hospitals arkansas · approval to extend the Arkansas Private Option (APO) into 2016. His request,...

ArkAnsAs HospitAls I Spring 2015 1

hospitalsarkansas

SPRING 2015 www.arkhospitals.org

A MAGAzINe foR ARkANSAS heAlthcARe PRofeSSIoNAlS

health-System Pharmacistsleading change

one ceo’s Story:how healthcare chose Me

Hospitalslearning to Fly

2 Spring 2015 I ArkAnsAs HospitAls

We’re a knowledgeable connector of people, physicians and health care places.

One way we keep physicians and patients connected is through a Personal Health Record (PHR), available for each Arkansas Blue Cross, Health Advantage and BlueAdvantage Administrators of Arkansas member. A PHR is a confidential, Web-based, electronic record that combines information provided by the patient and information available from their claims data.

A PHR can help physicians by providing valuable information in both every day and emergency situations.

To request access, contact PHR Customer Support at 501-378-3253 [email protected] or contact your Network Development Representative.

arkansasbluecross.com MPI 2003 11/13


3929168is published by

Arkansas Hospital Association419 Natural Resources Drive • Little Rock, AR 72205

501.224.7878 / FAX 501.224.0519www.arkhospitals.org

Elisa White, Editor-in-ChiefNancy Robertson Cook, Editor & Contributing Writer

Cindy Lewis, Editorial & Layout AssistantEmily Cavallo, Art Director

Board of directorsDoug Weeks, Little Rock / Chairman

Walter Johnson, Pine Bluff / Chairman-ElectDarren Caldwell, DeWitt / Treasurer

Ron Peterson, Mountain Home / At-Large

Peggy Abbott, CamdenChris Barber, Jonesboro

Jerry Berley, WarrenDavid Berry, Little RockKristy Estrem, BerryvilleJohn Heard, McGeheeEd Lacy, Heber SpringsJim Lambert, Conway

Corbet Lamkin, CamdenJames Magee, PiggottDan McKay, Fort Smith

Ray Montgomery, SearcyRobert Rupp, Helena

executive teamRobert “Bo” Ryall / President and CEO

W. Paul Cunningham / Executive Vice PresidentTina Creel / Vice President of AHA Services, Inc.

Elisa M. White / Vice President and General CounselJodiane Tritt / Vice President of

Government RelationsPam Brown / Vice President of

Quality and Patient SafetyLyndsey Dumas / Vice President of Education

distriButionArkansas Hospitals is distributed quarterly

to hospital executives, managers and trustees throughout the United States; to physicians,

state legislators, the congressional delegation, and other friends of the hospitals of Arkansas.

edition 90

Created by Publishing Concepts, Inc.David Brown, President • [email protected]

For Advertising info contact Michelle Gilbert • 1.800.561.4686 ext.120

[email protected]

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departments

cover story

quality and patient safety

4 From the President

6 Editor’s Letter

6 Education Calendar

7 Newsmakers and Newcomers

7 All About Hospitals

8 Soaring as a High Reliability Organization

15 Focus on Quality

16 A New Voice for Patient Safety

19 Arkansas’s Antimicrobial Stewardship Collaborative

21 Symposium Focuses on the Patient Experience

22 New Recommendations for Pneumococcal Vaccines

25 2015 Governor’s Quality Award Healthcare Seminar

feature

news

26 Protection Against Measles

29 NewsSTAT

30 MyIndyCard Rollout: Tips for Hospitals

32 CEOs in Action: Kristy Estrem – “Blessed that Healthcare Chose Me!”

36 AHA Services Spotlight: Bottom Line Systems, Inc.

39 Pandemics and Legal Policy: Planning Ahead Prevents Panic

special report

42 The Best Reason to be in Washington, D.C., May 3-6, 2015

legislative advocacy

45 From the Arkansas Capitol… an Exciting Time for Healthcare!

hospitalsarkansas


The biggest news of this quarter came when Governor Asa Hutchinson asked for and received legislative approval to extend the Arkansas Private Option (APO) into 2016. His request, made in an early speech as governor, also calls for formation of a task force to study the APO and seek ways to improve Arkansas healthcare in the future.

The extension of the APO means we will have even more impact data to bring to the legislature and the legislative task force. The AHA will be called upon to testify to the APO’s impact on hospitals and healthcare, and we’ll be ready.

Because of the APO and patients signing up for health insurance through the Insurance Exchange, we’re seeing thousands of newly insured patients being integrated into our Arkansas hospital systems. As of the end of February, 239,350 Arkansas citizens had been approved for healthcare eligibility through the APO. Additionally, more than 65,000 Arkansans have signed up for insurance through the state’s Health Insurance Marketplace over the first two years of its existence, adding people to the rolls of the insured where they previously had no healthcare insurance.

Having this rise in insured patients is a great help to our Arkansas hospitals, lowering the amount of uncompensated

care tremendously and allowing patients to seek care before they become critically ill. It’s a win-win for all concerned.

We’re also on the threshold of new movements in the area of hospital quality and patient safety. We’re proud of the Arkansas hospitals that participated in the American Hospital Association/Health Research and Educational Trust’s Hospital Engagement Network (HEN) 2011-2014. In fact, our Arkansas hospitals were one of only two state groups in the HRET HEN that met national goals and expectations of reducing healthcare acquired conditions and the number of patient readmissions.

We have seen HEN improvements lately become tied to reimbursements; with HEN 2.0 on the horizon, we hope more of our Arkansas hospitals will join the HEN and get a leg up on what are certain to be reimbursement requirements in years to come. Getting this advanced “practice” is exciting in itself, and Arkansas has become a proven

leader in developing successful ways to improve and manage quality of care.

And on the near horizon? We can greatly affect change in positive ways by attending the American Hospital Association Annual Meeting and visits to Capitol Hill this spring, May 3-6. I hope you’ll consider joining me this year to hear from members of Congress and cutting-edge leaders in the world of healthcare as they help us traverse the many changes that define healthcare today.

To many, the challenge of change is seen as negative. I choose to see it as positive in healthcare’s brave, new world; we all must embrace change and improve healthcare...for our patients’ sake.

Bo ryallPresident and CEO Arkansas Hospital Association

CHAngeas a Positive

Photo courtesy of Jason Burt

from the President

Change is the order of the day in healthcare, no matter which “day” we speak of. The change is rapid, requires quick response and keeps us all moving forward. Gone are the days when anyone in healthcare could dig in and say, “We’re not going to change the way we do business!” Today, we’ve been pushed and pulled into a bigger understanding that, yes, requires big change. It’s an exciting time for those of us in healthcare, and our patients are the winners.

Having this rise in insured patients is a great help to our Arkansas hospitals, lowering the amount of uncompensated care tremendously and allowing patients to seek care before they become critically ill.


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Yes. Let us show you how.


With the entire nation focused on improving the healthcare system, there has never been a more exciting time to be involved in healthcare. We have the opportunity to burn the old rule book and create a new one that makes care better, safer and more accessible to those who need it. In facing these changes, however, many in our industry struggle with what Tom and David Kelley from the design and consulting firm IDEO call the “fear of the messy unknown.”1 According to the Kelleys, this fear keeps designers working

in the safety of their offices instead of getting out into the world to engage with their customers.

Many leaders are braving the messy unknown by collaborating with physicians and staff to transform their hospitals into high reliability organizations (HROs). Borrowing from the airlines and other industries that operate within a hazardous, high-stakes environment yet maintain an extremely low error rate, these hospitals achieve remarkable levels of quality and patient safety and sustain improvements

by integrating HRO concepts into their culture. Our cover story offers a case study illustrating the remarkable results one hospital achieved on its HRO journey.

We salute you, the hospital community, and join you in the messy unknown as you work to provide safe, high-quality and efficient care for your patients.

excitementand Fear

editor’s letter

When Eleanor Roosevelt said do one thing every day that scares you, she wasn’t talking about modern healthcare, but she could have been. The challenge of transforming care to improve quality, while simultaneously increasing efficiency, can be daunting to say the least.

elisa White, Editor-In-Chief

Program information is available at www.arkhospitals.org/events.

arkansas Hospital association

eduCAtion CAlendArApril 10, Little RockArkansas Association for Healthcare Quality (AAHQ) and Arkansas Organization for Nurse Executives (ArONE) Spring Conference, Pulaski Academy

April 10, SearcyArkansas Healthcare Human Resources Association (AHHRA) Spring Conference, White County Medical Center

April 15-17, Hot SpringsHealthcare Financial Management Association (HFMA) Arkansas Chapter2015 Spring Conference, Embassy Suites

April 17, Little RockArkansas Association for Medical Staff Services (ArkAMSS) Spring Conference,Arkansas Hospital Association

April 23, Little RockAddressing 2015 Key Compliance Issues: HIPAA and EMTALA, Crowne Plaza

April 24, Little RockArkansas Social Workers in Health Care (ASWHC) Spring Conference,Arkansas Hospital Association

April 29-May 1, Fairfield BaySociety for Arkansas Healthcare Purchasing and Materials Managers (SAHPMM) Annual Meeting and Trade Show, Fairfield Bay Conference Center and Lodging

May 3-6, Washington, D.C.American Hospital Association Annual Meeting, Washington Hilton Hotel

May 6-8, Hot SpringsArkansas Association of Healthcare Engineers’ (AAHE) 50th Annual Meeting andTrade Show, Arlington Resort Hotel and Spa

May 12-14, Little RockBasic Crisis Response Training,Arkansas Hospital Association

June 17-19, Downtown Nashville, TNHospital Executive Leadership Conference,DoubleTree by Hilton

June 26, Little RockArkansas Healthcare Human Resources, Association (AHHRA) Summer Conference,Arkansas Hospital Association

1Reclaim Your Creative Confidence, Harvard Business Review (Dec. 1, 2012), https://hbr.org/2012/12/reclaim-your-creative-confidence.


◼ AliCiA kunert has been named executive director of Conway Regional Rehabilitation Hospital. With nearly 30 years’ experience in healthcare, Kunert has held leadership roles at The BridgeWay, Pinnacle Pointe Behavioral Healthcare System, Prudential Insurance and NovaSys Health Network. In addition, she was the chief executive officer of Arkansas Specialty Orthopaedics for seven years, administrator of the Conway Orthopaedic and Sports Medicine Clinic, and most recently served as the chief administrative officer of Radiology Associates, P.A. (since January 2011). She has also been the president of FYG Consulting since 2007.

◼ AlBert pilkington, iii has been named CEO of Johnson Regional Medical Center, joining the organization on January 5. Pilkington, a member of the American College of Healthcare Executives (ACHE), is a career healthcare executive with more than 27 years’ experience. He has held CEO positions with Virginia University Hospital-East, Fairmont

General Hospital, Muhlenberg Community Hospital, Mena Medical Center and St. Edward Mercy Medical Center, but most recently served as the CEO at a hospital in China. An Arkansas native, Pilkington received his MBA and BBA from the University of Central Arkansas in Conway.

◼ roBert rupp, who served as CEO of Harris Hospital in Newport for the past three years, has been named Project CEO with Community Health Systems. He is currently filling in as CEO of Helena Regional Medical Center while a decision is made on a full-time replacement for BuddY dAniels, who accepted another position with a CHS facility outside of Arkansas.

◼ sHAnon nACHtigAl, Bsn, rn, has been named Vice President/Chief Nursing Officer for Baxter Regional Medical Center. Nachtigal is a graduate of the University of Arkansas at Little Rock School of Nursing and is currently working to complete her master’s degree in nursing administration from

Chamberlain University. She has been a registered nurse for 26 years, with 23 years spent in various roles at BRMC. She most recently served as BRMC’s Interim CNO.

◼ pollY dAvenport is the new President of CHI St. Vincent Infirmary and CHI St. Vincent North. She replaces CHAd Aduddell at CHI St. Vincent Infirmary, who is now Interim Market Chief Executive Officer for CHI St. Vincent. Davenport was most recently the Chief Executive Officer at Ochsner Medical Center-North Shore Region, Slidell and Covington, Louisiana, where she served since 2011. She has a bachelor of science in nursing from the University of Texas at San Antonio, a masters of business administration from Our Lady of the Lake University in San Antonio, and recently completed a doctorate of science, health administration at the University of Alabama, Birmingham. Davenport is a Fellow of the American College of Healthcare Executives and of the Johnson & Johnson/Wharton School of Business Nurse Executive Program.

newsmAkersand newComers

ArkAnsAs

all about HospitAls◼ wHite CountY mediCAl

Center in Searcy has announced the purchase of Harris Hospital and its 11 affiliated clinics in Newport. The organization has changed its name to Unity Health, and the two facilities are now known as Unity Health–White County Medical Center and Unity Health–Harris Medical Center.

