Summer 2025 AAHQ Newsletter

2025 Summer Newsletter

From the President’s Desk

Submitted by: Devin Terry, PhD, RN, ACNS-BC, CPHQ

Hello AAHQ Members,

I hope you’re enjoying these warm and sunny summer days—and taking time to slow down and enjoy the company of friends, family, and all that Arkansas has to offer. Whether it’s a long weekend getaway or a simple staycation, we encourage you to relax and recharge!

While summer is a season of rest for many, your AAHQ Board is hard at work planning our next big event—the Fall Membership & Educational Conference! We’re building an exciting agenda that we can’t wait to share with you.

Our Spring Conference, held on May 2, “Navigating the Future of Quality Together,” was a tremendous success thanks to your incredible participation and thoughtful feedback. Your engagement helps us grow and evolve, and we’re using your insights to make this fall’s conference even better.

Mark your calendars! The Fall Conference will take place in October 2025, helping to prepare us for Healthcare Quality Week. Expect top-notch educational sessions, valuable networking opportunities, fun prizes, and shared momentum toward enhancing the quality and safety of healthcare across Arkansas.

Looking ahead, NAHQ Next will also offer virtual CPHQ continuing education opportunities in September 2025. Be sure to stay connected through our AAHQ social media channels and email updates for important announcements and opportunities from both AAHQ and NAHQ.

We hope you enjoy this newsletter and everything we have in store for the rest of the year. If you have any questions, ideas, or feedback, please don’t hesitate to reach out to me or any of our board members—we’re always here for you.

Until next time, stay safe, stay cool, and enjoy your summer!

Warm regards,

Devin Terry

AAHQ President

Protocol Update

Submitted by: Chelsey Davidson, BS, CPHQ

Happy July to all of our AAHQ members!

Hot off the press — AAHQ is excited to offer seven scholarships for AAHQ members to attend the upcoming NAHQ Next Virtual Conference (September 8 – 10^th, 2025). Preference will be given to AAHQ members who hold their Certified Professional in Healthcare Quality (CPHQ) certification and have attended an AAHQ Conference in the past twelve months. NAHQ Next scholarship recipients will be asked to submit an article or presentation for an upcoming AAHQ newsletter and/or conference. If the number of eligible applicants exceeds the number of scholarships available, a drawing for the scholarships will occur.

Scholarship requests can be submitted to Chelsey Davidson, AAHQ Protocol Team Lead, at chelsey.davidson@conwayregional.org through 12:00PM on Thursday, July 17^th. Scholarship recipients will be announced on Friday, July 18^th.

As a reminder, the focus of the AAHQ Protocol Team is review and maintenance of association bylaws, policies, and board job descriptions, as well as the nomination and election of officers. As quality improvement professionals, we all love rules and guidelines – I encourage you to consider joining our Protocol team and putting your skills to use!

Chelsey Davidson

Protocol Team Lead

October 3, 2025

2025 AAHQ Fall Quality Conference

CHI St. Vincent Infirmary Auditorium

2 St Vincent Circle Little Rock, AR 72205

Professional Development/External Relations Update

Submitted by: Justin Villines, MBA, BSM

Working on Quality in Healthcare:

Tips and Tricks for Hospitals and Clinics

In today’s healthcare landscape, improving quality isn’t just a regulatory requirement, it’s a strategic priority. For hospitals and clinics, a strong focus on quality can drive better patient outcomes, improve staff satisfaction, reduce unnecessary costs, and build trust in the communities they serve.

Whether you’re starting a quality improvement (QI) program or refining an existing one, the following tips and tricks can help healthcare leaders and frontline staff embed quality into daily operations.

Build a Culture of Quality

Quality improvement starts with people. Creating a culture where every team member—from front desk staff to medical providers—feels responsible for quality is essential.

Tip: Integrate quality into everyday conversations. Discuss metrics during huddles, recognize staff for improvement efforts, and provide ongoing training. A culture of continuous learning and accountability will naturally lead to better results.

Use Data as a Compass

Data is the foundation of quality. Understanding where gaps exist and tracking progress over time allows teams to make informed decisions.

Tip: Leverage data from your Electronic Health Record (EHR) and Health Information Exchange (HIE) to monitor key metrics such as readmissions, infection rates, and preventive care screenings. Utilize visual dashboards to make data accessible and actionable for all staff.

Strengthen Transitions of Care

One of the most vulnerable moments for patients is during transitions—such as discharge from the hospital to home or between providers. Improving communication during these handoffs can prevent readmissions and adverse events.

Tip: Implement standardized discharge protocols and post-discharge follow-up processes. Use real-time ADT (admission, discharge, transfer) alerts to notify primary care and behavioral health providers when a patient is admitted or discharged.

