2024 Winter Newsletter

From the President’s Desk

Submitted by: Teresa Jeffus, MSN, RN, CPHQ, CPPS

AAHQ Members:

As I reflect on 2024, I think it has been a great year. I am particularly proud of our first very successful in-person education conference since Covid.

Each board member did their part to make the conference a success and such dedicated teamwork made me proud to be part of this association. I would like to sincerely thank each member of the board for their commitment and hard work that is all done on a volunteer basis. Not only attending monthly board meetings but then doing extra additional work, outside of the meetings.

Thank you AAHQ Members once again for the privilege of leading this association.

I wish you all a joyful, peaceful holiday and a great new year!

Teresa Jeffus

AAHQ President

CPHQ Spotlight

Submitted by: Cindy Crump, MBA-HM, BSN, RN, CPHQ

First, I would like to thank the AAHQ board for allowing me to contribute to the winter newsletter. While I was going to go a different direction with my article, my fearless leader wanted me to talk about my experience with sitting for my CPHQ this year, and my backstory on why it took me so long to do it. If you choose not to keep reading, I want to heavily emphasize now…IF YOU ARE ON THE FENCE ABOUT TAKING IT, JUMP OFF THAT FENCE!! Susan Jeffers said “Feel the fear and do it anyway”. I wish I had pushed through my fear before now.

Quick back story on me…I have been in Quality Assurance to some degree since early in my career, working on The Joint Commission prep team while at the bedside all the way to being a Quality Director in a hospital, and now working at a state level on CMS contracts. I am not new to this world, all in all around 20 years doing QAPI. But I was SCARED to sit for my CPHQ. What if I am not smart enough to pass? That is a lot of money to waste on a chance. What if I mess up the test or read every question wrong, what if, what if, what if… for 6 years at every work evaluation, I would tell my boss…this year I am going to sit for my CPHQ…every year she put it on my professional goal plan and every year I wouldn’t do it. I made way too many excuses; we are traveling too much this year, I’m heading a huge project and won’t have time, COVID, lots of personal challenges and changes, COVID again; I could find an excuse every single year. This year, instead of telling her I was going to do it, I just made up my mind quietly. It wasn’t any one thing that prompted me to do it, but I think I can sum it up in two ways: I needed to personally prove to myself that I could do it. And professionally, I needed to show my colleagues and peers that I am an expert in my field. I don’t like to be the center of attention at all, but having CPHQ behind your signature helps others take you seriously when in professional settings.

So, here is how I did it…in the span of one evening, I printed out the material, talked with the fella who put a ring on it 27 years ago, and helps me with all my hard decisions ( it’s an expensive test), and I sat down and scheduled it before I went to bed, so I wouldn’t chicken out. Once that credit card was charged, I was in it to win it.

The next morning, I was doing that self-doubt thing and went to change the date or see if I could cancel it. Reading that bottom line…you can change the date one time without a penalty. I need to start studying NOW and use that save for an emergency. I had about 8 weeks until test day. I already had the NAHQ book, so I started reading it, and quickly realized that with a middle-aged brain, I can’t read volumes anymore. I needed something else. So, I bought flashcards that had free pre-tests and practice tests that came with it. Just remember, everybody’s way of studying is different. While I learned better with flashcards, some of you might do better highlighting a text. One thing I will say is, don’t just study the book and think you will be ready. There were lots of “what would you do if you were the quality professional” type of questions. For you nurses out there, it’s very similar to the “best right answer” and “application of knowledge” questions on the NCLEX.

I won’t go too much into detail about those eight weeks, but I studied a lot. I took all of the practice exams three times each; I reviewed the questions I missed, and I restudied those sections until I was confident I knew it and wasn’t just memorizing an answer. I googled a lot of the rationales and used professional resources like NAHQ, IHI, AHRQ. There is absolutely no way to study wrong, unless you just don’t study at all.

I did not cram the night before like I used to in college. I had prepared and if I didn’t know it after 8 weeks and 20 plus years, I wouldn’t know it in a cram session. I got plenty of sleep, got to the testing center 45 minutes early, sat in my car and prayed for a bit then went in and registered. The testing center proctor let me start early, which was awesome. So I jumped right in. I took my time but was able to finish it with plenty left over to answer the ones I skipped. That three hours was a blur. I was shaking so hard when I hit the submit button and thought I was going to throw up, waiting for the pass/fail. It took forever to pop up on screen, but when I saw that PASS, all the fear and anxiety and imposter syndrome of feeling not good enough or smart enough just melted away.

Here is my TLDR: Just do it. Take the chance. Stop making excuses. Don’t wait five years or 20 years, OR never. I won’t lie…it is way harder than the NCLEX was, to me. But it is worth every second of being able to add those credentials to your professional arsenal.