◼ The st. BernArds mediCAl Center CAnCer progrAm has earned accreditation with commendation from the Commission on Cancer of the American College of Surgeons.

Accreditation with commendation signifies the program as a comprehensive community cancer program that exceeds standard requirements. St. Bernards Medical Center is located in Jonesboro.

◼ A sales tax initiative for ouACHitA CountY mediCAl Center in Camden passed handsomely in a special election February 10. There were three options on the ballot: a one-half cent for five years for building and maintenance, an improvement bonds issue and a refunding of bonds issue. All

three passed following an intense grassroots campaign launched by the hospital.

◼ spArks mediCAl Center– vAn Buren has committed $10 million for the building of a new emergency room and the addition of outpatient services. Announced at the re-naming ceremony which changed the former Summit Medical Center to Sparks Medical Center-Van Buren, the investment will include the addition of gynecological services, gastrointestinal services and outpatient urology services.


soaring as a High reliability organization

Cover story

one Hospital’s Journey to improve Care and save $1.2M per Year

by Stephen Harden, Chairman and CEO, LifeWings Partners, LLC

Reports indicate that 1 in 5,500 surgeries results in an incidence of a retained foreign object (RFO), and 68 percent of the time that object is a sponge.1 The Operating Rooms at University of New Mexico (UNM) Hospital exceeded this published average with an error rate of almost two RFOs per quarter. Associated malpractice costs alone averaged $200,000 per case. To address the issue and others like it, leaders at UNM Hospital decided to seek training to become a High Reliability Organization (HRO) using Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPSTM), a program developed from the Air Force checklist and team communications program.

strAtegY session


Knowing that the foundation for a successful HRO journey requires a strong, three-pronged approach — leadership commitment, an organizational culture of safety and robust process improvement — senior leaders at UNM Hospital chose to implement a TeamSTEPPS-based patient safety program to provide the structure for their journey. The TeamSTEPPS Program is a teamwork and communication system for healthcare professionals developed by the Department of Defense’s Patient Safety Program in collaboration with the Agency for Hospital Research and Quality (AHRQ). It is rooted in more than 20 years of research and practice originating with the United States Air Force as a teamwork communication and cross-check system to help pilots and flight crews communicate effectively to maintain flight safety.

TeamSTEPPS is implemented with the help of coaches with extensive experience in high reliability systems and was determined by UNM Hospital to be the most effective way to combine all three required foundational elements (leadership commitment, organizational culture of safety, commitment to process improvement). UNM leaders chose LifeWings Partners of Memphis, Tennessee as their partners in patient safety and quality improvement. The LifeWings system melds the most successful, scientifically proven elements of teamwork and communications training with process improvement methods based on Lean principles. UNM Hospital implemented a five-step program designed to help its organizations become HROs and has trained approximately 350 staff, faculty and residents to date.

Since the Perioperative Team at UNM Hospital implemented the LifeWings high reliability program, the hospital has had zero cases of objects retained. Savings are estimated at $1.2M per year. Additionally, the hospital became more efficient and increased surgical volumes without adding resources, while also reducing surgical infections and increasing patient safety.

overall outstanding legacy of service, butleaders knew they Could improve

Exceptional quality medical care has always been the norm at the UNM Hospital. It has the distinction of being named one of the 100 top-performing hospitals and top 10 academic facilities in the U.S. This is especially impressive because it is the only Level 1 Trauma Center in New Mexico and provides a critical public safety net for patients who are uninsured.

The demands of being the only Level 1 Trauma Center in the state were the catalyst for a sweeping improvement program to gain efficiencies, reduce errors and improve staff and patient satisfaction by becoming an HRO. Hospital leaders started the HRO journey in Surgical Services. Due to the high volume of trauma cases, the operating rooms were used to capacity. This high utilization resulted in inefficiencies, errors and poor communication. Because of the financial demands associated with its public safety mandate, simply adding more resources was not an option. Hospital leaders knew it was time to make culture changes that were measurable, quick-to-implement, and most importantly, sustainable.

Due diligence on successful improvement programs convinced hospital leaders that their soundest

strategy to drive their ambitious program to become an HRO was to combine a customized TeamSTEPPS program that also included Lean process improvement methods. A focus on process improvement for sustainability was key.

LifeWings’s development of hospitals and healthcare teams as HROs is as important for what it is not as for what it is: it is NOT a cookbook method of how to practice medicine.

It IS all about turning a group of healthcare experts into a reliable and expert team – the heart of high reliability – that consistently uses communication and team action principles to reduce errors and improve patient outcomes.

Dr. David Pitcher, Chief Medical Officer at UNM Hospital, declares that commitment to a culture of safety is a critical part of becoming an HRO. He emphasizes that hospital leaders made the decision to implement the program as a “gateway” to the whole improvement plan. “Before we made policy and process changes, we knew we needed staff to communicate better, or else those new policies would not be successful,” he says as a hint to other hospitals on the HRO path.

methodologyUNM Hospital’s Surgical Services

area followed a five-step program on its journey toward becoming an HRO.

continued on page 10

unm leaders chose lifewings partners of memphis, tennessee as their partners in patient safety and quality improvement. the lifewings system melds the most successful, scientifically proven elements of teamwork and communications training with process improvement methods based on lean principles.


Step 1. Develop change-initiative skills for key leadership positions and an organizational structure that will support the new culture. Realizing no change would occur without partnership with the institution’s physicians, UNM Hospital recruited physician champions, briefed all physicians in perioperative services through monthly meetings and surgery Grand Rounds, and made sure each physician understood the methodology, potential results, and “what’s in it for you” for supporting the initiative. This was an important step, as UNM Hospital already had very high levels of patient safety in other areas.

Next, key leaders at both the institutional and departmental levels were trained on leading change initiatives. Skills learned included:• Responding to difficult questions

about the initiative;• Recruiting champions and coaching

low performers; and• Conducting rounding (a version of

Gemba Walks in Lean methodology) for patient safety.Organizational development to

support the initiative included:• A project oversight and steering

committee;• Revisions to policy and procedure

manuals;

• Alignment of leadership assessment systems to support the culture;

• A data collection and analysis plan for project measurement; and

• Making the training and new safety tools mandatory for all physicians and staff — including consequences for non-compliance.Step 1 was perhaps the most

important part of the methodology, as research shows that “end user” adoption of culture-changing behaviors and tools is primarily a function of effective leadership commitment and action.

Step 2. Provide training in teamwork and communication to support the desired culture of safety. Following a site visit, a thorough patient care processes review and preparation of a teamwork scorecard, we developed customized courseware targeting the needs of UNM Hospital (Surgical Services) and presented it to physicians and staff. The training was interdisciplinary (and included physicians). It was experiential and made heavy use of healthcare case studies. It provided and taught evidence-based teamwork and communication skills that create the organizational trust necessary for all frontline staff to feel comfortable identifying,

discussing and reporting safety concerns, including near misses.

Step 3. Using Lean process improvement methodology, create and implement site-specific safety tools and standard processes to hardwire teamwork behaviors into daily work life. Small work groups of physicians and staff met and worked with LifeWings coaches to: 1) identify points in their workflow where improvements in patient safety were most needed, and 2) create safety tools such as checklists, structured handoffs, protocols and communication scripts to facilitate these needed improvements. An education and implementation plan was created for each tool, and tools were implemented over a period of weeks. The first tool completed and implemented was a Pre-Procedure Briefing for surgical cases that incorporated the Universal Protocol. The tool also included checklist items to ensure all staff and needed equipment were available and operational, and that the patient was completely prepped for the procedure to begin.

Step 4. Collect and analyze data to document results. UNM Hospital created a measurement plan to analyze results by closely examining safety measures. Measures examined include safety climate surveys, teamwork and communication issues, and process reliability and efficiency.

Step 5. Conduct training for “master trainers.” UNM Hospital wanted to bring the culture-changing initiative in-house as quickly as possible and avoid an extended engagement with an outside consultant. To develop their internal capacity, trainers were chosen to learn to provide critical teamwork skills training and to create and implement the necessary safety tools. Once qualified, these trainers assumed responsibility for the rollout of Steps 1 through 4 in other departments of the hospital. UNM Hospital continues to roll out the system with plans to implement the HRO process throughout its entire hospital.




dramatic results Created program demandin other departments

Since the HRO program was implemented in Surgical Services, senior leadership can draw a direct line to significant improvements that have immediate and long-term effects on the hospital.

Before implementation, the OR had an error rate of almost two RFOs per quarter. In addition to the substantial malpractice costs associated with each case, typically $200,000 for each, there were other significant damages to the hospital and patients. When the hospital had to deal with an RFO case, much staff time and energy was required, and the disappointment experienced by the OR staff was demoralizing. For patients, there could often be further complications such as infections or conditions that required additional procedures that put them at risk. The cumulative effect of multiple cases for many years caused an incalculable degradation of the OR department. Eliminating these errors was just one of the many objectives of the OR improvement plan at UNM Hospital — but it was one of significant priority.

The results are remarkable. Since the OR team has learned and implemented the communication, safety and debrief tools taught in the LifeWings program and added the use of radiofrequency-based scanning devices to help track sponges, the hospital has had zero cases of objects retained.

Dr. Pitcher acknowledged that the effort had a “direct effect on the elimination of retained objects. There is no doubt in my mind that the communication techniques we learned were the catalyst.” Based on the hospital’s history, eliminating this type of error has resulted in a potential savings of $1.2M per year — and that is just one benefit the hospital has noted.

Keeping in line with the original objective of the training, leadership leveraged the program to implement new “rules of the road” for the department. The results of these new policies are impressive:

• Higher OR volumes without additional resources;

• Reduced surgical infections; • Faster response times for patients; and• Operating rooms utilized far more

efficiently with more surgeries done during the daytime hours instead of in the evenings.

greatly enhancednurse satisfaction

Another significant benefit of becoming an HRO has been measureable improvements in nurse staffing. Prior to implementation, the reputation of the existing culture and intra-personal experiences in the OR made recruiting and retaining nurses difficult. Communication between all members of the team was poor, at best. The hospital had to supplement its OR staff with 30-60 percent traveling nurses. The additional expense and administrative demand of the staffing problems weighed on the department’s performance, morale and budget. Since the adoption of the customized TeamSTEPPS-based program, the improved experience in the OR has garnered UNM Hospital the reputation as a desirable place to work.

Dr. John Russell, Chairman of the Department of Surgery, expresses his perspective on the most remarkable

result of the department’s journey toward becoming an HRO. “When new staff and travelers are in the OR, they now actively comment that the culture and communications are better than any other place they have ever worked,” he says. He adds his guarantee that this dramatic culture change is a result of communication skills gleaned in their customized training. “They would not have said our ORs were desirable places to work prior to that implementation.”

UNM Hospital is now able to recruit and retain more full-time nurses, using travelers to supplement only approximately 10 percent of their staffing needs. Nurses are not the only staff supportive of the program. Dr. Pitcher estimates that 95 percent of the UNM perioperative physicians are supportive of the journey and are active champions of the tools and methodologies used.

Dr. Russell was also part of the group that evaluated and helped implement the improvement effort. He indicates that the most important aspect of the program’s success is, without a doubt, having physician champions. “If people thought it was an effort directed just by administrators, people would not buy into it at all. Having physicians on board who are seen as influential with other staff is crucial.”


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moving ForwardThough the overall improvement

program has been consistently viewed as a success, hospital leaders acknowledge that continual improvement is a priority and is key to long-term ROI and elimination of patient harm. “All improvements we have made are systemic, not one-time quick fixes,” Dr. Russell says. “We are working on implementing post-surgical debriefs with regularity, knowing this is an area that will help ensure our continued progress.”

The positive buzz of the initial implementation created demand from other departments eager to replicate the OR’s results. Several staff have completed the Master Train-the-Trainer Program and have begun implementing the HRO program in other units and service lines, including Behavioral Health.