Focus on Patient-Centered Care

Patients are more likely to engage in their care when they feel heard and respected. Patient-centered care not only improves satisfaction—it leads to better outcomes.

Tip: Collect patient satisfaction feedback and use it to improve services. Involve patients in care planning and ensure that education materials are understandable, accessible, and culturally appropriate.

Standardize Workflows, Then Innovate

Consistency reduces variation and improves safety. Once standard procedures are in place, look for opportunities to improve and innovate.

Tip: Use evidence-based clinical pathways for chronic disease management. Audit and refine workflows regularly. After achieving baseline consistency, explore tools like remote monitoring and telehealth to enhance access and care coordination.

Measure What Matters

It’s easy to get overwhelmed by dozens of metrics. Focus on what matters most to your organization, patients, and payers.

Tip: Align quality initiatives with programs such as HEDIS, MIPS, or Medicaid value-based purchasing. Choose a few high-impact measures—like chronic condition management or maternal health equity—and dig deep. Be sure to track disparities and address gaps in care delivery.

Collaborate Across the Continuum

Quality doesn’t stop at the hospital doors. It requires collaboration with community providers, social services, payers, and public health.

Tip: Join or form regional quality collaboratives. Participate in Accountable Care Organizations (ACOs) or Clinically Integrated Networks (CINs) to share data, insights, and best practices. These partnerships can expand your reach and accelerate quality outcomes.

Final Thoughts

Improving quality in healthcare is a journey, not a destination. By building a culture of accountability, using data effectively, and centering care around the patient, hospitals and clinics can deliver safer, more effective, and more equitable care. The key is to start small, stay consistent, and never stop learning.

Justin Villines

Professional Development Lead and External Relations

AAHQ Board Member Spotlight

Member-At-Large

Tiffany Holland, MBA, BSN, RN, CPHQ, CPPS, TTS

What motivates you to be involved with the AAHQ organization?

My motivation to be involved with the AAHQ stems from both my professional background and my current role. Before joining the Arkansas Foundation for Medical Care (AFMC), I spent the majority of my career working in rural critical access hospitals. During that time, having access to a network of peers, educational events, and resources was invaluable as I navigated the challenges of serving underserved populations. These connections helped me stay informed and effective in improving care quality in resource-constrained environments.

Now, in my role with the Outreach Quality Department at AFMC, I have the privilege of working with healthcare professionals and stakeholders from across the state. This has deepened my appreciation for the importance of networking and continued education in driving improvements at a larger scale. AAHQ offers a unique platform for quality professionals to connect, share best practices, and access critical resources—and I am excited to be part of this dynamic organization.

Ultimately, I’m motivated by the opportunity to collaborate with like-minded professionals who share a commitment to advancing healthcare quality in Arkansas. Being involved with AAHQ allows me to both contribute to and learn from a community dedicated to enhancing the quality of care for our state’s population.

What’s on your 5-year bucket list?

In the next five years, my main focus will be balancing personal and professional growth while also cherishing time with my family. One of my goals is to start working on a doctoral degree, but I also recognize that the years with my two sons, Spencer (13) and Slade (9), are flying by. With Spencer graduating in 2029, I’m especially mindful of soaking up every moment with him before he heads off to college. Time with my kids is precious, and I want to make the most of it.

As a family, we love to travel, and one of our lifetime bucket list items is to visit all of the NBA arenas. My husband and I have been talking about how amazing it would be to catch games in different cities, blending our love for sports and travel.

On a more personal note, I’m looking forward to completing another half-marathon and also tackling my first sprint triathlon. These are both goals that push me to stay active and challenge myself physically. All in all, it’s a balance of personal ambitions, family time, and a bit of adventure that I’m looking forward to in the next five years.

What do you see as emerging trends in the healthcare quality industry?

Emerging trends in the healthcare quality industry are being shaped by rapid advancements in technologies such as artificial intelligence (AI), telehealth, and remote patient monitoring. These innovations are revolutionizing the delivery of care by improving access, efficiency, and personalization. As healthcare systems adopt these technologies, quality leaders are gaining access to unprecedented volumes of diverse data, ranging from real-time health metrics to patient-reported outcomes.

With this influx of data, one of the key challenges for quality leaders will be to effectively analyze and integrate these insights into actionable strategies that improve patient outcomes.

What is your greatest professional achievement?

One of the most rewarding aspects of my career has been the ability to lead quality improvement initiatives in resource-limited settings. Throughout my nearly twenty year career as a registered nurse, I’ve had the privilege of working in rural Critical Access Hospitals where I served vulnerable populations and wore many hats—from Emergency Department staff nurse and clinical informaticist to Chief Nursing Officer and Director of Quality Improvement, Risk Management, and Compliance. These roles allowed me to directly influence patient safety, care standards, and operational excellence.

