Arkansas Hospitals, Spring 2020 by Arkansas Hospital Association

ARKANSAS

HOSPITALS Spring 2020

empowered

to CARE

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2 SPRING 2020 | ARKANSAS HOSPITALS

The Quality Issue COMMUNICATING QUALITY

10 Empowered to Care

14 CANDOR: A Candid Approach to Care

18 The Language of Caring

PATIENT SAFETY FIRST

22 Coming to the Table

26 Reducing Maternal Mortality

30 Saving Arkansas Moms

NEWS

36 COVID-19: Hospital Resources

37 International Year of the Nurse

38 Evolution of Quality Professionals

39 Building a Culture of Ownership

43 AHA Services Presents

48 COVID-19: Personal Resources

IN EVERY ISSUE

5 President’s Message

6 Virtual Learning

7 Editor’s Letter

8 Hospital Newsmakers

32 Coach’s Playbook

45 The Capitol Report

ARKANSAS

HOSPITALS Arkansas Hospitals is published by The Arkansas Hospital Association

419 Natural Resources Drive | Little Rock, AR 72205 To advertise, please contact Brooke Wallace magazine@arkhospitals.org Elisa M. White, Editor in Chief Nancy Robertson, Senior Editor & Contributing Writer Ashley Warren, Associate Editor Katie Hassell, Graphic Designer

BOARD OF DIRECTORS

Chris B. Barber, Jonesboro / Chairman Ron Peterson, Mountain Home / Chairman-Elect Peggy Abbott, Camden / Treasurer Darren Caldwell, Jonesboro / Past-Chairman Ryan Gehrig, Fort Smith / Director-at-Large Greg Crain, Little Rock Barry Davis, Paragould David Deaton, Clinton Marcy Doderer, Little Rock Jan Gardner, North Little Rock Phil Gilmore, Crossett Vince Leist, Harrison James Magee, Piggott Mike McCoy, Danville Gary Paxson, Batesville Rob Robinson, El Dorado Larry Shackelford, Fayetteville Brian Thomas, Pine Bluff Debra Wright, Nashville

EXECUTIVE TEAM

Robert “Bo” Ryall / President and CEO Jodiane Tritt / Executive Vice President Tina Creel / President of AHA Services, Inc. Elisa M. White / Vice President and General Counsel Pam Brown / Vice President of Quality and Patient Safety Lyndsey Dumas / Vice President of Education

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 Central Arkansas Media. 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 Arkansas Hospital Association. 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, email magazine@arkhospitals.org.

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PRESIDENT’S MESSAGE

New Visions

in Quality Care I

t has always been AHA’s role to help Arkansas hospitals. We did so, initially, through advocacy, and then we added education and communication resources, followed by support for the expanding realm of data services. As each area grew, so did the association’s value to its members. The addition of the Quality Team to the AHA mix brought a heightened focus on patient safety and an explosion of new member services. Since February 2012, when Pam Brown joined us as Vice President of Quality and Patient Safety, AHA has put members on the cutting edge of the national quality movement. Pam’s team (Nikki Wallace, BSN, RN; Cindy Crump, MBA-HM, BSN, RN; and departmental assistant Cindy Harris) maintains a framework of support within which we can assist our hospitals as they seek to comply with new regulations, adopt identified best practices, and implement the latest methods of infection control. Their service is particularly visible as AHA works for our hospitals during the pandemic, allowing us to get valuable information into hospital leaders' hands on a moment's notice. The pandemic changes the nature of those team-to-team interactions, but it doesn't stop them. When social distancing is no longer necessary, our Quality Team members will again be inside our hospitals throughout the state, providing hands-on instruction and customized programs that further the pursuit of quality improvement. Each of our team members brings a unique perspective to quality groups within our hospitals, and together they provide access to the most recent, vetted resources available. AHA’s focus on quality informs our advocacy agenda at both the national

and state levels. It allows the association to tie the national quality agenda directly to our local hospitals. It makes Arkansas quality improvement data and patient stories available to the state legislature as new health care bills are considered. During this pandemic, we look back at the 2012 addition of the Quality Team to AHA with overwhelming gratitude. That intensification of our interactions with local hospitals paved the way for the valuable assistance we provide today. National quality improvement initiatives, including the Hospital Improvement Innovation and Hospital Engagement Networks, guide our efforts, but it’s the in-hospital team visits that make the difference as hospital quality and patient safety continuously evolve.

We’re dedicating this issue of Arkansas Hospitals to Patient Safety and Quality, highlighting a variety of quality-related programs and projects from around the nation. Included here is a look at Quality Improvement since publication of the Institute of Medicine’s blockbuster report, To Err is Human, 20 years ago; we also look at what hospitals are doing to improve hospital care and health outcomes for America’s mothers. We are especially proud of our Quality Team’s work with Patient and Family Engagement: You can read on page 24 about our own Patient and Family Advisory Council and how it works with individual hospitals that want to begin or grow their own committees. We also bring you ideas on the tough subject of patient harms: how to communicate compassionately and quickly when they occur. We take an important look at how to incorporate the “language of caring” into your hospital culture. When To Err is Human was published, the health care field was knocked back on its heels, and the modern patient safety movement was born. Improvement research and interventions are making a difference; safety challenges in the areas of medication errors, hospital-acquired infections, and preventable harms show improvement. But new challenges continue to emerge. There will always be room for process improvement and a space for positive interventions. We pledge that AHA will be with our hospitals every step of the way.

Bo Ryall

President and CEO Arkansas Hospital Association ARKANSAS HOSPITALS | SPRING 2020 5

2020 Virtual Learning To protect our health care teams during the COVID-19 pandemic, AHA’s in-person educational offerings are on hiatus. But webinars are always on tap to meet your training needs. Go virtual with these courses and series.

WEBINARS APRIL

April 21

CMS Radiology and Nuclear Medicine Hospital Conditions of Participation 9:00 a.m. – 11:00 a.m.

MAY

April 7

Chargemaster Management Best Practices 12:00 noon – 1:00 p.m.

April 7

Essentials of Hospital Finance 2020 12:00 noon – 1:00 p.m.

April 14

Emergency and Outpatient Services: Complying with CMS Hospital CoPs 9:00 a.m. – 11:00 a.m.

CAH Swing Bed Requirements 9:00 a.m. – 11:00 a.m.

May 5

Open Meetings in the Age of Technology 12:00 noon – 1:00 p.m.

May 7

2020 Vision for Wound Care Product Choices and Best Practice 1:30 p.m. – 3:00 p.m.

JUNE June 9

Building and Fostering a HighPerforming Board 12:00 noon – 1:00 p.m.

Try out one of our webinar series! Cultivating Good Health Through Personal Vitality, six sessions for stress reduction and resiliency, begins in April. We also offer a four-part Employment Law series and a fourpart series on Governance; both begin in May. For details on these webinars and information on registering, visit arkhospitals.org.

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2020 DIAMOND AWARDS Did your hospital produce an award-worthy marketing and/or public relations project in 2019? Submit it for consideration in the 2020 Diamond Awards. Sponsored by AHA and the Arkansas Society for Healthcare Marketing and Public Relations, the competition recognizes excellence in health care marketing and public relations across nine categories: • Advertising-Print/Digital. • Advertising-Special Visuals. • Advertising-Television. • Advertising-Total Campaign. • Annual Report. • Foundation. • Publication. • Special Event. • Writing. Submission deadline is May 1. Find entry information at arkhospitals.org.

EDITOR’S LETTER

In Support of

Caregivers H

ospitals must prioritize quality and patient safety in times of crisis, just as they do in times of calm. But a crisis like the present one certainly raises the stakes, as hospitals face unprecedented demands and a kaleidoscope of new challenges during the ongoing COVID-19 pandemic. For the past 20 years, hospitals throughout the U.S. have created operational cultures that prioritize quality and patient safety. AHA’s Quality Team has worked closely with Arkansas’s hospitals to build-in a sturdy framework of processes, tools, and information that has produced major gains in quality measures throughout the state. This issue of Arkansas Hospitals celebrates hospital quality and patient safety initiatives. Many of these articles were written just days prior to the COVID-19 outbreak in the U.S. Though the focus of hospital quality and patient safety has shifted dramatically in the past weeks, the tried-and-true structure that the Quality movement has built makes our response to the virus more agile, efficient, and effective. In AHA’s world, the virus’s rapid spread raises concern not only for patient care but also for our health care workers and medical professionals who selflessly serve. Levels of stress, exhaustion, and concern are on the rise – yet a groundswell of cooperation, collaboration, and mutual support lifts us all. While you’re tending to Arkansans stricken with the virus, we’re working with state leaders to locate new sources of the PPE to keep you safe. While you’re racing to keep tabs on all your patients, we’re rushing news and needs to Governor Asa Hutchinson, keeping him apprised of conditions in our hospitals. While you’re caring for those who are falling ill, we’re working with the Arkansas Department of Health to increase testing availability in our state. Through it all, we stand in awe of your bravery and compassion. We know who the angels and heroes are through this outbreak: They’re each of you and every person supporting the care you so willingly give.

They’re the ambulance drivers and EMS teams. They’re hospital cooks and supply chain managers, maintenance engineers and housekeepers, administrators and infection control officers. From our very hearts, we salute every person who is right now caring for patients, and we give thanks also for the network of support that surrounds them. But beyond our thanks, we offer our total support. We have your backs, and we will continue to do all we can to support your crucial work, in times of crisis and beyond.

Elisa M. White Editor in Chief

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HOSPITAL NEWSMAKERS

The 2020 Governor’s Quality Award Healthcare Seminar will be held June 10 at the Embassy Suites Hotel in Little Rock. This year’s featured presentation is by Karen Kiel Rosser, Vice President & Quality Improvement Officer for 2019 Baldrige Quality Award recipient Mary Greeley Medical Center. The annual event is sponsored by AHA, AFMC, Arkansas Health Care Association, Community Health Centers of Arkansas, and the Arkansas State Chamber. Registration is available online at arkansasstatechamber.com.

