Fall 2024 Newsletter

AAHQ Quality Conference

Please join us for our Fall Educational Conference, our first in-person event in 4 years! This year’s conference, themed “Innovating Healthcare through Integrative Strategies,” promises to be an enlightening & transformative event for all healthcare professionals committed to enhancing quality and innovation in our field.

As space is limited, we encourage you to secure your spot today. Don’t miss this opportunity to network with peers, learn from industry leaders, and gain valuable insights into the latest strategies for healthcare improvement.

Click link below to Register:

2024 AAHQ Quality Conference-Registration

Full Flyer with biographical information or to print for faxed registrations, click below:

AAHQ-Fall-Conference-2024

From the President’s Desk

Submitted by: Teresa Jeffus

Welcome to Fall!

We are all excited for our upcoming conference on October 11th, 2024 at CHI St. Vincent Infirmary Auditorium. I am looking forward to seeing all of you there as we discuss important healthcare issues. With a packed agenda, great networking opportunities including our welcome exhibitors and a fun Silent Auction it will be a great conference. Registration is open now. I hope this is on your calendar!

Best,

Teresa Jeffus

AAHQ President

Healthcare Quality Week 2024

October 20-26, 2024

As we celebrate #HQW 2024, we honor the pursuit of excellence in healthcare Quality & Safety. To the professionals working to advance Quality & Safety, thank you for your passion, your knowledge, and your commitment to making a difference in the lives of all patients. To help raise awareness and help professionals celebrate locally, @mynahq is hosting complementary webinars, and providing other free resources and support. Learn more about the week’s events, by clicking the picture below.

Communications Update

Submitted by: Joel Anderson

Did you know that AAHQ accepts job postings from AHA affiliated members? Organizations are welcome to send their job postings to Joel Anderson, AAHQ Communications Team Lead by emailing andersonj@jrmc.org. All files should be sent in PDF format. Postings should be submitted by the 20^th of the month in order for them to be posted by the 1^st of the next month. Postings will be added to the AAHQ website, Facebook, and LinkedIn social media platforms. (AAHQ reserves the right to decline to post a job opening if the content of the job is not geared towards the AAHQ audience.) Job postings will be removed from the AAHQ website after 30 days.

National Healthcare Quality Week is October 20-26, 2024 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

Communications Team Lead

Protocol Update

Submitted by: Erin Bolton

Fall weather appears to be on it’s way to Arkansas. I can’t wait! I would take fall or spring weather year around if I could! However, we have seasons for a reason!

Maybe you are in a new season yourself. Are you looking for a change? A way to advance your career? Obtaining your CPHQ might be just what you need to do and we at the AAHQ would love to assist you! Once you have taken and passed your CPHQ exam, apply for one of the AAHQ scholarships to help pay for your testing expenses. We’ll also brag about you in our newsletter! If this sounds like something you would be interested in, please feel free to reach out to me at boltone@jrmc.org for additional details.

For those of you who already have your CPHQ but it’s time to renew, please consider applying for an AAHQ scholarship to help cover your renewal expenses. Again, reach out to me for additional details.

I hope to see you at the Fall Conference on October 11. In the meantime, get out and enjoy the fall weather!

Erin Bolton, BSN, RN, CPHQ

Protocol Team Lead

A Guide to the Survey on Patient Safety Culture for Hospitals, Medical Offices and ASCs

Submitted by:

Introduction

Ensuring a culture of safety within healthcare facilities is essential for delivering high-quality care. The Hospital Survey on Patient Safety Culture (HSOPSC), developed by the Agency for Healthcare Research and Quality (AHRQ), is a key tool for hospitals to assess their safety culture and identify areas for improvement. This guide provides an overview of the requirements and best practices for implementing this survey, including its implications for the Leapfrog Hospital Survey, to help quality leaders enhance patient safety culture in their organizations.

For a comprehensive guide to the Survey on Patient Safety Culture, including what Leapfrog asks in their Hospital Survey about it, visit ADN’s Comprehensive Guide to the Hospital Survey on Patient Safety Culture.