Since 2021, through my work in the Outreach Quality Department at the Arkansas Foundation for Medical Care, I’ve had the incredible honor of collaborating with providers and stakeholders across Arkansas to improve outcomes for Medicare beneficiaries and work towards driving systemic change.

Throughout my career, I’ve been active in community health coalitions and served on various local and state-level boards and committees. I’ve continually pursued professional growth, completing an MBA and becoming credentialed as a Certified Professional in Healthcare Quality (CPHQ), Certified Professional in Patient Safety (CPPS), and Tobacco Treatment Specialist (TTS).

Ultimately, I believe my greatest professional achievements are the consistent focus on improving care quality, supporting my peers and teammates, and advocating for the health of my community.

What’s the best piece of advice you’ve ever received?

“You can never communicate enough”. I have been blessed to work for some amazing leaders over the years, so I have received a lot of great guidance. A particularly exceptional leader and mentor I was privileged to work for regularly emphasized the importance of communication as our team worked through both complex and minor issues. We were able to preserve the integrity of our team dynamic and learn from our peers, each of whom offered a diverse set of skills and perspectives, while arriving at the best possible solutions through ongoing, transparent communication.

What’s the most interesting thing you’ve learned recently?

Professionally, it’s hard to pick just one thing – our team has been deep in preparation and work for several contracts that cover a wide range of topics and populations, so I’ve been in constant learning mode.

Personally, though, I’ve been getting a crash course in Star Wars, thanks to my 13-year-old. He’s become a huge fan and has taken it upon himself to guide me through the entire galaxy. He’s mapped out an ambitious viewing schedule for us this summer – movies, TV series, the whole canon. We’ve even gone down more than a few YouTube rabbit holes doing our background research. I’m a Harry Potter nerd at heart, but I’m doing my best to keep up. I love his passion for sharing things he’s interested in and am so excited he’s bringing me along for the journey.

Finance Team Update

Submitted by: Trey McCorkindale

As of the end of May, AAHQ had a cash balance of $32,417.60. I hope you have been enjoying our conferences. We are going to try to maintain this bi-annual schedule of conferences. The spring conference was a great success, it was well attended, and almost close to all feedback was positive. We look forward to bringing you more great speakers and information to the conferences in the future. The AAHQ dues and the conference fees also help us to not just pay for the expenses but bring in more scholarship funds for our members that need financial assistance in the pursuit of the CPHQ certification. The support of the attendees and their employers helped to raise $5K in funds to cover the expenses of our speaker guests, food, and future scholarships. The AAHQ board is already underway planning for the fall conference and we look forward to seeing you all again and maybe some new faces.

For the YTD financial results through May, AAHQ had total revenue of $18,565 and total expenses of $9,120.25 (Net revenue surplus, $9,444.25). On a YTD comparison to FY24 ending 5/31/24, that’s an almost $12K improvement.

Please let us know if you there’s anything we can do to enhance the benefits of membership and the participation, learning, enjoyment, and networking of the AAHQ conferences.

We look forward to seeing you at the next conference.

Robert “Trey” McCorkindale

Finance Team Lead

Communications Update

Submitted by: Joel Anderson, GC-MGMT, BBA

Happy Summer,

Hope everyone is enjoying the beautiful weather and the many outdoor amenities that Arkansas has to offer, but please don’t forget to apply your sunscreen! The AAHQ Communications Action Team promotes 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 your not following us on Facebook and LinkedIn , I would highly encourage you to do so. Our website is also a great resource for members and includes information on upcoming educational events. Please bookmark the website and visit often!

AAHQ Communications is looking for any members interested in serving on our Communications Action 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, social media, newsletter development, and so much more? If so, then this is the team for you! Please reach out to me at andersonj@jrmc.org.

Joel Anderson

Communications Team Lead

Membership Services Update

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

We’re in that time of year when we don’t see a lot of new members joining the association. But if your organization is like ours, it is the senior quality leaders who are members of the association and participate in its activities. If that’s the case, please give consideration for who benefits the most from the association. Quality Professionals who are relatively new to the field benefit the most from education offerings and network opportunities that the association has to offer. It may be that they are working in a specific part of the quality profession that is outside the scope of your own experience and they might benefit from finding a mentor in the society. So be thinking about who in your organization that is not currently a member who might benefit the most from what the association has to offer. Before too long, it will be time to budget for the coming year, and making sure your early career employees have access to resources that will help them grow in their profession.

The application form can be found at www.arkahq.org.