Marcy Doderer, FACHE, President and CEO of Arkansas Children’s, is Women & Children First’s 2020 Woman of the Year. The organization presented Doderer with the award at the Woman of the Year Gala, an event that raises revenue for yearly operation of The Center Against Family Violence shelter. Scott Dickson, MD, Assistant Professor in the Department of Family and Preventive Medicine at the UAMS College of Medicine, Chief of Staff at St. Bernards Medical Center, and Residency Program Director for the UAMS Northeast Regional Campus, Jonesboro, was invested February 6 in the Arkansas Blue Cross and Blue Shield, George K. Mitchell, MD, Endowed Chair in Primary Care. An endowed chair is among the highest academic honors a university can bestow on a faculty member.

Chris Barber, FACHE, Chairman of the AHA Board, appointed Marcy Doderer, FACHE, President and CEO of Arkansas Children’s, to serve as an ex-officio member of the AHA Board. John Heard is the new CEO of Chicot Memorial Medical Center in Lake Village. He formerly served on the AHA Board and is a longtime hospital administrator in Arkansas. Ryan Geib, MBA-HA, is Mercy Fort Smith’s new COO, coming to Arkansas from Pensacola, Florida, where he served as the assistant administrator for HCA Healthcare’s West Florida Hospital. He also previously worked as HCA’s Director of Facility Management in Myrtle Beach, South Carolina. Josh Bright, PharmD, has been promoted to Vice President of Operations for North Arkansas Regional Medical Center in Harrison. He most recently served as the hospital’s Director of Pharmacy. A native of Jasper, he earned his Doctor of Pharmacy from UAMS in Little Rock.

Washington Regional in Northwest Arkansas held a ground-breaking ceremony in mid-February to kick off construction of the new J.B. Hunt Transport Services Cancer Support Home. The home, which is expected to be completed late this year, will expand on services at the current Cancer Support Home, offering overnight lodging and services at no cost to cancer patients and their families. NEA Baptist ground-breaking

NEA Baptist held a ground-breaking ceremony in late January for expansion of its Outpatient Physical Therapy Clinic in Paragould. The expansion will add 2,200 square feet to the facility, and it will include treatment and traction rooms, a waiting area, and gym space.

Washington Regional ground-breaking

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Brian Welton, MBA-HA, is the new Administrator and CEO at Baptist Memorial Hospital-Crittenden. He previously served as Assistant Administrator at Baptist Golden Triangle, and as Operations Director for Baptist Medical Group.

Baptist Health and UAMS have entered a joint venture designed to bring 120 new medical residents to Central Arkansas. The Baptist Health-UAMS Medical Education Program will be located on the Baptist Health-North Little Rock campus in a $32 million, four-story, 160,000 square foot facility featuring state-of-the-art equipment, conference rooms, and clinical areas for patient care.

Northwest Medical Center-Springdale has opened a new Simulation Lab to enhance training opportunities for medical providers. A ribbon-cutting ceremony was held in mid-January to allow the public to tour the new center, which is the only hospital-based Sim Lab in the region.

Birch Wright, MPA-HA, has been named Chief Operating Officer and Administrator of Washington Regional Medical Center in Fayetteville. He previously served as Associate Medical Director and COO of the Veterans Healthcare System of the Ozarks and in other roles in the VA Healthcare System, including Business and Financial Operations Director and Chief Financial Officer. He steps into the role upon the retirement of Mark Bever, who has served Washington Regional for more than 15 years. Rawle â&#x20AC;&#x153;Tonyâ&#x20AC;? Seupaul, MD, is the new Chief Medical Officer at UAMS. He continues to serve concurrently as Chairman of the Department of Emergency Medicine in the UAMS College of Medicine.

Public tours of the Sim Lab at ribbon-cutting

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Quality Improvement in Arkansas:

Empowered to Care By Nancy Robertson

n 1999, the Institute of Medicine (IOM) released To Err is Human: Building a Safer Health System, a report that detailed the incidence of medical errors and preventable deaths in the U.S. The nation was shocked and found it difficult to fathom the fact that nearly 100,000 preventable deaths were occurring in our hospitals each year. The publication launched a nationwide pursuit of improvement interventions and new research on the question of how to better – and more safely – deliver care. Simply asking that safety be improved would be misguided, IOM committee members said. They laid out a plan asking Congress to create a National Center for Patient Safety within the Agency for Healthcare Research and Quality, effectively establishing a new field of health care research, error analysis, and innovation. Early projects designed to foster quality improvements included the 100,000 Lives Campaign (2005), the 5 Million Lives Campaign (2006), and the Wristband Standardization Initiative (2008), among others. In 2012, as state hospital associations throughout the U.S. grappled with what their role would be in the pursuit of industry-wide quality improvements, the AHA established its own Quality and Patient Safety department, ushering in an entirely new area of service for our member hospitals.

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Nationally, hospitals began to see that standardization of care practices might lower errors and preventable deaths. Care delivery teams brought together nurses, physicians, infection preventionists, and pharmacists to collaborate on process improvement. In fact, process improvement itself made a huge leap, and common procedures – things like catheter insertion-to-removal times, placement and care of central lines, and ventilator use assessment – came under nationwide scrutiny and “bundles” of standardized methods and measures became the new norm.

AHA’S QI PROGRAM

The three-year "Partnership for Patients" campaign to reduce hospital-acquired conditions by 40% and unnecessary readmissions by 20% was launched in December 2011. By February 2012, AHA had its new Vice President of Quality and

Patient Safety, Pamela Brown, in place and ready to build its program. AHA joined a national collaborative of 31 state hospital associations sponsored by the Health Research & Educational Trust (HRET) of the American Hospital Association. Called the Hospital Engagement Network (affectionately known among members as the HEN), the collaborative would use a combination of process research, practice standardization, outcomes measurement, and close documentation to address quality, cost, and disparities in health care delivery. Nearly 1,500 hospitals, including 47 from Arkansas, joined the HRET HEN. The AHA’s quality improvement program was off and running. “Our ultimate goal was to help our hospitals improve care with proven processes and methods,” Brown says. “We would work toward the transparent, compassionate delivery of care without harms.”

Compliance with new, nationally standardized measures changed everyday life in every hospital unit everywhere. The world of health care was changing fast. In the 80s and 90s, physicians had ruled health care and were not questioned; policies and procedures differed significantly between hospitals, even within the same system. Then came release of the report, and from 2000 on, it became valid – even vital – to question every policy and practice based on a team approach to patient safety. Over the years, understanding of what “Quality” entails, when it comes to hospitals, has morphed, Brown says. “People at every level of the hospital first had to get comfortable with new approaches, and they had to realize that they would not be ‘punished’ if they raised questions.” Early on it was all about the data. Compliance with new, nationally standardized measures changed everyday life in every hospital unit everywhere. “We reported compliance with the measures and kept data on error rates and other elements,” Brown says. “Hospitals were graded as a result of the data, but we weren’t good at moving past data collection to data-driven improvement.” But with time and experience, teams formed and performance advanced. Opportunities for improvement and processes for addressing them were and are identified every day. “Quality is always guided by regulatory influences and reimbursement rules,” she says, “but data is now being shared, and today’s public reporting brings a whole new world of transparency to the table.”

QUALITY IMPROVEMENT IN ARKANSAS

Members of the AHA Quality Team work with the hospitals every week, helping quality teams put the latest, best practices into service. “We work with hospital quality leaders on specific improvement areas (early sepsis identification, avoidance of ventilator-acquired pneumonia, C. difficile containment, etc.) and on the

year’s overall improvement goals,” Brown explains. “These might deal with reducing inpatient harm by a certain percentage or lowering the number of readmissions within 30 days of discharge. No matter how many improvements we make, we will always have new conditions and concerns to address.” Looking forward, she says that sustainability will be the major factor in quality improvement. “With experience, we improve safety and

The AHA Quality Team works with hospital Quality Improvement teams, raising the bar on patient safety and quality in the state. From left: Cindy Harris, Administrative Assistant; Cindy Crump, MBA-HM, BSN, RN, Quality Specialist; Nikki Wallace, BSN, RN, Quality Specialist; Pamela Brown, BSN, RN, CPHQ, Vice President of Quality and Patient Safety.

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quality,” she says. “But ‘Quality’ is really a part of the whole patient experience. It’s not only a question of ‘How can we improve this procedure,’ but also, ‘How can we improve the care experience for each patient, family, and caregiver?’ and ‘How can we sustain improvements we have worked so hard to achieve?’”

THE PERSONAL SIDE

As a longtime nurse and quality specialist, Brown says the hard work of quality improvement gives her a feeling of satisfaction and self-worth. “I have feelings as a clinician,” she says, “but I bring with me a multitude of experiences in dealing with my immediate family’s health challenges.” Her father, mother, brother, sister, husband, and younger daughter have, or have had, significant issues with their health. As the nurse in the family, Brown has been their caregiver and deals with health care quality and patient safety from what she calls “the other side of the bed.” “I’d like to see a reduction in the burden of more required measures,” she says. “At the hospital level, we are moving toward more automated processes for data management, which will help in identifying opportunities for improved care delivery. I’d like to see a more vigorous focus on support of hospital quality and the professionals who deliver care every day. A nationwide effort to show how to apply and align our quality work, and ways to embed strategies that are cross-cutting, would be very effective. I’d also like to see more alignment of leadership, processes, core measures, and delivery of care. The more those in positions of hospital governance and administration are involved in the work of quality and patient safety, the more successes we will see.”