Merry Christmas and Happy New Year to you all. Make a resolution to gain your CPHQ next year. You won’t regret it, I promise!!!

This will likely be one of the hardest exams of your career. But, I promise, it will be one of the most rewarding.

Communications Update

Submitted by: Joel Anderson, GC-MGMT, BBA

Happy Holidays from AAHQ Communications! As we reflect on 2024 and make our 2025 New Year resolutions, the Communications Action Team is looking forward to a fantastic 2025. The AAHQ Communications Action Team wants to highlight the quality achievements of our members and organizations across the state. Did your organization receive a quality award in 2024? Did you earn a CPHQ Certification? If so, please reach out by emailing andersonj@jrmc.org. We would love to spotlight these accomplishments in our next quarterly newsletter!

Are you interested in getting more involved with AAHQ? One way to get involved with AAHQ is by becoming a member of one of our action teams. Not only will you be networking with quality leaders from around the state, but also 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 2025!

Joel Anderson, GC-MGMT, BBA

Communications Team Lead

Health Information Exchange and the Evolution of Health Data Utilities: Benefits for Hospitals, Providers, and Payers

Submitted by: Justin Villines, MBA, BSM

In the evolving landscape of healthcare, the terms “Health Information Exchange (HIE)” and “Health Data Utility (HDU)” are gaining prominence, signaling a shift toward a more integrated and impactful approach to managing health information. These innovations not only enhance data exchange but also empower hospitals, providers, and payers to deliver better care, improve outcomes, and manage costs effectively.

What is a Health Data Utility?

Traditionally, HIEs served as hubs for sharing health information between disparate electronic medical records (EMRs) and healthcare organizations. They acted as a backbone for interoperability, ensuring that the right information reached the right provider at the right time. However, as healthcare becomes increasingly data-driven, there is a need for a more comprehensive and proactive approach. This is where the concept of the Health Data Utility (HDU) comes into play.

An HDU builds on the foundation of HIEs by expanding their scope and functionality. HDUs act as data utilities that:

Aggregate and standardize data from diverse sources, including hospitals, clinics, pharmacies, public health agencies, and social services.
Provide advanced analytics and insights to support population health management and value-based care models.
Enable seamless data sharing across healthcare and non-healthcare sectors to address broader determinants of health.
Support compliance with regulations such as the 21st Century Cures Act by facilitating real-time data access and notifications.

The Benefits of Health Data Utilities for Hospitals, Providers, and Payers

For Hospitals

Enhanced Care Coordination: HDUs provide hospitals with a comprehensive view of patient health histories, including data from external facilities. This enables smoother transitions of care, reduces duplication of services, and minimizes errors.
Improved Operational Efficiency: By integrating real-time data into workflows, hospitals can streamline operations, such as bed management, discharge planning, and resource allocation.
Regulatory Compliance: HDUs ensure hospitals meet regulatory requirements, such as the 21st Century Cures Act’s mandates for real-time admission, discharge, and transfer (ADT) notifications.

For Providers

Comprehensive Patient Insights: HDUs equip providers with longitudinal patient records, encompassing lab results, imaging, medication histories, and social determinants of health (SDOH). This holistic view supports accurate diagnoses and personalized care.
Streamlined Workflows: Providers benefit from actionable alerts and clinical decision support tools integrated into their EMRs, reducing administrative burdens and enabling them to focus on patient care.
Support for Value-Based Care: As the industry shifts toward value-based care, HDUs help providers track quality metrics, manage chronic conditions, and engage patients proactively, all of which are essential for achieving better outcomes.

For Payers

Data-Driven Decision Making: HDUs enable payers to access real-time clinical data, improving risk stratification, care gap analysis, and population health management.
Improved HEDIS Scores: With streamlined access to clinical data, payers can efficiently report on Healthcare Effectiveness Data and Information Set (HEDIS) measures, leading to better performance ratings and compliance.
Reduced Costs: By identifying and addressing inefficiencies, such as unnecessary hospitalizations or duplicated tests, HDUs support cost containment while improving the quality of care.

Addressing Broader Determinants of Health

A key feature of HDUs is their ability to incorporate data beyond traditional healthcare settings. By integrating information from social services, housing agencies, and other community organizations, HDUs provide a more complete picture of a patient’s circumstances. This capability is critical for addressing social determinants of health (SDOH), which significantly impact outcomes and healthcare costs.

