H O S P I TA L S Fall 2017
Innovation arkhospitals.org
ARKANSAS HOSPITAL ASSOCIATION . 1
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CONTENTS ARKANSAS HOSPITALS IS PUBLISHED BY THE ARKANSAS HOSPITAL ASSOCIATION 419 Natural Resources Drive • Little Rock, AR 72205
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Elisa M. White, Editor-in-Chief Nancy Robertson, Senior Editor and Contributing Writer Jamison Mosley, Art Director Marrissa Miller, Graphic Designer BOARD OF DIRECTORS
FEATURES 12
Cover Story: The Linchpin of Innovation
The Joint Commission Center for Transforming Health Care focuses on safety culture as an essential component of improving care.
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Can a Bag of Food Improve Health?
Arkansas Children’s Hospital addresses food insecurity and social determinants of health.
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Creative Ideas from Arkansas Hospitals
Across the Natural State, the dedicated professionals at Arkansas hospitals are continuously innovating for better patient care.
Departments
News
5 President's Message
21 Arkansas’s Medical-Legal Partnerships
7 Editor's Letter
32 Community Pharmacy Enhanced Services Network
8 AHA Calendar 10 Newsmakers and Newcomers 10 All About Hospitals
52 Forward Momentum in Healthy Active Arkansas 54 Leadership Profile: Debra Wright
Quality and Patient Safety
57 Medical Marijuana: A Fast-Approaching Reality in Arkansas
38 The Baldrige Way to Creating and Sustaining Excellence
60 AHA Services Presents: Passport to Clinical Rotations
47 Good Catch, Arkansas!
Policy and Advocacy
50 Rural Patients’ Superheroes
Coach's Playbook 44 How Committing to Improvement Can be Innovative
27 The PASSE: Arkansas’s New Plan to Manage Care for Vulnerable Patients 62 Reducing Opioid Deaths Will Take All of Us
Darren Caldwell, Newport / Chairman Peggy Abbott, Camden / Treasurer Chris Barber, Jonesboro / At-Large Molly Burns, Magnolia Barry Davis, Paragould John Heard, McGehee Ed Lacy, Heber Springs Jim Lambert, Little Rock Vincent Leist, Harrison James Magee, Piggott Dan McKay, Fort Smith Jason Miller, North Little Rock Ray Montgomery, Searcy Ron Peterson, Mountain Home Robert Rupp, El Dorado Margaret Underwood, Harrison Doug Weeks, Little Rock Debra Wright, Nashville EXECUTIVE TEAM Robert “Bo” Ryall / President and CEO W. Paul Cunningham/ Executive Vice President Tina Creel / President of AHA Services, Inc. Elisa M. White/ Vice President and General Counsel Jodiane Tritt / Vice President of Government Relations Pam Brown / Vice President of Quality and Patient Safety Lyndsey Dumas / Vice President of Education Suzanne Bierman / Vice President of Data and Policy DISTRIBUTION Arkansas 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. Arkansas Hospitals is produced quarterly by Vowell, Inc., 910 W. 2nd St., Suite 200, Little Rock, AR 72201. Periodicals postage paid at Little Rock, AR and additional mailing offices.
The contents of Arkansas Hospitals are copyrighted, and material contained herein may not be copied or reproduced in any manner without the written permission of the publisher. Articles in Arkansas Hospitals should not be considered specific advice, as individual circumstances vary. Products and services advertised in the magazine are not necessarily endorsed by the Arkansas Hospital Association. To advertise call 501-244-9700.
Please recycle this magazine. ARKANSAS HOSPITAL ASSOCIATION . 3
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PRESIDENT’S MESSAGE
INNOVATING FOR ARKANSANS
O
ver the years, Arkansas Hospitals has been proud to share many creative solutions advanced by hospitals – both in Arkansas and around the nation – in the areas of patient experience, quality improvement, resource management, education and policy development. We dedicate this entire issue of the magazine to the topic of innovation, believing that the presentation of ideas successfully put in motion by others can be borrowed, tinkered with, refined and applied on patient floors and in C-suites across the state. Health care innovation can take the form of new tools and technologies, but it can also apply to new ideas in transparency, communication and strategy. Here, we highlight ideas from The Joint Commission to Baldrige Award-winning hospitals, from the Arkansas Pharmacists Association to Healthy Active Arkansas, and from solutions for food insecurity to the start of Arkansas’s new PASSE program. In
addition, we shine the light on more than ten Arkansas hospitals which share their resourceful innovations, large and small. Perhaps the most innovative health care policy strategy to come from Arkansas in the past few years is the Arkansas Private Option, now known as Arkansas Works. We were the first state in the nation to receive approval from the federal government for a Section 1115 demonstration waiver allowing the use of federal funds to purchase private insurance coverage for certain lowincome individuals. Eventually, this program has allowed Arkansas to cover more than 300,000 formerly uninsured citizens under the requirements of the Affordable Care Act. This innovation, often borrowed by other Medicaid expansion states, has made a real difference in the way Arkansans seek medical care. The newly insured are receiving more primary and preventive care, leading to better management of chronic disease and improved health in the state overall.
It has also led to a significant reduction in uncompensated care for our hospitals, reducing financial burdens that previously threatened many smaller hospitals’ viability. Just as the innovations in Arkansas Works have improved the health of Arkansans and Arkansas hospitals, so the ideas presented here can improve the processes and strategies at play every day in health care organizations across the state. Please take these ideas, tweak them, use them and make them your own. We’re celebrating Arkansas health care innovation, and we invite you to do the same.
Bo Ryall President and CEO Arkansas Hospital Association
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EDITOR’S LETTER
SIMPLY INNOVATIVE
D
isney CEO Bob Iger says, “The heart and soul of a
economic and regulatory environment. Innovation helps us find direction,
simple innovations that created such value for their organizations.
company is creativity and
clarify strategies and convey individual
innovation.” As in other
responsibilities. It helps us reach
blankets? Give everyone a fleece jacket.
businesses, innovation
goals in creative, new ways. It helps
Post-procedure patients uncomfortable
in today’s hospitals leads not only to
us engage our employees and our
in those open-backed hospital gowns?
improvement in practices, but also to
communities. Innovation is more than a
(And really, who isn’t?) Issue them a
formulation of key ideas for survival
buzzword. It’s the result of the collective
comfy robe! Need to remind staff to
and success.
imagination of all of us involved in health
reposition patients? Why use an alarm
care.
when you can schedule dance breaks
Yet hospital innovation is different than what we see at manufacturing or
Perhaps those who believe innovation
Patients are cold but tripping over
into the day?
tech companies. For us, it’s all about
is overused are overthinking it a bit. In
people. Every successful innovation
our multi-tasking, hyper-digitalized lives,
innovations like these make such an
brings better care and quality of life for
we may be tempted to equate innovation
impact. Bonus points for adding fun to
our patients, directly impacting our over-
(and perhaps even intelligence)
workplace!
arching purpose of improving the lives of
with complexity. But complexity is
Harkening back to Bob Iger, I think
our friends, neighbors and communities.
not knowledge. Complexity is just
these and the other innovations featured
complexity. True genius lies in simplicity.
in this edition get right to the heart and
Some say “innovation” is among the most overused words in the English
Steve Jobs, the man some regard
Everyone wins when simple
soul of the hospital.
language. As a communications
as an innovation icon, was obsessed
professional and admitted “word nerd,”
with simplicity. Focusing his company
heart and soul what health care is all
I like to explore the use of words, and I
on a narrow range of products and
about?
believe we can pinpoint reasons for this
relentlessly pursuing simple designs and
overuse.
operations, he created an empire.
In every field, innovation matters. It’s
Because when we get down to it, isn’t
I find it incredibly exciting to see a
critical to an organization’s survival. And
simple change paying great dividends.
never more so than today, it’s essential
That’s why one of my favorite articles
for the survival of hospitals, both
in this magazine is the collection of
large and small, in our ever-changing
vignettes from Arkansas hospitals about
Elisa M. White Editor-in-Chief
ARKANSAS HOSPITAL ASSOCIATION . 7
IATION C O S S AL A HOSPIT
R A D ALEN SAS
ARKAN
C
Sign up now for the Novem ber 2 meeting of the Arkansas Association of Hospital Trustees. Join your colleague s at AHA Headquarters to hear from We ston Smith, former CFO of HealthSouth. Smith will tell the behind-the-scenes story of He althSouth and the corporate culture motivating its financial statement fraud. This will be foll owed by a Legislative Update by our ow n Vice President of Government Relations, Jodian e Tritt. Register at www.arkhospitals.org, or by call ing 501.224.7878.
October 4-6 AHA 87th Annual Meeting and Trade Show Little Rock Marriott and Statehouse Convention Center
October 4-6 AHAA 59th Annual Meeting and Trade Show Embassy Suites, Little Rock
October 19-20 Arkansas Health Care Human Resources Association Fall Conference Red Apple Inn, Heber Springs
October 27
November 9 Arkansas Hospital Auxiliary Association Board Meeting AHA Boardroom, Little Rock
November 10 Arkansas Hospital Association Board Meeting AHA Boardroom, Little Rock
Arkansas Association for Health Care Engineering Fall Conference Delta Resort and Spa, Tillar
November 15
October 27
November 16
AHA Compliance Roundtable AHA Headquarters, Little Rock
Arkansas Association for Health Care Quality Fall Conference Gilbreath Conference Center, Little Rock
AHA Workers’ Compensation Self-Insured Trust 14th Annual Education Conference AHA Headquarters, Little Rock
October 27
November 23-24
Society for Arkansas Health Care Purchasing and Materials Management Fall Conference AHA Headquarters, Little Rock
December 5
November 2 Arkansas Association of Hospital Trustees Fall Workshop AHA Headquarters, Little Rock
November 2 Stopping Sepsis Conference Hilton Garden Inn, Little Rock
November 3 AHA Workers’ Compensation Self-Insured Trust Board Meeting AHA Boardroom, Little Rock
AHA Office Closed CPT Coding Updates for 2018 AHA Headquarters, Little Rock
December 7-8 Certified Professional in Health Care Quality (CPHQ) Review Course AHA Headquarters, Little Rock
December 8 CPT Coding Updates for 2018 Hilton Garden Inn, Jonesboro
December 22 and 25 AHA Office Closed
November 3 Arkansas Social Workers In Health Care Fall Conference AHA Headquarters, Little Rock 8 . FALL 2017
AHA Education Program information is available at www.arkhospitals.org/events.
ARKANSAS HOSPITAL ASSOCIATION . 9
NEWSMAKERS and NEWCOMERS GARY L. BEBOW, Administrator/CEO of White River Health System, recently received the Grassroots Champion Award from the American Hospital Association. The award is presented annually to one recipient per state in recognition of leaders who most effectively inform and educate elected officials on how major issues affect the hospital's role in the community. The recipients demonstrate dedication to expanding community support and serve as strong advocates for their patients. TIM HILL, Vice Chancellor for Regional Campuses at the University of Arkansas for Medical Sciences (UAMS), has been named Chief Operating Officer for the UAMS Health System. He also continues his role as Vice Chancellor. Before joining UAMS, Hill was President
and Chief Executive Officer of Arkansas Heart Hospital, and served for many years as President and CEO of North Arkansas Regional Medical Center in Harrison. He is a former Chairman of the Board of the Arkansas Hospital Association and a past recipient of the prestigious A. Allen Weintraub award.
in Grove, Oklahoma, where he began his tenure in January 2015. Prior to that time, he served as CEO of Mena Regional Health System for four years, during which time he was recognized by the Arkansas Health Executives Forum as the 2012 C.E. Melville Young Administrator of the Year.
TAMMY GAVIN, RN, Chief Ancillary/ Support Services Officer at White River Medical Center in Batesville, has been elected to the Council of the American Hospital Association Section for Psychiatric and Substance Abuse Services. She will serve from January 2018 through December 2020.
Following a six-month national search, ADAM HEAD has been named President and CEO of CARTI. He most recently served as COO at the Arkansas Heart Hospital in Little Rock, where he had worked since 2013. Head had earlier served as Assistant Administrator at the Heart Hospital and formerly held COO positions at HealthSouth Lakeshore Rehabilitation Hospital in Birmingham, Alabama and at Medical Assets Holding Company in Little Rock.
TIM BOWEN, has been named Vice President and Administrator of Baptist Health Medical Center-Conway. He returns to Arkansas after serving as President of INTEGRIS Grove Hospital
all about HOSPITALS IZARD COUNTY MEDICAL CENTER is the new name of the former Community Medical Center of Izard County after a sale of its assets to a subsidiary of Americore Health. CEO Kim Skidmore retains the leadership role at the hospital, and all other staff members were retained under the new arrangement as well. Although its name has changed, the hospital’s core mission of providing its patients and community with quality, personal health care
The National Institutes of Health has awarded $11.5 million to the Arkansas Children’s Research Institute at ARKANSAS CHILDREN’S HOSPITAL to develop the Center for Translational Pediatric Research. Under the direction of Alan Tackett, PhD, the Scharlau Family Endowed Professor of Cancer Research at the University of Arkansas for Medical Sciences, the center will result in new treatments and therapies developed specifically for children.
remains the same. BAXTER REGIONAL MEDICAL CENTER in Mountain Home and NORTH ARKANSAS REGIONAL MEDICAL CENTER in Harrison have each been named to the Top 100 Rural and Community Hospitals in the United States by the National Rural Health Association’s Rural Health Policy Institute.
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THE ARKANSAS COLLEGES OF HEALTH EDUCATION at Fort Smith is planning to begin construction in the spring on a second college. The $15 million, 60,000-square-foot College of Health Sciences is expected to be ready for classes in 2020. It joins the Arkansas College of Osteopathic Medicine, which opened its doors to its inaugural class of 150 students on July 31.