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LOOKING BACK, LOOKING FORWARD

It takes a large ship a long while to turn, and health care, she says, is a very large ship. “When I look back at how far health care quality improvement has come, I feel a great sense of connection,” she says. “Quality improvement work and the fellowship of team commitment to positive outcomes…this gives people a sense of personal worth.” When working with member hospitals, Brown says she enjoys seeing Arkansas hospital clinicians, professionals, and quality team members learning from and sharing experiences with one another. They

gain access to national best practices and make important networking contacts through AHA initiatives like the HEN, or its latest iteration, the Hospital Improvement Innovation Network (HIIN). “We have evolved from the punitive nursing and clinical environment of the 80s and 90s to the cooperative and collaborative environment in place at many health care organizations today,” she says. “Health care quality and patient safety are very personal, whether you’re caring for patients as a clinician or for your own family members. Either way, the quality movement makes a difference to our patients. Either way, the patient always wins.”

The more those in positions of hospital governance and administration are involved in the work of quality and patient safety, the more successes we will see.

Nancy Robertson, MAC, serves as Senior Editor of Arkansas Hospitals magazine. She originated the AHA Quality Team’s weekly e-newsletter, the Tuesday Takeaway. You may reach her at nrobertson@arkhospitals.org.

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CANDOR Comes to Arkansas:

A Candid Approach to Care By Dr. Tim McDonald, MD, JD & Ryan Solomon, JD

Is your health care organization known for speaking openly and honestly, frankly, directly, and sincerely with patients, families and employees? Especially when a patient harm occurs, are you known for communicating quickly, truthfully, with compassion and with candor?

hough health care has straightforwardly tackled preventable harms in the two decades since To Err is Human was published, experts still believe that medical errors represent the third leading cause of death in the United States. (Heart disease and cancer are numbers one and two.) Though the goal of zero harms remains elusive, areas of excellence continue to emerge, and health care organizations are making great strides in patient safety and quality. Hospital leaders around the country continue the search for solutions that will eliminate preventable harms and hardwire a safety culture within the industry.

A NEW NORMAL

Arkansas Children’s is among the leaders in improving patient outcomes and safety and the system 14 SPRING 2020 | ARKANSAS HOSPITALS

adopts specific programming to this end. During the last five years, the health system has assembled a team relentlessly focused on creating a culture of safety. Together, team members have reduced serious safety events by more than 80%. Marcy Doderer, President and CEO of the system, so firmly believes in creating cultures of safety that she advocates nationally for transparency in all aspects of patient safety reporting. She believes that full transparency results in better patient outcomes and fewer employee injuries across the spectrum of health care organizations. “Empowering team members to establish a safety culture that values everyone, including patients and the team members who serve them, is essential,” she says. Under her leadership, the Arkansas Children’s team very

recently implemented a program called “Communication and Optimal Resolution” (CANDOR). This highly specific, innovative program focuses on normalizing compassion and transparency while creating processes to improve care for patients and caregivers in all areas of the organization. Two years ago, members of the Children’s system first learned about CANDOR through Solutions for Patient Safety, a network of 135 children’s hospitals across the United States formed to reduce preventable harm. Earlier this year, Doderer, along with clinical and enterprise risk leaders, hosted a week-long intensive training for more than 200 clinical, administrative and medical staff members focused on how to communicate with families and team members following harm events, helping them develop the

ability to have difficult conversations. Employing both didactic learning and simulations featuring professional actors, the training had a profound impact on all who attended.

CANDOR'S ORIGINS

The CANDOR approach began with Dr. Steven Kraman’s 1999 report, which demonstrated the importance of open and honest communication and early financial resolution following harms in health care. Each harm event presents its own set of challenges, and Kraman wanted to do right by his patients in every instance and to help others do so by describing his experience of being transparent with patients and families from the outset. In the years that followed the report, organizations began to think differently about how to respond to harm events. The University of Michigan, in what has become known as “the Michigan Model,” provided convincing evidence for its principled approach following unexpected harm: It includes the two-fold approach of early, open, and honest communication coupled with resolution. The University of Illinois Hospital and Health Sciences System in

Every hour that passes without effective communication represents another harm.

”

Chicago also built its patient safety program on the same principles. In addition, this approach focused on the establishment of shared accountability, event reporting, event analysis, peer support, and process improvement – all aimed at preventing harm to patients. Inspired by this work, the U.S. Agency for Healthcare Research and Quality (AHRQ) funded a series of patient safety grants to accelerate innovative approaches to reducing both preventable patient harm and medical liability costs. Based on data from these grants, AHRQ next funded the creation of a toolkit designed to

provide a comprehensive response to patient harm. The toolkit, developed by a multidisciplinary and multiinstitutional team, was released in May 2016 and named CANDOR.

NUTS AND BOLTS

CANDOR represents a paradigm shift from a guarded, defensive posture to a more timely, open and honest response to patient harm. CANDOR emphasizes immediate, ongoing and transparent communication with patients and caregivers; a human-factors-based analysis and process redesign; and a fair, transparent resolution process with families. Its focus is on transparency, honesty, and improvement. When an organization starts its CANDOR journey, it will initially conduct a readiness/gap analysis with the expectation of designing a customized roadmap for education and integration. Organizations seeking to adopt CANDOR should have a robust and established event reporting system in place. Accurate event reporting is vital to the identification of variances and events that should trigger a rapid response to harm. It will also help point out events that may benefit from

This page: Marika Engelhardt (right), an actor with the CANDOR educational team, engages with Ashley Sparks, an ENT Specialty nurse at Children's. Practicing situational dialogue, such as supportive discussions around staff errors, helps ingrain CANDOR's communication tools. Facing page: Andrew Ramsey (left), an actor with the CANDOR team, and Bruce Lambert, PhD (right).

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immediate review, communication with patients and families, or the provision of emotional first aid for clinicians or other hospital staff. This includes the identification and reporting of unsafe conditions and “near misses.” The CANDOR toolkit and its successful implementation rely upon several critical components. Leadership engagement is imperative: in order for clinical leaders to understand how CANDOR differs from traditional risk management strategies, they need to know they are operating on the same set of principles as are their administrators and risk managers. Following a harm event, CANDOR’s signature rapid response protocol calls for quickly addressing patient and family members’ concerns. Every hour that passes without effective communication represents another harm. CANDOR helps with the crucial step of identifying people within your organization who are skilled in empathic communication. CANDOR provides tools, including a communication skills assessment, that assist in the identification of these exceptional communicators who can consult with or coach other clinicians in complex, harm-related situations. Empathic communication training teaches that “disclosure” is a process rather than a single event, and organizational communicators integrate proactive, immediate, and

ongoing emotional first aid for staff, as well as patients and families, into the organization’s wellness and resilience efforts. CANDOR then helps with the process of human-factors-focused event analysis. With improvement as a core goal, event analysis can help organizations develop processes that both apply just culture principles and lead to sustainable improvement. And of course, resolution is also at the heart of every analysis.

RESOLUTION

With this foundation, organizations can apply the principles of shared accountability in their quest for sustainable improvement. Resolution

– both financial and non-financial – requires organizations to create processes for communicating the results of every event review, whether it reveals that care was appropriate or inappropriate. If inappropriate, the process for coming to fair resolution must be understood and implemented. (Support occurs regardless of the appropriateness of care.) Taken together, CANDOR’s components provide a road map for the principled management of patient harm from the moment it occurs – through review of the event and emotional support of patients, family members, clinicians and other health care staff – until resolution and learning have taken place.

Bruce Lambert, PhD (right) leads a session on CANDOR at Arkansas Children's.

Tim McDonald, MD, JD, is the President of the Center for Open and Honest Communication at the MedStar Institute for Quality and Safety, a Professor of Law at Loyola University-Chicago, and President of Transparent Health Consulting. Ryan Solomon, JD, serves as Assistant General Counsel and Director of Enterprise Risk Management at Arkansas Children’s. For more on Communication and Optimal Resolution (CANDOR), the CANDOR Toolkit, and access to modules, go to ahrq.gov and search for CANDOR.

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The Language of Caring By Jill Golde, MS

How you can achieve a caring community where staff love to work, physicians want to practice, and patients rave about caregivers and their care

t all started when Wendy Leebov, a longtime expert and advocate for “the great patient experience,” got a call for help. The plea came from her nurse executive friend, Audrey: “Will you help us figure out why our efforts to raise patient survey scores yield insignificant results? We’ve hit a wall!” Wendy agreed to help, and she began by observing the nursing team’s care of patients over several days. Her observation was profound: While the nurses, doctors, and other staff clearly cared about their patients and one another, that sense of caring was not apparent. Understandably task oriented, the teams appeared to be both busy and pressured, completing their to-do lists with efficiency and speed. What was missing was the communication of compassion and caring. Their care seemed impersonal, and their caring didn’t come across. The missing, intangible element was caring. Beyond care, caring conveys empathy and compassion. It offers a sense of nurturing, of kindness. Don Berwick, MD, founder of the Institute for Healthcare Improvement, explains it this way: “I think health care is more about love than about most other things. If there isn't, at the core of [health care], two human beings who have agreed to be in a relationship where one is trying to help

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relieve the suffering of another, which is love, you can't get to the right answer here.” “Most of us entered our health care professions because we care about people and want to help them,” Wendy says. “When we get caught up in tasks without communicating empathically, patients and families don’t realize we’re the compassionate people we are. And this hurts us, too, because when we fail to connect with people, we lose touch with our purpose and miss out on the satisfaction of knowing we’ve helped make a difference in our patients’ lives.”