The success of the program has also resulted in a plan to teach the skills and concepts to new doctors and graduates in the UNM Medical School.

results Achievable byAll Hospitals

All hospitals can, with leadership commitment to both culture and process change, and the inclusion of physician champions, learn to soar by using TeamSTEPPS and Lean tools and teachings. Becoming an HRO means your staff operates as a team, and all team members can speak

openly and freely when it comes to patient safety.

As an HRO, your organization will not only enjoy increased patient safety and team satisfaction, it will also soon be able to equate dollar savings and financial improvements to your efforts in reaching HRO status.

1http://www.ncbi.nlm.nih.gov/pubmed/18589366

Partners with PurposeStephen Harden, a former Top Gun flight instructor, is Chairman and CEO of LifeWings Partners, LLC. LifeWings is a team of physicians, astronauts, nurses, pilots and Toyota-trained Lean experts who pioneered the effective adaptation of proven high reliability tools to healthcare. The team has worked with more than 150 healthcare organizations in the U.S. and abroad to implement the best safety practices derived from aviation and other high reliability industries. You may reach Mr. Harden at [email protected].


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FoCus on

QuAlitY

Quality and Patient safetyAdding a Contemplative Voice to the Conversation on End-of-Life Care is the subject of Executive Insights, a publication by l.e.K. Consulting, llC. it addresses innovative approaches being made in the fields of palliative care, hospice care and other end-of-life choices. find the publication at www.lek.com and click on Knowledge Center.

two new toolkits are available from the California Maternal Quality Care Collaborative. you may download the Improving Health Care Response to Preeclampsia and OB Hemorrhage toolkits by going to https://cmqcc.org.

Officials from the National institutes of Health and the city of Washington, d.C. have launched a clinical trial to examine whether primary care physicians and other healthcare providers, such as nurse practitioners and physician assistants, can use a new antiviral therapy as effectively as specialist physicians to treat people with hepatitis C virus (HCv) infection. the trial, which will involve 600 adult d.C. residents infected with HCv alone or co-infected with HCv and Hiv, also will examine the long-term effects of the treatment. for more, go to www.nih.gov and click on news & events, Press releases.

Global Patient Safety Alerts is a publicly available, evidence-informed, online collection of patient safety alerts, advisories and recommendations from 26 international organizations around the world. recognized by the World Health organization and its member countries, the collection contains more than 1,200 alerts and 6,100 recommendations from contributing organizations and serves as a centralized location for sharing and learning from patient safety incidents. Many toolkits and other resources are also available. Go to www.globalpatientsafetyalerts.com.

the arkansas Hospital association is proud of Baxter regional Medical Center, which was featured in Healthcare Executive magazine’s March-april edition. the article, “targeting Zero Harm,” discusses healthcare quality improvements made through the three-year Hospital engagement network (Hen) of the national Partnership for Patients program. Baxter is known for its innovations in quality improvement. Great job, Baxter!


Quality and Patient safety

A new voice for patient safety

Health-system Pharmacists Lead Quality Collaborative

By Niki Carver, PharmD, CPPS, Arkansas Continued Care Hospital of Jonesboro

When the Arkansas Association of Health-System Pharmacists (AAHP) and the Arkansas Hospital Association (AHA) joined forces in January 2014, no one could anticipate the incalculable life-saving achievements this highly-charged collaborative would deliver. Nor that those results would blossom with a broadened focus, resulting in the development of new processes, bringing down hospital costs, while saving countless lives now and into the future.

CAre AdvAnCement


The Pharmacist-Led Collaborative to Reduce Adverse Drug Events (ADEs) was co-sponsored by the AAHP, AHA and its hospital quality arm, ARbestHealth. We eventually named ourselves AHSPARC – the Arkansas Health-System Pharmacists ADE Reduction Collaborative.

By definition, an adverse drug event is “an injury resulting from the use of a drug.” Under this definition, the term ADE includes harm caused by the drug (adverse drug reactions and overdoses) and harm from the use of the drug (including dose reductions and discontinuations of drug therapy).

The collaborative, the first of its kind in Arkansas, saw health-system pharmacists take the lead role in identifying causes of and barriers to reducing ADEs in three drug classes in the hospital setting. Working closely with our colleagues – hospital leadership, physicians, nurses and quality/patient safety team members – we tackled ADEs associated with anticoagulants (specifically Warfarin), hypoglycemic agents and opioids, making some giant strides (while also taking some baby steps) in reducing these events throughout Arkansas hospitals.

Our nine-month collaborative results were dramatic, not only in the number of ADE reductions and discoveries made, but also in the development of collegial relationships among our hospital participants.

“Participating in the ADE collaborative has increased our relationships with other hospitals and improved the safety of our patients,” says Maggie Williams, Director of Pharmacy at White River Medical Center in Batesville. “We have seen a decrease in our Warfarin and hypoglycemic adverse events since we started the program. In addition, the relationships we have built through this program continue to foster more communication about other initiatives we are working on.”

The collaborative was built on a foundation of meeting three times face-to-face (January, June and October), with conference calls monthly between. In addition, participants found ourselves calling each other directly for answers to questions, ideas to share and details on lessons we had learned.

From the beginning, it was understood that this collaboration was built to share successes and barriers, questions and answers. Our goal was to work together to solve problems that no one hospital can solve alone. We developed processes, policies and procedures, order sets and protocols, educational materials, consistent methods of data collection, and even ways to coordinate processes through each hospital’s use of its electronic medical records.

Pam Brown and Nancy Godsey from the AHA were the greatest of partners in our effort! And we can’t forget Cindy Harris, who put all of the meetings, calls and details together. The AHA created an email distribution group for updates and sharing information. We also started a LinkedIn group for AHSPARC, which was designed for participating members to share and discuss any trending reports or latest news with the entire collaborative.

Participating hospitals agreed to collect baseline data for each ADE

measure identified by the collaborative and report data monthly. All data would be collected by AHA and reported in the aggregate. This helped us know how we were doing in meeting our goals.

what were the goals?Because the AHA was a part of

the American Hospital Association/Health Research and Educational Trust’s (HRET) Hospital Engagement Network (HEN), we matched our collaborative goals for the three targeted drug classes to those of the AHA/HRET HEN. The goal was to reduce adverse events for each drug class by at least 40 percent. We also wanted to develop a way to share patient safety improvement methods across the state.

It was important to the AHA and to those of us in the collaborative to share our discoveries with all Arkansas hospitals, regardless of HEN participation. In fact, several of our collaborative pharmacists began serving as mentors for hospital pharmacists in hospitals not participating in the collaborative. Our goal of spreading successes and reducing barriers was being met!

measures and end resultsWarfarin

We measured excessive anticoagulation with Warfarin. By the time we met at our last face-to-face in October, the collaborative had some remarkable numbers to report.

In January, only eight of our hospitals were collecting baseline data and reporting on ADE measures regarding Warfarin. By the end of the collaborative, 34 hospitals were reporting. The ADE rate for Warfarin dropped from 4.9 percent to 3.6 percent, a 25.5 percent reduction.

What does that mean for our patients? Because of changes made through collaborative processes, 181 ADEs were prevented, and related to this, Arkansas hospitals saved approximately $543,000 (estimated cost per ADE is $3,000).



Glycemic aGentsWe measured hypoglycemia in

inpatients receiving insulin or an oral glycemic agent.

At the beginning of our collaborative, only two hospitals were reporting on ADE measures regarding glycemic agents. By the end of the collaborative, 33 hospitals were reporting. The ADE rate for glycemic agents dropped from 6.3 percent to 6.2 percent, a 2 percent reduction, well shy of our goal. There is considerable improvement work to be done in this area. However, any improvement, even just the slightest, makes an impact on our patients.

Speaking of our patients, though the reduction rate was low, we still prevented 42 ADEs, and because of this hospitals saved $126,000 (again, estimated cost per ADE is $3,000).

opioidsWe measured oversedation caused

by opioids, excluding ED patients and opioid use for nausea or pruritus, by looking at naloxone administration.

When our journey began, no hospital participating in the collaborative was reporting data on ADE measures regarding opioids. By October, 34 hospitals were reporting. The ADE reduction rate for opioids was 48.2 percent, dropping from 0.8 percent to 0.4 percent. This exceeded our reduction goal!

And again, for our patients? Process improvements helped prevent 198 ADEs. Because of this, hospitals across the state saved $594,000 (estimated cost per ADE is $3,000).

“Sharing the collaborative’s findings and successes with our non-AHSPARC HEN hospitals made an impact on our state’s ADE reduction rates,” says Pam Brown, the AHA’s Vice President of Quality and Patient Safety. “We knew this was an area that needed focus, so we made it a priority for both the collaborative and the HEN. Hospitals that embraced the work served as mentors to others and shared their journey during the collaborative, so we had hospitals that had not yet worked on ADEs learn from those blazing the trail.”

startinG, and GroWinGThe first meeting in January 2014

almost didn’t happen. Icy roads across the state were a challenge we thought would prevent people from attending, and yet they came.

Hospital pharmacists, pharmacy residents and students, physicians, nurses, and others on quality teams met to discuss our purpose, plan the path going forward, and introduce the idea of pharmacists not only joining the effort to increase patient safety and reduce ADEs, but leading the way. It was decided that hospital pharmacists would guide not only pharmacy personnel, but also quality, medical and front-line nursing staff in a united approach to reducing ADEs.

What We learned early on: it’s an inter-disciplinary process

One thing learned early on from Matt Grissinger, one of our keynoting experts, was that a truly inter-disciplinary team is necessary when setting up your ADE reduction program. That group must include:• Chief medical officer;• Nurse executive;• Director of pharmacy;• Clinical information technology

specialist;• Medication safety officer/manager;• Risk management and quality

improvement staff;• At least 2 staff nurses from different

specialty areas;• At least 2 staff pharmacists (1

clinical and 1 from distribution); and• At least 1 active staff physician

who orders the type of drug class you’re targeting.Grissinger, a pharmacist himself, is

Director of Error Reporting Programs with the Institute for Safe Medication Practices (ISMP).

And so, we began. By the time our mid-course, face-to-face meeting came around, the weather had greatly improved, and we were beginning to gather hospital stories demonstrating lives saved due to our shared ADE process changes and lessons learned. Participants were again highly involved; breakout sessions targeting each drug category and data collection were spirited and stimulating. It was obvious that comfortable, collegial relationships were becoming the norm.

“Participation in the ADE collaborative has been invaluable to me and to the North Metro Medical Center,” says Paige Ballard, Director of Pharmacy. “The spirit of collaboration between hospitals has been so encouraging. The help from Pam and Nancy and those who supported them at the AHA has been wonderful. All of this has enabled our staff to assure the best care possible for our patients.”

At the June meeting, Dr. Steven Tremain, Physician Advisor for ADE Reduction with Cynosure Health, led us through several exercises to help us locate ADE data easily (believe it or not, it’s not easily found). His main rule: “You have to LOOK for it!”

Mehrdad Afsharimehr, Director of Pharmacy at the Medical Center of South Arkansas in El Dorado, says, “I believe the most important point we gained as a result of this collaborative is to do what Dr. Steve Tremain referred to as ‘Engineer Out the Problem.’ What this means is that every time we look to fix a faulty process and are tempted to turn to education as our first means of correction, we instead need to think again and correct the process by not allowing the error to occur at all.”

In our months together, we learned what the national Partnership for Patients tells us is true: Every hospital has a medication safety challenge. We have to make a commitment to reduce ADEs by:• Making improvements in harm

across the board; • Taking a strong leadership stance to

build a common vision and generate results; and

AgentADEs

PreventedCost

Savings

Warfarin 181 $543,000

Glycemics 42 $126,000

Opioids 198 $594,000


• Generating bold commitments from all hospital staff to get the job done.At our final meeting in October,

while celebrating our successes, we found that it really wasn’t to be our final meeting at all. So much good work had been done, and our strengthened relationships had made collaboration a verb instead of a noun...so we decided to embark upon another pharmacist-led collaborative for 2015 focusing on Antimicrobial Stewardship.

“The first AHA/AAHP collaborative provided an ideal networking opportunity to learn from pharmacists’, nurses’ and physicians’ struggles and successes,” says AAHP president Marsha Crader, PharmD. “Collaboratives such as this one are needed to ultimately improve patient care throughout all Arkansas hospitals, no matter how large or how small they are.”