Understanding the Hospital Survey on Patient Safety Culture (HSOPSC)

The HSOPSC is designed to help hospitals evaluate the safety culture within their facilities. It gathers data on staff perceptions of patient safety, error reporting, communication openness, and management support for patient safety. By utilizing this survey, hospitals can benchmark their performance, identify strengths and weaknesses, and foster an environment where patient safety is prioritized.

Key Components of the AHRQ Hospital Survey on Patient Safety Culture (Version 2.0)

The HSOPSC covers ten critical areas:

Communication About Error: Staff are informed when errors occur, discuss prevention strategies, and are updated on changes made.
Communication Openness: Staff feel comfortable speaking up about unsafe situations and asking questions.
Handoffs and Information Exchange: Important patient care information is effectively transferred across units and during shift changes.
Hospital Management Support for Patient Safety: Management demonstrates that patient safety is a top priority and allocates adequate resources.
Organizational Learning—Continuous Improvement: Work processes are regularly reviewed, changes are implemented to prevent mistakes, and their effectiveness is evaluated.
Reporting Patient Safety Events: Mistakes, including near misses and those that could have harmed patients but did not, are reported.
Response to Error: Staff are treated fairly when mistakes occur, with a focus on learning and support.
Staffing and Work Pace: Adequate staffing levels are maintained, workloads are manageable, and reliance on temporary staff is appropriate.
Supervisor, Manager, or Clinical Leader Support for Patient Safety: Leaders consider staff suggestions, discourage shortcuts, and address safety concerns.
Teamwork: Staff collaborate effectively, assist each other during busy times, and maintain mutual respect.

The Link Between Safety Culture and Overall Performance

Recent studies, such as one published in the Health Care Management Review (2024), have demonstrated a strong link between a hospital’s culture of safety and its overall performance, including its score on the Centers for Medicare & Medicaid Services (CMS) Total Performance Score (TPS). Hospitals with a robust safety culture tend to have better patient outcomes, higher patient satisfaction, and improved financial performance. Investing in safety culture not only enhances patient safety but also leads to higher CMS reimbursement rates tied to quality performance.

Leapfrog Survey Questions about the Hospital Survey on Patient Safety Culture (HSOPSC or SOPS)

The Leapfrog Hospital Survey is a comprehensive assessment tool used by hospitals to evaluate their performance in various safety, quality, and efficiency measures. One critical area Leapfrog focuses on is the hospital’s culture of safety, captured under Section 6B: NQF Safe Practice #2 – Culture Measurement, Feedback, and Intervention. It specifically asks whether hospitals have conducted a culture of safety survey using a nationally recognized tool like the HSOPSC from AHRQ, as well as a number of other items relating to the culture survey. For the specific questions asked, visit ADN’s Comprehensive Guide to the Hospital Survey on Patient Safety Culture.

Key Leapfrog Requirements for Conducting the Survey on Patient Safety Culture

Survey Administration

Tool Utilization: Hospitals must conduct a culture of safety survey using a nationally recognized tool, such as the AHRQ HSOPSC, that has demonstrated validity and reliability. The surveyed units should represent at least 50% of total patient care and include high-risk areas.
Frequency: The survey must be conducted at least once every 24 months to maintain consistent feedback and allow time for improvement initiatives.

Reporting and Benchmarking

Results Presentation: Hospitals must compile and present the survey results in a report that includes both hospital-wide and unit-level data. This enables targeted interventions and awareness of specific areas for improvement.
Benchmarking: Results should be benchmarked against external organizations to understand performance relative to peers and identify areas of excellence or needed improvement.

Accountability and Improvement

Actionable Feedback: Senior leaders must use the survey results to debrief relevant units and staff, ensuring feedback leads to tangible improvements while maintaining respondent anonymity.
Incorporating Survey Results in Performance Evaluations: Survey results should be integrated into the performance evaluation criteria for senior leadership to ensure accountability for improving the culture of safety.

