4th Quarter 2023 Newsletter

From the President’s Desk

Submitted by: Devin Terry

Happy Holiday’s AAHQ Members!

As we end one year and begin another, it is sometimes tradition to reflect on accomplishments or growth over the previous year and to set goals for the upcoming year. I have been so excited to see AAHQ accomplish many of its goals in this past year. I know that this next year will be just as great while meeting even more goals.

This past year your AAHQ Board organized and sponsored educational events, including sponsoring several scholarships to the 2023 NAHQ virtual Conference. The Board also set a goal to see increased membership to AAHQ. While we cannot ever have enough new members, we are so excited to see the new members of 2023 and cannot wait to see what great ideas they not only take to their institutions but also bring to AAHQ.

This next year many of your AAHQ board members are staying on the Board and are ready to hear your ideas and help support you as we all attempt to make a difference in this post-pandemic world of healthcare. I would like to encourage you to get involved in AAHQ by serving on one of the action teams. Your input, suggestions, expertise, and enthusiasm are always welcomed.

Thank you to the AAHQ board members and to you, the members, for everything you do for AAHQ and healthcare quality. The citizens of Arkansas are better because of you.

Sincerely,

Devin Terry PhD, RN, ACNS-BC, CPHQ

AAHQ President

Reimagining Healthcare Quality – Making the Case for Change

Submitted by: Chelsey Davidson

During Healthcare Quality Week, I joined NAHQ’s virtual webinar Rebranding Quality presented by Stephanie Mercado and was greatly inspired by the case she made for redefining healthcare quality, as it currently exists. At present, the description for this line of work given by those outside the field of healthcare quality often centers around countless measures and standards mandated by regulatory agencies that result in frontline staff requirements that may or may not solve the problems faced by patients and certainly require “hoop-jumping” in a time when staffing is already unstable. The focus of this webinar couldn’t have resonated with me more – the need to shift from REACTING to quality and safety concerns to a PROACTIVE excellence mindset is ever present in healthcare institutions throughout Arkansas and the United States.

Although this message resonated with me, I found myself thinking about the challenge it would be to bring other healthcare professionals outside of healthcare quality along on this journey. As healthcare quality leaders, we cannot be successful in reimagining and redefining our field if we are unable to successfully align teams around the changes that are so desperately needed. One helpful tool to assist with navigating through necessary changes such as this is Gleicher’s Formula for Change. Originally created by Richard Beckhard and David Gleicher, and then later refined by Kathie Dannemiller, this model provides an equation that demonstrates when an effective case for change exists.

D x V x F > R

In this equation, the “D” represents dissatisfaction with the current state. Unfortunately, as a healthcare quality leader, your personal dissatisfaction with the current state is not enough. Instead, this dissatisfaction should be felt by all stakeholders. As a leader in the field, it is your job to use influence to help those who don’t have enough dissatisfaction with the current state to understand the healthcare quality issues at hand. The “V” in this equation stands for a compelling vision of what the future should look like. Again, dissatisfaction alone is not enough. To make an effective case for change, dissatisfaction must be combined with a compelling vision of what the future without this problem looks like. Furthermore, in addition to these things, “F” or first steps that are consensus-based must also be present. If the need to rebrand quality is the change we are working towards, some reasonable first steps might involve re-centering your organizations focus on patient priorities (safety, access, or efficiency), comprehensive-disease state management, or other unit-based challenges that fall outside of the ever-growing list metrics and standards we are all so accustomed to. It’s important to note that when defining the compelling vision and first steps to solving problems we are faced with as healthcare quality professionals, collaboration with stakeholders is key. Finally, when “D”, “V”, and “F” are multiplied, Gleicher’s Formula for Change states that enough momentum exists to overcome “R”, the natural resistance to change.

Reimagining healthcare quality and the work we do for our patients is not an impossible task. Through collaboration with stakeholders to identify dissatisfaction with the current state, a compelling-vision for what the future of healthcare quality at our organizations could look like, and first-steps towards making this change, we can overcome the resistance to change that naturally exists. Although each of our organizations face unique challenges, I think we can all agree that the work we do is so much more than metrics and standards. Let’s help the rest of the healthcare workforce see that too!

Chelsey Davidson

AAHQ Past President

Membership Services Update

Submitted by: Tim Copeland

As I reflect upon the past year, I thought about the three new members we added, which is fewer than I had hoped for but we’re thankful to have them! It has been a year of significant change for me. I left a facility that had about 10 members of the association and multiple CPHQs. And I’ve come into a facility with only one member (who is also a CPHQ!). I think about the great educational opportunities we had over the past year and more that are in the works for the coming year. The networking opportunities that provide access to resources and ideas outside our facility is an asset, the value of which far exceeds the annual membership dues. In my new facility, we have at least eight professionals who would benefit greatly from membership in our association.