UNITY HEALTH - WHITE COUNTY MEDICAL CENTER in Searcy recently held its 21st annual “A Day of Caring,” where 1,340 uninsured and underinsured residents of White County and the surrounding area received assistance and services from more than 450 medical and community volunteers, including physicians, physician residents, dentists, eye doctors and pharmacists. 93 medical exams, 136 dental screenings and 76 eye screenings were performed, and 31 prescriptions filled for participants. Other services provided included pap exams, depression screenings, blood sugar checks, haircuts and child carseat safety checks. 590 bags of school supplies and 650 pairs of shoes were distributed to children; 550 bags of groceries, 370 bags of personal care items, diapers, children’s socks and underwear were also provided.
ARKANSAS HOSPITAL ASSOCIATION . 11
COVER STORY
A LINCHPIN OF INNOVATION Safety Culture Essential for Excellence
By Anne Marie Benedicto, MPP, MPH, Joint Commission Center for Transforming Health Care espite serious and widespread efforts to improve
Trust is the foundation of a safety culture, leading
quality and safety in health care, many patients
concerned employees to report unsafe conditions and identify
still suffer harm every day within the very organi-
opportunities for improvement. When reports are taken
zations where they seek healing and treatment.
seriously and employees see positive results from the actions
Hospitals find improvement difficult to sustain. Leaders and employees within health care organizations suffer 1
“project fatigue” because so many problems need attention.
they take, they are further motivated to speak up and point out improvement opportunities. This, in turn, builds greater levels of trust and leads to
This current state is very different from the goal of high
more improvement, driving the innovation that transforms
reliability health care – health care that is consistently safe and
organizations. However, the “virtuous cycle” of trust-report-and-
consistently excellent across all services and settings – that
improve can easily stall. For example, progress stops when
many health care organizations have adopted.
employees believe that there are negative consequences to
Yet our work with health care organizations has shown that hospitals and health systems can and do progress toward
speaking up about errors, mistakes and unsafe conditions.4 The vast majority of errors that contribute to harm result
excellence and innovation through specific foundational
from flawed systems and processes.5 Unfortunately, health
changes that transform an organization and its care delivery.
care organizations don’t always act on this knowledge, and
These three foundational changes are leadership’s commitment
individuals are still blamed for mistakes they could not prevent.
to achieving zero harm, a fully functional culture of safety
In addition, some employees experience intimidating
throughout the organization, and the widespread deployment
behaviors at work, such as condescending language, verbal
of highly effective process improvement tools.
abuse and bullying. The Institute for Safe Medication Practices
While these three domains are interrelated, I’d like to focus on safety culture.
describes disrespectful behaviors as ranging from “overt acts of abuse and bad behavior to insidious actions so embedded
Safety culture is the sum of what an organization is and does 2
in the pursuit of safety. It is the product of individual and group
in our culture that they seem normal – gossip, for example.” A punitive and disrespectful culture is a dangerous culture
beliefs, values, attitudes, perceptions, competencies and
where there is little trust, teamwork is difficult, reports are
patterns of behavior.3 That culture facilitates your organization’s
inhibited, and where the communication and collaboration
commitment to quality and patient safety.
that are essential for excellent patient care are compromised.
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Organizations with such cultures are not likely to learn from mistakes, making harm more likely. According to The Joint Commission, adverse events result from the following behaviors: • Insufficient support for patient safety event reporting; • Lack of feedback or response to staff and others who report safety vulnerabilities; • Intimidation of staff who report events; • Inconsistent, or lack of priority for, implementation of safety recommendations; and • Failure to address staff burnout.6
SAFETY CULTURE, A JOB FOR LEADERSHIP As hospitals, where do you begin? You begin at the top. Effective leadership sets the tone for values and behaviors within an organization, including the paramount importance of safety among many competing priorities. Creating a thriving safety culture at your hospital is the direct responsibility of leadership, including the governing board. Your governing board, senior leaders, physician leaders and nurse leaders must work together to make it a priority. Given the important link between reporting and improvement, it is crucial for leaders to identify, understand and eliminate the barriers employees experience when reporting unsafe conditions, including close calls when an unsafe condition is addressed and mitigated before harm occurs.
create safe environments for employees,
must be eliminated. Everyone must be
patients and visitors. Disrespectful
accountable for consistent adherence
cultures lead to a disengaged and
to safe practices with uniform
disempowered workforce – a truly
assessment of errors.
dangerous condition in health care,
Joint Commission standards provide
which relies on the care and dedication
a foundation. They require leaders to
of a skilled workforce.
create and maintain a culture of safety
High reliability organizations have
and quality throughout the organization
vibrant cultures where engaged and
through requirements that serve as
empowered employees not only prevent
essential steps:
harm, but also are inspired to generate
• Regularly evaluating the culture
ideas, improvements and innovations
of safety and quality using valid and
that drive transformation. The workforce
reliable tools;
of a health care organization is its
• Developing a code of conduct
most expensive and valuable asset.
that defines acceptable behavior and
As leaders adopt more high reliability
behaviors that undermine a culture of
practices, engineering a culture that
safety; and
maximizes the talent and capabilities of
• Creating and implementing a process
its employees should be a focus and a
for managing behaviors that undermine a
pathway to a stronger safety culture.
culture of safety. Recently, leaders of our Center for
STEPS TO CREATING A SAFETY CULTURE
Transforming Health Care have been
This is important to understand:
that The Joint Commission laid out in
includes a corporate commitment to
Safety culture is not a “blame-free”
its Sentinel Event Alert Issue 57: The
provide employees with the knowledge,
culture. Highly reliable organizations
essential role of leadership in developing
skills and support they need to identify
balance learning and accountability
a safety culture.
situations and conditions that may lead
by separating blameless errors
to harm.
that are learning opportunities
to follow the series on The Joint
from the errors that are cause for
Commission website, jointcommission.
discipline. Intimidating behaviors
org (Daily Update), as we examine each
For instance, staff members do not always recognize unsafe conditions, and they don’t always know what to report. Therefore, a strong safety culture
In addition, health care leaders need to address intimidating behaviors and
blogging about 11 tenets of safety culture
I encourage you and your teams
ARKANSAS HOSPITAL ASSOCIATION . 13
11 Tenets of a Safety Culture Definition of Safety Culture Safety culture is the sum of what an organization is and does in the pursuit of safety. The Patient Safety Systems (PS) chapter of The Joint Commission accreditation manuals defines safety culture as the product of individual and group beliefs, values, attitudes, perceptions, competencies, and patterns of behavior that determine the organization’s commitment to quality and patient safety.
1 2 3 4 5 6 7 8 9 10 11
Apply a transparent, nonpunitive approach to reporting and learning from adverse events, close calls and unsafe conditions. Use clear, just, and transparent risk-based processes for recognizing and distinguishing human errors and system errors from unsafe, blameworthy actions. CEOs and all leaders adopt and model appropriate behaviors and champion efforts to eradicate intimidating behaviors. Policies support safety culture and the reporting of adverse events, close calls and unsafe conditions. These policies are enforced and communicated to all team members. Recognize care team members who report adverse events and close calls, who identify unsafe conditions, or who have good suggestions for safety improvements. Share these “free lessons” with all team members (i.e., feedback loop). Determine an organizational baseline measure on safety culture performance using a validated tool. Analyze safety culture survey results from across the organization to find opportunities for quality and safety improvement. Use information from safety assessments and/or surveys to develop and implement unit-based quality and safety improvement initiatives designed to improve the culture of safety. Embed safety culture team training into quality improvement projects and organizational processes to strengthen safety systems. Proactively assess system strengths and vulnerabilities, and prioritize them for enhancement or improvement. Repeat organizational assessment of safety culture every 18 to 24 months to review progress and sustain improvement. See Sentinel Event Alert Issue 57, “The essential role of leadership in developing a safety culture,” for more information, resources and references.
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of these 11 actionable steps toward
vulnerabilities, and prioritize them for
safety culture with additional insight and
enhancement or improvement.
practical resources: 1. Absolutely crucial is a transparent,
11. Repeat an organizational assess-
By committing to strengthen their organization’s safety culture, hospital leaders can create high-reliability
ment of safety culture every 18 to 24
workplaces in which team members
non-punitive approach to reporting and
months to review progress and sustain
trust peers and leadership, report
learning from adverse events, close calls
improvement.
vulnerabilities and hazards that require
and unsafe conditions.
SELF-ASSESSING YOUR CULTURE
2. Establish clear, just and transparent risk-based processes for recognizing and separating human error and
One way you can determine how well
error that arises from poorly designed
your organization is doing on its journey
systems from those unsafe or reckless
risk-based consideration, implement solutions to the problem identified, and communicate the benefits of these improvements back to involved staff. I have seen it first-hand.
to zero harm is through application of
Strengthening your organization’s
actions that are truly blameworthy.
the “High Reliability Maturity Model,” a
safety culture decreases the likelihood
3. To advance trust within the
practical framework for hospitals and
of sentinel events. It is one of the most
organization, CEOs and all leaders must
health systems. This is the model our
important steps for leadership to take on
adopt and model appropriate behaviors,
Center developed through our work
the road to high reliability, and it is the
as well as champion efforts to eradicate
with The Joint Commission, and we
linchpin of innovation for better patient
intimidating behaviors.
collaborate with hospitals to apply it in
care.
4. Establish, enforce and communicate to all team members the policies
their own organizations. It emphasizes leadership commitment,
that support safety culture and the
safety culture and Robust Process
reporting of adverse events, close calls
Improvement® as the three domains
and unsafe conditions.
critical to high reliability within a health
5. Recognize care team members who report adverse events and close
care organization. And, it works. For hospital leaders seeking tools to
calls, who identify unsafe conditions or
assess their safety culture, leadership
who have good suggestions for safety
and Robust Process Improvement®
improvements.
performance, our Center for
6. Establish an organizational baseline
Transforming Health Care offers an
measure on safety culture performance
Oro™ 2.0 High Reliability Organizational
using the Agency for Health Care
Assessment and Resources Tool
Research and Quality (AHRQ) Hospital
(centerfortransforminghealthcare.org/
Survey on Patient Safety Culture (HSOPS)
oro).
or another tool, such as the Safety Attitudes Questionnaire. 7. Analyze safety culture survey results from across the organization to
The assessment helps to establish a baseline to prioritize action planning and gauge progress on the road to high
?
1 Chassin MR and Loeb JM, “High-reliability health care: getting there from here,” The Milbank Quarterly 2013; 91(3):459–490. 2 Reason J and Hobbs A., Managing Maintenance Error: A Practical Guide. Ashgate Publishing Company: 2003. 3 The Joint Commission, Comprehensive Accreditation Manual for Hospitals: The Patient Safety Systems Chapter, Update 2. January 2015. 4 Chassin and Loeb, note 1 above. 5 Connor, M., D. Duncombe, E. Barclay, S. Bartel, C. Borden, E. Gross, C. Miller, and P.R. Ponte. 2007. “Creating a Fair and Just Culture: One Institution’s Path Toward Organizational Change,” Joint Commission Journal on Quality and Patient Safety 33 (10):617-24. 6 The Joint Commission Sentinel Event Alert, Issue 57, www.jointcommission.org/ sea_issue_57/, (accessed August 14, 2007). Internal citations omitted; see original text for references. 7 Connor, et al., note 5 above.
reliability.
find opportunities for quality and safety improvement. 8. In response to information gained from safety assessments and/or surveys, develop and implement unit-based quality and safety improvement initiatives designed to improve the culture of safety. 9. Embed safety culture team training into quality improvement projects and into organizational processes to strengthen safety systems. 10. Proactively assess system (such as medication management and
Anne Marie Benedicto is the Vice President of the Joint Commission Center for Transforming Health Care. She is an expert in Robust Process Improvement (RPI®) and high reliability methods applied to health care clinical and business processes. At the Center for Transforming Health Care, Ms. Benedicto leads the Center’s initiatives to transform health care into a high reliability industry through systemic approaches that address today’s most critical safety and quality issues.
electronic health records) strengths and ARKANSAS HOSPITAL ASSOCIATION . 15
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ARKANSAS HOSPITAL ASSOCIATION . 17
CAN A BAG OF FOOD IMPROVE HEALTH? Arkansas Children’s Hospital initiative addresses food insecurity and other social determinants of health By Anna Strong, MPH, MPS, Executive Director of Child Advocacy and Public Health, Arkansas Children’s Hospital
H
ospitals and health care providers work diligently to treat illness and promote health for their patients. Population health research shows, though, that 80% of the factors that determine health outcomes are outside of clinical care: education, employment, income, health behaviors, community safety and housing. As payment models evolve to add value-based components that depend on these health outcomes, health care providers are exploring innovative, systematic ways to bridge the gap between medical and social needs to improve
outcomes for patients. We at Arkansas Children’s Hospital (ACH) are no exception. Over the past 15 months, we have been screening patients in a primary care clinic for social needs and providing associated resources, including a medical-legal partnership and programs to address food insecurity, in an effort to ensure our patients are better today and healthier tomorrow. 18 . FALL 2017
A COMMUNITY-DRIVEN STRATEGY To determine what social needs the hospital should address,
• SNAP applications: ACH financial counselors assist qualified families in applying for the Supplemental Nutrition Assistance
a multi-disciplinary team looked to ACH’s 2016 Community
Program.
Health Needs Assessment. The team noted the shocking fact
• On-Campus WIC clinic: ACH partners with the Arkansas
that one-quarter of children in Arkansas are food insecure,
Department of Health to offer a Women, Infants, and Children
while 18% of the overall population lacks, at times, enough
enrollment clinic each week.
food for all family members to lead a healthy, active life.