Education and Resources

Staff Education Programs: Hospitals should conduct education programs tailored to the survey results, focusing on improving safety culture based on specific feedback.
Budget Inclusion: Costs associated with culture assessment and follow-up activities should be included in the patient safety program budget to ensure adequate resource allocation.

Key Deadlines for the Leapfrog Hospital Survey (2024)

Survey Launch Date: April 1, 2024
Submission Deadline: June 30, 2024 (initial responses and required CPOE Evaluation Tools)
Public Reporting Dates:
- July 12, 2024: Survey results available on the Hospital Details Page
- July 25, 2024: Public reporting of survey results begins
Late Submission and Performance Update Deadline: November 30, 2024 (last date for updates or corrections)
Corrections Deadline: January 31, 2025 (final deadline for submitting corrections to 2024 survey data)

How ADN’s SOPS Service Can Help You Meet These Requirements

ADN’s Survey on Patient Safety Culture (SOPS) service provides comprehensive support for hospitals, medical offices, and ambulatory surgery centers aiming to enhance their patient safety culture. Here’s how the service can help:

Survey Development: ADN builds a customized electronic version of the AHRQ SOPS survey for your facility, ensuring relevant data capture aligned with your organization’s goals.
Distribution Strategy: Assistance with the survey distribution process, including communication templates and timeline development, to maximize response rates. ADN monitors response rates and offers recommendations to boost participation.
Comprehensive Analytics Report: Within 30 days of survey closure, ADN provides a detailed report identifying strengths and areas for improvement, with comparisons to AHRQ SOPS databases for benchmarking.
Deep Dive Report: ADN conducts in-depth analyses to identify top opportunities for improvement, providing recommended next steps and resources tailored to your organization’s needs.
Senior Leadership Presentation: A virtual presentation to explain and interpret the survey results to your leadership team, facilitating effective communication and strategy development.

By choosing ADN’s SOPS service, your organization gains a trusted partner committed to enhancing your patient safety culture and meeting Leapfrog’s requirements.

Integrating the Medical Office Survey on Patient Safety Culture or the SOPS Ambulatory Surgery Center Survey

Building a culture of safety extends beyond hospitals to outpatient settings like medical offices and ambulatory surgery centers. The AHRQ’s Medical Office Survey on Patient Safety Culture (MOSOPS) and the SOPS Ambulatory Surgery Center Survey provide valuable insights into safety culture in these environments, assessing areas such as teamwork, leadership support, communication openness, organizational learning, and work pressure.

For healthcare organizations looking to improve safety culture across all care settings, integrating MOSOPS or ASCSOPS with the HSOPSC offers a comprehensive view of safety culture throughout the organization. This unified approach leads to better patient outcomes and a stronger overall culture of safety.

ADN’s SOPS service is designed to help both hospitals and medical offices meet these requirements, offering tailored support, detailed analysis, and expert guidance to enhance patient safety culture and achieve organizational goals.

Hospital Quality Spotlight

Jefferson Regional Medical Center

The employees of Jefferson Regional Medical Center celebrated World Patient Safety Day on September 17, 2024. This day is an opportunity to raise public awareness and foster collaboration between patients, healthcare workers, policymakers, and healthcare leaders to improve patient safety.

This year the theme is “improving diagnosis for patient safety” with the slogan “Get it right, make it safe.”, highlighting the critical importance of correct and timely diagnosis in ensuring patient safety and improving health outcomes. The Jefferson Regional Quality Department provided employees with hand sanitizer and lifesaver candy!

Arkansas Medicaid’s Commitment to Improving Patient Care: The Success of the Inpatient Quality Incentive Program

Submitted by: Steve Chasteen, PHD, RN

For nearly two decades, Arkansas Medicaid has partnered with the Arkansas Foundation for Medical Care (AFMC), the Arkansas Hospital Association (AHA), and healthcare quality experts from participating hospitals to enhance patient care across the state through the innovative Inpatient Quality Incentive (IQI) program. This initiative highlights the power of collaboration and innovation in addressing health care challenges.