I encourage everyone to think about who in your organization might also find the resources, connections, and education we provide advantageous. Do you know of Quality professionals in other organizations who are not currently members? Contact them and let them know about us. This is the time of year when membership dues go the farthest! Encourage them to go to our association website, complete the application and join!

Tim Copeland, MHSA, BS(MT)
Membership Services Team Lead

Finance Team Update

Submitted by: Trey McCorkindale

At the end of October, AAHQ had a balance of $24,064.45. For the 4 months ending 10/31/23, there was $3,025 in revenue from dues ($650) and meetings ($2,375). Currently, there are 84 members. Total expense for the same period was $7,039.48, $6,144 of which was attributable to the national meeting.

Trey McCorkindale, Finance Team Lead

Communications Update

Submitted by: Joel Anderson

Happy Holidays! The AAHQ Communications Action Team goal is to promote recognition and visibility of the AAHQ organization through our website, newsletter publications, and social media platforms. One way to accomplish this goal is by increasing our followers on social media. If you are not following us on Facebook and LinkedIn , I would highly encourage you to do so. Another way to get involved with AAHQ is becoming a member of an action team. Not only will you be networking with quality leaders from around the state, but you can learn so many other things that can enhance your skillset, i.e., website design and maintenance, bylaw creation, organizational finance, conference planning, and membership recruitment activities. Please reach out to a Board member and join one of our teams in 2024!

Joel Anderson, GC-MGMT, BBA
Communications Team Lead

Protocol Update

Submitted by: Erin Bolton

Happy New Year from the Protocol Team! I cannot believe that the holidays are over and we have a whole new year in front of us!

I had the privilege of attending NAHQ Next this past fall thanks to a scholarship from the AAHQ. There were many great sessions that you could attend during the 3 days of the conference or that you could access virtually for several months after the conference ended. If it is your year to renew your CPHQ, this is a great way to get many hours!

One of the sessions I attended was called “Swimming in the abyss: Preparing for unannounced accreditation and CMS/state surveys”. It was presented by Ellen Evans, MN, MPH, RN, CPHQ, CJCP, CPPS, Director of Accreditation and Patient Safety. I must admit that sometimes I see these sessions and wonder what else they might could tell us about being prepared for a survey. However, Ellen’s presentation was inspiring! She started by asking how you respond when surveyors arrive. Do you respond as if it is an unplanned visit from your in-laws or as a planned party? I hope that my team feels like it is a planned party!

Her strategy for Unannounced Surveys is a three-pronged approach: Planning, Knowledge, and Observations. The planning portion includes making sure that you know who should be involved in the survey, developing a communication strategy so that everyone is aware of what is going on, and making sure that you are aware of any new changes to the standards or regulations. For the Knowledge prong, she talked about making sure all members of your team (Leadership, Quality Staff and Front line Staff) have the knowledge they need for a successful survey. She encouraged providing the basics to the front line staff in the areas of patient safety, standards, human factors, medication management, infection control, emergency management and environment of care. The Observations portion involves the auditing and tracer completion and communicating the results.

What really jumped out to me about this presentation was her wrap-up. She gave the example of the NCAA Women’s Final Four Games. Her first take-away was Importance of making free throws. Iowa made 14 of 14 free throws during the game while South Carolina made 9 of 13. Iowa won the game by 4 points. The “free throws” are the things that we should be doing every day with every patient (wash your hands, good documentation, communication, not blocking the fire extinguishers, etc.) whether we are in our survey window are not. Free throws are just good care but we have to make sure that it is being done. Her second take-away was the Importance of Having a Strong Bench. She talked again about the Iowa team this time in their game against LSU. Both teams had multiple starters that got into foul trouble early. Iowa’s bench scored two points during the second quarter while LSU’s bench scored 20 points during the second quarter. LSU won by 17 points. We have to make sure that EVERYONE is survey ready….from our C-Suite to our front-line staff. Everyone has to know their role and what they can do to make a difference.

I think this is a great approach to communicating what a survey is all about! We need everyone to be survey ready ALL THE TIME. I intend to use these suggestions with the staff at my facility as we continue to wait on surveyors to arrive.

I hope this helps you as you strive to always be survey ready. I hope it will also cause you to pause and think about attending NAHQ Next this year. It will be worth it!

Erin Bolton, BSN, RN, CPHQ

Protocol Team Lead

Embracing Interoperability for Enhanced Healthcare Quality

Submitted by: Justin Villines

In the evolving landscape of healthcare, the integration of interoperability across various healthcare settings – hospitals, provider practices, behavioral health facilities, and Long-Term Post-Acute Care (LTPAC) – is pivotal for elevating the quality of care we provide. Interoperability, the ability of different information systems, devices, and applications to access, exchange, integrate, and cooperatively use data in a coordinated manner, is not just a technological advancement; it’s a patient-centric approach that can revolutionize healthcare outcomes.

