Third Quarter 2023 AAHQ Newsletter

From the President’s Desk
Submitted by Devin Terry

Dear AAHQ Team,

I hope you have enjoyed the break from the triple-digit temperatures and humidity! As I write this letter, I am enjoying the fog as it covers the pond and field in front of my home and makes me wonder where this year has gone. As they say, “Time flies when you are having fun” and during the last ten months your AAHQ Board has been having fun and staying very busy on your behalf working on the fall conference, sending AAHQ members to the NAHQ Next Steps virtual conference in September, and looking forward to celebrating with you National Healthcare Quality week October 15-21, 2023.

I encourage all members to attend the Fall Conference; registration is on the AAHQ website and is made easy for you to navigate. As usual, the Professional Development Team has worked hard to plan an incredible agenda helping advance your knowledge and resources as you better the health of our great state. Please also encourage your colleagues to attend and then to become AAHQ members!

As the year comes closer to the end, I encourage each of you to get involved in one of the action teams. It is very rewarding to be an active part of the team. Your AAHQ Board members are all volunteers and continue to serve in multiple roles as board members and full-time employees in healthcare quality throughout the state. To maintain the great membership opportunities and education your Board needs everyone’s assistance.

I hope to see each of you at the fall conference!

Sincerely,

Devin Terry PhD, RN, ACNS-BC, CPHQ

AAHQ President

Registration is Open

AAHQ Virtual Education Conference

October 13, 2023

Excellence in Action: Unleashing the Power of Quality

Join us for the virtual AAHQ Fall Quality Education Conference where those of you that are focused on improving healthcare quality will learn more about challenges and solutions impacting quality outcomes in Arkansas. A variety of topics will be covered, including:

• Resilience in times of stress and burnout
• How to optimize healthcare
• Hospital care and its impact on community health and wellness
• Data and transforming healthcare
• Post-acute options for the Medicaid population
• Ensuring excellence with new graduate nurses

Registration fee*
$75 AAHQ Members
$125 Non-Members

*If you are logged in and are receiving the non AAHQ member rate, your 2023 AAHQ dues have not been received. You must pay your dues before you register to receive the member registration fee. Refunds will NOT be given after registration transaction has been completed.

APU Statement
Arkansas Hospital Association is approved with distinction as a provider of nursing continuing professional development by the Midwest Multistate Division, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

Continuing Education
7.0 Nursing Contact Hours will be awarded to all nurses who REGISTER FOR THE EVENT prior to event start, attend the virtual event in its entirety, and complete the follow-up evaluation process attesting to their attendance via Survey Monkey within one week following the event date.

7.0 CPHQ continuing education credits approved by NAHQ®.

Full flyer with biographical information or to print for faxed registrations, CLICK HERE.

How to Register
>> AHA member hospital employees are now able to register for events online by signing in with their username and password. If you have any questions regarding logging into the AHA website, please contact Cindy Crump via email ccrump@arkhospitals.org

>> If you are not an employee of an AHA member hospital and would like to inquire about attendance, please reach out to the event contact below.

When

10/13/2023 8:00 AM – 4:00 PM

Where

Virtual Event

For Registration Questions
Please Contact: Cindy Harris

Visit https://www.sepsis.org/get-involved/sepsis-awareness-month/

Professional Development Update
Submitted by Justin Villines

Unlocking Career Opportunities: The Benefits of CPHQ Certification in Healthcare Quality

The Certified Professional in Healthcare Quality (CPHQ) certification offers a range of advantages to healthcare professionals. First and foremost, it serves as a powerful tool for career advancement by opening up opportunities for higher-level positions and increased earning potential within the healthcare industry. It’s also a recognition of your expertise in healthcare quality management, signifying that you possess the knowledge and skills necessary to enhance patient care and safety. This certification provides a competitive edge in the job market, setting you apart from other candidates when applying for healthcare quality-related roles. Additionally, the knowledge acquired while preparing for the CPHQ exam can lead to improved job performance, benefiting both your organization and the patients you serve.

Moreover, obtaining CPHQ certification demonstrates your commitment to maintaining and improving healthcare quality standards, which is highly valued in the healthcare sector. It also offers networking opportunities by connecting you with other professionals in the field and granting access to valuable resources. Many healthcare employers recognize and prioritize CPHQ certification, with some requiring or preferring it for quality-related positions. Thus, holding a CPHQ certification can be a significant asset to your career in healthcare quality management.