LANGUAGE MATTERS

Realizing that other hospitals face the same challenge, Wendy joined Jill Golde and Dorothy Sisneros to found the Language of Caring program. Language of Caring engages all staff and providers in consistently communicating their caring and empathy with patients, families, and coworkers. It makes staff empathy visible and effective. Language of Caring teaches that it’s not about what you do; it’s about how you do it. Since its founding, the Language of Caring program has helped many health care organizations – including Audrey’s – achieve significant breakthroughs in the patient experience. These improvements very often yield higher HCAHPS scores.

Language of Caring founders Dorothy Sisneros (left), Wendy Leebov (center), and Jill Golde (right).

To date, more than 200 health care organizations – including Johns Hopkins, the American Red Cross, and Children’s Hospital of Philadelphia – are implementing the Language of Caring program. And in 2019, Language of Caring joined forces with Planetree International, known for establishing the “international gold standard” for personcentered care. This collaboration allows global expansion of its services.

HOW TO MAKE CARING VISIBLE

Making compassion and caring visible is what Language of Caring is all about. Our culture-building and training approaches for professional staff, physicians, and the entire health care team (from transport to housekeeping) create alignment through development of a common language that results in effective, caring communication. The typical implementation process for intervention with both staff and physicians includes three stages: 1) Onsite Alignment, Consulting and Planning; 2) Leadership Kick Off, Facilitator Training and Skill Building; and 3) Sustaining Improvement and Leadership Development Support. These steps ensure our three pillars of success: leadership engagement, the building of in-house capacity for skillbuilding and coaching; and laying the groundwork for accountability and sustainability of the new skills and culture. The flagship Language of Caring Program for Staff is grounded in the powerful Heart-Head-Heart Model for communicating with empathy and compassion. Short, videobased learning modules engage you and your colleagues in learning and teach how to apply concrete skills that open the door to communicating with “heart.” Video enactments of everyday interactions (such as the handling of complaints, responding to a patient’s pain, explaining delays, and simply saying, “No”) visibly show how these skills move staff performance survey scores from a 3 to a 5. Here’s one example:

Ms. Jackson asks, “When will I get my results?” Task and fact-oriented response: “I really don’t know. There are lots of tests in the queue. It shouldn’t take more than three days. You’ll get a call when the results are in.” Language of Caring response: “I realize you might be anxious to hear the results, and it can be very hard to wait. We’ll call you as soon as we get the results from the lab … on Monday at the latest. The fact is, the culture needs time to grow before the lab can give us complete and reliable results. I’m so sorry you have to wait.”

APPLYING THE SKILLS

Caring communication easily applies to many health care initiatives, making each of them more effective. Consider the common process of rounding: Why are so many leaders disappointed in the results of nurse rounding? Because of the task-oriented way it’s often implemented. A nurse can pop in and say, "Need anything?" and check off that he or she has rounded. Language of Caring helps with the how to, raising many strategies from good to great. Hundreds of interactions occur between staff and patients. Let’s look at just one – a patient’s arrival: Transporters escort patients. Nurses greet, orient, and take the patient’s history. Physicians arrive for patient/family updates. Respiratory therapists coach patients through breathing exercises. Housekeepers clean rooms. Care managers make follow-up phone calls. Each of us is a part of these interactions. The changes brought about when interactions move from care to caring are all-encompassing. When compassion and caring thread through each of these interactions, the culture itself changes. Language of Caring also offers strategies proven to help medical staff communicate with more compassion.

ARKANSAS HOSPITALS | SPRING 2020 19

IMPACT ON HCAHPS

Language of Caring consistently demonstrates positive HCAHPS impact in adult acute care, children’s acute care, and both adult and pediatric ambulatory care. Figure 1 shows Language of Caring’s impact on Top Box Results of the Nurse Communication Composite at one large midwestern medical center.

Nurse Communication Composite 82% 80.9%

80%

TOP BOX %

79.7%

79.0%

78%

77.1%

77.5% 77.6%

76% 74%

77.6%

76.7% 76.4%

77.3%

78.1%

81.0%

80.2%

79.1% 78.9% 78.9%

79.0%

73.1%

72% 70%

01 22 Q

01 Q

20 4Q

20 3Q

20 2Q

20 4Q

20 1Q

20 3Q

20 2Q

20 1Q

20 4Q

20 3Q

20 2Q

68%

FIGURE 1

ACADEMIC ACUTE CARE SETTING: TOP BOX SCORES Physician – Overall Rating 91% 90% 89% TOP BOX %

Skills taught in this series elevate effectiveness and reduce burnout for physicians and Advanced Practice Providers. The Language of Caring for Physicians program engages providers in strengthening competencies that improve relationships with patients, patient engagement, and partnership – as well as teamwork with health care colleagues. Language of Caring also offers an entirely online CME version of this program for individual providers.

LARGE ACUTE CARE SETTING IN MIDWEST ORGANIZATION TOP BOX RESULTS

89.1%

88.9%

88%

87.6%

87%

86.5%

86%

85.8%

85.5%

85% 84%

87.5%

84.4%

84.1%

84.9%

83% 82%

1Q2017

2Q2017

3Q2017

4Q2017

1Q2018

2Q2018

3Q2018

4Q2018

Q12019

Q22019

QUARTER & YEAR

FIGURE 2

20 SPRING 2020 | ARKANSAS HOSPITALS

IMPACT ON PHYSICIANS

Language of Caring programs for physicians also demonstrate highly positive impacts, as indicated by improvement in HCAHPS scores on the Physician Communication Composite (Figure 2). Results of the Maslach Burnout Survey show reduced burnout, an important component of keeping physicians both satisfied and engaged, lengthening their time of active practice.

Impact – Direct Care: Leaders, Managers & Supervisors Leader Caring My immediate supervisor cares about making the world a better place

5.1

My immediate supervisor shows that she/he cares deeply about our patients

5.1

5.34

My immediate supervisor shows compassion and caring for the people who work here

5.44 4.99

Supervisors, managers, and leaders seem to care about each other here

5.59 4.58 4

IMPACT ON CULTURE

It stands to reason that when people learn to communicate in the Language of Caring, interactions in the work environment, home environment, and generally throughout life will change for the positive. Language of Caring data proves this positive impact on the health care organizational culture. Language of Caring engaged four clients who conducted multi-year studies using the “Caring Culture Survey” to monitor perceptions of culture. The time frames spanned were two- or three-year periods. Major factors measured were: Caring with Patients, Leader Caring, and Co-worker Caring. As illustrated in Figures 3-5, results from just one large, integrated health care system in the Northeast show dramatic culture change around the “caring factor.”

6.17

2019

4.5

5.5

languageofcaring.com

FIGURE 3

Direct Care: Relationships with Co-workers Coworker Caring 6.15

My coworkers let me know that they appreciate me

4.49

5.34

I feel a personal connection with my coworkers

4.8

5.75

My coworkers show empathy and caring to me

4.94

4.5

2019

5.5

6.5

2018

languageofcaring.com

planetree.org

FIGURE 4

Direct Care: Personal Caring Personal Caring I feel appreciated by my patients and families

5.69

4.77

I am able to stay centered and compassionate when I am with a challenging or distressing patient

6.28

5.15

I feel a lot of empathy towards my patients and their families

5.65

I feel a personal connection with my patients

Jill Golde, MS, is Senior Vice President of Language of Caring, a branch of Planetree International. For more information on program options, visit the Language of Caring website at languageofcaring.org or contact Jill Golde at jgolde@languageofcaring.org.

planetree.org

EXPECT THESE RESULTS

Results you can expect when you adopt Language of Caring as your organization’s communication norm: An exceptional and healing patient and family experience, higher HCAHPS scores, fewer anxious patients, a greater number of engaged patients, reductions in staff burnout, and an energized, gratified workforce.

6.5

2018

5.46

I am able to tune in and really focus on my patients

5.85 5.88

5.22

I feel proud of the work that I do here

5.9

5.72

I often show empathy and caring to my coworkers

5.76

5.29 4

4.5

2019

languageofcaring.com

5.79

5.5

6.5

2018

planetree.org

FIGURE 5 ARKANSAS HOSPITALS | SPRING 2020 21

Coming to the Table

The AHA PFAC Inspires Engagement By Cindy Crump, MBA-HM, BSN, RN

hen patients take a role as active participants in their health care – especially in their hospital care – it can lead to measurable improvements in the quality and safety of care they receive. But how can health care teams encourage patients and their families to shift to a more engaged, participatory mindset, if they aren’t already engaging on their own? AHA’s Quality Team helps Arkansas hospitals form and expand their own Patient and Family Engagement (PFE) efforts. We have seen the difference it can make in hospital quality and patient outcomes.

SPARKING INTEREST

Like everything in the Quality world, PFE progress is measured. As part of the Health Research & Educational Trust (HRET) Hospital Improvement Innovation Network (HIIN) of the American Hospital Association, hospitals in our network are graded on five PFE measures set forth by the Centers for Medicare and Medicaid Services. Results from 2017 showed need for improvement in our PFE metrics (see graph, March 2017), so in the fall of 2018 we developed a strategic plan for helping our hospitals achieve better results. We set out to form a state-level advisory committee to determine the specific needs of Arkansas patients and hospitals, knowing that, in order to provide a model for PFE statewide, we needed to understand exactly where we were beginning. We invited hospitals to join our Patient and Family Advisory Committee (PFAC) through an application process we hoped would 22 SPRING 2020 | ARKANSAS HOSPITALS

yield 12-15 hospital and patient representatives. The program launched in January 2019, with 14 members representing 10 hospitals. Of the original members, nine were Patient Engagement Leaders/Advisors and five were patients or family members. We meet monthly, by phone, and we’re still recruiting patients and family members, in the hopes of drawing members from rural areas of the state.

CHARTING OUR COURSE

Understanding patient needs through the patient’s voice is a critical need for our committee. All hospitals that participate in the statewide PFAC have PFE strategies that include patients on committees and in decision-making areas. We have added members since the project launched, and we now have 11 hospitals represented on the statewide committee.