• Pantry resource list: ACH maintains a list of neighborhood
Adding to the problem of food insecurity, Arkansas is one
food pantries that families can access when they return home.
of two states in the nation lacking an implied warranty of
FOR HOUSING NEEDS
habitability for tenants that would require landlords to maintain livable homes for tenants, and almost 22,000 children in Arkansas are homeless. The team also observed that just 31% of fourth graders read proficiently, with significant disparities by race and ethnicity. Community members echoed the need to address these three issues – food insecurity, housing and educational
• Medical-Legal Partnership: ACH partners with Legal Aid of Arkansas to address patients’ health-harming legal needs, including housing issues such as evictions or housing quality. • Shelter resource guide: Families at risk of homelessness are referred to community programs that help prevent homelessness and are given a guide to local shelters if they currently lack a safe, stable home.
attainment. As ACH developed its social needs screening form, one principle guided the work: the team would not ask questions that couldn’t be answered. The hospital’s cross-departmental team sought a way to quantify social needs, but it was equally important to give clinicians the tools to address a problem and focus on clinical care. The team selected validated questions that were written at appropriate reading levels for patients’ families. ACH’s initial screener included 14 yes-or-no questions written at the 6th grade level, and it was printed double-sided in English and Spanish, on bright green paper. Any “yes” response was a positive screen. To address food insecurity, housing and educational attainment, ACH worked with existing community partners through the Natural Wonders Partnership Council to develop solutions. Within the hospital, ACH’s Food Insecurity Workgroup and Medical-Legal Partnership team coordinated hospital resources. TO ADDRESS FOOD INSECURITY • Helping Hand food bags: A neighborhood food pantry, which is a member of the Arkansas Food Bank, provides bags of healthy, non-perishable food to the clinic, which distributes them to families that identify an immediate need for food. • Helping Hand mobile pantry: A previously-used school bus, retrofitted by a local church to be a grocery store on wheels, stops at the hospital weekly and distributes fresh and nonperishable food to patients’ families. • Summer and afterschool meals: Through a partnership with the USDA, ACH distributes summer and afterschool meals to children – more than 60,000 have been given out since the program began in 2013. The lunches are prepared by students from local high schools’ community-based instruction classes.
• Utilities Assistance guide: ACH provides a handout regarding utility assistance if a family is concerned about electricity, gas or water being turned off, and the clinic provides letters of medical necessity to families. TO ASSIST WITH EDUCATION • Medical-Legal Partnership (MLP): ACH partners with Legal Aid of Arkansas, which employs one of the only special education attorneys in the state. The MLP addresses issues such as individual education plans or special education services that are not being implemented properly.
PILOTING THE PROCESS Once the screening tool (the “screener”) was developed and resources were identified, the screening and referral process was piloted in a busy primary care clinic with a volume of around 20,000 visits each year. The clinic’s payer mix was about 80% Medicaid. The multi-disciplinary screener team trained staff on social determinants of health and the screening process. Front desk staff distributed the paper screener, and families filled it out as they waited. During triage, nurses reviewed the positive results with the families, providing resources and referrals with the help of a “cheat sheet” posted at the nurses station that outlined resources for each question. The nurses documented interventions on the screener and shared the results with physicians, who aimed to document the needs and interventions in the electronic medical record (EMR). Screeners were then placed in a green screener basket for collection by staff. The screening team ensured that support staff were in the clinic during the first couple of months of the screening to help with the transition. After the screener was piloted and moved to implementation, process improvement projects helped to ARKANSAS HOSPITAL ASSOCIATION . 19
ACH’s community garden provided more than 3,000 pounds of produce for Helping Hand food pantry during the summer of 2017.
streamline and simplify the clinic flow, improve accuracy of data tracking and guard against abuse of the program.
MAKING AN IMPACT The team used grant and donor funding to support data
Of the patients who completed the screener: • 29% screened positive for food insecurity. • 15% said they “need food today.” • 15% had at least one housing need. • 4% were concerned about rats or pests in their home.
entry and analysis of the screener data. This was the only
• 10% were concerned about their utilities being turned off.
new staff employed for this project. The results were kept
• 7% had at least one educational services need.
in an Excel spreadsheet that allowed the team to monitor trends and project resource needs. Over the first 15 months of the program, staff distributed
Families welcomed the resources. The clinic made more than 800 referrals to the medical-legal partnership. They distributed more than 1,200 bags of food and more than
screeners at more than 20,000 visits. Approximately 56%
2,500 food pantry packets to clinic patients. Financial
of these were completed and had a positive consent. Of
counselors supported more than 900 families who wanted
those completed, 43% had at least one positive screen.
to apply for WIC or SNAP.
20 . FALL 2017
After the pilot, ACH wanted to share this success with
The hospital’s Community Outreach team teaches
other clinics. Through the Natural Wonders Partnership
Cooking Matters classes to help families plan, budget,
Council’s Innovation Fund, four successful community
shop and cook healthful food. Pop-Up Cooking Matters
clinic pilots were conducted in southeast, southwest,
offers a portable version of the shopping curriculum to high
northeast and central Arkansas, proving that with the right
school students across Arkansas. These evidence-based
supports, any clinic can work to address social needs.
programs are the result of a partnership with the Arkansas
CHANGING CULTURE ACH’s efforts to improve awareness of social needs
Hunger Relief Alliance and the national No Kid Hungry Campaign. Going forward, hospital staff members hope to embed the
also extend beyond the social needs screener and into
screener and resource provision into the EMR and expand
the community. A vibrant community garden on the corner
the program to new clinics to reach more families. As ACH
of ACH’s campus grows fruits and vegetables that are
works to further its mission of bringing care close to home
donated to Helping Hand and often come back to ACH
for families across Arkansas, it’s hard to imagine anything
families. During the summer of 2017, the GardenCorps
closer to home than a healthy dinner served served on a
service member who manages the garden oversaw
family’s own kitchen table.
harvesting of more than 3,000 pounds of produce.
ARKANSAS’S MEDICAL-LEGAL PARTNERSHIPS By Kesia Morrison, Legal Aid of Arkansas
According to the National Center for Medical-Legal
can live in a safe and healthy environment. A student can get
Partnership, only 20% of an individual’s health is determined
help asking her school for educational services that meet her
by genetics, medical care and personal choices. The
individual needs.
remaining 80% is determined by where an individual lives,
Legal Aid of Arkansas is a nonprofit law firm that provides
works, learns and plays. Factors include income, access
free legal services to low-income Arkansans. Legal Aid
to care, education, housing, access to healthy food, stable
operates
employment and personal safety. Individuals living in poverty
Mid-Delta Health Systems, with Friday, Eldridge & Clark;
face many barriers to good health outcomes that cannot be
Arkansas Children’s Hospital, with Walmart Legal; Mid-
treated in an exam room. How can healthcare professionals
South Health Systems; Veterans Healthcare Systems of the
ensure good health outcomes for their patients when so
Ozarks; Lee County Cooperative Clinic; and CHI St. Vincent.
much is beyond reach?
Additionally, our sister organization, the Center for Arkansas
A medical-legal partnership (MLP) embeds attorneys in the healthcare team to “treat” legal problems that are
six
medical-legal
partnerships
in
Arkansas:
Legal Services, partners with the Central Arkansas VA Health Care System Day Treatment Center.
affecting health. It helps to think of the attorney like another
MLP is an important part of Legal Aid’s service delivery
specialist. When the medical partner knows it is a medical
model because we understand that poverty and health
issue, she refers to the appropriate medical specialist. If the
are connected. Poverty is the single most defining factor
patient has a shattered bone, he is referred to an orthopedic
in a person’s life. Poverty is the best predictor of whether
surgeon. If the patient has grand mal seizures, she is referred
a person will have good health, live in a safe environment,
to a neurologist. If it’s a mystery rash, refer the patient to
get a good education and have employment opportunities.
a dermatologist. When the medical partner identifies or
Unresolved social and economic problems can perpetuate
suspects a health-harming legal need, the patient is referred
poverty and its effects. Many of these problems have legal
to the legal partner.
solutions, and addressing them with legal help can provide
For example, if the patient cannot get well because of
a path out of poverty and a path toward a healthier future.
the conditions in her apartment, that problem could have a
Legal Aid hopes to create a statewide network of medical
legal solution. A patient who cannot get a medical device
and legal partners. Such a network could bring together
because Medicaid will not cover the cost can be referred
stakeholders to facilitate research collaboration, systemic
to MLP for help getting Medicaid to pay for the device. A
advocacy and other opportunities. Working together, medical
victim of domestic violence can be referred to MLP for help
and legal partners can identify solutions to the most pressing
securing an order of protection and a divorce so that she
health-harming legal needs facing Arkansans.
ARKANSAS HOSPITAL ASSOCIATION . 21
Arkansas Hospital
I N N O VAT I O N eniorCare Behavioral Health at Sparks Regional
A
Medical Center now provides fleece jackets to patients,
as they entered their meeting were long tables filled with
after identifying blankets as trip hazards among the
food and equipment for packing ready-to-serve meals.
psychiatric geriatric population. Staff was also concerned
Donning hats and gloves, the leaders went to work packing
that the blankets could lead to infection control issues as
an incredible 53,656 Pack Shack* meals to help fight hunger
well. The new fleece jackets allow patients to keep warm
in area communities. The healthy meals included Arkansas
while participating in daily group therapies. It also gives them
rice, soy protein, dehydrated vegetables and 19 minerals and
freedom of movement without dragging a blanket around. Since
vitamins – all at a cost of 25 cents per meal. Baptist Health was
patients began using the jackets for warmth, the number of
honored to partner with the Pack Shack, Arkansas Foodbank,
falls related to tripping on blankets has decreased and hasn’t
Feeding America and the Hunger Relief Alliance to help address
been noted as a causal factor in patient falls in over 18 months.
needs of the one-in-five Arkansans suffering from hunger.
- Alicia Agent
- Matt Dishongh
recent
half-day
Baptist
Health
“System
Update” was not the typical quarterly gathering of vice presidents, directors, managers and
S
supervisors from around the system. Greeting the leaders
*The Pack Shack originated in northwest Arkansas and arranges “food packing parties” to help address the issue of food insecurity across the state. 22 . FALL 2017
F
alls on a med-surg unit at North Arkansas Regional Medical
Center
were
increasing
despite
implementation of huddles, rounding for success,
fall assessments, staff education, fall contracts and fall process analysis. So, our Director of Nursing, Director of Quality, Chief Nursing Officer, Nurse Managers and front line staff came together to find a solution – The Fall Tree. It is a tree that was placed in the nurses’ t. Bernards has set up a broad-based program of initiating
S
station – at first with no leaves. For each
change that draws on the knowledge and observation of
day there are zero falls on the unit, the
our employees. We were looking for new ideas that would
tree gains a leaf. If a fall occurs, the tree
make tangible financial impacts by the end of our fiscal year by
loses all of its leaves. At the end of each
focusing on improving quality, reducing expenses or increasing
30 days with no falls, an animal is added to
revenue. An in-house leadership team worked with Risk Ventures
the tree. All of our staff participate because
Healthcare Analytics to develop a process to accept ideas,
they don’t want the tree to lose its leaves!
evaluate them and fast-track implementation of those deemed
Since we have introduced the Tree on
most promising. A resource team was assembled to do initial
the unit, we find that staff is more reactive to
reviews of plans for the program, which is called “St. Bernards
the call lights and more proactive with patient
Excellence.” Ideas are entered through a designated portal
needs. Patients and families are part of the discussion about the
on our intranet site. Individuals submitting the most promising
Tree and what it means, including what it means if the leaves
ideas are invited to present them in a "Shark Tank" type setting,
“fall” off. At the time of writing this article, we have 3 animals
and ideas approved are assigned to appropriate leaders for
and over 90 leaves…and still counting! Because of The Fall
implementation. We have been able to document additional
Tree, patient outcomes have improved, staff is engaged and
revenue, decreases in length of stay, better utilization of staff and
we have reduced the risk of this hospital-acquired condition.
more. And it's all because of great ideas from our employees!
The Fall Tree is a visual commitment to our patients' safety!
- Rebecca Rasberry
- Sammie Cribbs
W
e had two glaring concerns with patients admitted to Ozark Health Medical Center. Though they were given a variety of information upon admittance, many appeared not to know how to access the exact information they needed. This resulted either in multiple questions or no questions. Patients also felt very uncomfortable in the traditional open-backed hospital
robes if they were in a recovery area of the facility. Our Director of Guest Services and Marketing Department came together to find solutions. To make our patients feel welcome and more comfortable, patients were offered their own Ozark Health tote bag with higher-end toiletries to fit their needs. Also inside the tote was a folder that contained very detailed information regarding their care at Ozark Health. We included a list of important phone numbers and a large-print TV channel guide, as well as handouts with helpful information about services that might be needed after discharge. Along with this, patients were presented with a spa-quality robe and hotel-grade pillow for their use while in the hospital to help them feel more at home while they are receiving the care they deserve. The new tote/robe/pillow kits are working so well! Our patients tell us they feel more at home, though in a hospital setting, and they are more informed about the services we offer both before and after their discharge. Patients are even speaking out on social media! One patient said, “I have never seen such hospitality in a setting such as this.” We believe the new Admit Kits improve our customer service, which is very important to Ozark Health Medical Center because our patients are the most important members of our team. - Kortney Fowler
ARKANSAS HOSPITAL ASSOCIATION . 23
O
ur concept was to promote circulation and decrease
L
ocated in a retirement community with a large number of veterans and elderly persons suffering from Parkinson's disease, Baxter Regional Medical Center (BRMC)
the occurrence of pressure ulcers caused from patients sitting in one spot most of the day at Unity
Health’s Clearview Unit (inpatient geriatric behavioral health).
saw the need for a program that would help patients reduce
The Hospital-Acquired Pressure Ulcer Prevention Team came
the impact of this illness and regain some control. The Baxter
up with the solution of “Boogie Time” to get patients up and
Regional Hospital Foundation and several prominent community
moving aside from their regular meal and bath intervals. At 9
members got together to bring in the Rock Steady Boxing
and 11 a.m., and again at 2, 4 and 7 p.m., lively music is played
Program, a non-contact boxing exercise program that works
in the Dayroom, and any of our patients who are able get up
to move all planes of a person's body through forceful and
and move/dance; those who cannot get up are repositioned at
intense exercise. “Fighters” are given a measured assessment
these times. The staff assist as needed, and many times, they
at the beginning of their training and again every six months to
dance along with their patients. Patients and staff both enjoy this
monitor progress, and all of them have experienced remarkable
time. It also improves the mood of the patients. This helps with
improvement. BRMC is currently serving 20 community members
patients’ functionality, helps them rest better, prevents pressure
through this program, and is always taking more recruits. BRMC
ulcers and makes our unit a happier place for everyone.
wants to help patients win their fight against Parkinson's!