Join the ranks of nearly 15,000 CPHQ certified professionals working in healthcare quality.

Learn more: https://nahq.org/individuals/cphq-certification/

Justin Villines, MBA, BSM
2023 Professional Development Team Lead

Communications Update
Submitted by Joel Anderson

Happy fall! Hope everyone is enjoying the beautiful fall weather and the many outdoor amenities that Arkansas has to offer! National Healthcare Quality Week is October 15-21st, 2023 and will be here before you know it! Join AAHQ in celebrating the dedicated professionals who work tirelessly to ensure high-quality care and patient safety. How does your facility plan to celebrate? The Communications Action Team would love to receive pictures of how your healthcare teams are honoring this monumental week. Please email your pics to andersonj@jrmc.org. We would love to highlight some of your activities in the next newsletter.

Joel Anderson, GC-MGMT, BBA
2023 Communications Team Lead

Protocol Update
Submitted by Erin Bolton

I hope you are enjoying this touch of fall weather that we are having! I love fall and the weather has been perfect for Friday night football games!

I would like to congratulate Rebecca Gorman, RN of Jefferson Regional for being awarded a scholarship from AAHQ to get her CPHQ certification. Once Rebecca takes her CPHQ test and passes, AAHQ will reimburse her for the cost of the test. More of these scholarships are available! Please reach out if you are considering getting your CPHQ and need some financial assistance. The scholarship form is available on the website.

I would also like to congratulate Pam Blake, RN, CPHQ of Jefferson Regional for being awarded a scholarship from AAHQ to assist with renewing her CPHQ certification this year. If it is time for you to renew your CPHQ certification, additional scholarships from AAHQ are available. Again, please reach out to me if you need an application. The end of the year will be here before you know it!

We are now taking nominations for the President-Elect position on the AAHQ Board. According to the AAHQ by-laws, the President-Elect must have his/her CPHQ certification. In the absence of the President, the President-Elect shall perform the duties of the President. The President-Elect shall perform all duties assigned by the President and will become familiar with and prepare for the duties of the office. In the event, the President cannot fulfill his/her tenure of office; the President-Elect shall serve out the unexpired term and then, begin his/her own term of office.

If you are interested in serving as the President-Elect or if you know someone, whom you think would make a great President-Elect for the AAHQ board, please submit your nominations to me by October 31, 2023. You can email me at boltone@jrmc.org. If you have any questions about the position, please let me know and I will try to answer them for you. We will hold the election in November so please watch your emails to cast your ballot.

I was very fortunate to receive a scholarship from the AAHQ Board to attend NAHQ Next in September. They had many great sessions and I am still absorbing the information. I will be sharing some things that I learned in my next article.

Thanks for reading my article! I hope you will consider serving on the AAHQ Board or applying for a scholarship. If you would like a mentor in the Quality field to help you with questions that you might have, please contact me and we will get you in touch with someone who can assist.

Happy fall y’all!

Erin Bolton, BSN, RN, CPHQ

Protocol Team Lead

870-541-3294 or boltone@jrmc.org

Building a Foundation of Trust: Inter-Rater Reliability’s Impact on Hospital Quality Departments

Submitted by:

Introduction

In the dynamic landscape of healthcare, Inter-Rater Reliability (IRR) holds a pivotal role,
especially within the realms of hospital quality departments. It acts as a barometer,
gauging the level of consistency among different evaluators as they assess identical
data. Within the walls of hospitals, the imperative of fostering a high degree of IRR is
crystal clear—it’s the linchpin ensuring the precision and dependability of clinical data.
In an environment of data-driven decision-making, the ripple effect of IRR is profound,
influencing care quality, shaping compliance, and steering the overall delivery of patient
care.

Importance to Quality Departments

1. Quality of Patient Care: Quality departments in hospitals are responsible for
monitoring and improving the quality of patient care. High IRR ensures that the
data used to assess and enhance patient care is accurate and reliable, leading to
better-informed decisions and improved patient outcomes.
2. Compliance and Accreditation: Hospitals are subject to various regulations and
standards set by accrediting bodies such as the Centers for Medicare & Medicaid
Services (CMS). High IRR in clinical data abstraction is essential for maintaining
compliance, as it ensures the accuracy and consistency of the data reported to
these entities.
3. Performance Measurement: Accurate and consistent data is foundational for
assessing the performance of healthcare providers and the effectiveness of
clinical interventions. IRR supports performance measurement by reducing
variability in data abstraction, thereby enabling more accurate evaluations and
comparisons.
4. Resource Optimization: Inconsistent data can lead to misinformed decisions and
misallocation of resources. By ensuring high IRR, quality departments can
optimize the allocation of resources, enhance efficiency, and improve the overall
quality of healthcare services.