Comprehensive Patient Care: Interoperability allows for seamless access to patient data across different healthcare facilities. This holistic view aids clinicians in making well-informed decisions, ensuring that each patient receives personalized and comprehensive care based on their entire medical history.
Enhanced Communication and Coordination: In a connected healthcare environment, communication between primary care providers, specialists, and acute and post-acute care facilities becomes more efficient. This coordination is crucial for patients with complex care needs, particularly in transitions between care settings.
Reduced Duplication and Errors: With interoperability, the likelihood of duplicated tests and procedures is significantly reduced, not only saving costs but also minimizing the risk of errors associated with repeated interventions.
Improved Patient Safety and Outcomes: Access to a patient’s complete medical records can prevent adverse drug interactions and other safety concerns. It also enables healthcare providers to track and analyze outcomes more effectively, leading to continuous quality improvement.
Empowerment through Patient Access: Interoperability empowers patients by providing them access to their health records. Engaged and informed patients are more likely to adhere to treatment plans and make educated health decisions.
Data-Driven Healthcare: Interoperable systems facilitate the aggregation and analysis of large data sets, paving the way for advanced research, predictive analytics, and evidence-based medicine.

The journey towards full interoperability is complex and requires collaboration, commitment, and a shared vision. As members of the Arkansas Association for Healthcare Quality, we have a unique opportunity to lead this transformative journey. By advocating for and adopting interoperable systems, we can significantly improve the quality, safety, and efficiency of healthcare in our communities.

Let’s come together to harness the power of interoperability for a healthier Arkansas.

Justin Villines, MBA, BSM

Professional Development Team Lead

The Relevance and Importance of Electronic Health Documentation

Submitted by: Pam Blake

Provider documentation in the electronic health record should be accurate and complete, to ensure the coded medical record accurately reflects the acuity and the care provided to patients. The Centers for Medicare and Medicaid Services (CMS) implemented programs that financially reward providers and hospitals for the quality of the care provided. Additional programs link reimbursement to quality. These programs can either financially reward or penalize hospitals, depending on performance. These quality programs affect hospital reimbursement, for conditions that could reasonably be preventable. Quality scores are ratings to inform patients and communities, about the quality of care delivered by healthcare providers and hospitals. They are reported publicly and can be compared among other healthcare providers and hospitals.

Hospital Clinical Documentation Improvement (CDI) Specialists serve as an interpreter between the language of clinical care and the language of coding. CDI Specialists obtain additional clinical documentation in the medical record, concurrently, to assist the coder with accurate code and Diagnosis-Related Groups (DRG) assignment. As the areas continue to intertwine, the importance of CDI has increased. An effective CDI process bridges the gap between the clinical and financial functions of hospitals, by serving as a liaison. Initially, CDI had limited focus on DRG assignment and reimbursement. The CDI process and team are key to the overall performance and success of care providers, with a greater focus on quality initiatives. CDI is designed to improve the accuracy and completeness of the clinical information in the medical record. Traditionally, there was little, if any, focus on the impact of documentation on quality initiatives. Now, hospitals recognize the importance of complete and accurate documentation across the entire care continuum, regardless of the payer. CDI Specialists serve as an interpreter between the documentation of clinical care and coding. They review the medical record to determine if clinical information is missing or incomplete. CDI Specialists utilize a query process and encourage providers to include all necessary clinical documentation to the highest level of specificity that accurately reflects the patients’ conditions.

Provider documentation is the key to reflect the acuity, severity of illness, risk of mortality of patients, and the care provided to them. The quality ratings are crucial. They affect hospitals by patient choice of care, commercial and managed care contracts, community perception, and accurate reimbursement. CMS safeguards the Medicare Trust Fund against fraud, waste, and abuse. This is accomplished by using a variety of contractors with varying responsibilities, such as the Recovery Audit Contractors (RACs), Zone Program Integrity Contractors (ZPICs), Carrier and Fiscal Intermediary (Part A/B MAC) Program Integrity Units, and Comprehensive Error Rate Testing (CERT).

Moy, A. J., Schwartz, J. M., Chen, R., Sadri, S., Lucas, E., Cato, K. D., & Rossetti, S. C. (2021). Measurement of clinical documentation burden among physicians and nurses using electronic health records: A scoping review. Journal of the American Medical Informatics Association, 28(5), 998-1008. https://doi.org/10.1093/jamia/ocaa325

Pam Blake, MHA, BSN, RN, CPHQ

Director of Case Management, Jefferson Regional Medical Center

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