We continue to work on ADEs in our hospitals and strengthen

the collaboration we have built. Participation may wax and wane as we all are very busy professionals with lots on our plates, but we will not stop our efforts to improve patient safety and the quality of care we provide. That my friends, is apparent! There are hands reaching out FOR help reciprocated by hands reaching out TO help. This is the power of

collaboration. And so we began again in February 2015, on another snowy winter day, to collaborate on Antimicrobial Stewardship. With the addition of the Arkansas Department of Health, the Arkansas Foundation for Medical Care and UAMS, our newest collaborative can only expand and improve. You’ll find information on this exciting project below.

new kid on tHe BloCk:arkansas’s antimicrobial stewardship Collaborative

What started last year as a simple affiliation between the Arkansas Association of Health-System Pharmacists (AAHP) and the Arkansas Hospital Association (AHA) developed into a complex, process-questioning, problem-solving, policymaking, safety collaborative.

The Pharmacist-Led Collaborative on Adverse Drug Events (ADEs) helped medical teams in hospitals all over the state drill down into why ADEs were occurring and what, for our patients’ sake, we could do to avoid them.

Now, it’s time for Chapter Two. As we closed the first collaborative, the

participants felt that so much progress had been made and such close working relationships had been built that we were not ready to be finished. There was almost unanimous agreement to continue on in the new year with a new focus...Antimicrobial Stewardship.

By Pamela Brown, RN, BSN, CPHQ, CPPS, Vice President of Quality and Patient Safety, Arkansas Hospital Association


Niki Carver, PharmD, CPPS is the Pharmacy Director at Arkansas Continued Care Hospital of Jonesboro. Dr. Carver previously served as the Assistant Director for Medication Safety at the University of Arkansas for Medical Sciences (UAMS) Medical Center and preceptor for the UAMS College of Pharmacy from 2005 to 2014. Her duties in this role included education and training for pharmacy staff, drug use evaluation, and other quality assurance and medication safety activities within the pharmacy department and the institution. Dr. Carver is a member of the Arkansas Association of Health-System Pharmacists (AAHP) and currently serves as the Chair of the AAHP Council for Programs and Education as well as a member of the AAHP Board. You may reach her at [email protected].

our goal was to work together to solve problems that no one hospital can solve alone. we developed processes, policies and procedures, order sets and protocols, educational materials, consistent methods of data collection, and even ways to coordinate processes through each hospital’s use of its electronic medical records.


Once again the AHA is partnering with AAHP, and the collaborative will be pharmacist-led. But for Chapter Two, we are adding new seats at the table: the Arkansas Department of Health (ADH), Arkansas Foundation for Medical Care (AFMC), University of Arkansas for Medical Sciences (UAMS) and the Centers for Disease Control and Prevention (CDC).

While we hear a great deal of discussion about “teamwork” and “cooperation” these days, there is something very real happening with this group behind the buzzwords. This project has greater significance than many of us realize. Lives are being lost because of superbugs and our inability to treat them. The only way to get control again is to reduce treatment with antibiotics so that bacteria don’t become resistant to our treatments. We hope to see this collaborative produce trendsetting, even revolutionary, results on behalf of our patients.

“Arkansas has had real and widespread problems with resistant bacteria for two decades, but we are only, in the last couple of years, really beginning to address the problem. A big aspect of the problem has been a lack of coordination among health providers and facilities,” says Dr. Gary Wheeler, MD, MPS, Medical Director,

Infectious Disease Branch, ADH. “This new effort is a result of joining private and public partnerships in setting our agenda to control this critical health problem. The AHA/pharmacist-led collaborative is one of the most significant first action steps to put our state on the right path forward.”

In setting his budget for fiscal year 2016, President Barack Obama identified antibiotic resistance as one of the most pressing health issues facing the world today. He nearly doubled the amount of funding requested for combating antibiotic resistance in the budget now under consideration.

In Arkansas, we recognize the breadth of the problem as well. Our first Antimicrobial Stewardship Program (ASP) collaborative meeting was held in February, one of the stormiest on record. Even with necessary weather-related cancellations from our southern counties, we had more than 70 people representing 28 unique hospitals in the room for our first face-to-face.

Dr. Wheeler gave us the State of the State regarding antibiotic resistance, and set us on our path to combat it. Our keynote speaker was Susan Davis, PharmD, Program Director of MAD-ID Research Network and Assistant Professor (clinical) from the Wayne State University Department

of Pharmacy Practice. She gave us insight into where we are, what we are fighting, and ideas of how to proceed.

It’s always eye-opening to hear actual from-the-trenches stories from our hospitals. We thank these four experts for setting the stage for our collaborative: Dr. J. Ryan Bariola, Associate Professor of Medicine (Infectious Disease), UAMS; Holly Maples, PharmD, Associate Professor of Pharmacy Practice, Arkansas Children’s Hospital; Mehrdad Afsharimehr, Director, Pharmacy, Medical Center of South Arkansas; and Sarah Cochran, PharmD, Pharmacist, Baxter Regional Medical Center.

Planning our path forward with round table discussions to address organizational assessment and planning, along with measurement criteria, wrapped up our first session.

There was so much energy in the room; it was remarkable. Because this is a current priority for so many organizations (AHA, AAHP, ADH, UAMS and AFMC), it makes sense to align efforts to support our hospitals in this work. The project ultimately will mean better outcomes for Arkansas patients, chipping away at antibiotic resistance and eventually eliminating conditions such as MRSA, CRE and C. difficile.

The CDC estimates that each year at least two million illnesses and 23,000 deaths are caused by antibiotic-resistant bacteria in the U.S. alone. Antibiotic resistance limits our ability to quickly and reliably treat bacterial infections, and can hamper our ability to perform modern medical procedures. In addition, resistant infections account for $20 to $35 billion in excess direct healthcare costs and up to $35 billion in lost productivity due to hospitalizations and sick days each year.

Our goal with this collaborative? Bring down those illnesses and deaths in Arkansas. Save patients’ lives, and change the landscape so we can make our medicines effective once more.

For information on the collaborative, please give me a call. You may reach me at 501.224.7878 or [email protected].

“Arkansas has had real and widespread problems with resistant bacteria for two decades, but we are only, in the last couple of years, really beginning to address the problem. A big aspect of the problem has been a lack of coordination among health providers and facilities. this new effort is a result of joining private and public partnerships in setting our agenda to control this critical health problem. the AHA/pharmacist-led collaborative is one of the most significant first action steps to put our state on the right path forward.”


The first UAMS Patient- and Family-Centered Care Patient Experience Symposium was held to share lessons learned on how to create partnerships between patients, their families and caregivers to improve care.

“Every employee at UAMS (and every hospital), whether clinical or not, has the responsibility to be a caregiver in some form or fashion,” says Julie Moretz, UAMS Associate Vice Chancellor for Patient- and Family-Centered Care. “We are all responsible for taking care of our patients and their families or supporting those who do.”

She stresses that inter-professional practice and teamwork are clear-cut ways to improve communication within hospital teams and with patients. “The symposium was designed to challenge us all to identify our personal roles and how we are held accountable for improving the patient experience,” she says.

Pam Brown, Vice President of Quality and Patient Safety for the Arkansas Hospital Association (AHA), attended the symposium and stresses the continued importance of hospital growth in the area of patient- and family-centered care. “As we focus on patient outcomes both nationally and at the local hospital level, our goal is providing the best care possible in the hospital setting,” she says. “We are seeing a more focused approach to patient- and

family-centered care as an outgrowth of our work in quality improvement and heightened patient outcomes.”

“Having these forums is important as we work together toward patient- and family-centered care,” Brown says. “Getting together with a common focus helps us improve and get there faster.”

Moretz stresses the importance of teamwork in patient care. “The symposium specifically spoke to front-line staff in all disciplines, healthcare leaders, physicians, nurses and other clinicians, residents, and students as well as patient advisors, because we are all in this together – we ARE the patient experience.”

symposium Focuseson the patient experience

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Shawnetta Duncan, RNDirector of Nursing

Next step to SUCCESS forClinical Managers

12 months • 100% online or on ground • YOU decidewww.harding.edu/mba • 501-279-5789


A packed house of more than 200 physicians, nurses, staff and advisors from the University of Arkansas for Medical Sciences and Arkansas Children’s Hospital, along with numerous web participants from hospitals and sites across the state, were in attendance on January 27, when UAMS hosted “The Power of Partnerships: Driving the Patient Experience.”


The revised vaccination schedule from the CDC’s 2015 Advisory Committee on Immunization Practices (ACIP) recommends that adults 65 years or older receive two vaccines: Routine use of pneumococcal conjugate vaccine (PCV13, brand name Prevnar 13®) for immunocompromised adults, and the pneumococcal polysaccharide vaccine (PPSV23, brand name Pneumovax®). The two vaccines work in different ways; receiving both offers broader protection.

Pneumococcal infection – Streptococcus pneumoniae – causes the deaths of as many as 4,000 Americans annually. Influenza and pneumonia combined were the eighth leading cause of death in the United States in 2012.1

Older adults have an increased risk of life-threatening infection from these bacteria. The incidence of invasive disease in adults 65 years or older is nearly 10 times higher than in adults ages 18-34. About a third of the 40,000 cases of invasive pneumococcal disease in the United States each year occur in older adults.

Pneumococcal disease is a serious health threat. Bacterial infections are the leading cause of serious illness, and many strains of Streptococcus pneumoniae are resistant to antibiotics. Complications from pneumococcal disease can last a lifetime and include heart problems, hearing loss, seizures, blindness and paralysis.

Although there has been a slight increase in adult vaccination rates in recent years, higher vaccination rates are still needed. Immunization rates, historically low among adults, vary between types of vaccines and, even more, between racial and ethnic groups.

Both pneumonia vaccines are safe and effective. The Community-Acquired Pneumonia Immunization Trial in Adults (CAPITA), a randomized controlled trial, demonstrated that PCV13 was 75 percent effective at preventing vaccine-type invasive pneumococcal disease (IPD), and 45 percent effective in preventing vaccine-type nonbacteremic pneumonia (NBP) in adults 65 years or older.2 When this data was presented to ACIP at its

June 2014 meeting, members voted to recommend routine PCV13 vaccination for adults 65 years or older.

Coinciding with the new recom-mendation, as of February 2, 2015, Medicare covers an initial pneumococcal vaccine for beneficiaries who have never received a pneumococcal vaccine, and a different second pneumococcal vaccine one year after the first vaccine. Retail cost of PPSV23 is about $80; PCV13 is about $170. Medicare beneficiaries can receive both vaccines at no cost, from any provider that accepts Medicare, under their Part B benefit.

when to vaccinateThe timing of when a patient

receives pneumonia vaccines is crucial because it can affect effectiveness. Pneumonia vaccines can be given at any time of the year.• Adults 65 years or older, who

have never received any type of pneumococcal vaccine, should receive PCV13 first, followed by PPSV23 six to 12 months later.

new recommendations forpneumococcal vaccinesPneumococcal disease causes more deaths annually in the United States than all other vaccine-preventable diseases combined. That’s why the Centers for Disease Control and Prevention (CDC) now recommends that older adults routinely receive two vaccines to protect them from pneumonia, sepsis and meningitis.

By Lynda Beth Milligan, MD, FAAFP, CPE, CHCQM, Vice President and Medical Director, AFMC


ImmunizationType Total White Black Hispanic Asian Other

Seasonal Influenza > 18 years3

42.2% 45.4% 35.6% 33.1% 43.6% 34.9%

Seasonal influenza Medicare claims4

53.52% 71.7% 55.33% 33.99% 56.11% N/A

Pneumococcal > 65 years5

59.9% 64% 46.1% 43.4% 41.3% 44.7%

immunization rates by immunization type, race, and ethnicity


• Adults 65 years or older who have already received PPSV23 should receive one dose of PCV13 at least one year after receiving PPSV23.

• If revaccination is needed, wait to revaccinate for at least five years after the last dose of PPSV23 is given, or six to 12 months after PCV13.

• Adults 65 or older, who received PPSV23 before age 65, will need a booster shot if it’s been more than five years since vaccination.It is even more important for all

providers (pharmacies and medical clinics) administering the vaccinations to communicate with the patient and the patient’s primary care provider about which vaccine is given. This information must be accurately documented in the patient’s medical record.

vaccinating younger adultsCertain younger adults are at

increased risk for pneumococcal disease. One or two doses of PPSV23, given five years apart, are recommended for adults 19 to 64 years of age who: • Have chronic illnesses such as lung,

heart, liver or kidney disease; asthma; diabetes or alcoholism;

• Have conditions that weaken the immune system (HIV/AIDS, cancer or damaged/absent spleen);

• Live in nursing homes or other long-term care facilities; or

• Smoke cigarettes.PCV13 is recommended for adults

19 and older with asplenia, sickle-cell disease, cerebrospinal fluid leaks, cochlear implants or conditions that cause weakening of the immune system.