PFE 1: Preadmission Planning Checklist PFE 2: Shift Change Huddles or Bedside Reporting PFE 3: Designated PFE Leader PFE 4: PFAC or Representative on Hospital Committee PFE 5: Patient Representative(s) on Board of Directors

This graph shows national and Arkansas benchmarks for the five PFE metrics, and the improvements made by Arkansas hospitals from program onset in January 2019 through November of that year.

Each PFAC hospital brings its own experience to the table, helping direct our improvement efforts. Initially, the AHA Quality Team thought it best for hospitals to specifically work only on the five HIIN measures for an entire year. But in discussing the way forward with PFAC members, we discovered that they needed to back away from the metrics and start with the very basics of PFE. Hospitals said they needed to understand the foundation of Patient and Family Engagement before we could even hope to improve the data. We developed a needs assessment and sent it to our 53 HIIN hospitals. Data collected from that assessment helped us determine that our hospitals need resources. Most asked for general help with PFE. Some asked for specific items such as checklist examples, policy examples with patient-centered language, and leadership engagement assessments to determine senior leader readiness to support PFE activities. This is where the idea of an Arkansas PFE toolkit was born. After a few months of research, it was the opinion of the committee members

that existing kits we found were all too overwhelming. Around the same time, another state hospital association shared a toolkit that is very concise and focused. One of the benefits of being part of a national network is having access to proven tools and resources; with the association’s permission, we are in the process of editing, branding, and finalizing an Arkansas version of the PFE toolkit for distribution. From asking family members what type of bedside chairs are most functional and comfortable to inviting a patient to round with a Safety Team and offer observations on hospital cleanliness, the toolkit will provide simple ideas Arkansas hospitals can implement to improve PFE and transform the experiences of patients and their families.

HOSPITALS VOICE STRUGGLES

We’re learning that even those hospitals with longstanding, inhouse PFACS struggle with member engagement; hospitals say it’s difficult to recruit volunteers who understand

AHA’S PATIENT AND FAMILY ADVISORY COMMITTEE (PFAC) VISION STATEMENT

Our vision is for all health care in Arkansas to engage patients and families as partners to deliver care that is safe, equitable, effective, efficient, and timely.

MISSION STATEMENT

Our mission is to promote and support acceptance and positive changes in health care across Arkansas by creating an environment where patients and family members feel safe, respected, and empowered to be partners in their care.

Several members of the founding AHA PFAC gathered at AHA for a launch party in early 2019.

ARKANSAS HOSPITALS | SPRING 2020 23

hospital PFE policies well enough to provide constructive feedback. And, of course, member engagement is the whole point! It has also been a learning experience to hear patient stories and their perceptions of care. For instance, one hospital planned to place ceiling tiles painted with “Call, Don’t Fall” above each patient bed. When surveyed, several patients indicated that they “would not want

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to look at something like that the entire time they are in bed.” They said that the tile’s message wouldn’t necessarily remind them to call before getting out of bed, and that it would be something they would not like to see while flat on their backs in the hospital. PFAC member Mica Houston, Director of the Utilization Review, Transitions of Care, and Switchboard departments at St. Bernards, says that

the hospital embraces its local PFAC more readily now that AHA has a Statewide PFAC. “It feels like AHA’s support of PFE brings validity to the issue, especially when explaining how important PFE is to quality and patient safety,” she says. She adds that her local hospital PFAC members are very eager to learn about what is happening at the state level. “This statewide focus makes them feel more important in their role as local advisors.” Simply linking local organizations to a statewide committee seems to expand interest at the local level. This is eye-opening. “We like having a voice to advocate for the greater good of our state, not only for the patients and families that interact with our organization,” says Hilary Spurgeon, Patient Family Experience Manager at Arkansas Children’s Hospital. As AHA’s PFAC members build networks throughout the state, they feel more empowered. “I’m learning that others have the same struggles, which is unfortunate, but it gives us a chance to collaborate on working toward more positive outcomes and increased leadership buy-in and engagement,” Houston says. Spurgeon adds that, because of what they’ve learned through the statewide PFAC, her hospital has further structured its onboarding process and reporting of local PFAC success within its boards. Shana Kersey, Risk Manager and PFAC Lead at Conway Regional Health System, says, “The ‘awareness factor’ is increasing now that our administrators know we have [PFE and patient representation] on the statewide PFAC. It’s valuable to [learn] how other hospitals have implemented their PFACs and included patients and families in their work processes. There are so many different ways [of doing this], and since I was solely responsible for implementing [our] PFAC, it has been beyond helpful to get other ideas and bounce ideas off of other people.”

WE’RE LEARNING, TOO

Though we’re still at the level of working on “the basics,” Arkansas hospitals are showing significant improvement across all measures data was established in 2017. Our goal is to have fully functioning PFACs at every Arkansas hospital. While we know that may not be feasible in the short term, we are building a “Just Start Somewhere” section into the toolkit to help hospitals implement small changes that include patients in decision making at the hospital level. We’re learning a lot about how to encourage and engage non-clinicians. Patients must not only be willing to serve; they must commit to serving in a meaningful way. Hospital leaders must be willing to actively listen to the patient voice and implement changes based on patient and family feedback. All parties must be engaged and passionate about working together to improve care in a patient-centric manner. We have also seen that it often takes just one conversation to spark interest. Through the statewide PFAC, Arkansas hospitals are starting to hear about Patient and Family Engagement from many different sources: CMS is talking about it, AHA’s Quality team is talking about it, and the Quality Improvement Organizations (like AFMC) are talking about it. PFE is present in all aspects of health care now; we are even seeing it become the main event through national forums dedicated to patient- and family-centered care. At the national level, leaders have dedicated time and talent to PFE for several years now. In Arkansas, we’re just getting started. But we are so

excited about how far we have come and where we are going. “It is so very rewarding for me, personally, as a patient and family member, to see the dial begin moving the past several years in the area of patient- and family-centered care in the state of Arkansas,” says Jodie McGinley, Parent Partner at Arkansas Children’s Hospital. “I noticed the shift begin in 2010 and now, in 2020, I believe this state is making great strides to

improve the patient experience. Being a member of the statewide PFAC gives me great hope that soon, that dial will shift for all Arkansas hospitals and that each one of our patients and families will soon be receiving consistent care statewide. And partnerships between patients and families alongside their health care teams are being formed across the state of Arkansas. It is a great time to be a part of the PFAC!”

Cindy Crump, MBA-HM, BSN, RN, is a Quality Specialist with the Arkansas Hospital Association. She and other team members work closely with the statewide PFAC to increase PFE in Arkansas. The PFAC is currently recruiting patient and family members. For information on how to get involved, please contact her at ccrump@arkhospitals.org.

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Reducing Maternal Mortality:

California Collaborative Sees Success By Cathie Markow, MBA, RN

Editor’s Note: Addressing the challenge of new mothers dying during, or due to complications of, childbirth is a quality improvement priority in Arkansas. Although women of every race and ethnicity are affected, the data show racial disparities. Black mothers in the U.S. and in Arkansas die more frequently from these causes than do mothers from other races/ethnicities. AHA sought expertise from a national leader in maternal research to learn more.

omen in the United States have the highest rate of maternal mortality when compared to other high-income nations of the world. Reducing this rate is a high priority as Quality Improvement experts in the U.S. set short- and long-term goals. The California Maternal Quality Care Collaborative (CMQCC) is a multistakeholder organization committed to ending preventable morbidity, mortality, and racial disparities in California maternity care. CMQCC uses research, quality improvement toolkits, statewide outreach collaboratives and its innovative Maternal Data Center to improve health outcomes for mothers and infants. This collaborative shares its research, resources, and toolkits with other states, and the toolkits are also used internationally. CMQCC was founded in 2006 at Stanford University School of Medicine, in cooperation with the State of California, to respond to rising maternal mortality and morbidity rates. Since CMQCC’s inception, California has seen maternal mortality decline by 55 percent between 2006 and 2013, while the national maternal mortality rate continued to rise. 26 SPRING 2020 | ARKANSAS HOSPITALS

KEY SUCCESSES

Working together, the collaborative is showing remarkable results in improving maternal and child health. Recent successes include: • Significant decline of California’s maternal mortality rate – more than 55% – from 2006-2013, saving 9.6 lives per 100,000 births. • Prevention of 120,000 early births from 2009-2014, with an increase of 8% of births making it to full term. • Reduction of maternal morbidity of 20.8% between 2014-2016 among the 126 hospitals participating in our projects designed to reduce maternal hemorrhage and preeclampsia. • A reduction in California’s low-risk, first-birth cesarean rate (Nulliparous, Term, Singleton, Vertex Cesarean Birth Rate, or NTSV) from 26.1% in 2014 to 23.0% in 2019. • Engagement of more than 200 hospitals in California – representing 95% of deliveries – that voluntarily submit their data to our Maternal Data Center and use it to support their quality improvement activities. • Development of three quality measures endorsed by the National Quality Forum (NQF). • Development and publication of seven Quality Improvement toolkits, with three more currently being finalized, and many peer review journal articles related to improving maternal outcomes. These accomplishments are due to the collaboration of a broad set of partners throughout the state, including the California Department of Public Health, professional societies, funders, payers and purchasers, and most importantly the hardworking staff at our member hospitals.

SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013.