Tim Copeland

Membership Services Team Lead

Important Pre-admission Screening and Resident Review (PASRR) Updates: Ensuring Safe and
Appropriate Nursing Facility Placement

Beginning July 1, 2025, the Arkansas Department of Human Services (DHS), Division of Provider Services and Quality Assurance (DPSQA), will transition to a new vendor, Arkansas Foundation for Medical Care (AFMC), for conducting Level II PASRR assessments. The change is part of DHS’s ongoing efforts to support high-quality, efficient evaluation and placement processes for individuals referred to nursing facilities.

What is PASRR?
The Pre-Admission Screening and Resident Review (PASRR) is a federally mandated process that ensures individuals who are being referred for nursing facility (NF) admission are screened for the presence of mental illness (MI) or intellectual disability (ID)/Developmental Disability (DD). The PASRR process consists of two levels:

Level I Screening (DMS-787 form) is the initial brief screening to determine whether the individual may have an MI or ID/DD. If there is no indication of these conditions, the screening is negative, and the process is complete.
Level II Assessment is required for individuals who screen positive for MI or ID/DD. This comprehensive assessment evaluates the specific needs and ensures the person receives appropriate care.

A diagnosis of MI or ID/DD does not automatically prevent an individual from being placed in an NF. Instead, it triggers a full evaluation to ensure the most appropriate placement based on the individual’s needs and if any specialized services are needed.

Why PASRR Matters
Just like triage in an emergency room helps determine the right level of medical care, the PASRR process helps identify whether someone referred for NF admission is truly best served in that environment. A diagnosis of MI or ID/DD doesn’t rule out NF placement, but it does require a more thorough review, the Level II PASRR assessment, to inform decisions about care and services. Although there are operational changes, the PASRR federal requirements have not changed. The goal remains the same: to ensure individuals with MI or ID/DD receive care in the most appropriate and least restrictive setting.

What’s Staying the Same

The Level I Screening form (DMS-787) is still used to identify individuals needing further evaluation.
Facilities are still required to complete a Level I before admission.
All individuals entering a Medicaid-certified NF must be screened, regardless of payer source.

What’s Changing

Bock Associates will no longer receive Level I forms after June 25, 2025.
DHS will receive and review all positive Level I screenings after June 25, 2025.
AFMC will conduct all Level II PASRR assessments starting July 1, 2025.

The Updated Process (Beginning June 26, 2025):
While the foundational elements of PASRR remain in place, there are a few key steps providers need to follow under the new workflow:

Complete the Level I (DMS-787) before NF admission.
- If negative, do not submit it—keep on file at the facility for surveyor review.
- If positive (indicating MI or ID), email it to:
  MedNeeds.PASRR@dhs.arkansas.gov
- To expedite the PASRR process, also send supporting medical records:
  - Face sheet, H&P, physician orders, MAR
  - Progress and nursing notes (last 3–5 days)
  - Social history, psych evals, guardianship/POA documents
  - Any relevant testing or previous discharge summaries
DHS reviews the referral. If a Level II is needed, DHS sends the referral to AFMC.
AFMC will contact the facility to schedule an in-person Level II assessment and request any missing records. Records may be securely uploaded via AFMC’s portal.
AFMC will complete the Level II assessment and send findings to DHS.
DHS will review AFMC’s assessment and issue a final determination.
AFMC will send final Level II assessment results to the client, facility, and representative/guardian.

Support and Contact
DHS, AFMC, and Bock Associates are working closely to ensure a smooth transition. Our shared goal is to reduce delays and place individuals in the most appropriate setting for their needs. If you have questions or need assistance:

DHS DPSQA

(501) 682-2441 ext. 8
medneeds.pasrr@dhs.arkansas.gov

AFMC (starting July 1, 2025)

AAHQ Sponsors

Gold Level Sponsors

American Data Network

Founded in 1994, American Data Network provides clinical, quality, safety and financial data applications and services to healthcare executives, allowing them to better manage costs and care quality, influence physician practice patterns and meet demands for public accountability and disclosure. For more information about ADN and its services, please visit www.americandatanetwork.com.

Arkansas Foundation for Medical Care

For more than 35 years, AFMC has helped improve the quality of healthcare in Arkansas. As the federally designated quality improvement organization (QIO), we work with staff in every health care setting and offer free tools and resources. Together, we’re working to make health care safer, more effective and more efficient. For more information about AFMC’s services, please go to www.afmc.org.

Empower Healthcare Solutions

Founded in 2018, Empower is the largest of four Provider-led Arkansas Shared Saving Entities (PASSE) in Arkansas. Empower is committed to helping members live fuller, healthier lives at home and in their communities. For more information about Empower Healthcare Solutions, please visit https://getempowerhealth.com/

Sentact

Sentact’s digital, enterprise-wide rounding solutions help hospitals to create safer environments, increased patient engagement, and improved overall quality of care. For more information about Sentact’s services, please go to http://www.sentact.com