- Brooke Pryor
- Tobias Pugsley
S
tatistics indicate that 10% of patients account for 70% of healthcare expenditures. These patients usually have multiple chronic conditions, require multiple medications and are at high risk for hospital readmission. To improve the health and quality of life for our patients, reduce readmissions and reduce costs, Dr. Chris Steel led the development of the Community
Care Network (CCN) at White River Medical Center (WRMC). The CCN connects patients, post-discharge, to community resources outside the hospital to help them manage their health. The signature accomplishment of our CCN is a successful collaboration between WRMC and Lyon College to train pre-professional students at Lyon as Health Coaches. Health Coaches assist patients in understanding their health status, discuss symptoms and problems to report to their providers, ensure patients understand and take medication properly, and connect patients with outpatient care and community resources. A patient is typically admitted into the Health Coach Program post-discharge through their primary care provider and spends anywhere from 3 to 6 months in the program. The Health Coach will visit with their patient, in their home, a minimum of one day per week and call them at least once per week. After completing the program, some patients continue to request the Health Coaching service if they feel they need continued support. We have found that by providing post-hospitalization support with CCN Health Coaches, unintended hospital readmissions have declined, hospital expenses have been reduced and patient satisfaction has improved. - Jerrika Davis 24 . FALL 2017
NEWS
STAT TJC REVISES PAIN ASSESSMENT AND MANAGEMENT REQUIREMENTS The Joint Commission (TJC) has announced that new and revised pain assessment and management standards for hospitals accredited by the organization will go into effect January 1, 2018. Look for the following new requirements for TJC-accredited institutions: • Identification of a leader or leadership team that is responsible for pain management and safe opioid prescribing; • Involvement of patients in developing their treatment plans and setting realistic expectations and measurable goals; • Promotion of safe opioid use by identifying high-risk patients; • Monitoring of high-risk patients; • Facilitation of clinician access to prescription drug monitoring program databases; and • Conducting performance improvement activities focusing on pain assessment and management to increase safety and quality for patients. Find the pre-publication standards at www.jointcommission.org. Questions? Contact Trina Crow, RN, MJ, associate project director, Department of Standards and Survey Methods, TJC, at tcrow@joint commission.org.
ARKANSAS HOSPITAL ASSOCIATION . 25
26 . FALL 2017
MANAGING CARE FOR VULNERABLE PATIENTS: Medicaid's Provider-Led Arkansas Shared Savings Entity (PASSE)
By Suzanne Bierman, Vice President of Data and Policy, Arkansas Hospital Association
T
hroughout its long
Nevertheless, that move began to take shape during the
history, which dates
2017 Arkansas Legislative Session with enactment of Act
back more than 40
775 of 2017. The Act set the stage for the state’s initial push
years, the Arkansas
away from that fee-for-service structure into the world of
Medicaid program has
Medicaid managed care, although one based on a hybrid
paid for the health care services used by program recipients under a fee-for-service payment model.
managed care model and fixed on a limited population. The law created the Medicaid Provider-Led Organized
Hospitals, physicians and every other health care provider
Care Act, which establishes a system for providing medical
type have been paid a preset amount for a defined unit
care to “certain Medicaid beneficiaries with behavioral
of service – whether an inpatient day of care, a medical
health needs or those with intellectual or developmental
procedure or an increment of time. While the per-unit
disabilities through risk-based provider organizations.”
payments have always been less than adequate, health
Under Act 775, the Arkansas Department of Human
care providers have typically been united in the belief that
Services (DHS) is charged with developing and
moving away from the fee-for-service model and toward the
implementing an innovative service delivery system to
use of pre-paid, risk-based managed care would further
promote coordinated care for this specific subgroup
reduce payments, even for approved services, and impose
of Medicaid beneficiaries. DHS is currently laying the
a more cumbersome process for getting claims paid.
regulatory foundation for this program and the operating ARKANSAS HOSPITAL ASSOCIATION . 27
THE PASSE MODEL: AHA’S VIEW As the health care delivery system continues to evolve and focus more sharply on aspects of care coordination to improve patient outcomes, the Arkansas Hospital Association will continue to serve as an advocate for our hospitals as they serve patients, their families and our communities. Because the PASSE model places control with Arkansas providers who are directly involved with patient care and hold patients’ best interests at heart, we at the AHA are cautiously optimistic that this innovative payment/delivery model will maintain and improve the state’s infrastructure for truly managing the care – not just costs – of our most vulnerable patients, while continuing to ensure access to efficient, quality health care for all patients. We applaud the Arkansas Department of Human Services for its decision to refrain from copying other states’ choices and simply outsource their oversight responsibilities to Medicaid Managed Care Companies. Those decisions too often have proven unsuccessful by creating unnecessary roadblocks to appropriate care and allowing Medicaid Managed Care companies to hold state budgets hostage as they profit from taxpayers’ dollars. Working together, Arkansas providers have the best opportunity to improve on Arkansas’s previous and current provider-led reforms that have created savings in the Medicaid program while providing excellent care to patients. 28 . FALL 2017
Estimated initial PASSE Enrollment based on 2016 Medicaid data 7,437 27%
20,344 73%
BH
ID/DD
entities that will be involved. Those
2016. The behavioral health recipients
organizations have been referred to by
accounted for 65% of the amount, with
a number of different names since the
the intellectually or developmentally
passage of the Act in March of this year.
disabled population’s expenditures
Individually, each one is most commonly
comprising the remaining 35%.1
known as a Provider-Led Arkansas Shared Savings Entity (PASSE). The PASSE program will focus on
Under this organized care model, instate health care providers will partner with organizations that perform the
coordinating care for this small group
administrative functions of managed
of Medicaid’s highest cost enrollees.
care companies. That differs from more
Initially, intellectually or developmentally
traditional managed care programs in
disabled individuals who meet DHS’s
which state Medicaid agencies contract
institutional level of care criteria and
with large managed care organizations
individuals with behavioral health needs
(MCOs) that often work in multiple
that meet the rehabilitative or intensive
states. Under those contracts, MCOs
level of need will participate in the
accept a set per-member-per-month
PASSE program.
(capitation) payment for conducting
DHS estimates that total initial participation in the PASSE will be
these care coordination services. According to DHS, this PASSE model
27,781 Medicaid beneficiaries, with
was selected because it allows Arkansas
27% of that population meeting the
to “merge its history and tradition of
institutional level of care for intellectual
strong provider leadership with the tools
or developmental disabilities, and the
and risk-bearing expertise offered by
remaining 73% meeting the criteria
managed care companies.”
for behavioral health needs. Together,
The PASSE entities must meet the
this group accounted for an estimated
requirements of federal Medicaid
$1.25 billion in Medicaid expenditures in
managed care regulations and must
operate on a statewide basis. They may provide health care services
Total Cost Of PASSE Population based on estimated 2016 Medicaid Expenditures
directly to these Medicaid beneficiaries or may use a direct service provider who is a participating provider, a direct service provider subcontracted by the risk-based provider organization, or an independent provider who enters
$394,306,835 35%
into a provider agreement or business relationship with the direct service provider. The PASSE organizations must include within their membership a provider of developmental disabilities services, a provider of behavioral health
$731,389,729 65%
services, a hospital or hospital services organization, a physician practice and a pharmacist. Fifty-one percent of the ownership in a risk-based provider organization must be from entities or persons who deliver health care services
BH
to these Medicaid populations.
ID/DD
The remaining 49% ownership in the PASSE organization may come from an insurance company, a health
behalf of the University of Arkansas for
has an extremely long waiting list for
maintenance organization, medical
Medical Sciences; and USAble HMO,
services. The revenue also will fund an
service corporation, an administrative
Inc.)
incentive pool for PASSE organizations
entity, a federally qualified health center,
• Forevercare, Inc. (Gateway Health
a rural health clinic, an associated
Plan; Community Service, Incorporated;
participant, or any other type of direct
Arkansas Pharmacists Association;
that meet specified performance measures. In order to determine whether
service provider that delivers or is
Rehabilitation Network of Arkansas;
Medicaid beneficiaries with behavioral
qualified to deliver health care services
Community Clinic; and Ouachita County
health needs and intellectual or
to these Medicaid populations.
Medical Center)
developmental disabilities meet the level
Five organizations filed the required
• Arkansas Provider Coalition
of care requirements for participation in
letter of intent by the filing deadline,
(Arkansas Provider Coalition, LLC and
the PASSE program, DHS will administer
signaling their intent to become PASSE
Amerigroup Partnership Plan, LLC).
an independent assessment. Individuals
organizations:
The Arkansas Department of
who meet PASSE participation criteria
Insurance will be responsible for
will be required to receive their
(Beacon Health Options; Woodruff
regulating the PASSE organizations as
Medicaid-funded services from a
Health Group, LLC; Preferred Family
insurance entities (risk-based provider
PASSE organization. DHS is developing
Health Care; The Arkansas Health
organizations). This means the state’s
an attribution methodology based on
Care Alliance, LLC; Stratera, LLC;
2.5% premium tax on insurance entities
existing provider relationships to assign
Independent Case Management Inc.;
must be paid by each PASSE.
qualifying Medicaid beneficiaries to a
• Empower Health Care Solutions
and Arkansas Community Health Network, LLC)
The premium tax revenue will be used by DHS to fund, among other
PASSE organization. Beginning in October of 2017, DHS
things, additional slots under the
will pay PASSE organizations monthly
LifeShare Management Group, LLC; and
state’s Community and Employment
care coordination fees for each Medicaid
Arkansas Health & Wellness Plan, Inc.)
Supports waiver, which provides
beneficiary enrolled in the PASSE. The
home and community-based services
remainder of the services for PASSE
Health; Bost, Inc.; The University of
for individuals with intellectual or
enrollees will continue to be reimbursed
Arkansas Board of Trustees, for and on
developmental disabilities and currently
on a fee-for-service basis until January
• Arkansas Total Care (Mercy Health;
• Arkansas Advanced Care (Baptist
ARKANSAS HOSPITAL ASSOCIATION . 29
30 . FALL 2017
FOCUS ON QUALITY NEW C. DIFF RESOURCES
The Agency for Healthcare Research & Quality (AHRQ) offers two new informative resources regarding diagnosis, treatment and prevention of the extremely serious Clostridium difficile infection (C. diff). Written for clinicians, "Diagnosis, Prevention and Treatment of C. Difficile: Current State of the Evidence" summarizes findings from a review of recent evidence regarding the accuracy of diagnostic tests and the effectiveness of interventions for prevention and treatment of C. diff. A clinician summary of the full report is available at www. effectivehealthcare.ahrq.gov. A companion resource, designed for patients, is written specifically to help patients and their caregivers understand and discuss treatment options. Titled "Treating and Preventing C. difficile Infections: A Review of the Research for Adults," the patient guide may be downloaded at the same website. Search for report 2477.
ARKANSAS HOSPITAL ASSOCIATION . 31
PHARMACISTS AS HEALTH CARE TEAM MEMBERS By John Vinson, PharmD, Vice President of Practice Innovation, Arkansas Pharmacists Association Megan Smith, PharmD, Assistant Professor, University of Arkansas for Medical Sciences Jordan Foster, Director of Communications, Arkansas Pharmacists Association
I
n 2014, guided by the Triple Aim to improve the patient’s experience of care, improve population health and reduce health care costs, Community
Care of North Carolina (CCNC) created the Community Pharmacy Enhanced Services Network (CPESN), an open network of North Carolina pharmacies dedicated to expanding pharmacists’ services available to patients. The network was designed to benefit the
what people normally think of as a
patient clinical information. They
patient, the payer and the pharmacist.
pharmacy’s services – prescription
identify actual or potential drug therapy
dispensing and basic patient education.
problems, provide patient care plans
This model demonstrated that
Working collaboratively with other
with recommendations to resolve these
elevates the level of care that patients
health care providers, health systems,
problems, and provide ongoing follow-
receive, especially when addressing
health insurance companies and
up and monitoring services.
social determinants of health care for
additional stakeholders, the Arkansas
highly complex patient populations.
CPESN seeks to optimize medication
pharmacists want to ensure that patients
The success of the program led to the
therapy to ensure patients are achieving
are getting the best possible outcomes
creation of CPESN-USA, a partnership
positive therapeutic outcomes and
through safe and effective drug therapy.
between CCNC and the National
reduce overall health care costs.
bringing pharmacists into the care team
Community Pharmacists Association that
Key to the Arkansas CPESN approach
Why do this? Arkansas CPESN
These enhanced services have been shown to improve patient health,
helps states create their own CPESN
is the active integration of community
increase patient accountability and
programs.
pharmacists with the larger care team,
responsibility for their own well-being,
including primary care physicians,
and decrease overall costs compared to
Arkansas, with their partners at the
specialty providers such as behavioral
patients who are non-adherent to their
Arkansas Pharmacists Association,
health professionals and the extended
therapy plans.
UAMS College of Pharmacy, Harding
care teams in Patient Centered Medical
College of Pharmacy and CPESN-
Homes.