KEY RESOURCES FOR HOSPITALS

We provide our member hospitals with three key resources: the Maternal Data Center, our evidence-based toolkits, and implementation collaboratives. CMQCC’s Maternal Data Center (MDC) is a user-friendly tool that enables rapid-cycle performance measurement and insights for improvement, and it is the foundation for all our Quality Improvement (QI) programs. More than 200 hospitals use the MDC to: • Compare hospital performance to statewide, regional, and system benchmarks. • View provider-level results and benchmarks. • Generate one-click reports for OB Committees. • Perform drill-down analysis to identify a hospital’s unique QI opportunities. • Identify data coding issues that impact performance measure results. • Create system-level dashboards for multi-hospital networks. • Facilitate performance reporting requirements to the Leapfrog Group, the CMS Inpatient Quality Reporting Program, and the Joint Commission OPPE program (and others).

CMQCC toolkits provide evidence-based guidance for the delivery of high-quality care and have been downloaded by thousands of clinicians across all 50 states and internationally. They provide detailed, evidencebased, multi-disciplinary implementation guidance for improving perinatal quality in the inpatient setting. Toolkit topics include: • Improving Health Care Response to Cardiovascular Disease in Pregnancy and Postpartum. • Elimination of Early Elective Delivery. • Improving Health Care Response to Maternal Venous Thromboembolism. • Improving Health Care Response to Obstetric Hemorrhage. • Improving Health Care Response to Preeclampsia. • Improving Diagnosis and Treatment of Maternal Sepsis. • Supporting Vaginal Birth and Reducing Primary Cesareans. CMQCC’s mentor-driven QI collaboratives help participating hospitals implement the evidence-based care presented in our toolkits. Ultimately, our dedicated team of data, clinical, and quality improvement experts are the glue that makes it all work.

SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013.

ARKANSAS HOSPITALS | SPRING 2020 27

BIRTH EQUITY COLLABORATIVE

The California Birth Equity Collaborative, a CMQCC quality improvement initiative to improve birth care, experiences, and outcomes for Black mothers and birthing people in California, is an example of how the CMQCC system works. Using data from our state’s maternal mortality review, we show that Black women are three-to-four times more likely to die from pregnancyrelated causes than other populations – a clear call to action. Each member hospital can now access a recently developed equity dashboard that highlights metrics with a racial disparity (see Variation for Severe Maternal Morbidity and NTSV for California Hospitals at right). We often hear from providers that they “treat all patients the same, so there should be no difference;” however, our data shows a disparity, which alone has helped to raise awareness of the issue. Based on early work we did with community-based organizations to learn directly from Black women about their birthing experiences, we are developing a short, patient-reported experience survey to complement clinical outcomes with the perceptions of the families being cared for, and to provide further insight into needed QI activities. Other interventions currently in development and testing include: • Active Bystander program for culture change. • Birth equity education programs that go beyond implicit bias and include cultural humility. • Workforce diversity and hiring practices guidelines. • Hospital engagement with local, community-based organizations. Ultimately, the health equity “lens” will be applied to all our QI projects to ensure best practices and achieve equity for all women. To learn more, visit our website at www.cmqcc.org.

Cathie Markow, MBA, RN, is Administrative Director, CMQCC/RPPC/ MCCPOP, at the Stanford University School of Medicine’s Division of Neonatal and Developmental Medicine. You may reach her at cmarkow@stanford.edu. 28 SPRING 2020 | ARKANSAS HOSPITALS

SOURCE: California Maternal Quality Care Collaborative Maternal Data Center

ARKANSAS HOSPITALS | SPRING 2020 29

Quality Improvement Initiatives

Save New Moms in Arkansas Michelle Murtha, RN; Tina Hedrick, BSN; and Shaneca Smith, BSN

ccording to the Centers for Disease Control and Prevention (CDC), more than 700 women die each year in the United States due to childbirth-related complications. The CDC defines a pregnancy-related death as the death of a woman occurring while she is pregnant or within one year of the end of a pregnancy, excluding accidental or incidental causes. More than half of all maternal deaths are preventable. Arkansas’s maternal death rate is the fifth highest in the nation. It’s a disturbing statistic, but one that has spurred health care professionals throughout the state to work to decrease the number of Arkansas families affected by the tragedy of maternal mortality. Hospital OB and emergency departments must be prepared to recognize and diagnose a patient with a potentially life-threatening childbirthrelated complication, and patients must be educated and empowered to recognize childbirth-related complications up to a year following delivery, so that they know when to seek help.

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EDUCATION MATTERS

AFMC’s Medicaid Quality Improvement (MQI) team focuses on raising awareness regarding maternal morbidity and mortality statewide. Outreach education for moms, families, and health care staff includes videos, tools, and other materials that identify warning signs that can occur in the hospital post-delivery, after hospital discharge, and up to one year following delivery. In Arkansas hospitals, we provide obstetrical units and emergency departments with education about postdelivery warning signs and preventing maternal mortality. The MQI team also educates physicians, including both obstetrical/gynecological (OB/GYN) specialists and primary care providers who deliver at these facilities. In any critical access hospital where there is no obstetrics unit, women with post-delivery complications may be admitted, so these hospitals too are included in the MQI team's education efforts.

Together, we can decrease the number of families affected by the tragedy of maternal mortality. COLLABORATIVE PROGRAMMING IS KEY

Other programs combating maternal mortality in Arkansas include Arkansas Medicaid’s Inpatient Quality Incentive’s (IQI) three new obstetrical performance measures, which are all designed to improve maternal safety. IQI-participating hospitals are now required to have a hemorrhage cart immediately available on all maternity units, and they must have an OB hemorrhage policy with procedures outlined. Participating hospitals are required to report severe maternal morbidity indicators. The Joint Commission recently released 13 new elements of performance focused on improving maternal safety throughout pregnancy and the postpartum period. Effective July 1, 2020, Joint Commission-accredited hospitals are required to implement evidence-based practices to prevent maternal mortality triggered by hemorrhage and hypertension. The Arkansas General Assembly and Governor Asa Hutchinson in 2019 addressed maternal deaths by establishing a Maternal Mortality Review Committee to collect and analyze data and pinpoint the causes of maternal deaths in our state. The Arkansas Department of Health (ADH) established a Maternal Mortality Review Board that reviews mortality cases; the board then provides feedback, along with education and process recommendations for hospitals, with the goal of preventing maternal deaths. An initiative established by the University of Arkansas for Medical Sciences (UAMS) in collaboration with the Arkansas Department of Human Services, the Perinatal Outcomes Workgroup through Education and Research (POWER)

is a conglomerate of 39 hospitals that offers OB services in Arkansas. They are collaborating to reduce maternal mortality and morbidity by implementing maternal safety bundles addressing hypertensive emergency in pregnancy, postpartum hemorrhage, and racial disparities. Continuing education regarding team-based simulation training and bundle implementation is offered to all collaborating hospitals. The majority of delivering hospitals have completed implementation of a substantial portion of the maternal safety bundles. POWER uses educational/social platforms for networking and assisting with implementation of the safety bundles. It fosters patient engagement by working with staff and ADH to educate mothers and the community on post-delivery warning signs. POWER and AFMC’s MQI partner with the Association of Women’s Health, Obstetric, and Neonatal Nurses to provide free, evidence-based educational materials to delivering hospitals, patients and OB/GYN clinics.

PREVENTING DEATHS IN ARKANSAS

AFMC and UAMS POWER are available to offer guidance and training to prepare Arkansas hospitals to recognize and treat childbirth-related complications. Together, we can decrease the number of families affected by the tragedy of maternal mortality. For assistance with education and materials concerning post-delivery warning signs, contact AFMC at newmom@ afmc.org. For guidance with implementing maternal safety bundles, contact UAMS POWER at idhi@uams.edu.

Michelle Murtha, RN, is a Manager of Outreach Quality at AFMC. Tina Hedrick, BSN, RN, PCMH CCE, CPHIMS and Shaneca Smith, BSN, RN, CNOR(E) are Outreach Specialist RNs in AFMC’s Outreach Quality Department.

ARKANSAS HOSPITALS | SPRING 2020 31

COACH'S PLAYBOOK

New Visions of Quality Care:

Improve Performance With Baldrige by Kay Kendall

irst, an easy question: Is evidence-based medicine practiced in your hospital? Your answer is likely “Yes,” because your organization wants to achieve treatment excellence using proven protocols. Now, the harder question: Does your hospital practice evidence-based management? If your answer is “No,” I’d challenge you by asking, “Why not?” No matter the size or location of your health care organization, engaging your teams utilizing The Baldrige Excellence Framework will help you achieve performance improvement at many levels. Whether your goal is delivering increased value to your patients, families, communities, and stakeholders; enhancing

32 SPRING 2020 | ARKANSAS HOSPITALS

effectiveness by targeting specific areas for quality improvement; or just bringing your entire organization onto the same page across its many divisions, the Framework can bring laser focus to your hospital’s outcomes, satisfaction ratings, and leadership practices. As Steve Bovey, Quality Improvement Coordinator for Adventist Health Castle and a 2017 Baldrige Award recipient, says, “If you are tired of putting out fires – and the left hand not knowing what the right hand is doing – then you may want to consider using the Baldrige Framework. It’s not so much about an award as it is about helping you get the results you need.”