The IQI program engages hospitals statewide by encouraging the collection and submission of data on various quality measures. These measures, chosen by an advisory committee of quality directors, hospital staff, and representatives from Arkansas Medicaid/Division of Medical Services, AFMC, and the AHA, are thoroughly analyzed and validated. Hospitals that show improvement in health care outcomes are rewarded with bonus payments. Participation is open to all Arkansas hospitals and those in border states that accept Medicaid reimbursement.

Among the key indicators tracked by the IQI program are early elective deliveries (EED) and nulliparous term singleton vertex (low risk) cesarean deliveries. The national rate of cesarean sections (C-sections) has surged from 5% in 1970 to 33% in 2009, with only a slight decline to 32% by 2020. Similarly, induced deliveries increased by 223% from 1990 to 2020, reaching 31% of all U.S. births. While C-sections can be lifesaving in certain situations, non-medically indicated procedures pose significant risks to both newborns and mothers, including respiratory complications, infections, and extended NICU stays.

Guidelines and public health campaigns since the mid-2000s have recommended delaying elective deliveries until at least 39 weeks of gestation, which has helped slow the rise in these procedures. Despite this, the rates remain high, and the associated health risks underscore the need for ongoing improvement efforts.

The national target for early elective deliveries is 5%. Arkansas hospitals have achieved remarkable progress due to the implementation of the IQI program. In SFY 2011, the rate of early elective deliveries among participating hospitals was 25.7%. By SFY 2024, this rate had dramatically decreased to 2.42%, marking a 90.6% reduction.

Similarly, the rate of low-risk first-time C-sections has decreased from 28.4% in SFY 2013 to 20.5% in SFY 2024, reflecting a 28% reduction. This is a notable achievement, considering the national average for such procedures is 24.6%, as reported by the Leapfrog Group.

The persistently high rates of elective C-sections and inductions highlight the ongoing need for improved healthcare delivery interventions. The Arkansas Medicaid IQI program has demonstrated its effectiveness through its collaborative and innovative approach, significantly reducing elective C-sections and induced deliveries. The continued success of this program illustrates the positive impact of collective efforts in enhancing health care quality in Arkansas.

Other quality measures include identifying and treating tobacco use and dependence and suicide risk screening. Tobacco use is the leading cause of premature disease and death in the U.S. It is a primary driver of hospitalizations for cancers, stroke, cardiovascular and respiratory diseases, and pregnancy and newborn complications. Tobacco use also interferes with recovery and contributes to delayed bone and wound healing, infection, and other post-operative complications.

Hospitalizations are an ideal time to encourage tobacco users to quit. Every hospital in the U.S. must provide a smoke-free environment if it is to be accredited by the Joint Commission. Hospitals in Arkansas have implemented smoke-free campus policies, and since the introduction of tobacco cessation measures into the IQI program, the performance results have been remarkable, with consistent year-to-year improvements. Evidence from research suggests that if a hospitalized smoker is offered and uses cessation medication to manage withdrawal symptoms and has a positive experience, the individual may be more likely to continue using that medication to permanently quit after discharge. As a result of IQI, tobacco use screening is consistent and completed on most all individuals admitted to a hospital in Arkansas. Patients with a positive screen for tobacco use are offered and provided tobacco cessation counseling and FDA-approved medications upon admission and again at discharge.

The rate of suicide is increasing in America. Suicide is the 10th leading cause of death overall in Arkansas. On average, one person dies by suicide every 15 hours in the state. 1 in 10 of those who die by suicide are seen in an emergency department (ED) within the two months before their death. Despite national guidelines and resources for suicide screening, risk assessment, and follow-up care, suicidal ideation and behavior continue to go undetected in emergency departments, leading to gaps in care. Suicide risk screening was implemented as a quality metric in IQI in 2018. The baseline results in that first year were 82.5%. As of today, suicide risk screening in the ED has improved to 97.6%, representing an 18.3% increase in screening.

Find more information about this program here: Arkansas Medicaid Inpatient Quality Incentive (IQI) Program (afmc.org)

Gold Sponsors

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