Now, community pharmacists in
USA, have brought the same type of
Medication optimization, including
Within the Arkansas CPESN, participating network pharmacies provide the following services:
enhanced network to the Natural State.
medication therapy management, is one
And pharmacists across the state have
service network pharmacists provide
Personal Medication Record: Not to
embraced the initiative.
that particularly helps improve patient
be confused with automatic refills,
health outcomes. Through medication
medication synchronization is a step-
Enhanced Services Network (Arkansas
therapy management, Arkansas CPESN
by-step process that helps ensure
CPESN) unites cooperating pharmacies
pharmacists work closely with patients,
patients have available – and are taking
into an engaged network capable of
patient representatives and other health
– their medications as prescribed. First,
providing services above and beyond
care providers to collect pertinent
each patient in the program receives a
The Arkansas Community Pharmacy
32 . FALL 2017
• Medication Synchronization with
comprehensive medication assessment; then, refills of their regular medications are aligned to be dispensed on the same day. With each fill, the pharmacist has a discussion with the patient to verify any medication changes and to assess the patient’s progress toward his or her desired health goals. This allows the pharmacist to monitor medication adherence and address any problems with non-adherence. As part of this service, the patient also receives a personal medication record, which is a comprehensive record of the patient's active medications (including prescription and over-thecounter medications, vitamin or herbal supplements and medications taken only as needed). • Adherence Assistance: Network pharmacists also help patients develop a system to organize medications and take them appropriately at the correct time of day. This makes it easier for
Pharmacies across the Natural State have joined the Arkansas CPESN, and the network continues to grow.
patients to adhere to their prescribed treatment. The adherence assistance services may include working with the
continuity of health care as patients
recommended immunizations, educate
patient or caregiver to determine an
transfer between different settings.
patients about needed immunizations
appropriate packaging system, such as
Medication reconciliation, medication
and provide various immunizations
bubble packaging, medication strips,
therapy management and patient
for their patients, including flu,
med planners or the use of an automated
education form the core activities of
pneumococcal and shingles vaccines.
medication dispenser.
the network pharmacist. These are
With additional pharmacies joining
services designed to improve patient
the network each day, Arkansas CPESN
with Follow-up: Each of the patient’s
• Comprehensive Medication Review
care provided during critical transition
is actively looking for partnerships
medications – prescription and non-
periods.
with health systems, other providers
prescription – is individually assessed to
This type of service is provided
and payers to create innovative health
determine appropriateness for the patient,
on referral and is targeted toward
effectiveness for the medical condition
patient populations at increased risk
These additional pharmacy services
and safety. Any concerns or issues then
for readmission. These patients may
will benefit the payer’s bottom line, the
can be resolved by the care team to
include those with heart failure, chronic
pharmacist’s ability to thrive in a shifting
assure that the patients’ medications are
obstructive pulmonary disease, asthma,
health care environment, and most
helping to achieve their overall health
advanced age, low health literacy,
importantly, patients’ health.
goals. Pharmacists then provide any
or those who experience frequent
appropriate patient-specific follow-up
hospitalizations.
monitoring, such as collecting vitals and
solutions.
Pharmacies will also offer a non-
other objective measures (blood pressure,
dispensing, 24-hour on-call service
For additional information about the
blood glucose, weight, etc.).
to assist in care transitions and may
Community Pharmacy Enhanced
provide home delivery, as needed.
Services Network, visit www.cpesn.com
• Transition of Care: An essential component of the enhanced services network is the coordination and
• Immunizations: Network pharmacists also actively screen patients for
or email Max Caldwell at AR@cpesn. com. ARKANSAS HOSPITAL ASSOCIATION . 33
34 . FALL 2017
ARKANSAS HOSPITAL ASSOCIATION . 35
FOCUS ON QUALITY SEPSIS NURSES
Nurses dedicated to early sepsis identification and timely treatment can make a marked difference in lives saved, according to Sepsis Alliance, the largest sepsis advocacy organization in the United States. Though many U.S. hospitals have sepsis-reduction programs in place, the St. Joseph Hoag Health system in Orange County, California has dedicated members of the nursing staff to the identification and control of this often-deadly condition. Every hospital in the network always has a dedicated sepsis nurse on duty. Identification of patients at risk for sepsis is key. Then, intense monitoring begins: sepsis nurses watch for any drop in blood pressure, confusion, increased heart rate, high whiteblood-cell counts and any progression of infection. The program is producing remarkable results. Over the twoyear period 2015-2016, the death rate for all sepsis cases over the St. Joseph Hoag Health system dropped by 3%; at St. Joseph Hospital, the number of septic shock cases dropped by 50%. More info at www.khn.org. – Kaiser Health News
36 . FALL 2017
ARKANSAS HOSPITAL ASSOCIATION . 37
THE BALDRIGE WAY TO CREATING AND SUSTAINING EXCELLENCE
www.nist.gov/baldrige
By Brenda S. Grant, BSN, MBA, Chief Strategy Officer, CAMC Health System
W
e all know how important and difficult it is
Association, too many times, strategic planning is primarily
to create excellence. After all of that hard
top-down, with some limited input from middle and front-line
work, wouldn’t it be nice if it were easy to
managers. “When the plan is held in the arms of just a few, it’s
sustain excellence
difficult to sell downstream,” study authors comment. “That’s
and if fixing a process
one time would create lasting change?
how we run into execution gaps, because people have not
Instead, we often find that sustaining an improvement is just
been brought into the process until after the plan is in place.
as – if not more – difficult as attention and focus shifts to other
They don’t know where you’re trying to go and how you’re
priorities now that a problem has been “solved.” Yet, achieving excellence is just the beginning of the journey. Maintaining improvements while continuously looking for additional opportunities to improve requires a strategic approach to avoid the “one and done” mindset that can lead us to revert to the old way of doing things. At the CAMC Health System in Charleston, West Virginia, we found our organizational performance accelerated as we became process driven. We rely on the Baldrige Performance Excellence Framework to guide us in creating a systems approach to process improvement for quality and safety. Integrating this framework throughout our organization led to development of our Leadership System, Enterprise Model, Performance Improvement System, Workforce System and Strategic Planning Process. Our strategy is to follow the Baldrige way to continuously improve. If your health care organization has not yet tried improving processes by committing to and applying the Baldrige Excellence Framework, we urge you to seriously consider doing so. This article will acquaint you with some of the Baldrige terminology and will show you how our system has innovated to achieve sustainable excellence. We hope you will be able to see how your hospital/system can do so, too.
STRATEGIC PLANNING According to a recent study from the Society for Healthcare Strategy and Market Development of the American Hospital 38 . FALL 2017
Leadership System
The Enterprise Model shows a high-level view of each system within CAMC.
going to get there. That can sometimes cause resistance, or it
requirements; they obtain input from their manager and team,
could just take you longer to get to your objectives.”
and then they establish a Learning and Development Plan to
At CAMC, the epicenter of our approach is a fully-aligned and integrated strategic planning process that brings our
address opportunities for improvement. Our education team then aligns our organizational education
corporate goals down to every department and to every
programs to support skill development for these requirements.
employee. The outcome has been the true engagement of our
At CAMC, we recognize that sustained excellence cannot be
workforce in improving performance!
achieved without the foundation provided by a skilled and
So, how are these key systems used to build and sustain a workforce culture and mechanism to drive organizational excellence and high performance?
IT STARTS WITH LEADERSHIP Our mission and vision form the foundation of the leadership
committed leadership team.
THE ENTERPRISE MODEL Next, we knew it was important for every member of our workforce to understand how his or her job helps CAMC meet its mission. Everyone’s job, no matter how large or small, is
system. Leaders in our organization must understand the
essential to our success, and everyone has a role to play
key requirements of our patients and families and those of
in sustaining excellence. The Enterprise Model helped us
our key stakeholders (employees, physicians, partners and
understand and visualize this.
community).
The Enterprise Model is a high-level representation of the
They must then be able to do the work of leading: set
organization’s mission, functions, processes and systems. At
direction, align and cascade goals, implement action plans,
CAMC, we have designated three types of systems: systems
achieve the plan, mentor and develop people and change
that guide; systems that do work; and systems that support.
systems and structures.
Our enterprise model highlights how each system relies upon
In addition, our leaders cannot delegate the responsibilities of building commitment, motivating and resourcing, reviewing
the other for meeting patient needs. In a state with a declining population, one of the oldest
and adjusting, making change last, rewarding and recognizing
populations in the nation and 80% government payers, we
and raising the bar.
must design our work systems and work processes to not only
Leadership skills become well-honed and operationalized as individual leaders do their self-evaluation for each of these
deliver the best care for our patients, but also to increase our competitive advantage as a low-cost provider in our region. ARKANSAS HOSPITAL ASSOCIATION . 39
ABOUT CAMC HEALTH SYSTEM CAMC Health System is comprised of Charleston Area Medical Center, the CAMC Foundation, CAMC Health Education and Research Institute, and Integrated Health Care Providers. The Charleston Area Medical Center (CAMC) includes 4 hospitals – CAMC General, CAMC Memorial, CAMC Women and Children’s Hospital and CAMC Teays Valley Hospital – with a total of 956 licensed beds, over 500 medical staff and 7,000 employees. CAMC is the largest hospital in West Virginia, serving 12 counties with a population of nearly 600,000
The Top 5 Boards are visual representations of each department’s goals. The actual board, when filled in, may cover an entire wall in the department.
people. The CAMC Health System was a 2015 Malcolm Baldrige National Quality Award recipient.
THE MAGIC HAPPENS WHEN GOALS ALIGN Most organizations have goals. And people who work in these organizations have goals, too. But we see magic happen when corporate goals align with hospital goals, departmental goals and individual goals. Such goal alignment improves outcomes and operations, boosts employee morale and creates ownership of the organization’s success. Most importantly, it also leads to more satisfied patients who benefit exponentially from smoothly running processes and motivated workforce members. CAMC Health System’s Goal Cascade Process is used to align the organization’s annual goals throughout the entire system and with those of every department. Deployment of the plan throughout the organization has been instrumental in creating excellence. Cascading goals is the process of taking the overall goals of the company, then adopting related goals and activities at different levels within the company to ensure that our departmental and individual activities and objectives are aligned with the long-term goals of the company. CAMC uses “Top 5 Boards” in all departments to bring our goals into the day-to-day work of our employees. Our Top 5 Boards are 4×6-foot boards in each department, each with five columns that address the define, measure, analyze and improve components of our performance improvement methodology. Each column shows the work of a department improvement team addressing an issue that comes (or “is cascaded”) from our overall corporate goals. Every person in the department participates on one of the five improvement teams. This creates an environment where each person understands his or her goals, how they relate to the corporate goals and how (and what) to improve. These boards create transparency of goals, action plans and results to drive the culture of quality and safety. The Top 5 Boards are located in visible areas so that the performance improvement work is fully transparent to the
40 . FALL 2017
workforce, patients and visitors.
The CPICU team stands in front of the department’s Top 5 Board. The goal cascade has been instrumental in improving
There is no greater satisfaction than seeing an enthusiastic
overall organizational results by ensuring our focus remains on
Top 5 Board team member share about the work of the team
key improvement areas.
and how they have directly impacted achievement of a goal.
For example, a key measure (what we call a BIG DOT) under our quality pillar is Value-Based Purchasing–HospitalAcquired Infections. This is cascaded to applicable nursing departments as CAUTI (Catheter-Associated Urinary Tract
SOME ADDITIONAL KEY LEARNINGS FOR US INCLUDE: • The Baldrige Criteria align with and support required
Infections). The nursing departments have CAUTI as a Top-5
accreditation processes. Show the connections! We are
Board improvement project and monitor the implementation of
working toward ISO certification to support the aldrige criteria
“bundles of care” that need to take place every day to prevent
focus on processes.
these infections. As a result of this focus, CAMC’s CAUTI
• Transparency supports engagement and is required to
rate for 2016 was 0.30, which is better than the Centers for
drive commitment. Through the Goal Cascade Process, CAMC
Medicare and Medicaid (CMS) top-quartile performance of
Health System shares its strategic direction and the “why”
0.90. Not only are clinical results improved, our Top 5 Boards
behind its plans.
have the added value of engaging employees in their daily work to achieve corporate goals. As a cycle of learning, to continue our focus on sharing best
• Comparisons and benchmarks are critical to knowing how you perform. Ask the question, “How do you know?” • Having systematic processes in place (including CAMC
practices and knowledge management, we have added Top
Health System’s Organizational Sustainability Framework)
5 Board report outs from each of our hospitals and corporate
helps prepare health care organizations to work through the
areas. It becomes readily apparent that our Leadership System
challenges and instability of delivering health care in today’s
is aligned with strategic planning. Leaders must set direction,
environment.
align and cascade, implement the plan, and achieve the plan at every level of the organization.
OUR INVITATION Sustaining the excellence you have created through
CLOSING THE LOOP – PERFORMANCE MANAGEMENT
programs, projects and just plain hard work is a challenge
The Performance Management System closes the loop for
Baldrige journey. By committing your organization to use of
in today’s health care setting. We invite you to join us on the
sustaining excellence. At the organizational level, we use the
the Baldrige Performance Excellence Program, we believe
BIG DOT report of our key measures to review organizational
you, too, will see systems improvement, better employee
performance quarterly with our Board of Trustees. Each
engagement and higher satisfaction at all levels, including the
corporate entity, hospital and corporate department has an
most important – your patients and their families.
aligned scorecard that is then cascaded to each department and individual performance planner. Performance reviews are based on accomplishment of these cascaded goals. At the department level, accomplishment of Top 5 Board results is a significant percentage of the annual review process. A key cycle of learning for us was to ensure that we only address goals that we can directly impact at each level; otherwise, we dilute our impact and create what our workforce calls “busy work,” which is a waste of their time.
As Chief Strategy Officer, Brenda Grant is responsible for development and deployment of strategic and business plans for the CAMC Health System. She has served as a Senior Examiner for the Baldrige Performance Excellence Program and is a judge for The Partnership for Excellence. CAMC won the Malcolm Baldrige National Quality Award in 2015, and Brenda continues to lead the CAMC Health System’s Baldrige efforts. Find more about the Baldrige Way at www.nist.gov/baldrige. ARKANSAS HOSPITAL ASSOCIATION . 41
42 . FALL 2017
THINK TICKS AREN’T AN ISSUE IN YOUR COMMUNITY? THINK AGAIN. Health care providers in city and suburban areas that have never even seen a case of Lyme disease should beware: A variety of tick species are moving out of their native regions and across the country. The lone star tick, for instance, originated in the Southwest but has now been found in 39 states, including Arkansas. And these various invaders are not just bringing the familiar and dreaded Lyme disease, Aneri Pattani reports in the New York Times, they’re carrying other diseases that are so new to certain regions many physicians may not realize what’s making their patients sick. Of special concern is babesiosis, which one expert tells Pattani can cause malaria-like symptoms and require hospitalization and intensive care. For some patients, the infections are fatal. -H&HN Online ARKANSAS HOSPITAL ASSOCIATION . 43
UP to
EXCELLENCE How Committing to Improvement Can be Innovative
44 . FALL 2017
W
hat comes to mind when you hear the word
recipients to those from all competing hospitals within a 25- to
“innovation”? A photo of Albert Einstein?