A booster shot may be needed after five years. A second dose of PPSV23 is recommended for adults 19 to 64 years of age who have:• A damaged spleen or no spleen;• Nephritic syndrome;• Weakened immune system due to

medications such as chemotherapy or long-term steroids;

• Cancer, leukemia, lymphoma or multiple myeloma;

• A prior organ or bone marrow transplant;• HIV/AIDS; or• Sickle cell disease.

effective strategiesHealthcare providers can make

a significant impact in reducing the morbidity of pneumococcal disease among adults. To increase immunization rates, the National Vaccine Advisory Committee6 recommends that all practitioners:• Build an immunization needs assess-

ment into every clinical encounter;• Make a strong recommendation about

needed vaccine(s);• Administer vaccine(s) or refer the patient

to another provider for immunization;• Stay current on vaccine

recommendations, educate patients about them and send patient reminders;

• Implement changes in clinical care to incorporate routine vaccine assessment; and

• Learn how to access immunization information systems (IIS) and document vaccines in the IIS.

Dr. Milligan is Vice President and Corporate Medical Director with the Arkansas Foundation for Medical Care.

REfEREnCES:1C1Xu JQ, Kochanek KD, Murphy SL, Arias E (2014).

Mortality in the U.S., 2012. NCHS Data Brief no.168.2Bonten M, Bolkenbaas M, Huijts S, et al. Community

acquired pneumonia immunization trial in adults. Program and abstracts of the 9th International Symposium on Pneumococci and Pneumococcal Diseases; (2014) Hyderabad, India. Abstract 0-015.

3CDC (2014) Flu vaccination coverage in the U.S., 2013-14 influenza season.

4CDC (2014) Interactive mapping tool: Live-tracking flu vaccinations of Medicare beneficiaries.

5Williams WW, Lu PJ, O’Halloran A, Bridges CB, et al. (2014) Noninfluenza vaccination coverage among adults-U.S., 2012. Morbidity and Mortality Weekly Report. 63(5), 95-102.

6National Vaccine Advisory Committee (2014) Recommendations from the NVAC: Standards for Adult Immunization Practice. Public Health Reports, 129, 118.

What do they all have in common?

Diane, Age 50 Heart Disease

Miguel, Age 55 Diabetes

Lily, Age 65

David, Age 30 Asthma

Patricia, Age 41 Lymphoma

Everyone 65 and older and all adults with certain health conditions are at risk.

Learn more at: adultvaccination.org/pneumococcal

Carl, Age 37HIV

Getting vaccinated is the safest, most effective way to protect yourself.

Pneumococcal disease can cause pneumonia, meningitis, or bloodstream infection (sepsis), which can lead to severe complications, hospitalizations, or death.

PharmacyMedical Office

Ask your healthcare provider about pneumococcal vaccination today.

Bill, Age 28 Smoker

They are all at increased risk for an infection called pneumococcal disease.

Nearly one million people get pneumococcal pneumonia in the US every year and 5 to 7 percent of them die.

Pneumococcal meningitis and bloodstream infection are less common, but more deadly.

One in every four to five people over the age of 65 who get it will die.


1: Berrington de Gonzalez, A., et al., Projected cancer risks from computed tomographic scans performed in the United States in 2007. Arch Intern Med. 2009. 169(22): p. 2071-7.

THIS MATERIAL WAS PREPARED BY THE ARKANSAS FOUNDATION FOR MEDICAL CARE INC. (AFMC) UNDER CONTRACT WITH THE ARKANSAS DEPARTMENT OF HUMAN SERVICES, DIVISION OF MEDICAL SERVICES. THE CONTENTS PRESENTED DO NOT NECESSARILY REFLECT ARKANSAS DHS POLICY. THE ARKANSAS DEPARTMENT OF HUMAN SERVICES IS IN COMPLIANCE WITH TITLES VI AND VII OF THE CIVIL RIGHTS ACT. MP2-AMS.CTED.AD,2-6/14

LET’S ENSURE YOURPATIENTS AVOID UNNECESSARY RADIATION. The Arkansas Foundation for Medical Careand the Arkansas Departmentof Human Services are working to helpreduce unnecessary CT imaging tests.

Visit afmc.org/CT for more information.

Overuse of radiationfrom computed tomography (CT)

is projected to contribute to 29,000 future cases of cancer

in the United States.1

29,000


“HEALTHCARE IN ARKANSAS: BRIDGING GAPS AND IMPROVING OUTCOMES”

June 23, 2015 | Embassy Suites Hotel, Little Rock | 8:30 a.m. - 3 p.m.5.5 hours pending from the National Association for Healthcare Quality

2015 Governor’s Quality Award Healthcare Seminar

www.arkansas-quality.org

www.arkhospitals.org

Presenting Sponsors

Overall Sponsor

www.americandatanetwork.com

Cost is $50 and includes lunch. To register go to www.arkansas-quality.org. For more information, contact Sue Weatter at 501-372-2222 or [email protected].

8:30 – 8:45 a.m. Welcome8:45 – 10:15 a.m. “Mosaic Life Care: A New Model in Health Care” Martha Davis, MSM, FABC Mosaic Life Care, St. Joseph Missouri 2009 Baldrige National Quality Award Recipient With a mission to improve the health of individuals and communities located in the region and provide the right care in the right place at the right cost, Mosaic Life Care—formerly known as Heartland Health—is transforming itself to more fully meet the health, wellness and well-being needs of the populations it serves. Hear their best practices in improving quality and the care experience through improved care management, provider and clinical staff engagement, and enhanced employer partnerships.10:15 – 10:30 a.m. Break10:30 – 11 a.m. “The State of Healthcare in Arkansas” Nathaniel Smith, MD, MPH DirectorandStateHealthOfficer Arkansas Department of Health11 a.m. – 12 p.m. “Bridging Gaps Between Rural and Urban Healthcare” Arkansas Foundation for Medical Care Arkansas Healthcare Association Arkansas Hospital Association Community Health Centers of Arkansas, Inc.12 – 1 p.m. Lunch1 – 3 p.m. “Using Data to Improve Performance and Drive Accountability” Kay Kendall, ConsultantIn a data-rich, information-poor healthcare environment, are meaningful metricsidentifiedtodriveimprovementinyourorganization?Doyoupracticeeffectivemanagementofpatientdataforbetteroutcomes?Kendallwillofferpractical approaches to identify the right measures that drive improvement, provide data analysis methodologies to identify gaps and strengths and show howtogetdatatotellthestorythroughvisualizationtechniques.

Nathaniel Smith, MD, MPH, is a member of the Governor’s cabinet and serves as Director and State Health Officer of theArkansas Department of Health. In this position, he provides senior scientific andexecutive leadership for the agency with over 5000 personnel and a budget of over

400 million dollars delivering services throughout the state in over 94 different locations. Dr. Smith has a strong commitment to the mission of ADH, “To protect and improve the health and well-being of all Arkansans.”

Kay Kendall, CEO, Baldrige Coach, has spent more than 20 years as a quality executive leading large-scale change initiatives across diverse industries including aerospace and pharmaceuticals. She completed a five-year assignment asa Six Sigma Master Black Belt. She also

has extensive experience using the Baldrige Criteria, Lean, Balanced Scorecards, Hoshin Kanri, and benchmarking to deliver results. She currently works with many clients in the health care sector on their improvement journeys.

Martha Davis, MSM, FABC, leads Heartland Health/Mosaic Life Care’s Institute, which wasestablishedtosharetheorganization’sjourney to transform into a consumer-centric, accountable care organization.Since 1989, Martha has been extensively

involved in leadership and talent selection, development and performance management at Heartland Health. During the past three years, she has been supporting the organization’swork to transform the patient and caregiver experience.

Featured Speakers

GQAHealthcareSeminar2015AdForAHApub_8.3125inx10.625in.indd 1 2/20/15 4:07 PM


protectionAgainst measles

Help for Hospitals, Help for arkansans

By Jennifer Dillaha, MD, Director of Immunizations, Arkansas Department of Health

meAsles. In years past, the thought of contracting measles put concern, even fear, into U.S. families. Measles is the most contagious disease known to humans, and it causes very serious illness. For example, measles causes acute encephalitis, which often leads to permanent brain damage; encephalitis occurs in 1 per 1,000 children with the disease. Between 1 and 3 children out of every 1,000 who get the measles may die.

puBliC HeAltH

feature


Since the measles, mumps, rubella (MMR) vaccine was introduced in 1971, the incidence of measles in the U.S. has plummeted, and measles was declared eliminated in 2000. Two generations have now been immunized against this infectious disease, and as a result many people have never seen or experienced a case of the measles. Therefore, most parents of young children haven’t witnessed the severe complications measles can bring. For that reason, awareness of the serious nature of measles has dwindled.

Fear of vaccinations;no link to Autism Found

At the same time, fear of potential harm from the MMR vaccine itself has become widespread. Consequently, some families have failed to have their children vaccinated against the measles. Much of the misinformation about the MMR vaccine claims the vaccine is linked to a rise in autism. On the contrary, there have been

numerous, well-designed scientific studies

investigating any possible link between

the vaccine and autism, and none has been found.

Nevertheless, some families are opting out of vaccination and putting their children at risk for contracting the serious, sometimes deadly, measles virus.

There has been a marked increase in measles cases around the U.S. in recent years. The annual number of people reported to have measles has ranged from a low of 37 in 2004 to a high of 644 in 2014.

Already in 2015 between January 1 and February 20, 154 people in 17 states were reported as having measles. Most of those cases are part of a large outbreak that originated in Disneyland in California involving 133 people in 7 states. There are additional, unrelated outbreaks in Illinois and Nevada. So far this year no measles cases have reached Arkansas. The last year a case of the measles was reported in Arkansas was 2012.

In addition to the current outbreaks in the U.S., there have been large outbreaks in recent years in other parts of the world, including the Philippines, as well as Eastern and Western Europe. Germany, Italy and France have been particularly hard hit.

For that reason, measles continues to be brought into our country when unvaccinated U.S. residents return from travels to other nations where they acquired the infection.

lowest immunizationrates in nation

The major concern we have in Arkansas is that our childhood immunization rates are low. According to the 2013 National Immunization Survey (the latest year for which data is available), Arkansas ranked last for the combined immunization series for children aged 19-35 months. That is, we ranked 51st among the 50 states and District of Columbia. With regard to the MMR vaccine specifically, Arkansas ranked 49th for 19-25 month-olds.

The CDC Advisory Committee on Immunization Practices recommends that children receive their first MMR vaccine at 12-15 months and a second dose at age 4-6 years. Arkansas requires that children attending daycare have a single dose and children attending kindergarten have the booster. However, only 86.5 percent of Arkansas kindergarteners have met this requirement, and this number is considered unsafely low according to accepted immunological standards.

Students attending grades 1-12 are also required to have two doses of the MMR vaccine. The MMR vaccine is required for college students as well.

In Arkansas, parents may refuse to have their children vaccinated, seeking philosophical or religious exemptions. There are also occasional, rare medical exemptions. The number of exemptions in Arkansas continues to increase every year. But combining all of these exemptions together cannot explain the tremendously low rate of MMR vaccination in Arkansas. Some

say there are just too few convenient locations for parents to get their children immunized.

Of course, each Arkansas county has an Arkansas Department of Health (ADH) unit where children may be immunized, and there are many other immunizing clinics around the state. However, there are more than a dozen counties where the Health Department is the only place offering vaccinations, and we realize not all people can easily make it to the town where their county health unit is located.

Why should parents, doctors and hospitals be so concerned about the uptick in the number of measles cases? “Measles is the most contagious disease out there,” says State Epidemiologist Dirk Haselow, MD, PhD. “It’s important that everyone born after 1956 be vaccinated. This is the key to keeping both childhood and adult cases of measles at bay. Adults younger than 58 who haven’t had their second MMR dose need to get one. And all of our children need to have their 12-month and pre-kindergarten vaccines. People don’t understand this is such a priority, and that measles is such a dangerous disease.”