Challenges and Solutions

Achieving high inter-rater reliability is not without its challenges. These challenges stem
from the diverse backgrounds of abstractors, variations in training, and the evolving
nature of medical documentation and technology. Addressing these challenges is
essential for upholding the integrity of clinical data.

Addressing the challenges associated with IRR is crucial for ensuring the accuracy and
reliability of clinical data abstraction. Here, we delve into a few of the challenges and
explore potential solutions:

1. Training and Skill Variability:

The diversity in the educational and professional backgrounds of abstractors, ranging
from nursing to health informatics, enriches the pool of expertise but also introduces
variability in data interpretation. Coupled with the logistical challenges of maintaining
training consistency across multiple departments and facilities, especially amidst high
turnover rates, this variability necessitates a robust solution. Implementing
standardized, centralized training programs and leveraging digital platforms can align
interpretations across diverse backgrounds and ensure consistent training delivery,
mitigating the risks of inconsistencies during periods of staff changes and guideline
updates.

2. Complexity of Clinical Data:

Clinical data often present complexities, with medical records containing ambiguous or
incomplete information, especially in unstructured data like clinical notes. The rapid
advancement of medical practices further compounds this complexity, necessitating
continuous adaptation by abstractors. To navigate this, the introduction of advanced
data processing tools and specific training on handling ambiguous data are essential.
Additionally, fostering a culture of continuous learning and providing access to updated
resources can help abstractors stay abreast of evolving practices and guidelines.

3. Documentation Practices:

The unique documentation styles and preferences of physicians pose challenges for
abstractors interpreting data from multiple sources. Additionally, the periodic revisions
in medical documentation standards, such as ICD or CPT codes, require adaptability.
Developing comprehensive guidelines and training modules can aid abstractors in
navigating diverse documentation styles. Timely communication and training on new
standards can ensure seamless adaptation to revisions and maintain the integrity of
data abstraction.

4. Subjectivity in Data Interpretation:

Abstractors, like all individuals, bring inherent biases to their interpretations, influenced
by their experiences, beliefs, and external factors such as workload and stress.
Fostering awareness of potential biases and implementing standardized procedures
can help mitigate the impact of subjectivity on data interpretation. Creating an
environment that recognizes and addresses the influence of external factors can further
enhance the reliability of data abstraction.

5. Lack of Regular Feedback:

The absence of regular feedback can lead to the perpetuation of errors, compromising
the integrity of the entire data set. Establishing a structured feedback mechanism is
essential for promptly identifying and correcting errors and reinforcing best practices.
Utilizing feedback sessions as learning opportunities can address knowledge gaps,
reinforce correct interpretation practices, and serve as a cornerstone for continuous
education and improvement.

6. Resource Limitations:

In many facilities, time constraints and the lack of a dedicated IRR champion or team
can lead to rushed interpretations and undetected errors, impacting the overall reliability
of data. Optimizing workflows and allocating sufficient time for thorough data
interpretation are pivotal in minimizing errors. Many facilities simply don’t have at least
2 abstractors trained in every registry or measure, which is required to have a truly
separate set of eyes conducting IRR. For this and many other reasons, many leaders in
quality are leveraging strategic partnerships to smart source some or all of their data
abstraction so they can focus the majority of their time and resources on using the data
to drive performance improvement efforts. Strategic allocation of resources and
exploring collaborative approaches can ensure effective IRR, even in environments with
resource limitations.

Conclusion

Inter-rater reliability is a cornerstone for quality departments in hospitals, underpinning
the accuracy and reliability of clinical data abstraction. It plays a pivotal role in
enhancing patient care, ensuring compliance, optimizing resources, and supporting
performance measurement. Addressing the challenges associated with achieving high
IRR through standardized training, adaptation to evolving standards, and partnership
integration is essential for upholding data integrity and advancing healthcare quality. By
prioritizing inter-rater reliability, quality departments can significantly contribute to the
realization of healthcare excellence.

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