50-mile radius of the winners. Statistically significant differences
George Foreman inviting you to contact his
were found in 9 of the 10 measures for patient experience, with
®
the Baldrige Award recipients outperforming their competitors.
friends at InventHelp ? Graduate students in an engineering competition at MIT? It
Patient engagement leads to patient loyalty, which results
turns out that the Baldrige Excellence Framework has an inter-
in recommendations for the organization to other potential
esting definition of innovation – “Making meaningful change to
customers.
improve health care services, processes, or organizational effectiveness and create new value for stakeholders.” Creating new value for stakeholders produces a competitive
In another study published by Truven Health, results show a strong correlation exists between Baldrige Award recipients and the 100 Top Hospitals winners. “The identification of a growing
advantage. And right now, is there any other sector that needs a
overlap between use of known best management practices
competitive advantage more than health care? Increasing regu-
(Malcolm Baldrige program) and the objective measure of
lations, uncertainty in the insurance landscape and – for many
leadership impact on an organization (100 Top Hospitals pro-
– operating in a crowded market, all contribute to the need for
gram) is a testament to the enormous potential of the emerging
differentiation with improved health care services, processes
science of management,” says Jean Chenowith, writing for the
and organizational effectiveness. The question is how to do this
study.
in an already challenging environment. Evidence-based medicine and evidence-based practice emerged in the early nineties as the new approach to health care that underscored the use of proven best practices in the treatment of patients with demonstrably better outcomes. There is a similar approach to organizational improvement
When leaders of hospitals and health care systems commit to a performance excellence journey, they are beginning to lay the groundwork for innovation in their organizations. But as the aldrige definition for innovation states, it also requires that leaders pay attention to creating the right culture. The glossary of the Baldrige Excellence Framework indicates that “innovation benefits from a supportive environment, a pro-
with its own body of evidence. Since the Baldrige National Quality Award program expanded
cess for identifying strategic opportunities, and a willingness to
to include the health care sector in 1999, there has been an
pursue intelligent risks.” Does this describe your organization’s
explosive growth in the use of the Baldrige Excellence Frame-
culture?
work by health care organizations. There have been 22 Baldrige
If not, what will you need to do to move it in the right direction?
Award recipients in health care since 2002, when SSM Health
As the leader of an Arkansas hospital, are you satisfied with
Care became the first to win this award. 2016 marked another
the results that your organization is achieving, or are you ready
milestone when the first long-term care facility, indred Nursing
to see breakthrough improvements that allow you to leapfrog
and Rehabilitation Center - Mountain Valley, achieved this pres-
over your competitors? Now is the perfect time to begin your
tigious award.
own performance excellence journey!
So, where is the evidence that use of the Baldrige Excellence
Our first book, The Executive Guide to Understanding and
Framework makes a difference in health care organizations? As
Implementing Baldrige in Healthcare: Evidence-Based
it turns out, the evidence appears not only in results achieved
Excellence, is written in plain English for people new to
by these 22 award recipients, but also through the results of
the Baldrige Criteria. It describes a practical approach to
several independent studies.
implementing the essential systems to create a foundation for
The first is a study conducted by Ron Schulingkamp and
excellence and then continuing to build organizational capability
John Latham, who compared the publicly reported measures for
and maturity. If you’re ready to take this first step, contact me
health care outcomes and patient experience of Baldrige Award
and I’ll happily send you a complimentary copy of our book.
As CEO and Principal of BaldrigeCoach, Kay Kendall coaches organizations on their paths to performance excellence using the Malcolm Baldrige National Quality Award criteria as a framework. In each edition of Arkansas Hospitals, Kay offers readers quality improvement tips from her coaching playbook. Contact Kay at 972.489.3611 or Kay@Baldrige-Coach.com.
ARKANSAS HOSPITAL ASSOCIATION . 45
46 . FALL 2017
GOOD CATCH, ARKANSAS! By Susan Y. Allen, American Data Network PSO
A
merican Data Network PSO’s (ADNPSO) Good Catch campaign is transforming the way Arkansas hospitals approach patient safety. Frontline staff, managers and senior leaders in 43 facilities are discovering the value of a
traditionally under-reported type of patient safety event – the "near miss." Good Catch promotes a proactive mindset by empowering staff to speak up when potential risk is identified, because a near miss reported today could prevent an error tomorrow. Close calls are free lessons that reveal weaknesses and strengths in processes while accentuating opportunities for improvement. Prior to the campaign’s January launch, ADNPSO provided training related to near miss reporting and an online tool kit
in reports at shift change and a heightened sense of urgency
featuring a Blueprint for Success. The PSO releases new
in fixing a problem when a safety concern is shared. One
resources, including infographics and tip clips, quarterly.
of the more challenging issues addressed at LMH involves
At the end of July, hospitals had collectively reported over
how changes are made to “Do Not Resuscitate” orders when
2,000 near misses and reinvigorated their commitment to
patients are discharged to the nursing home.
growing a strong safety culture. Facilities have reinstituted idle
“Near miss data helped us see that our process wasn’t
patient safety committees, engaged leadership and enhanced
working,” Lory Williams, Med/Surg Director, said. “We needed
communication among departments.
to find a better way to pull nursing home leadership into the
Tiffany Richardson, Director of Quality Initiatives & Clinical Informatics at Ouachita County Medical Center (OCMC), said the hospital has seen a significant increase in near miss
communication process with the patient, family and hospital staff, and now, that’s exactly what we’re doing.” While ADNPSO established a Good Catch Awards program
reporting after deciding to pilot Good Catch in its nursing
to reward extraordinary achievement in using near miss data to
and pharmacy departments. One process improvement,
drive change, hospitals are using various in-house strategies
recommended by the pharmacy director, involved a change in
to encourage staff and sustain campaign momentum. For
the hospital’s Coumadin protocol and has made a huge impact.
instance, when staff report near misses at LMH, their names are
“Implementation of a ‘Hard Stop’ policy, which requires
entered into a pool. At the end of each six-month period, the
drawing a baseline INR on all patients prior to receiving
hospital staff draw names from the pool and award three $50
Coumadin, brought our instances of hypercoagulation down to
prizes.
ZERO over the last three months,” Richardson said. Now that processes are in place for appropriate reporting, measuring and tracking, OCMC is set to go hospital-wide with Good Catch in October. “We believe the impact will prove immeasurable for our patients’ safety,” Richardson said. Lawrence Memorial Hospital (LMH) has seen an increase
“Simple rewards, like candy bars, can be ample incentive,” Williams said. “It’s really about listening to the staff. ‘Small but enjoyable’ seems to work well for us.” LMH even had an EMT report a near miss. Staff told him about the Good Catch campaign and showed him how to fill out a report. He earned a candy bar, and word of the Good Catch concept was carried beyond the hospital setting. ARKANSAS HOSPITAL ASSOCIATION . 47
48 . FALL 2017
ARKANSAS HOSPITAL ASSOCIATION . 49
RURAL PATIENTS’ SUPERHEROES Critical Access Hospitals Earn 5-Star Ratings
Brian “Superhero” Lee (front) joins the CAH Workshop attendees, along with AFMC, AHA and ADH staff.
By Michelle Sharp, MSN, RN, CPPS, and Mandy Palmer, RN, CPHQ, CPPS, Arkansas Foundation for Medical Care he Medicare eneficiary Quality Improvement
T
provided an opportunity to gain knowledge and share
Program (M QIP), overseen by Medicare’s
experiences that reflect the M QIP program and focus on
Rural Hospital Flexibility program (Flex), focuses
HCAHPS.
patient engagement, care transitions and outpatient care. All 2
his innovative approach, which weaves together the patient
Arkansas CAHs participate in the M QIP program by reporting
experience and patient engagement to change hospital culture.
data and actively working to improve care in rural areas.
It focuses on three cornerstones of engagement: engage,
on improving quality of care in critical access hospitals (CAHs) in four domains: patient safety,
The patient engagement domain includes the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a standardized survey that measures
The event featured nationally recognized speaker rian Lee, CEO of Custom Learning Systems. Mr. Lee presented
empower and transform. CAHs were inspired to push through the challenges that small, rural hospitals face. Attendees left the workshop with several key ideas and
patients’ perception of their hospital experience. The survey
interventions, including:
is important because it demonstrates the patients’ voice.
• Appoint a patient experience council to make patient
There is growing evidence of a positive association between
experience a top priority; be sure it’s supported by
patient experience and health outcomes, quality of care, and
management.
adherence to treatment and preventive care.
• now your HCAHPS scores and share results with all staff,
The Arkansas Foundation for Medical Care (AFMC), under
including reading patients’ comments at staff meetings.
contract with the Arkansas Department of Health’s Office of
• Educate staff about HCAHPS, recognizing that all staff are
Rural Health and Primary Care, recently hosted an annual CAH
caregivers and patient experience is everyone’s job.
workshop. ringing together Arkansas CAHs, the workshop
• As leaders, empower staff to impact HCAHPS domains.
50 . FALL 2017
Some specific innovative ideas to empower staff include:
cards. Additionally, the hospital focuses on HCAHPS comments
Issue a “License to Silence,” expecting everyone to speak in
for improvements, including stoplight noise meters for noise
gentler tones and report noise. Create a “No Pass one,” expecting any staff to offer assistance with call lights. Issue “Freedom to Clean” cards, empowering everyone to be housekeepers. Implement a rewards program, “Pain Care Angels,” recognizing staff for compassion, recognition and pain treatment. Allow staff to "own" recovery by developing patient advocates. Wear vests during medication pass that signal “do not disturb me,” to prevent errors. Use the best quality folders with your hospital logo for discharge packets. Sit down with patients and talk to them daily. “When you sit, you’re heart to heart,” Mr. Lee said. Arkansas CAHs perform as well or better than the nation in HCAHPS. Over the past few years, several Arkansas CAHs have achieved a Five-Star HCAHPS rating, placing them
reduction and upgrading patient amenities like vending and cable services. The hospital displays quarterly HCAHPS scores and celebrates with pizza and ice cream parties. Most recently, they created a banner picturing all employees. It hangs in their main hallway for all to see, stating, “We are ALL the Patient Experience.” At Mercy Hospital erryville, leadership places a strong emphasis on exceptional care and the importance of a great patient experience, recognizing that patients have a choice of where they receive care. Leadership routinely makes rounds to all departments and holds roundtable discussions where all staff are invited to meet and share ideas or concerns regarding the patient experience. The culture at Mercy is rooted in a focus on process improvement, recognizing that patient perception may not always match the intention. ecause of this, front line staff in every department are expected to play a role in improving the patient experience and carrying out Mercy’s mission. Staff appreciation is demonstrated during “Spirit Days” and
among the top 6% of hospitals in the nation. Most recently, this
“Opportunities for Fun” events throughout the year. A staff-
included CrossRidge Community Hospital in Wynne and Mercy
developed program allows peer recognition of excellence
Hospital erryville.
through selection of a monthly “Shining Star.”
CrossRidge Community Hospital has strong community
Leadership is fundamental to improving the patient
support. Active leadership engagement is reflected in the
experience and improving quality outcomes. Mr. Lee said
staff’s attitudes and beliefs. Pat Hamilton, quality director, says,
it best: “ our people can’t care about what they don’t know
“Our CEO is so eager to use data that he frequently asks for it
about. our role as a leader is to educate your people to know
before it’s even available.”
and inspire them to care.”
CrossRidge’s successful patient-centered processes include purposeful hourly rounds, communication white boards, bedside reports, discharge phone calls and patient thank you
Michelle Sharp is an Outreach Specialist and Mandy Palmer is Manager of Outreach Quality at the Arkansas Foundation for Medical Care.
(Left Photo) Representatives of Mercy Hospital Berryville’s patient engagement team are (left to right) Kathy Brown, Tyler Tanner, Delano Richardson, Tony White, Suellyn Fry, Dr. Richard Taylor, Joyce Eggert, Sherry Cooper, Laura Farmer, Dr. William Flake, Keresa Phillippe, Cindy Kendrick and Vickie Allen. (Right Photo) Janet Perry (left), Outreach Services Director, and Pat Hamilton, Quality Director, are proud of CrossRidge Hospital’s patient engagement banner. ARKANSAS HOSPITAL ASSOCIATION . 51
FORWARD MOMENTUM IN HEALTHY ACTIVE ARKANSAS Hospitals as Catalysts for Community Health Innovation By Craig Wilson, JD, MPA, Health Policy Director, Arkansas Center for Health Improvement
L
aunched in 2015, the 10-year, Governor-led Healthy Active Arkansas initiative was sparked by the state’s consistently poor ranking with respect to obesity rates. The initiative is now ripening as statewide and local efforts to encourage and
enable healthier lifestyles take shape through the recruitment and engagement of local leaders and the development of a statewide network to share resources and track progress. At an early stage in Healthy Active Arkansas’s planning, health and government leaders acknowledged that achievement of Healthy Active Arkansas’s single overarching goal – to
• Supporting breastfeeding; and • Implementing a communications and marketing program to support all priority areas. Nearly 250 local hospital executives, city and county officials,
increase the percentage of adults, adolescents and children
superintendents, college administrators, community advocates
who are at a healthy weight – required a framework that could
and others have joined the network and have committed to
be adopted and implemented in realistic ways by a diverse
changing norms and behaviors with respect to nutrition and
group of stakeholders. Local decision-makers in the business
physical activity where they live, work, pray and play.
community, nongovernmental organizations, educational and
During five regional meetings around the state, members of
faith-based institutions and engaged supporters at all levels of
the network generated more than 100 action plans identifying
government were the focus of recruitment. While centrally-
strategies, barriers and partners to create change in at least
initiated statewide policy efforts to address obesity were
one of the nine priority areas. Facilitated by technical assistance
laudable and certainly welcomed, local champions were
from the Healthy Active Arkansas priority area leads, plans are
recognized as the true agents of change.
already turning into action.