Because of the state’s low immunization rates, the Arkansas Immunization Action Coalition is establishing a Task Force on Childhood Immunizations. Our goal is to bring all parties to the table to look at our low vaccination coverage, identify and address barriers, and problem-solve the identified issues. We must get this low vaccination rate up to protect our children, the most vulnerable among us.

With regard to measles, for our state’s population to be protected, we need to have greater than a 90 percent vaccination rate. Ninety-two to 94 percent is the estimated level needed to establish herd (general population) immunity.

How Hospital ersCan get immediate Help

Because of the increased incidence of measles in the U.S., many healthcare providers have increased



their index of suspicion when they evaluate patients presenting with a rash and fever.

There are several steps that hospital emergency departments can take to protect their patients from exposure when a patient with possible measles comes through the door. “First, we recommend that patients with suspected measles be quickly moved into a negative pressure room, if one is available. And we ask that the ER physician immediately call the Health Department,” Haselow says. “We are available to help ER docs 24/7.”

Consultation with the Arkansas Department of Health can help emergency physicians understand their testing options. The ADH Public Health Lab can expedite testing, using either a Polymerase Chain Reaction (PCR) test that can identify the presence of measles DNA, or a serologic test for measles antibodies, and get results within 2 to 3 hours once the sample

is received. “Sending samples to private labs can result in days lost and heightened spread of the disease. The sooner we know what we’re dealing with, the better we’ll know whether to ramp treatment up or down,” Dr. Haselow says.

Obtaining a travel and vaccination history can be very helpful. Of course, not every patient presenting with fever and rash will have measles. However, if a patient with measles is identified, it will be important for the hospital to quickly involve the Health Department, thus enabling ADH communicable disease nurses to begin tracing contacts as soon as possible.

“I can’t over-emphasize how infectious measles is,” Haselow says. “It can spread quickly by others simply breathing air with droplets from the infected person’s breath...and those droplets can hang around for a long time. Riding in an elevator, sitting in a waiting room, or standing in line where a contagious person has been is all it

takes to contract this disease. When it comes to measles, there’s never a case of over-concern.”

The ADH emergency line is available 24/7 to help assess patients and determine the right test for each particular case. That number is 501.661.2136.

Of course, Arkansas’s best defense against measles is strong vaccination coverage with the MMR vaccine. To get there we must address Arkansas’s low vaccination rates and move ourselves forward to a level of vaccination coverage where our youngest and most vulnerable are not placed in harm’s way.

Jennifer Dillaha, MD, is the Medical Director for Immunizations and Medical Advisor for Health Literacy and Communication for the Arkansas Department of Health. You may reach her at [email protected].

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NewsstAt

arkansas’s Healthcare Protocol Manual for Sexual Assault has been updated and is now available from the arkansas Commission on Child abuse, rape and domestic violence. this guide for healthcare professionals who respond to victims of sexual assault will assist hospitals in developing victim-centered care sensitive to the needs of sexual assault patients. for a copy or more information, contact Michelle Cline, rape Project Coordinator, [email protected] or 501.661.7975, or go to www.accardv.uams.edu.

the u.s. department of Health & Human services is investing in enhancement of domestic preparedness efforts for ebola by awarding a total of $194,500,000 to states and other grantees for ebola healthcare system preparedness and response, and for the development of a regional ebola treatment strategy. arkansas’s share of the grant funding is $1,030,732.

don’t miss the 2015 Hospital executive leadership Conference to be held June 17-19 in nashville, tennessee. this annual event is sponsored by the arkansas Hospital education & research trust and will feature cutting edge information for hospital leaders. for more information, contact lyndsey dumas, aHa vice President of education, 501.224.7878.

neWs

a new agency for Healthcare research & Quality (aHrQ) report features hospitals’ use of lean process redesign to enhance the quality and efficiency of various healthcare processes. the report, Improving Care Delivery Through Lean: Implementation Case Studies, includes six in-depth case studies that explain how lean principles were applied in 13 distinct implementation projects. download your copy of the aHrQ report at: http://www.ahrq.gov/professionals/systems/system/systemdesign/leancasestudies/index.html.

the “diagnosis Coding: using the iCd-10-CM” Web-Based training Course (WBt) is now available from CMs. this WBt is designed to provide education on the International Classification of Diseases, 10th Edition, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS). It includes ICD-10-CM/PCS implementation guidance, information on the new ICD-10-CM classification system, and coding examples. Continuing education credits are available to learners who successfully complete this course. to access the WBt, go to www.cms.gov/MLNproducts, scroll to related links at the bottom of the web page, and click on Web-Based training Courses.

oral arguments in King v. Burwell were heard by the supreme Court of the united states on March 4. the case asks whether subsidies are available for patients in the 34 states whose health-insurance exchanges are federally facilitated. a complete transcript of the oral arguments is available at http://www.supremecourt.gov/oral_arguments/argument_transcript.aspx (case 14-114). a decision is expected in June.


neWs

Since January 1, Arkansas healthcare providers have seen a number of patients paying their co-pays using MyIndyCard. Patients with the MyIndyCard are enrollees in the Arkansas Health Care Independence Program (also known as the Private Option) who have health insurance coverage with the one of the following plans:• QualChoice Life and Health Silver;• AmBetter Balanced Care 2;• QualChoice of Arkansas Classic Silver;• Arkansas BlueCross and BlueShield

Silver 3500; or• Arkansas BlueCross and BlueShield

2000, Multi-State.The MyIndyCard is part of the newly

created health independence accounts (HIAs) for Arkansas Health Care Independence Program enrollees. In order to use MyIndyCard, an enrollee must make a monthly contribution of $5, $10 or $15, depending on their income. As long as the enrollee is current with their monthly HIA contributions, the MyIndyCard can be used like a credit card to pay co-payments.

Covered co-pays are only for medical services such as office visits, prescription drugs, inpatient hospital stays, lab tests, X-rays and physical therapy, as long as

the provider is in the patient’s health insurance network. There is no limit on the number of co-pays covered per month if the card is in good standing. Co-pays for emergency room visits and dental and vision exams are not covered.

Only Arkansas Health Care Independence Program enrollees with incomes between 100 and 138 percent of the federal poverty level (FPL) are required to pay co-payments. So, these are the individuals who will take part in the MyIndyCard program. The insurance card will not indicate that the patient has a MyIndyCard. However, if the patient is enrolled in one of the plans listed above and the insurance card shows required co-payments, then the patient is eligible for a MyIndyCard.

Each eligible individual will be issued their own card. The MyIndyCard cannot be used to cover co-pays for anyone

other than the person whose name is on the card.

Providers should process MyIndyCard in the same way they would a regular health savings account or flexible spending account card. There is no PIN associated with the MyIndyCard; it must be swiped or keyed in as a credit card. If the provider does not accept credit cards, then the patient must pay the co-pay on their own and submit a receipt to DataPath Administrative Services, the HIA administrator, for reimbursement.

If an enrollee’s MyIndyCard is declined, the enrollee must cover the co-pay on his/her own. Providers will not be reimbursed if they choose to see patients who cannot cover their co-pay. If there are questions about a card’s status, or if there is a dispute over whether a card should have been declined, call 1.866.207.3028 to speak with a representative between 8 a.m. and 5 p.m. Monday through Friday.

A webinar about the MyIndyCard and HIA program, as well as answers to frequently asked questions, is available at www.myindycard.org/provider, or providers can call the DataPath customer service center at 1.866.207.3028.

myindyCard rollout:tips for HospitalsBy John Carter, Manager, DHS Division of Medical Services

• Ensure you are in the enrollee’s insurance network.• Collect co-pays when the patient arrives or ensure the card is in good

standing before seeing the patient.• Process MyIndyCard as a credit card.

For more information:www.myindycard.org1.866.207.3028

myindyCard tips for providers:



Ceo proFile:kristy estrem

Mercy Hospital Berryville

neWs

“I graduated from college with a bachelor’s degree in business and was hired as Director of Marketing for Magic Springs Entertainment Park in Hot Springs,” Estrem says. “Essentially, I started my career selling fun. I was tasked with raising the park’s attendance levels, so I developed a company picnic program.”

Targeting the largest employer in town, St. Joseph’s Hospital, Estrem worked very hard to sell the employee picnic committee on the idea of boosting morale by hosting a family picnic at the park. The committee finally agreed, and it was a huge success with almost 2,000 in attendance. The following year, Estrem received a call from Ray Pelton, VP,

Human Resources at St. Joseph’s. She assumed he was calling to talk about another picnic, but instead he asked if she was interested in coming to work for the hospital. “I was shocked,” Estrem recalled. “I later interviewed with the hospital CEO, Randall Fale, and told him I didn’t know anything about healthcare. He assured me that when you find the right person who has what it takes on the inside, the details of the job will take care of themselves. And that’s how healthcare chose me. I went from having a job of selling fun, to being part of a ministry of health and healing. I’ve been with Mercy 24 years and feel truly blessed. Coming to work every day to a building with a cross on the roof is a huge responsibility, and I

am humbled to be part of this ministry started by the Sisters of Mercy in Dublin, Ireland.”

Estrem began in the marketing department, then was given the management role in the hospital print shop. From there, she moved into other management roles including senior adult services and later, cardiac rehab. Her business background gave her a management approach that was very effective in the healthcare setting.

In 1995, Estrem had an opportunity to move back to her hometown of Berryville as senior vice president at Carroll Regional Medical Center. There she was able to gain valuable experience in all operations of the hospital.

“Growing up in Berryville, I never expected to return here for my career and to raise my family,” she smiles. “My parents, now in their 90s, still live on our family farm where they once raised Charolais cattle. I live just a short distance from them.”

The Berryville hospital board was seeking partnership with a larger health system in Northwest Arkansas. Having just come from the Mercy system at St. Joseph’s, Kristy contacted her former CEO, who then contacted Ron Ashworth, head of the Mercy system headquartered in St. Louis; they were interested in making a presentation to the board since they already had a clinic in Berryville. “And the rest is history! Our vision and mission statements aligned perfectly, and the Carroll Regional Board voted unanimously to partner with Mercy in Springfield,” she says. “The

Ceos in Action: kristy estrem“Blessed that Healthcare Chose Me!”Kristy Estrem, CEO of Mercy Hospital Berryville and longstanding member of the Arkansas Hospital Association board of directors, didn’t enter healthcare through the usual doors and pathways.


Each day begins with a leadership team huddle led by Kristy Estrem (left).


• SomEthIng about mE that would SurprISE you even though i wear suits and high heels many

days, i’m a farm girl. several years ago, a mother cow was having difficulty having her baby. I checked on her at lunch and could see she was in trouble, so i called my neighbor, Mr. Barrows, and together we pulled the calf. Within the hour, i had showered, changed clothes and was back at my office working at my desk!

• SupErpowEr I’d lIkE to havEi’d like to be able to say anything i felt like saying in a situation just to get a reaction, and then wave a magic wand so no one could remember what i said! i always try to think of funny or witty things to say, especially in tense situations.

• what I’d do If I wErEn’t a CEoi would love to be a full time volunteer and work with the poor and vulnerable, both with children and also at pet shelters. i have a big heart for animals.

• what makES mE laughHearing other people laugh usually cracks me up.

• SomEthIng pEoplE don’t know about mEI twirled fire my senior year in high school, and our football team got a penalty because the game was delayed waiting for the stadium lights to come back on after my performance. and i can sing the lyrics to almost any 70s song!

• my lIfE phIloSophyray Pelton from st. Joseph’s taught it to me: Whatever principles you live by, add one more: “Have fun.” His advice has served me well! randall fale, from st. Joseph’s once told me, “Leaders are like conductors, and those you lead are in the orchestra. Keep your eyes focused on them as they look to you for direction and tempo. and most importantly, when each song is completed, move to the side so they can enjoy the standing ovation.” that advice has also served me well.

• THEmoSt InfluEntIal pErSon In my lIfE

Besides both of my parents, sister Mary roland, rsM, a religious sister of Mercy who was my personal friend and my son’s godmother prayed for me and my entire family daily until the day she passed away last november. i will be eternally grateful for the influence she has had and will continue to have on my life.

Ceo proFile:kristy estrem

Mercy Hospital Berryville


partnership was finalized in 1997, and I was once again working for Mercy. From a tenure standpoint, it was as if I had never left.”