BALDRIGE AND HEALTH CARE

Health care wasn’t even eligible to participate when the Baldrige National Quality Award was enacted into law in 1987. Was the thinking that health care didn’t “need” to address quality improvement in the same way that manufacturing and service industries do? Fast forward nearly a dozen years. Health care finally became eligible to apply for the Baldrige National Quality Award in 1998, with the amendment of Baldrige legislation to include both health care and education. Four more years passed before the first health care system earned a Baldrige National Quality Award. But since SSM Health Care received that first recognition in 2002, there has been at least one Baldrige Award recipient from the health care sector every single year. No other sector or industry can boast that impressive record. Why is this? Health care was very quick to embrace the Baldrige Excellence Framework, recognizing that it would pay off in huge performance improvement dividends. With quality and patient safety improvement at the top of every hospital’s goal list, working with and through the Framework is a natural match for health care. In fact, two research studies clearly show the superior performance of those health care organizations that choose the Baldrige Excellence Framework to guide their organizations.* But don’t just read the research. Listen to the CEOs of Baldrige Award recipients in health care: “[The Baldrige Framework] helped us create discipline around our processes, improved our financial performance, and improved our focus on key quality metrics.” —Kyle Bennett, President and CEO, Memorial Hospital and Health Care Center, 2018 Baldrige Award Recipient “The hard work is worth it. Getting to preeminence […] is where we want to be, and we know that the Baldrige Framework will help us get there.” —Greg Haralson, Chief Executive Officer (CEO), Memorial Hermann Sugar Land Hospital, 2016 Baldrige Award Recipient (Continued on p. 34) ARKANSAS HOSPITALS | SPRING 2020 33

“Before we engaged with the Baldrige Criteria, we thought that we wanted to be the best community hospital anywhere. And then we started to use the Baldrige Criteria, and we started to dream bigger. We thought about being the best hospital in the nation.” —Jayne Pope, CEO, Hill Country Memorial, 2014 Baldrige Award Recipient “The Criteria really focused us. [...] To stay on track and get results for our patients – both quality and safety – you have to have an engaged workforce. [...] When everyone’s engaged, we have very consistent results.” —Janet Wagner, CEO, Sutter Davis Hospital, 2013 Baldrige Award Recipient “[Baldrige] isn’t just about improvement and measurement. It is about our core values, our culture, and – ultimately – our vision for the future. […] For those considering the Baldrige Framework, I want to testify to the magnitude of the

34 SPRING 2020 | ARKANSAS HOSPITALS

results you can achieve. It can get discouraging, but I urge you to be relentless! When we occasionally grew tired, we fired up our strategic advantage – a “Can Do” spirit – and reminded everyone that it was the use of the Baldrige Framework that had boosted our ability to deliver better care to our patients. And, in the end, that is the most important thing. Delivering better care to our patients – and having a greater and more positive impact on the lives of all of our customers.” —Nancy Schlichting, CEO, Henry Ford Health System, 2011 Baldrige Award Recipient The Baldrige Excellence Framework is regularly reviewed and revised every two years. Revisions have one overarching purpose: for the Framework and the Criteria to reflect the leading edge of validated leadership and performance practice. That sounds like evidencebased management to me. Why not check it out for yourself?

The team at BaldrigeCoach would be glad to help guide your hospital’s quest for process improvement. 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. Her team, working with health care and other organizations, has mentored 23 National Quality Award recipients. 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.

Leader Dialogue:

A Podcast for Your Quality Quest! W ant help with your organization’s performance improvement work? Leader Dialogue is a weekly podcast designed to help business leaders (including those in health care) get expert help in executing their strategies, getting to what coaches call “playbook execution.” Sponsored by the Baldrige Foundation and SOAR Vision Group, the show’s format includes inviting one business owner or leader onto the show and learning about their business – what is working or not working for them. The hosts then help identify a key business performance principle that could be applied to immediately improve the business’s playbook execution performance. The following week, the hosts unpack that principle in more detail in a “deep dive” episode for the Leader Dialogue audience. The process is repeated every two weeks. The plan is to help business owners and leaders

become more knowledgeable and successful in their playbook execution through a podcast structured around fun, casual dialogue. Kay Kendall, CEO and Principal at BaldrigeCoach and regular contributor to Arkansas Hospitals, brought her expertise to a recent edition of Leader Dialogue, visiting with top management executives of the SOAR Vision Group about the value of learning directly from Baldrige Award recipients at the annual Quest for Excellence Conference. You can find current and past episodes of the podcast at leaderdialogue.com. Kay’s Quest for Excellence discussion is #55.

ARKANSAS HOSPITALS | SPRING 2020 35

FOCUS ON QUALITY

COVID-19: Resources and Tools

he CDC offers a range of resources and tools for use by health care teams who are dealing with the novel coronavirus outbreak that originated in Wuhan, Hubei Province, China in late 2019. By linking to CDC.gov and searching Coronavirus Disease 2019, youâ&#x20AC;&#x2122;ll be able to access basic worksheets on how the virus spreads, its symptoms, methods of testing, and FAQs, as well as protocols for prevention and treatment. Situational Updates include a rundown of all global locations with confirmed cases of COVID-19, graphics showing confirmed and presumptive positive cases in the U.S. and states reporting confirmed cases of the virus, as well as situational summaries and risk assessments. Specific information written for audiences including health care professionals, health departments,

36 SPRING 2020 | ARKANSAS HOSPITALS

laboratories; communities, schools and businesses; and those who must or have recently returned from travel are available at the site. For those health care organizations wishing to include communication resources for their communities and/ or organizational websites, CDC offers print resources, videos, images, a digital press kit, and real-time COVID-19 information linkages. Go to CDC.gov to access the most current information available.

Celebrate the International Year of the

Nurse and Midwife I

t’s the International Year of the Nurse and Midwife, and we want to join in the fun! In each of our issues this year, Arkansas Hospitals magazine will recognize remarkable achievements in the field of nursing in Arkansas and pay homage to nurses – past, present, and future.

GLOBAL RECOGNITION

The World Health Assembly, the governing forum of the World Health Organization (WHO), has designated 2020 as the International Year of the Nurse and Midwife, in honor of the 200th birthanniversary of Florence Nightingale, the founder of modern nursing. The 194 member nations of the Assembly want to express gratitude for the work of nurses everywhere by recognizing their vital role in providing health services throughout the world.

DID YOU KNOW…

• Nurses and midwives account for nearly 50% of the global health workforce. • Globally, 70% of the 43.5 million people in the health and social workforce are women; 20.7 million are nurses and midwives. • Nurses and midwives are often the first and only health point of contact in their communities.

PROGRAM GOALS

The designation of 2020 as the International Year of the Nurse and Midwife celebrates the work of nurses and midwives worldwide, highlights the challenging conditions they often face, and advocates for increased investments in the nursing and midwifery workforce. One of the stated goals of the WHO is to achieve universal health coverage by the year 2030. In order to do so, the world needs nine million more nurses and midwives. For that reason, the WHO wants to raise the status and profile of these professions and encourage global investment in the two professions. Partnering with the WHO in this global effort are the International Confederation of Midwives, International Council of Nurses, Nursing Now, and the United Nations Population Fund. ARKANSAS HOSPITALS | SPRING 2020 37

FOCUS ON QUALITY

Evolution:

Health Care Quality Professionals

ince the publication 20 years ago of To Err is Human: Building a Safer Health System, aspects of health care ranging from patient expectations to payment reforms have constantly been changing. One thing that has not changed is the need for health care quality professionals who can identify and address opportunities for improvement and provide guidance on expanding data reporting requirements and quality initiatives. Health care quality professionals work across the continuum of care and are champions of improving quality in all care settings. Their role has grown

to include many areas of expertise ranging from compliance and risk management to patient safety and data analytics that support quality improvement in today’s environment. Health care quality professionals are a vital resource for organizations in their quest for improving quality. In 2019, The National Association for Healthcare Quality (NAHQ) released the Healthcare Quality Competency Framework that identifies eight dimensions of focus for health care quality professionals: Quality Review and Accountability, Professional Engagement, Quality Leadership and Integration, Performance and Process

Improvement, Health Data Analytics, Patient Safety, and Regulatory and Accreditation. Health care quality professionals are dedicated to helping organizations realize their missions for the highest quality of care for patients. More information regarding the Healthcare Quality Competency Framework can be found at www.nahq.org. Information on educational opportunities offered in Arkansas by AAHQ is available at www.arkahq.org.

We provide peace of mind so you can, too. We’ve been addressing the legal needs of the Arkansas healthcare industry for almost 120 years. • Medicare/Medicaid Reimbursement

• Licensure Matters & Board Hearings

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• Stark I and II & Anti-Kickback Compliance • Government Regulations

• Operations & Management

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38 SPRING 2020 | ARKANSAS HOSPITALS

Your Arkansas Health Law Team

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• HIPAA Compliance & Training • Medical Malpractice Defense • Drug Diversion Prevention

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Proceed Until Apprehended

for a Culture of Ownership By Joe Tye

everal years ago, I was making rounds with the Chief Operating Officer at Midland Memorial Hospital in Midland, Texas. When we reached the Facilities Management Department, the Director proudly showed us a chart illustrating a million-dollar reduction in utility expenses over the previous year. The primary factor, he told us, was not technological – it was cultural. As a result of our work to build a culture of ownership, people were turning off lights and turning down air conditioning when they left a room, just like they did at home. The most important three words in my book The Florence Prescription: From Accountability to Ownership are “Proceed Until Apprehended.” This phrase reflects the spirit that drives a culture of ownership: If you see a problem, fix it; if you see an opportunity, pursue it; if you need help, ask for it. At Midland Health that phrase has become part of the cultural DNA. Beyond the significant cost savings, the mindset it reflects has also spurred significant improvements in quality, safety, patient satisfaction, and nurse retention. At Children’s Hospital New Orleans (CHNOLA), just as at Midland Memorial, every associate receives The Florence Prescription, which includes a special foreword by CEO John Nickens. Among other activities, each day their safety huddle begins with

the team reciting The Pickle Pledge: “I will turn every complaint into either a blessing or a constructive suggestion.” When CHNOLA staff were invited to share their achievements at the annual Quality and Safety Conference of the Children’s Hospital Association, their presentation was titled: “Proceed Until Apprehended: A Cultural Journey.” Lisa Labat, Assistant Vice President for Nursing, was one of the presenters. She explains: “The ‘Proceed Until Apprehended philosophy’ has helped us break down silos and create a sense of urgency for preventing problems and fixing them as soon as they are discovered.”