To energize and equip communities with the tools to create
For example, one hospital’s action plan has resulted in a
change, the Arkansas Center for Health Improvement, with
system-wide assessment of healthy vending food options with
support from the lue & ou Foundation for a Healthier
the goal to incrementally but significantly increase the percent-
Arkansas, set out earlier this year to develop a statewide
age of healthy options available.
learning network to advance Healthy Active Arkansas’s
At least two counties have formed their own local Healthy
objectives in the initiative’s nine priority areas:
Active county collaborations, propagating further action planning
• Improving the physical and built environment;
within the community.
• Encouraging nutritional standards in government, institutions
Three Arkansas hospitals have implemented practices that
and the private sector;
protect, promote, and support breastfeeding and have received
• Ensuring nutritional standards in schools – early child care
designations through the aby-Friendly Hospital Initiative, while
through college;
four others are well on their way to obtaining such a designation
• Ensuring physical activity and education in schools – early
by year’s end.
child care though college; • Establishing healthy worksites; • Enhancing access to healthy foods; • Reducing sugar-sweetened beverage consumption; 52 . FALL 2017
Several businesses across the state also have committed to optimizing work environments to support breastfeeding. Leading by example, the Arkansas General Assembly and Governor’s office participated in the Capitol Go! Fitness Chal-
lenge, logging more than 32 million steps during the 2017
patients, but also everyone in their geographic communities, and
legislative session, and 53 schools and 20 hospitals participated
to broaden strategies to address non-medical determinants of
in the lue and ou Fitness Challenge this year.
health. With a focus on access to wholesome foods and
Hospitals are well-poised to drive community change to
opportunities for physical activity – major factors impacting
achieve a healthy, active Arkansas. Hospitals are among the
health – Healthy Active Arkansas offers a framework for
largest employers in many Arkansas communities. Faced with
community leaders, including hospitals, to align interventions that
budgetary constraints like other businesses, hospitals have
can help hospitals be more successful in these new payment
strong incentives to create a healthy environment for employees
models by preventing or reducing obesity-related health issues
in order to reduce their own health care costs and improve
and their associated costs.
employee productivity. Hospitals can also serve a critical
Now two years into the initiative, Healthy Active Arkansas is
function as respected leaders and role models to help establish
gaining considerable momentum. A tax exempt, non-profit
a business commitment to healthy worksites.
organization has been formed to provide infrastructure, authority
Non-profit hospitals can also satisfy federal tax requirements
and ownership, but local champions will continue to be the
to conduct community benefit and community-building activities
drivers of change to realize the vision of a healthier Arkansas –
identified through those assessments by plugging into Healthy
one in which Arkansans are more apt to maintain a healthy
Active Arkansas efforts. There is a heightened need to demon-
weight, allowing them as well as their communities to prosper
strate community benefit at a time when expanded health care
from reduced healthcare expenditures, higher productivity and
coverage is reducing the need for charity care. The nine priority
improved quality of life.
areas in Healthy Active Arkansas offer hospitals opportunities
A hospital’s core mission, of course, is to provide medical
to collaborate with non-traditional partners and to invest in their
care to its patients. However, with significant influence through
community’s ability to engage in healthy lifestyles.
their roles as respected organizations and large employers, as
Finally, hospitals are encountering new pressures under
well as their leadership expertise, hospitals are not only a critical
value-based payment models that reward providers for keeping
partner, but can also serve as a catalyst to foster a community-
people healthy. These new models are creating incentives for
wide infrastructure and align local strategies to combat obesity,
hospitals to define target populations that include not only their
an innovative investment with many returns.
ARKANSAS HOSPITAL ASSOCIATION . 53
LEADERSHIP PROFILE
INNOVATION IN ACTION By Nancy Robertson, Senior Editor
H
oward Memorial Hospital CEO Debra Wright is a health care innovator. Known for making accessible a cadre of specialists to this Critical Access Hospital located in Nashville, Arkansas and for successfully growing its outpatient business, Wright speaks passionately about the privilege of serving patients in Howard County and the surrounding area. “My heart has always been in the not-for-profit setting,” she
new services our patients need right here, so they do not have to travel a great distance to receive health care.” She is equally passionate about HMH being a great place to work for its 200 employees. “I’m a firm believer that no one person’s job or title is more important than any other in a hospital setting; every job and the person doing it make the contributions that are necessary to achieving good outcomes, employee and patient satisfaction and teamwork. Every
says. “Our focus is on our mission to improve the health of the
employee deserves a pleasant work environment, since we
communities we serve. Providing charity care to those who do
spend more time at work than we are able to spend with our
not have the resources to pay for health care is a perfect ex-
family and friends. Therefore, as leaders, we must do all we can
ample of how a not-for-profit hospital can improve health in its
to assure our hospitals provide the most pleasant work
local communities.”
experience and environment possible.”
In order to provide that charity care, however, the hospital
FIRST, THERE WAS NURSING
must be a strong business organization. “At Howard Memorial, (HMH) we understand that there has to be a margin in order
Wright comes to her role as CEO speaking the dual
to fund the mission (no margin, no mission),” says Wright, “so
languages of “clinician” and “business leader.” Wadley
we operate according to a Strategic Plan with annual goals to
Regional Medical Center in Texarkana, Texas was the large
guide us in our operational decision-making.”
facility where she worked as a registered nurse for more than
Wright believes that goals cannot be accomplished in isolation; achievement requires every employee to be engaged. “Critical Access Hospitals, especially, have limited resources,
20 years, caring for patients while taking on increasingly demanding leadership roles. “I feel very blessed to have worked with the staff at Wadley,”
so working together to achieve our goals ensures that funding
she says. “The culture there both encouraged and made
will be available to provide the charity care and implement the
possible numerous educational experiences.” Her nursing roles at Wadley included serving as an RN, Shift Director, Special Projects Coordinator, Executive Director of Nursing, CNO, and finally as the Chief Clinical Officer, responsible for nursing, the heart cath lab, cardio-pulmonary department, surgery, med-surg, ICU, lab, maternal health services, the GI lab and other non-nursing clinical departments. “I was a poster child for upward mobility opportunities!” she smiles. “As time went on, I realized that though I understood clinical language – how we communicate with physicians, etc. – the language of business was very different. That is why I pursued my master’s in business administration. My leadership role demanded that I be proficient in both areas.”
54 . FALL 2017
Debra Wright, CEO of Howard Memorial Hospital What is the best advice you ever received? The person who takes the time to give you constructive criticism cares about you the most. Everyone can learn from mistakes. ou cannot take back a mistake, so what you do the next time is what matters most.
What would you like to be doing if you weren’t in health care I have always been fascinated with architecture and design.
Something about me most people don’t know is I enjoy painting abstract art. Each person interprets an abstract painting differently.
What’s on your iPod playlist I do not have a playlist, but I listen to music of all kinds – jazz, blues, American Songbook classics, soft rock and oldies, depending on my mood.
What are you currently reading? Right now, I’m reading Camino Island by John Grisham.
Where would you most like to travel? Rome!
What inspires you? I am inspired by people who have a passion about what they do.
ARKANSAS HOSPITAL ASSOCIATION . 55
MEETING PATIENT NEEDS In 200 , Wright accepted the role as CEO at Howard Memorial. “I am grateful for the opportunity to have been chosen for this position,” she says. “When I joined HMH, the new hospital had just been built. It was a privilege to walk into this beautiful new facility, which was the right size for the services offered at the time. ut we soon learned there wasn’t a lot of growing room, though there was a need for added patient services.” Wright and the HMH oard first identified opportunities
When driving uphill to the hospital itself, a winding road leads past several of these physician clinics and outpatient service centers, but there is lots more room on the HMH campus for future growth. Wright reaches to pick up a leadership blog titled "Improving Rural Healthcare Delivery." The article affirms expanding outpatient programs, and HMH currently offers four of the five recommended services listed for rural hospitals’ consideration. “I was glad to see that we’re already offering almost everything suggested,” she says.
MORE INNOVATING
for meeting patient needs by increasing outpatient services several years ago, and they put into place not only physical sites, but also growth strategies. “Our first major, new project was the construction of a 4,300-square foot rehab space, for which the hospital foundation donated 200,000,” Wright says. That space is fully occupied, and now offers both inpatient and outpatient physical, occupational and speech therapy services. A need for behavioral health services was identified by the hospital through a Community Needs Assessment (a program the administrative team began in 2013), and the new outpatient geriatric clinic dedicated to these services opened in the summer of 2015. Also added have been a wound care clinic, sleep study program, mobile MRI, cardiac and pulmonary rehab and clinic space for a number of physicians. “We wanted all of our employed physicians to be located on our hospital campus,” Wright says. “The Foundation built our first clinic building, and a second medical office building was recently completed.” Specialties covered by visiting physicians include O G N, pediatrics, cardiology, hematology oncology, urology and dermatology. In addition, mobile PET CT scan units are frequently available on the campus. Coming soon to the HMH service line: an allergy clinic is slated for opening toward the end of the fourth quarter of this year.
56 . FALL 2017
“We have also tapped into a new opportunity that others might explore – HMH offers post-offer employment testing for the Pilgrim’s Pride Corporation,” Wright says. “We mostly test for physical capabilities through timed skill tasks, making certain workers are up to the demands of the positions offered.” Another innovation: HMH in Nashville serves as the -ray provider for a DeQueen Clinic. HMH’s radiologist offers the interpretive report within 15-30 minutes – a great improvement over the more than 1-2 week wait times clinicians at DeQueen had been used to before HMH services were employed. Hospitals today, no matter their size, are facing an increase in demand for doing more with less. The success of growing innovative methods of care at Howard Memorial Hospital has become a hallmark of its service, attributable, in great part, to Wright’s passion for patients and her savvy in both the business and clinical worlds. “As a hospital CEO, there is no greater reward than to work with employees who are dedicated to achieving the best possible outcomes for our patients,” she says. “They inspire me every day to strive for excellence.” Wright honors Arkansas by having been recently elected to the American Hospital Association’s Council for the Section for Small or Rural Hospitals. She is one of 18 elected members, of which two are from AHA Region 7 (Arkansas, Louisiana, Oklahoma and Texas). She will serve from January 2018 to December 2020.
MEDICAL MARIJUANA: A Fast-Approaching Reality in Arkansas By Stuart Jackson, J.D., Wright Lindsey Jennings
N
ow that the Arkansas General Assembly has
1. Cannot discriminate against an individual (which includes
passed and the Governor has signed into law
not hiring, disciplining, failing to promote or terminating
House ill 1460 (now known as Act 5 3, the
employment) or otherwise penalize an individual based upon
Arkansas Medical Marijuana Amendment of
the individual's past or present status as a qualifying patient
2016), employers in Arkansas have some level
or designated caregiver – basically, you should think of this as
of clarity about what they can and can’t do when it comes to medical marijuana. ut, that clarity only goes so far and, in my mind, landmines
another “protected class” under state law; 2. Cannot discipline a qualifying patient or designated caregiver for the medical use (which includes actual use or mere
still exist for employers, especially hospitals and medical care
possession) of marijuana according to the Amendment if he or
providers.
she possesses not more than 2
In this article, I will lay out the various protections both em-
ounces. Under the Amend-
ment, a rebuttable presumption exists that a qualifying patient or
ployees and employers have under the terms of the original
designated caregiver is lawfully engaged in the medical use of
Amendment and the modifications to the Amendment recently
marijuana if he or she is in actual possession of a registry identi-
made by the General Assembly. I will also talk about how most
fication card issued by the Department of Health and possesses
Arkansas employers should plan for this fast-approaching reality.
an amount of usable marijuana that does not exceed 2
EMPLOYEE PROTECTIONS IN THE ORIGINAL AMENDMENT From an employment perspective, the Amendment allows "qualifying patients" who have "qualifying medical conditions"
ounces;
3. Cannot discipline a qualifying patient or designated caregiver for giving a permitted amount of usable marijuana to another qualifying patient or designated caregiver for medical use if nothing of value is transferred in return; 4. Cannot discipline a qualifying patient or designated care-
and “designated caregivers” (those who have agreed to assist
giver for possessing marijuana paraphernalia to facilitate the use
disabled qualifying patients with the medical use of marijuana)
of medical marijuana;
certain protections in the workplace. For instance, employers:
5. Cannot discipline anyone for giving a “qualified patient” ARKANSAS HOSPITAL ASSOCIATION . 57
marijuana paraphernalia to use with medical marijuana; and 6. Cannot discipline a person for being in the presence or
• Permitting the discipline of an employee if there is a good faith belief that he or she used or possessed medical marijuana on
vicinity of the medical use of marijuana or for directly assisting
site or during work hours.
a physically disabled qualifying patient with the medical use of
• Permitting the discipline of an employee if there is a good faith
marijuana.
belief that he or she was under the influence of medical
"Qualifying medical conditions" presently include cancer,
marijuana on site or during work hours.
glaucoma, HIV AIDS, amyotrophic lateral sclerosis, severe
• Allowing employers to exclude a person (an employee or an
arthritis, posttraumatic stress disorder (PTSD), Tourette’s
applicant) from a safety-sensitive position if there is a good faith
syndrome, hepatitis C, Crohn’s disease, fibromyalgia,
belief that person is a current user of medical marijuana.