In March 2006, she was offered the role of president. “I plan to retire with the Mercy system,” she says. “The healthcare ministry and my roles in the system have been a good fit. Mercy has been good to me and my family through the years by supporting and encouraging me to advance my education in obtaining a master’s degree while offering me many other opportunities to advance my skills as a leader. In my opinion, the hospital board in 1995 couldn’t have been more wise and visionary in selecting to partner with Mercy. They understood the need for maintaining healthcare in this community well into the future. Mercy has been a solid, committed, long-term partner to this county and surrounding region.”

Investing over $16.2 million dollars in the Berryville facility to renovate, upgrade and expand the hospital and its service lines, Mercy’s philosophy is to talk to the community and identify needs through community roundtables, and then move forward from there. “The community is the real winner,” she says. “To have this type of care, access to physicians, and advanced technology and telemedicine in our back yard is wonderful!”

Estrem serves on the Legislative Committee of the AHA board and takes a leading role in the Health Executives’ Forum. “My job is to be a catalyst in helping AHA have a unified voice, and helping people spread the word about

our hospitals’ needs.”She’s honored to have been

on the board while the Arkansas Private Option has been offered, accepted, used as a national model, and now extended into 2016 while the new legislative task force seeks opportunities to refine and continue it. “There is nothing more rewarding than to be a part of the meetings where the APO is discussed and hear how we have affected the nation.”

The APO has changed Mercy Hospital Berryville and its patients in huge ways. “It has meant a $450,000-500,000 annual uptick for our bottom line and has brought new patients who haven’t had access to healthcare insurance before. We now have data for a full year and can show a 33.3 percent decrease in the number of self-pay patients. We’re seeing a great increase in the number of insured and Medicaid patients. Right across the border in Cassville, Missouri, where Medicaid expansion has not occurred, they report only a 5.9 percent decrease in self-pay patients utilizing the federal insurance exchange. That’s the difference Arkansas’s Private Option has meant for hospitals and the dramatic decrease in uncompensated care.”

Estrem’s business background led her to firm roots in process improvement. “Some of the things I enjoy most about my job are our Lean processes, designed to improve patient care and value for our patients. As in all Lean practices, we look to those closest to the work to give the best answers for

process improvement. That means every employee and staff member is constantly on the lookout for areas we can improve.”

Each day at 8:45 a.m., Estrem huddles for ten minutes or less with her entire leadership team. “We discuss in real time what’s happening in the hospital that day, talk about any safety or quality issues which may have arisen over the past 24 hours, identify any barriers which may prevent us from running smoothly throughout the day, look at financial indicators and patient satisfaction scores, along with checking in on what we may be celebrating within the departments – such as did a department reach a specific goal, did a co-worker pass a test, have a birthday, etc. Being a spiritual organization, we also bring prayer requests to the group. We keep track of our processes on white boards right out where everyone can see them. Essentially, each meeting focuses on what’s happening in the building that day and what happened over the past 24 hours. Within ten minutes, our entire leadership team is on the same page. They in turn have huddles in their respective departments. And if issues are identified in their department, the leader can bring it to the administrative huddle the next morning. So information can flow up and down through the entire organization all within a 24-hour period. We are able to deal with issues in real time.”

Estrem states the Lean process has changed the way she leads the organization and also the way the leadership team members lead their respective departments. All but just a few remaining departments are conducting daily huddles. “Essentially, our Lean approach allows those who are closest to the process to have input and develop solutions for improvement to those processes. Our co-workers have the ability to own process changes, and they are empowered to work with other departments in identifying the best

“it takes a village to run a hospital, and we couldn’t do it without the assistance of our hospital auxiliary, foundation, co-workers, physicians, and community donors who donate the gift of time and/or financial resources to help us meet the growing needs of the community. i’m blessed to call this my home.”


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solutions. In essence, the organizational chart is turned upside down, where co-workers are empowered to make process changes, and leaders are assigned to remove any barriers the workers may experience as they are working with other co-workers or departments in identifying solutions.”

Estrem is proud that Mercy Hospital Berryville, as a Critical Access Hospital, continues to achieve Joint Commission accreditation, and its lab is accredited by the College of American Pathology. “Our radiation, mammography and ultrasound units are also accredited. We take part in the Mercy and ArSaves tele-stroke system, offering patients who present to the ER with stroke symptoms the ability to have an interventional neurologist work with the Emergency physician to determine the appropriate care plan. With stroke, time is of the essence, so technology allows this expertise to be available in the rural parts of the state.” Mercy Berryville also participates in the statewide trauma system network.

Working as part of the Hospital Engagement Network, Mercy Hospital Berryville is diligent in reporting data and is constantly upgrading quality performance as national protocols change.

But dearest to her heart, Estrem says, are the many volunteers and supporters for the hospital. “It takes a village to run a hospital, and we couldn’t do it without the assistance of our hospital auxiliary, foundation, co-workers, physicians, and community donors who donate the gift of time and/or financial resources to help us meet the growing needs of the community,” she says. “There are so many good people who live in this community, and so much good is being done every day. I’m blessed to call this my home.”


neWs

Hospital-based infusion billing is one of the most complex areas of billing and one of the most difficult areas in which to build a variance system model. Accommodating billing requirements for multiple payers creates a significant strain on resources in a hospital’s billing department. In establishing control measures, a financial manager should consider these key indicators to ensure proper payments are collected under the terms of the hospital’s managed care agreements:

1. Billing Correct Units for Drugs – What do Payers Really Want to See? For drug units or descriptions, payers can differ as to the information required on a claim form. Some payers require drug units to be billed in Healthcare Common Procedure Coding System (HCPCS) units with no additional description. However, when billing unclassified drugs, claims need National Drug Codes, units of measure and quantity added, which may or may not be the same as the HCPCS units. Yet Medicaid, as well as managed Medicaid plans, requires this information whether or not the drugs are considered unclassified.

2. Billing for Waste – To Bill or Not to Bill, and How? CMS encourages the administration of drugs and biologicals in the most efficient manner, so providers should avoid

waste whenever possible. However, according to Chapter 17 of the Medicare processing manual, CMS recognizes instances when this cannot be avoided, particularly with single dose vials of medication. In these cases, Medicare reimburses providers up to the total billable units on the vial size used. Depending on the local contractor, this may require using a “JW” modifier to distinguish the discarded portion of the vial from the administered portion. Still, some contractors do not require this modifier and list the entire dose administered and discarded on one line. Additionally, the JW modifier is never used on CAP (Competitive Acquisition Program) drugs. Regardless of the waste reporting method, the exact amount discarded versus administered should always be clearly documented in the patient’s medical record.

3. Billing Services When the Patient

is in a SNF. When a patient resides in a SNF (Skilled Nursing Facility) but is transported to a hospital-based clinic, some services can be excluded from the SNF consolidated payment. If so, these services should be separately payable to the hospital or outpatient clinic. For example, some chemotherapy drugs are specifically excluded from the SNF payment and are separately payable if the claim is submitted with the appropriate codes.

4. Infusion Administration Coding – More than Choosing the Correct Initial Code. The American Medical Association’s (AMA) CPT* guidelines differ in many ways from CMS’s

guidelines. For example, CMS requires an initial code per episode of care while the AMA’s CPT guidelines require an initial code per each date of service. This is crucial, especially in instances of billing emergency department and observation claims that span multiple dates of service. Moreover, Medicare Advantage plans may or may not follow CMS’s guidelines, and commercial payers may use either set of guidelines. Further, there are even instances when it is appropriate to bill more than one initial code, such as when there are two vascular access sites. In this case, it is appropriate to bill two initial codes. Another instance occurs when there are multiple encounters on the same day. In either case, modifier 59 is required on one of the initial codes to avoid triggering edits within the billing system.

5. Pursuing Reimbursement on Bundled Denials. A hospital’s reimbursement department should watch for denials on infusion charges provided in the ER. Payers consistently underpay claims for ER infusion services when they are not incidental to an imaging procedure. However, providers should be fully paid for hydration, pain management medication or other types of infused treatment protocols. Ensuring modifier 59 is used when billing will identify the infusion code as separate and distinct, and payable under the terms of the contract or rate schedule.

These are a few of the complex rules to be considered when modeling infusion claims in a billing system or

spotlight:Five things to know About infusion BillingBy Melissa Blank-Harbert, Bottom Line Systems, Inc.


variance program. Business office administrators are constantly challenged to stay current on billing and coding rules, and must do so while managing the rest of the revenue cycle.

Infusion finance managers gain significant advantages by retaining an associate business partner well-versed on the complexities of the infusion arena. Online resources such as subscription service RevenueCyclePro.com** and Centers for Medicare & Medicaid Services (www.cms.gov), as well as industry trade publications, also can assist an organization in staying up-to-date on the countless issues surrounding infusion billing and payment.

Bottom Line Systems, Inc. is an endorsed vendor of AHA Services, Inc. and provides services at a discount to AHA member hospitals. For information, contact Tina Creel at AHA Services, Inc., 501.224.7878 or [email protected].

Melissa Blank-Harbert is Vice President of Infusion Services for Bottom Line Systems, Inc. She has over 20 years’ experience in the hospital-based infusion and home infusion field, which includes DME, home health and hospice. Ms. Blank-Harbert can be reached at [email protected]; 859.426.3329.

*Current Procedural Terminology (CPT) is copyright ©2012 American Medical Association (AMA). All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

**RevenueCyclePro.com copyright ©2015 Optum360. RevenueCyclePro.com is an online, web-based subscription service that provides assistance in analyzing problems, resolving claim rejections, reviewing medical necessity issues and appealing rejection decisions, and is a wholly separate entity, unaffiliated with the author and/or the author’s employer. Mention of this service was provided for informational purposes only and no funding has been provided for inclusion in this article.

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By Stuart Jackson, Delanna Padilla and Hayden Shurgar, Wright, Lindsey & Jennings LLP

From a legal standpoint, how should hospitals, as employers, react to the challenge of employees contracting a serious (even deadly) disease while treating or interacting with patients exhibiting signs of a new pandemic or outbreak of serious illness?

patient safety planning and pandemic policy mesh

Your Patient Safety and Quality protocols will naturally put you into disease control mode. What you’re strategizing is the legal side of disease management among your staff.

The best strategy is to plan now for what you would do if an employee or group of employees started displaying symptoms of a serious, contagious illness or pandemic virus. Hold a planning meeting, and consider these questions:• What policies does your organization

already have in place that could impact your reaction to a pandemic?

• What would your organization do if a large part of your staff could not work due to illness? Would your normal attendance policies need to be modified if employees could not work for extended periods of time?

• How would your organization react if school closures affected your employees with school-aged children?

• Which employees are critical to your organization, and how would you replace them on a short-term basis? Is cross-training in preparation for a pandemic a viable option?

• How would management and staff

communicate with each other during a pandemic situation?

• Under what conditions would you consider limiting person-to-person contact within your facility? Would these limits extend to vendors, patient families and the public in general?

• On what occasions would you consider a partial or total shutdown of your organization?

• Are there any extraordinary steps to take regarding the cleanliness, safety or security of the hospital during a viral outbreak or pandemic situation?

• What happens if an employee displays symptoms or becomes ill at work? Who would respond, and what steps would be taken for those who were exposed to the employee?

• What happens if a patient arrives exhibiting symptoms? Who would respond, and what steps would be taken for those who were exposed to the patient?

• What if “healthy” employees refuse to come to work due to concerns about exposure at the hospital?

• How can you ensure employees have access to health information and appropriate healthcare, if needed, during a pandemic or quarantine?Your organization may already

have a pandemic plan in place dating to the 2009 H1N1 pandemic, so you may not have to reinvent the wheel. However, it would be wise during your planning meeting to modify that plan, keeping in mind any changes in patient safety and quality protocols in the last few years.

educate staff Before anoutbreak Hits

Your hospital policy can legally require sick employees to stay home. But it’s important that every member of your staff understands the rules

pandemics and legal policy:Planning ahead Prevents Panic

neWs

For the past year, the news media has been full of unsettling reports concerning contagious diseases, among them the Ebola virus and now, Measles. This worldwide focus on Ebola and Measles should encourage hospitals to revisit their pandemic/unexpected contagious disease awareness and associated legal planning.



and their implications before a serious outbreak occurs.

Educate your staff on the dangers of coming to work while sick. All employees must understand that if they are sick with any type of contagious illness, the hospital is within its legal rights to ask that person to go home, unless they need to be admitted to the hospital as a patient. Often, employees will be able to take some type of paid

leave or even unpaid leave, including Family and Medical Leave Act (FMLA) leave, if the illness amounts to a “serious health condition.”