Future Implications

As the healthcare landscape continues to evolve, the transition from HIEs to HDUs represents a paradigm shift. By providing hospitals, providers, and payers with robust data-sharing capabilities and actionable insights, HDUs pave the way for a more connected, efficient, and patient-centered healthcare system. This evolution supports the industry’s overarching goals of improving outcomes, enhancing patient experiences, and reducing costs. In conclusion, embracing the concept of a Health Data Utility is not just an operational decision; it is a strategic investment in the future of healthcare. Hospitals, providers, and payers that leverage this advanced approach to data exchange and analysis will be well-positioned to thrive in an increasingly interconnected and value-driven healthcare environment.

For Arkansas, your statewide HIE/HDU is the State Health Alliance for Records Exchange (SHARE).

Thank you and Merry Christmas!

Justin

Protocol Update

Submitted by: Erin Bolton, BSN, RN, CPHQ

This will be my last article as the Protocol Team lead. It has been my honor to serve you the last few years in this roll. It is a greater honor to be serving as your President-Elect in 2025. Chelsey Davidson will be taking over as Protocol Team lead. She will do a great job and we are excited that she will continue her leadership on the AAHQ Board.

As the end of the year approaches, it may be time to renew your CHPQ certification. Don’t forget that scholarships that are available from AAHQ to assist you with this. Feel free to reach out to me (boltone@jrmc.org) or Chelsey (chelsey.davidson@conwayregional.org) if you need an application or more information about this scholarship opportunity.

Maybe one of your New Year’s resolutions is to get your CPHQ in 2025. We also have scholarships available to assist you with new certifications as well. Please feel free to reach out to me or Chelsea if you have any questions or would like to apply.

I hope you all have a very Merry Christmas and a wonderful start to 2025!

Erin Bolton, BSN, RN, CPHQ

Protocol Team Lead

Hospital Quality Spotlight

Washington Regional Medical Center

The Washington Regional Medical Center Quality Department is led by CQO Anthony Williams, MD, Executive Director Terri Church, MSN, APRN, ACNS-BC, CPHQ, CPSS, Manager Merri Roy, MS, RN, NI-BC, NPD-BC, CPHIMS and Quality Analysts Dana Scott, RN, Mariah Biven, MSN, RN, CPHQ, Bryant Highfield, RN and Trevor Conner, BSN, RN.

The Quality Department strives to promote psychological safety and strengthen the Culture of Safety at Washington Regional through the implementation of a safety-focused program called “Shine the Light on Safety”. This program encourages best practice submissions and provides the ability to report patient safety concerns. Shine the Light on Safety allows us to create a culture where concerns are heard, vetted, and acted on appropriately while nurturing interdisciplinary collaboration among employees, facility leadership, and the Quality Department.

Utilizing data from our Shine the Light on Safety Program to propel process change, we have continued to focus on the maintenance of our Safety Culture, “where the right thing is the easy thing” by recognizing departments and/or employees who promote safety and facilitate a Just Culture. The Quality Department has recognized a department or employee on a quarterly basis since the Shine the Light on Safety program began in 2018.

The mission and vision of our Quality Department is to improve performance and systematically apply evidence-based principals of safety science to provide the safest experience and healing environment possible to the members of our community. We continually focus on standardizing and improving processes across the organization to drive optimal patient outcomes, team satisfaction, and safety of patients, caregivers, and staff. This dedication is evidenced by the achievement of six consecutive Leapfrog Hospital Safety Grade A’s.

When asking Terri Church, APRN, CPHQ, Executive Director of Quality and Patient Safety, about Quality at Washington Regional she stated, “Healthcare quality is about putting the patient and the family at the core of every decision we make. At Washington Regional Medical Center, it is our mission to improve the health of those in the communities we serve through compassionate, high-quality care. We have an excellent Quality Department that serves as a support system for oversight and continuous improvement, but if you ask me who is on the Quality Team, the answer would be found in the excellence-driven actions of every single employee.”

Membership Services Update

Submitted by: Tim Copeland, MHSA, BSMT, MT(ASCP)

From time to time, we like to highlight an association member in the interest of our members getting to know each other better. Our members come from a diverse set of backgrounds and have widely varying responsibilities in our positions within the Healthcare Quality profession. For this newsletter, we want to highlight our Communications Team Lead, editor of this newsletter and webmaster extraordinaire, Joel Anderson. Joel has been a member of AAHQ for 13 years and has served on the Board for 3 years.