Alzheimer’s disease, ulcerative colitis and any "chronic or debilitating disease or medical condition" with symptoms such as peripheral neuropathy, "intractable pain," seizures, "severe" nausea or "severe and persistent" muscle spasms. Of course, the protections in the Amendment are contingent on the patient or caregiver actually possessing a medical marijuana card issued by the Arkansas Department of Health.
"In my mind, landmines still exist for employers, especially hospitals and medical care
EMPLOYER RIGHTS UNDER THE AMENDMENT AND ACT 593
providers."
The Amendment and Act 5 3, when combined, provide significant protections for Arkansas employers, including those in the medical profession and industry. First, the Amendment does not require an employer to
These protections allow employers a wide variety of latitude when it comes to applicants or employees with a medical marijuana card. Employers are allowed (in certain situations) to
"accommodate the ingestion of marijuana” in the workplace. So,
refuse to hire an applicant, monitor and assess the job perfor-
unlike what might be considered the “normal” use of prescription
mance of an employee, reassign an employee to different job
drugs, Arkansas employers do not have to allow their employees
duties or positions, place an employee on paid or unpaid leave,
to “light up” or ingest medical marijuana on their property.
suspend or terminate an employee, and even require
Further, the Amendment states that nothing in its text permits a person to possess, smoke or use marijuana in a variety of
successful completion of a substance abuse program. ut, a word of caution – just because one has the right to do
locations, including schools of any type, alcohol or drug
something under the protections added by Act 5 3 doesn’t
treatment facilities, community or recreation centers, public
necessarily mean that one should. With the mix of state and
transportation and any "public places."
federal employment-related issues swirling around medical
Second, the Amendment does not require an employer to
marijuana, employers need to be very careful about how they
allow an employee to work "while under the influence of
treat employees with a medical marijuana card. nee-jerk
marijuana” and states that nothing in its text permits a person to
reactions will not serve employers well, especially when they
undertake any task under the influence of marijuana "when doing
lead to the first lawsuits to be filed by employees with medical
so would constitute negligence or professional malpractice."
marijuana cards.
Finally, the Amendment does not permit a person to operate, navigate or control any type of "motor vehicle, aircraft, motorized watercraft, or any other vehicle drawn by power other than muscle power" while under the influence of marijuana.
MEDICAL MARIJUANA DISCRIMINATION CLAIMS UNDER ARKANSAS LAW Let’s say you make a mistake with one of your employees; for
Act 5 3 adds other protections for Arkansas employers.
instance, you misclassify a job as safety-sensitive and decide to
Initially, it defines “employer” as those employers with nine or
terminate an employee based on his current medical marijuana
more employees. If you have fewer than nine employees, you
cardholder status.
may not have to worry about medical marijuana. Other provisions
What could happen? A lot! ou could get sued and face dam-
include:
ages for months or years of lost wages and benefits. ou could
• Allowing employers to have and enforce drug-free and
also face paying other types of compensatory damages, punitive
substance-abuse testing policies that apply to both applicants
damages and the terminated employee’s attorney’s fees and
and employees (which in some situations could be problematic
expenses. Plus, you might even have to reinstate the employee!
under the original terms of the Amendment). Federal contractors
Do not underestimate the consequences of running afoul of the
are certainly happy to see this.
medical marijuana laws.
58 . FALL 2017
START PLANNING FOR MEDICAL MARIJUANA Even though medical marijuana probably won’t be available in Arkansas until early 2018, start planning now for this fastapproaching reality. Here is a list of things to do: 1. Take a hard look at your written job descriptions, especially the ones you consider to be safety-sensitive. Update them as needed and be sure to indicate in writing which ones are, in fact, safety-sensitive. ut don’t go overboard by claiming all of your jobs are safety-sensitive. If the greatest risk inherent in a given job is a paper cut, it is probably not going to be safety-sensitive, and if you take action against an applicant or employee based on a mistaken belief that a job is safety-sensitive, you could face a lawsuit and significant damages. Don’t lose your common sense. 2. For truly safety-sensitive positions, make it a requirement that an employee disclose to your HR Manager that he or she is using medical marijuana. It’s possible you already have a rule in place like this for prescription drugs that may impact an
4. Consider adding a drug-free workplace or substance abuse-testing policy to your employee handbook. 5. Talk to your Medical Review Officer about how positive tests for marijuana will be reported if the person tested (an applicant or employee) has a medical marijuana card. 6. Don’t lose sight of the fact that other employment laws, like the Americans with Disabilities Act and the Family and Medical Leave Act, may come into play not because of the use of medical marijuana, but because of an underlying health reason. Arkansas employers will be faced with all sorts of scenarios in the coming months and years, from the medical marijuana user who is caught under the influence at work, to the long-time employee who is legitimately in need of medical marijuana, to the employee who posts a video on Facebook of himself or herself using medical marijuana at home. Think through the various scenarios, make sure you understand the law, and be ready to make a reasoned decision on how to react.
employee’s ability to safely perform the essential elements of his or her job. 3. Make sure your handbook is up-to-date and include in it
William Stuart Jackson has been practicing in the labor and
prohibitions against the use and possession of medical marijuana
employment field for twenty-five years and heads up the abor
at work or during work hours (if you so choose) and being under
Employment Team at Wright Lindsey Jennings in Little Rock. You
the influence of medical marijuana at work or during work hours.
can contact him at wjackson@wlj.com.
ARKANSAS HOSPITAL ASSOCIATION . 59
presents...
PASSPORT TO CLINICAL ROTATIONS careLearning com and the Passport Program
ou’re a college student in the health sciences and it’s time to egin your clinical rotations Some of your classmates will go to two different hospitals you’re assigned to three And then you find out that orientation for each hospital re uires different coursework That’s uite a challenge Or it used to e
E
nter the Passport Program. A common
Arkansas’s program just launched with fall classes that
orientation program developed by
began in August, but the Natural State has the largest group
careLearning.com in coordination with
of participating hospitals and colleges to date.
Arkansas hospitals and colleges that provide nurses training, the program consolidates
“This is really beneficial for all concerned – the hospitals, the colleges and the students,” says Laura Register,
all orientation curricula into one package. Health sciences
careLearning’s Executive Director. “More than 75 colleges,
students can now access one online curriculum that meets
hospitals and other providers are already participating.”
the compliance imperatives of all participating hospitals.
Students say they like the consolidated nature of the
Each hospital can also offer supplemental material to
compliance orientation, and they appreciate being able
meet its individual needs – including content specific to the
to complete orientation coursework for all of their hospital
facility where the student reports. This might include dress
rotations in one online package. Colleges report a reduction
code, parking, hospital rules and regulations and other
in paperwork and resource coordination hassles.
information each student must know in order to begin clinical work at that location. Paid for by the student, the Passport Common Orientation
Last fall, health care organizations and colleges from across the state came together to determine the common curriculum. Topics cover coursework needed to satisfy CMS,
Program has a once-annual 10 fee in Arkansas. The fee
OSHA, The Joint Commission and other common regulatory
may be paid outright, through a fee awards program or be
body requirements.
added to the student’s loan amount. That 10 fee covers all
Through its affiliation with the Arkansas Hospital
costs for the program, and for that price, the student is able
Association and AHA Services, Inc., careLearning.com was
to take any courses needed for the entire year.
selected as the online training vendor for this consolidated
The Passport Program was first offered by careLearning in
orientation program. Students take their orientation
200 in Rhode Island. South Carolina added the program in
coursework as part of the required curriculum at their
2012, and St. Louis came on board in 2016.
respective schools and present transcripts as they report
60 . FALL 2017
to the hospitals where their clinical rotations will be performed. Among the consolidated orientation topics available are: Disaster Preparedness, Bloodborne Pathogens, Abuse and Neglect, Fire and Electrical Safety, Hand Hygiene, Customer Service, Cultural Competence in the Workplace, Sexual Harassment, Tuberculosis Prevention, Hazard Communication, Workplace Diversity and Workplace Violence. Outcomes in other careLearning states have shown that, compared to previous methods, the consolidated orientation program has furthered student knowledge and skill. Both students and health care organizations save considerable time during the general orientation process, allowing health care organizations to place students into their rotations more expeditiously. Since the online content is always consistent, up-to-date and convenient, everyone can be confident that orientation requirements have been met. To learn more about the Common Orientation for Clinical Rotation Programs (Passport), contact Laura Register, Executive Director, careLearning, 866.617.3904, lregister@carelearning.com.
ARKANSAS HOSPITAL ASSOCIATION . 61
POLICY AND ADVOCACY
REDUCING OPIOID DEATHS WILL TAKE ALL OF US By Kirk Lane, Arkansas Drug Director
W
e see it on the news every day. We read
• In Arkansas in 2016, 114.6 prescriptions for opioids
about it constantly in our papers and
were written per every 100 persons. That’s more than one
online. Tragically, too many of us know
prescription per person for every man, woman and child in
those whose lives have been lost, their
Arkansas.
families grieving, their communities
• The Arkansas death rate from opioid overdose is on the
asking why. Too many of us are living this reality. It’s a nationwide problem: opioid abuse. Just how bad is it in Arkansas, and what are we doing to get a handle on this crisis?
rise. In 2015 (the last date for which figures are available), the opioid death rate was 6.6 per 100,000 population. That’s 186 opioid-related deaths, up 14% over 2014. The combined drug overdose death rate was 13.8 per 100,000 population. That is 3 2 deaths, up 10% over 2014. • We know that the number of reported deaths attributed to opioid overdose is low. • Prescription opioid addiction often leads to heroin use, as
< 57.2
heroin is less expensive than prescription opioids.
57.2 - 82.3
• 70% of the opioids taken without medical need come from
82.4 - 112.5
people the users know. They may be prescriptions for a family
> 112.5
member or pills left over from treatment of an earlier illness. Often, they are pills easily found in the medicine cabinets of friends’ and family’s homes.
Arkansas Prescribing Rates, by County: The rate of pre-
ARKANSAS ACTIONS
scribing opioids in Arkansas continues to be high, despite public awareness of the national opioid addiction crisis. This
Governor Asa Hutchinson is committed to reducing opioid
map shows the number of prescriptions for opioids written,
deaths and abuse in Arkansas. This year, he signed into law
per 100 persons, per county in the state in 2016. (Centers
Act 820, which requires prescribers to check the Arkansas
for Disease Control and Prevention)
Prescription Drug Monitoring Program (PDMP) database each time they prescribe a Schedule II or Schedule III opioid, and
STARK STATS • Arkansas currently ranks 2nd in the nation for the number
the first time they prescribe a benzodiazepine medication to a patient. Arkansas has had its own PDMP since 2011. (Every state
of opioid prescriptions written. Only Alabama has a higher
except for Missouri currently has an operational PDMP.)
prescribing rate.
Dispensers in Arkansas have been required to electronically
• As the number of prescriptions written for opioids goes up,
submit information regarding each prescription dispensed for a
the number of deaths from opioid abuse goes up. These go
controlled substance since that time. That has given our state a
hand in hand.
foundation of information upon which to call.
62 . FALL 2017
U S State Prescri ing Rates
-
U.S. Prescribing Rates, by State: Arkansas ranks second in the nation for the total annual number of opioid prescriptions written. In Arkansas in 2016, there were 114.6 opioid prescriptions written per every 100 persons. (Centers for Disease Control and Prevention)
The 2017 law additionally requires prescribers to check the PDMP with each prescription written for these drugs. This will give them information on whether or not their patients
mandate, collect hundreds of opioid pills over the course of a few weeks. I know of one physician, initially highly skeptical of the PDMP
have been prescribed these controlled substances by other
and its intended use, who is now speaking out on its behalf.
providers, as well as how much and how recently. This is not
The first two patients’ names he entered into the PDMP showed
a check ON providers; it’s a check FOR providers, so they
visits to other physicians recently, where they sought and were
can be better informed about their patient’s opiate use before
written prescriptions for opioids. He was taken by surprise;
prescribing.
he thought he knew these patients well. Instead of writing the
The new law will take some time to become routine for
prescriptions they asked for, he helped them seek counseling
prescribers, but statistics tell us it will make a real difference
for opioid addiction. He knew that they needed help, and he
in reducing opiate abuse. We realize that change is difficult
provided it.
and that there will be a period of time needed to increase acceptance and understanding. We also want to reassure prescribers that we have been
Together, our hospitals, physicians and other prescribers, along with prescriber policy voices like the Arkansas Hospital Association, Medical Society and Medical oard, can, with
listening to your concerns, and tweaking of the PDMP software
consistent use of the PDMP, assure that prescriptions written
for more timely access and ease of use is currently underway.
for opioids are done so with full knowledge of the patient’s
IT WILL TAKE ALL OF US I call the epidemic of opiate drug use an “opidemic.” What
prescription history. Arkansas’s “opidemic” can be turned around if we all accept our responsibilities in this tragic and growing crisis and work
we’re trying to do here in Arkansas is improve the numbers,
together collectively to make the difference. Using the PDMP
reduce deaths and reduce people’s reliance upon these drugs.
to its potential, improving prescribing habits, encouraging
The Governor is asking, and as Drug Director, I am asking,
more consumer use of existing Prescription Drug Takeback
that we all work together to reduce the opioid problem in
programs, helping those who have developed a reliance upon
Arkansas. States that have mandatory requirements for
these drugs to find help in overcoming addiction – these are
prescribers to check their PDMP have shown a 25% decrease
the tools that will turn the tide in Arkansas.
in deaths and emergency room visits. The new law is not aimed at depriving anyone of needed
Kirk Lane is the former Chief of Police in Benton, Arkansas.
medications but is directed at prescribers to make better
He is a former member of the Arkansas Drug and Alcohol
prescribing decisions based on history. We know that people
Coordinating Council, the Arkansas Prescription Drug Advisory
who are addicted to opiates often “doctor shop,” going from
Board and served on the advisory committee for the Arkansas
physician to physician stating that they need relief from
Prescription Drug Monitoring Program. He began his position
pain. One patient could easily, prior to the PDMP prescriber
as Arkansas Drug Director on August 7, 2017. ARKANSAS HOSPITAL ASSOCIATION . 63
64 . FALL 2017