In addition, be sure to educate your staff on basic Disease Management – not everyone who works in a hospital or a medical office is a doctor or a nurse. It is important for all employers to educate their employees about the symptoms of an illness, how an illness is spread and what protective steps to take. For good, reliable health information and visual tools showing how to slow the spread of any contagious illness, check the Center for Disease Control’s website at www.cdc.gov.

And, of course, all education programs must continually include emphasis on hand hygiene, attention to housekeeping protocols and other cleanliness issues. We realize this goes without saying.

the legalities: sick employees

Hospitals and medical clinics generally know what to do when a patient walks in with a highly contagious disease, but dealing with employees who might have come into contact with or who have contracted the disease presents another set of challenges. Big issues that arise include (a) the types of medical inquiries that can be made of employees under the Americans with Disabilities Act (ADA), and (b) maintaining confidentiality of employee (not just patient) health information.

The ADA limits the medical inquires you can make but does not disallow them entirely. Medical inquiries that are “job-related and consistent with business necessity” are permitted; so are certain medical inquiries during a pandemic that are based on objective evidence that an illness poses a “direct threat” to an infected employee or others.

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planning and education – not panic – are the best ways to address pandemic and/or contagious illness issues and their legal ramifications in the workplace.


The real dilemma is determining when one of those standards has been met. Fortunately, we have legal guidance from the Equal Employment Opportunity Commission (EEOC) on preparing for a pandemic at www.eeoc.gov/facts/pandemic_flu.html.

For instance, if you asked all employees who traveled abroad to undergo a medical screening for Ebola, regardless of which country they visited or the potential for exposure, you would be violating the ADA. However, if you found out that an employee came in direct contact with an Ebola patient, a screening and other precautions would be permitted.

Two other things to remember – it is not a medical inquiry when you ask about an employee’s potential exposure to a contagious illness during a pandemic situation, and if an employee is absent, you can ask the employee why he or she was absent.

If there is a serious outbreak that

shows real potential for hospitalization or even death, stringent practices can be put into place, such as requiring employees who have been exposed to an illness to telecommute or otherwise stay away from work during any incubation period, limiting travel to areas that are considered high risk, asking employees if they are experiencing symptoms of the illness, sending home (and possibly offering extended leave to) employees who show symptoms of the illness, requiring employees who have been exposed to take a test to determine if they have the illness before allowing them to return to work, or even shutting down all or part of a facility.

Finally, remember that employee health information must remain confidential. If an employee has a contagious disease, it is legally permissible to notify other employees who have been exposed to the contagious employee so they can take precautions, but you should not identify the contagious employee (although most

will figure it out assuming the contagious employee will be on leave/sent home). Be sure to educate the exposed employees on the symptoms of the disease and, if symptoms appear, tell them to go to the doctor and stay home until their doctors give them the “all clear,” all the while protecting their own right to privacy.

Planning and education – not panic – are the best ways to address pandemic and/or contagious illness issues and their legal ramifications in the workplace.

Stuart Jackson ([email protected]), Delanna Padilla ([email protected]) and Hayden Shurgar ([email protected]) are attorneys in the employment section of Wright, Lindsey & Jennings LLP, 200 West Capitol Avenue, Suite 2300, Little Rock, AR 72201, 501.371.0808 and 3333 Pinnacle Hills Parkway, Suite 510, Rogers, AR 72758, 479.986.0888.

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ARKANSAS HOSPITALS I Spring 2015 1

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A MAGAZINE FOR ARKANSAS HEALTHCARE PROFESSIONALS

Health-System PharmacistsLeading Change

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What would help your hospital the most?• Learning proven ways to survive and

thrive in urban and rural markets?• Personally keeping Congress

sensitive to the need for reining in out-of-control contractors who divert limited resources from patient care?

• Securing extensions of vital programs that enhance rural hospitals’ abilities to serve their communities?

• Demanding an end to the growing practice of cutting payments for hospital care to offset other program spending?Plan to attend the American

Hospital Association annual meeting in Washington, D.C. this year and gain valuable insights into these and many other healthcare challenges!

As a CEO, physician leader, nurse leader, trustee or auxilian, your attendance at this annual conference allows you the opportunity for one-on-one visits with the state’s congressional delegation and their aides. It can make a dramatic difference for your hospital.

Peggy Abbott, Arkansas Hospital Association (AHA) board member and CEO of Ouachita County Medical Center in Camden, is attending for the first time this year. “The strong advocacy provided by the American Hospital Association on behalf of hospitals and our patients has impressed me throughout my career in healthcare,” Abbott says. “I look forward to being part of this year’s Annual Meeting of the American

Hospital Association and benefiting from the rich value of interacting directly with the AHA staff and networking with hospital colleagues from throughout the nation.”

AHA board chairman Doug Weeks, executive vice president and COO of Baptist Health, says, “The meeting itself offers several tracks with a variety of topics, all with top-notch influencers in today’s world of healthcare. The speakers give us insight into the work they’ve done and are doing on behalf of healthcare and hospitals, and they offer their opinions and experiences. These speakers are the senators and representatives, the movers and shakers, most involved in healthcare today.”

tHe Best Reason to Be inWasHington, D.C., MaY 3-6, 2015:Helping Your HospitalBy Lyndsey Dumas, Vice President of Education, Arkansas Hospital Association

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He adds that the direct interaction with congressional delegates and their aides is time well spent. “We have up close and personal meetings where we can share very specific feedback about our own facilities,” he says. “It’s an important time when we can let them know what’s going on at home, and help the new aides understand what our hospitals and patients are facing.”

Being out of the office from Sunday-Wednesday of any week is tough, he says, but this is valuable time that is more than worth it.

“I’d say if you have one event where you can meet and speak to the top influencers in healthcare today and make a real difference to Arkansas hospitals, this is it!”

This year’s event will be held May 3-6 at the Washington Hilton. Registration is available on the American Hospital Association website: www.aha.org. You may download the registration form and mail your form and check, or receive overnight mail instructions and have any questions answered by calling 805.290.1336.

During the annual gathering of the American Hospital Association, the Arkansas delegation holds additional events for the congressional aides and Arkansas’s senators. As in years past, the AHA will host a reception at the Monocle on Capitol Hill for all congressional aides; this is an opportunity for hospital representatives to meet and form a direct line of communication with those in the congressional offices in D.C.

Also, each year AHA hosts a breakfast meeting for our senators so they may hear from Arkansas’s hospital leaders and establish meaningful dialogue. In the past, this breakfast has been solely for our attendees and our senators; however, due to the House being in recess and Arkansas’s representatives being in their home districts the week

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of May 4, we have invited the chiefs of staff and legislative health aides from each of the state’s four House district offices to attend, as well.

Walter Johnson, AHA board chairman-elect, says, “For me, the Washington event provides a unique opportunity to access our D.C. officials.

A couple of the most important events and opportunities are the reception for the legislative aides and the breakfast with our senators.”

The Arkansas Hospital Association will reimburse up to $1,000 for member hospital CEOs attending the annual meeting to help offset the cost of

annual meeting registration fees and airline ticket expenditures. To receive reimbursement, attendees are required to participate in the Arkansas-specific events – Monday evening’s reception for congressional aides and the Wednesday morning breakfast with Senators John Boozman and Tom Cotton, as well as selected House aides. Registration information for these events will be coming your way soon.

Questions? Please contact AHA Vice President of Education, Lyndsey Dumas at 501.224.7878 or by email at [email protected].

We hope you’ll join us for this year’s meetings and Hill visits. It’s an important year for healthcare in America, and you’ll want to be a part of this.

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“the speakers give us insight into the work they’ve done and are doing on behalf of healthcare and hospitals, and they offer their opinions and experiences.”

top 5 reasons to Attend1.Gainpersonal,face-to-faceaccesswithyourArkansassenators.

2.HelpcongressionalaidesunderstandhowpoliciesmadeinD.C.affectyourhospitalsandpatientsathome.

3.Accesstoday’stopthoughtleadersintheworldofhealthcare.

4.UnderstandhowtheAmericanHospitalAssociationisworkingonbehalfofournation’shospitalseveryday.

5.HearfromsuchnotablesashealthcaregovernanceexpertJamesOrlikoff,pandemic/Ebolapanelists(ledbyAmericanHospitalAssociationboardmemberRamRaju,M.D.),formerWhiteHousePressSecretaryJayCarney,nationalJournaleditorsnormOrnsteinandRonfournier,formerSenatorBillBradley,politicaljournalistsScottSimon(nPR),AnnCompton(ABC),andfrankSesno,andmembersofCongresswhowilldiscuss,explainandgivetheirtakeonthehottesttopicsinhealthcaretoday.


Our most pressing work going into this Session was once again to explain the importance of re-appropriating funds for and reauthorizing the Arkansas Private Option (APO). Because it is vital to Arkansas’s patients and hospitals, keeping the APO intact was our main advocacy focus.

Then, on January 22, Governor Asa Hutchinson, as part of his healthcare plan, recommended that the Arkansas legislature keep the APO intact until the end of 2016. At that time, the APO in its present form terminates. In the meantime, the Governor asked the legislature to form a special group, the Arkansas Health Reform Legislative Task Force, to study and make recommendations on:• How best to provide healthcare

coverage for the current group of Private Option enrollees; and

• How to reform the Arkansas Medicaid Program to meet not only today’s needs, but those of the future.The legislature made quick work

of approving the bill that continued to appropriate funds for the Department of Human Services, Division of Medical Services, which houses the appropriation for the APO; however, that appropriation is approved only through June 30, 2016. In order to continue the authorization for the APO, the legislature must either meet in a Special Session or approve the program again in the fiscal session that will begin in February of 2016.

The legislative task force became a reality when Senator Jim Hendren’s

SB 96 passed, establishing the 17-member group that will work on the future of the APO and issue a report with recommendations by the end of this year.

The law is specific that the purpose of the task force is “to recommend an alternative healthcare coverage model and legislative framework to ensure the continued availability of healthcare services for vulnerable populations covered by the Health Care Independence Program established by the Health Care Independence Act of 2013 upon [its] termination.”

Members of the task force met for the first time March 10, 2015, and determined that Senator Jim Hendren

and Representative Charlie Collins would chair the task force. Members also voted that Senator Cecile Bledsoe and Representative Reginald Murdock would serve as vice chairs. Those meetings may be live-streamed for the public.

At the AHA, we are eager to work with the appointed group of 16 legislators and ex-officio member, Surgeon General Dr. Greg Bledsoe, who will study and make recommendations for the future of the healthcare system in our state.

We stand ready to provide the task force members with data that eloquently paints the picture of how the APO has helped offset at least a small portion

From the Arkansas Capitol...an exciting time for Healthcare!

This historic legislative session is proving itself exciting for all who are a part of Arkansas healthcare...our patients, our hospitals, our medical staffs, our support staffs and certainly those of us at the Arkansas Hospital Association (AHA).

By Jodiane Tritt, Vice President of Government Relations, Arkansas Hospital Association

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of the federal payment cuts to our hospitals and how it is allowing more than 200,000 of our fellow Arkansans to have insurance and be able to pay for the medical care they need.

We will be calling on all Arkansas hospital CEOs, patients, hospital trustees, members of the business community – all who have a stake in the wellness of our citizens and the health of our hospitals – to join with us in keeping these task force members up-to-date on how their discussions impact the folks back at home.

Please be sure to reach out to these members and thank them for serving on this all-important task force and for the commitment of time and attention that each will be offering.

We at AHA look forward to working with the group, and with each of you, to improve the healthcare system in Arkansas.

Arkansas Healthreform legislative task Force

Sen. Cecile Bledsoe, RogersSen. Linda Chesterfield, Little RockSen. John Cooper, JonesboroSen. Jim Hendren, GravetteSen. Keith Ingram, West MemphisSen. Jason Rapert, ConwaySen. Terry Rice, WaldronSen. David Sanders, Little Rock Rep. Justin Boyd, Fort SmithRep. Charlie Collins, FayettevilleRep. Joe Farrer, AustinRep. Deborah Ferguson, West

MemphisRep. Michelle Gray, MelbourneRep. Kim Hammer, BentonRep. David Meeks, ConwayRep. Reginald Murdock, Marianna Ex Officio: Dr. Greg Bledsoe, Arkansas Surgeon General


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