Member Spotlight

Joel Anderson

A native Arkansan originally from Pine Bluff, he graduated from the University of Arkansas at Little Rock in 2015 with a BBA in Management and later obtained a Graduate Certificate in Management. Joel’s career in healthcare started in 2011 as a Direct Data Abstractor in the Quality Department at Jefferson Regional Medical Center. In 2015, Joel was promoted to the Quality Research Analyst position and served as the project lead of the HEN, HEN 2.0, HIIN, and HQIC quality collaborative in partnership with the Arkansas Hospital Association. He also served a two-year appointment on the AFMC-Medicaid Inpatient Quality Advisory Board. In 2017, Joel transitioned to Arkansas Children’s Hospital and served as the Professional Practice Program Manager of the Medical Staff Services division. His primary responsibility was managing the hospital wide Professional Practice Evaluation (PPE) process for all licensed independent practitioners for monitoring and evaluation of clinical and professional performance that promoted best practices for the improvement of patient safety and outcomes. Joel returned to his roots at Jefferson Regional in 2018 as the Quality Project Coordinator and is responsible for executing the hospital QAPI program.

On a personal note, Joel has been a trained vocalist for over 20 years and has performed & co-directed several musicals at the Arts & Science Center for Southeast Arkansas. His favorite role thus far was performing in the musical Hairspray portraying the role of “Edna Turnblad,” whom was also played by John Travolta in the hit movie. Director credits include Legally Blonde, Rock of Ages, Sister Act, 9 to 5, and Rodgers & Hammerstein Cinderella. Joel also serves as the Executive Director of the Miss South Arkansas/South Central Arkansas organization which is an official preliminary scholarship competition to the Miss Arkansas and Miss America Scholarship Organizations. Joel was recently awarded the esteemed Executive Director of the Year award at the 2024 Miss Arkansas Scholarship Competition.

Think DEEP about Diabetes Education

Submitted by: Jamey Mantz, RN

Diabetes is one of the leading causes of death in the U.S., with CDC estimates revealing 37.2 million Americans have diabetes and 96 million more have prediabetes.[1] According to the American Diabetes Association, approximately 290,000 adults, or 12.3% of the adult population in Arkansas, have been diagnosed with diabetes. Pivotal approaches to diabetes education involve interactive and patient-centered learning, putting them at the center of the conversation.

The University of Illinois Chicago’s Diabetes Empowerment Education Program (DEEP™) is a diabetes self-management education (DSME) program designed to empower individuals with diabetes to make proactive changes in their diet, activity, and understanding to better their health outcomes.

The DEEP™ curriculum is designed to teach self-management practices for preventing and controlling diabetes. Its collaborative, interactive format has been the gold standard for diabetes education and has improved people’s lives.

The DEEP™ workshop consists of six weekly sessions lasting an hour and a half. Participants engage in demonstrations, hands-on learning, and problem-solving techniques. The curriculum allows participants to learn from one another through eight modules that build on one another each week.

Nine AFMC employees completed a 20-hour training to become DEEP™-certified peer educators in Arkansas, allowing us to conduct workshops in the community. Four employees completed additional training to become DEEP™ lead trainers, enabling us to provide peer educator training. We recently conducted peer educator training for several community health workers and pharmacy techs for the Arkansas Rural Health Partnership and the University of Arkansas for Medical Sciences (UAMS), allowing them to hold community workshops in the areas where they live.

Because the DEEP™ curriculum covers so many topics, it’s the perfect learning tool for areas where resources are scarce. AFMC offers DEEP™ community classes in several counties, including Faulkner, Johnson, Dallas, Calhoun, Ouachita, Union, and Garland County. When we conduct a workshop in a rural part of the state, we know that attendees don’t have easy access to many resources available in bigger cities. The curriculum teaches them how to work with what they have to prevent and control their diabetes.

Many would achieve better health outcomes if they knew how to do better. For patients who don’t exercise often, being told by their provider to start doing so can be overwhelming. In DEEP™ module four, the focus is to Get Up and Move! We ask them to move around, vacuum the house, walk to the mailbox, or work in the yard. Controlling blood sugar levels doesn’t require a structured exercise plan; simple movement can still be beneficial.

Perhaps most importantly, effective, patient-centered education gives individuals hope. For many in rural areas, a diabetes diagnosis can feel like a death sentence. They’ve seen people they know lose a limb or need to be put on dialysis due to kidney failure from uncontrolled blood sugars. So, when they receive a diabetes diagnosis, they often give up hope. We renew their hope by bringing this type of education into their community. The goal at the end of the six-week workshop is to leave them believing they can do this and that they are going to be able to live a good life, even with their diagnosis.

The UIC website provides more information about the DEEP program.[2]

For more information about diabetes education, visit the AFMC Medicaid website at medicaid.afmc.org/diabetes.

[1] “Health and Economic Benefits of Diabetes Interventions,” National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, May 15, 2024, https://www.cdc.gov/nccdphp/priorities/diabetes-interventions.html.

[2] “DEEP™ Program Overview,” DEEP™ Program, University of Illinois Chicago Office of Technology Management, accessed October 8, 2024, https://otm.uic.edu/deep-program-2/deep-program-overview-2/.

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