regular obligations and tasks, and you don’t need to review the tools or train somebody in-house for a process that just happens each and every other year.

    Other benefits of outsourcing are more subtle: The right outsourcing company can help you (1) accomplish higher response rates that improve outcomes, and (2) collect a more modern and informative analytics report, faster than you might otherwise. (Our team turns the report around in less than 30 days.)

    AHRQ calls attention to several advantages of utilizing an outsourcing company in the User Guide

    1. Working with an external vendor might assist with guaranteeing the lack of bias and credibility of your outcomes.
    2. Staff might feel their responses will be more private when their surveys are returned to an external vendor.
    3. Vendors usually have come across staff to executive all necessary duties and assignments. An expert and experienced vendor might have the option to provide your hospital with better quality outcomes faster than if you somehow happened to do the tasks yourself.
    4. While considering these advantages and the reality that outsourcing is very affordable, it’s typically worth a brief discussion before you go excessively far down the road of investing internal time and resources in overseeing the SOPS yourself.
  1. Focus on Design Features. The traps of a poorly planned internet-based survey are various to such an extent that AHRQ delivered a webinar on best practices as an ally to the SOPS User Guide.Web-based surveying has essentially swapped paper surveys for many good reasons: online surveys keep members from offering two responses to the same question; they can catch responses in the event that the survey-taker neglects to complete all questions; and, most appealing, online survey responses are automatically arranged, resulting in actionable outcomes within days as opposed to months.

    Design components that truly matter consist of a proper grid layout, alternating row shading to assist respondents to move smoothly through the response choices, simple buttons for moving through the questions, and an advancement bar to encourage the user to finish the survey. Likewise significant is developing a survey that is not difficult to complete on a mobile phone, in addition to a desktop computer.

  2. Record the response rate. The capacity to record responses progressively is one of the great benefits of web-based surveying contrasted with paper surveys, yet that benefit is wasted if nobody is focusing until the end of the survey time frame. A good outsourcing company will record and update you frequently – ADN, for example, gives response rates no less than two times per week at the overall facility and individual department levels – so that designated special efforts can be executed on time by huddles or other staff meetings. Your response rate ought not to have an unexpected resolution.
  3. Promote, promote, promote. Indeed, even a well-planned survey will have a low response rate without reliable, multi-channel efforts to encourage, incentivize, boost and remind employees and other respondents to begin and complete the survey. That implies emails, ideally from the CEO; banners in common areas, verbal reminders at routine staff huddles; links on your intranet; and so on.In the case of partnering with ADN, we have a sequence of pre-composed email templates with suggested distribution dates/times that have been proven to be efficient.
  4. Encourage participation. Awards for departments with the highest response rates are more effective than random individual winners. Furthermore, the prize ought to mirror the worth your organization puts on understanding patient safety: an extra day off, a catered meal, or perhaps both. Through experience, our team has taken in a few creative and motivating incentives that we share with clients.
  5. Collect high-quality reports for sharing with key stakeholders. With much more data from an organization-wide survey, the quality of your analytics report can mean the contrast between an ocean of raw data or a stash of refined insights. The following are some best practices ADN suggests.w
    1. Identify strengths and opportunities by comparing them to external benchmarks. While understanding what’s happening at your organization is indispensable, ensure you check how your performance piles up to different organizations. When outsourcing with ADN, the extensive report you get incorporates comparisons with the most up to date available AHRQ SOPS databases, as well as an executive overview and outline breakdowns of the survey data to help with conveying the outcomes to all internal stakeholders.
    2. Search for contrasts from baseline and comparators at the department, position title, and workspace levels to help further characterize priorities. Recognizing opportunities for improvement is unquestionably a goal here, however remember to distinguish top performers too. Diving into the subculture of top-performers can provide an abundance of learning.
    3. Don’t disregard unstructured data. A great amount of knowledge can be covered in unstructured data like narrative answers. Deep-diving “other” responses and coding open-ended responses by subjects are great ways of guaranteeing you extract every single drop of insight from your survey data.
    4. Communicate survey results at all levels to promote organizational learning and transparency. While the essential audience expected to follow up on the survey responses might be senior administration, disseminating findings, strengths, and opportunities across other levels of the organization can be exceptionally helpful. It can deepen buy-in, demonstrate everybody plays a role in the improvement, encourage transparency, show that data is being analyzed to be acted on (not just collected), and considerably more.
    5. Promote multi-disciplinary report meetings to inform action planning. The frontline staff play a certain role in event identification and reporting, yet can have an even more significant impact when their private knowledge of internal systems is utilized in the PDSA cycle. Frontline can act as informed experts to help distinguish and characterize circumstances and logical results connections. While dissecting survey results by work areas or position titles or themes, a cross-discipline team will want to contribute unique perspectives that reveal or explain patterns seen inside the survey data. By including a portrayal from every discipline and levels involved, the team can probably add more context and better coordinate issues with actions and interventions.
    6. In addition to survey results, examine internal event reports, public safety scores, and other safety data. A portion of the SOPS survey questions give insights into the benefits of your existing interventions, for example, safety education, event reporting systems, and communication among teams. Assessing these connections can inform improvement efforts and resource distribution for addressing aspects that directly influence staff impression of safety culture and indirectly benefit other safety-related processes (e.g., upgraded safety guidelines and continuous education, better communication about medications and discharges, and so on.).

For more information about ADN’s Survey on Patient Safety CultureTM (SOPS®) Service, click here to contact our team.

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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




Member At Large – Shanda Guenther




Communications Team Lead – Dalana Pittman                                    dpittman@americandatanetwork.com




Professional Development – Justin Villines                                      justin.villines@hit.arkansas.gov




Membership Services – Devin Terry




External Relations – Christy Whatley




Finance Team Lead – Clay Leigh




Member at Large – Amanda Wyatt Hutto                                              amanda.wyatthutto@tmf.org




Member-at-large – Tim Copeland





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