Another Values Coach partner hospital found that the “Proceed Until Apprehended” philosophy was vital to implementing a new electronic health records system. Their go-live event was seamless. A comparably sized hospital in a nearby community implemented the same electronic health records system at about the same time, using the same outside consultants, but their go-live event was catastrophic. The difference was culture. At the first hospital, when problems arose people would “Proceed Until Apprehended” and either find a way to fix the problem or find the help they needed to get

"Proceeding Until Apprehended" for quality and safety at Children’s Hospital New Orleans.

ARKANSAS HOSPITALS | SPRING 2020 39

it fixed. At the second hospital, when the same sorts of problems arose people would complain that the software didn’t work, that administration didn’t support them, and that they could never reach the consultants.

IMAGINED HELPLESSNESS AND INSTITUTIONAL PTSD

One of the statements included in our validated VCI-17 Culture Assessment Survey is: “Our people don’t just complain about problems, they work to find solutions.” Every time we conduct the survey for a hospital, a significant majority of respondents disagree – and often strongly disagree – with that statement. We have never worked with a hospital in which more than 10 percent of respondents strongly agreed with it. This usually reflects a variation of what psychologists call learned helplessness, or imagined helplessness. A paradox we see in many hospitals is that people on the front lines are afraid or unwilling to take actions for fear of being “held accountable” by management, while management is frustrated that people at the front lines complain about problems rather than working to find solutions. In a letter to a friend, Florence Nightingale wrote, “I attribute my success […] to the fact that I never gave or took an excuse.” We hear all sorts of excuses for why people are unwilling to take action: union rules, corporate bureaucracy, no budget for whatever it is that needs to be done, fear of the consequences of wrong actions. One excuse people sometimes make for not pointing out problems or taking action to rectify those problems is a purported fear of retribution. I’m currently working with the Chief Nursing Officer of a large, academic medical center who is trying to push decision-making further down into the organization. Some of the resistance she faces springs from those fears. When she asks for specific examples

of actual experience of such retaliation, the answers are always ancient history; some years back, the organization had a shame-and-blame culture from the top down. I think of that as institutional PTSD. These three words, “Proceed Until Apprehended,” and the philosophy they reflect, are a sure antidote to the imagined helplessness and institutional PTSD that so often prevent people from taking the initiative to solve problems rather than just complain about them.

FROM ACCOUNTABILITY TO OWNERSHIP

Many of the organizations we work with list accountability as a core value or operating principle. As well-intentioned as this is, an excessive focus on accountability can be counterproductive. By definition, accountability is retrospective, negative, and almost always destimulating. People can only be held accountable for what they have done or not done in the past; you cannot hold someone accountable for what they might do in the future. Being held accountable is always seen as a negative; you don’t hold someone accountable for accomplishing something great, only for having failed to do so. And being told that you will be “held accountable” is almost always demotivating; it replaces any anticipation of accomplishment with a fear of consequences. As Farson and Keyes show in their book The Innovation Paradox, an excessive focus on accountability can cripple innovation and risk-taking and, when taken to an extreme, can cause people to behave unethically. As I write this, I’m thinking about a heartbreaking LinkedIn post by a health care professional for whom I have great respect. She’d taken her mother to a hospital emergency department where she spent her last night on this earth being boarded in the ED hallway because there were no beds

Whether or not you use [this] specific wording, I hope your organization is committed to encouraging people to

‘Always Do the Right Thing.’

This makes he decision to ‘Proceed Until Apprehended’ easy.

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available. When my friend asked for a milkshake for her mom, she was told that they were not available after 6 p.m. Of course, no one can be held accountable for the fact that they failed to ask a security officer to unlock the kitchen so they could pour milk and ice cream into a glass to fulfill a dying woman’s last wish. You can’t hold someone accountable for not doing something that wasn’t in their job description. But in that sense, accountability establishes a pretty low bar. Someone with a "Proceed Until Apprehended" mindset would have found a way to honor that last wish, even if it meant breaking into the kitchen after 6 p.m. Kalispell Regional Healthcare in Kalispell, Montana has a statement of five core values, to which is appended this overarching principle: “Above all ... do the right thing!” Whether or not you use that specific wording, I hope your organization is committed to encouraging people to always do the right thing. This makes the decision to "Proceed Until Apprehended" easy. If it’s the right thing to make a milkshake for a patient even though the kitchen is closed, if it’s the right thing to turn off the lights when you leave a conference room, if it’s the right thing to confront bullying behavior or turn a complaint into a constructive suggestion, then "Proceed Until Apprehended."

The Florence Prescription Creating a Positive Healthcare Culture

“Taking to heart the principles of The Florence Prescription has helped me to be a better leader. Focusing on our Invisible Architecture has helped my leadership team foster a more positive and healthy workplace environment for our people to be and do their best. This in turn has created a much better experience and outcomes for our patients and visitors to our hospital.”

STILL ONLY $5

Bob Dent, DNP, MBA, RN, NEA-BC, CENP, FACHE, FAAN, FAONL

TheFlorenceChallenge.com 319-624-3889 | Michelle@ValuesCoach.com | ValuesCoachStore.com

Joe Tye is founder and Head Coach of Values Coach Inc. He is the author or coauthor of 15 books including (with Bob Dent) Building a Culture of Ownership in Healthcare. He is also an Adjunct Assistant Professor in the University of Iowa Health Management and Policy Department. The 20th Anniversary edition of his book, The Florence Prescription, is available now. He can be reached at Joe@ValuesCoach.com. ARKANSAS HOSPITALS | SPRING 2020 41

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Join your fellow Arkansas Hospital Association members and tap into the carefully vetted business services offered through AHA Services, Inc. AHA membership means you don’t need to call in outside consultants when searching for business solutions. AHA Services, as a subsidiary of the AHA, is YOUR in-house consulting firm, trusted for years by hospitals of all sizes across the state, and ready to serve you.

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Offering business services at specially brokered rates to AHA member hospitals – that’s what we do. We bring you projectand/or department-specific consultations that help you connect with companies ALREADY VETTED, ALREADY PROVEN, HOSPITAL-SPECIFIC, and providing special rates for member hospitals.

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Tina Creel and Liz Carder are dedicated to our member hospitals, connecting them with the specific help they need to meet today’s health care business challenges. Whether it’s in the area of Information Management, Data Analytics, Quality Management, Insurance, Supply Chain Solutions, Staff Education and Certification or Financial Services, Tina and Liz will help your hospital tap into vetted and proven resources and services as your hospital seeks to improve upon its success.

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AHA SERVICES PRESENTS: QUALIVIS

The High Cost of Workplace Violence in the Health Care Industry By Sherry Kolb, RN

ospitals are the “safe spaces” in our communities where we go to recover when we’re ill or injured. However, that sense of security is increasingly threatened by acts of violence committed against the very people who have dedicated their career to caring for others. Reports from various national organizations indicate that workplace violence is on the rise; OSHA data shows that health care workers are four times more likely to be a victim of on-the-job violence than workers in any other industry. Reporting from the National Institute for Occupational Safety and Health (NIOSH), an arm of the Centers for Disease Control and Prevention, indicates that, in 2013, 9,200 non-fatal workplace violence-related injuries were reported among health care workers. This accounts for more than 67 percent of all non-fatal, workplace violence-related injuries across all industries. Research from the Occupational Safety and Health Administration (OSHA) paints a similar picture: Approximately 75 percent of nearly 25,000 workplace assaults reported annually occurred in health care and social service settings. A substantial majority of these incidents were perpetrated by patients or their family members. Aside from the obvious physical and emotional consequences of workplace violence against nurses and other health care professionals, these events take a financial toll as well. A

2017 report prepared for the American Hospital Association estimated that workplace violence cost U.S. hospitals and health systems $2.7 billion in 2016. This astronomical number includes:

•$280 million related to preparedness and prevention. •$429 million in medical care, staffing, indemnity, and other costs related to violence against hospital employees. •$852 million in unreimbursed medical care for victims. •$1.1 billion in security and training costs.

The same study found that health care workers who were victims of violence took an average of 112.8 hours per year of sick, disability, and leave time – 60.4 more hours per year than nonvictims. With such significant financial and operational costs following from instances of workplace violence, hospitals and health systems need to make risk reduction and prevention a priority. NIOSH has identified key risk factors for violence in hospital settings. One of them is understaffing – particularly during times of heavy activity, like mealtimes and visiting hours. NIOSH recommends that hospital administrators design staffing patterns to prevent workers from working alone, especially during busy times. The Joint Commission also lists staffing as an area of improvement in its zero-tolerance approach to workplace violence. With health care workers’ safety at risk and hospitals’ bottom lines at stake, a concentrated, industry-wide effort must be made to put in place programs that reduce risk – for staffing and otherwise – to prevent violence from continuing to plague the workplace. Enlisting the help of a workforce solutions provider to ensure adequate staffing is a good first step toward mitigating any violence risk that may exist in your facility.

Sherry Kolb, RN, is president of Qualivis. A registered nurse for more than 30 years, Sherry combines decades of bedside experience in various nursing roles with expertise in recruitment services to provide customized workforce solutions for hospitals in 16 states. Qualivis is an endorsed company of AHA Services, Inc. For more information contact Natalie Plumer, 404.226.2368, www.qualivis.com. ARKANSAS HOSPITALS | SPRING 2020 43

44 SPRING 2020 | ARKANSAS HOSPITALS

Fiscal Session 2020 –

Looking Back to Look Ahead By Jodiane Tritt and Melanie Thomasson

he fiscal session of the 92nd General Assembly kicks off on Wednesday, April 8, 2020. This year’s session marks the 10th anniversary of the fiscal session of the Arkansas General Assembly, created in 2008, when Arkansas voters approved Amendment 86 to the State Constitution. Historically, our state’s fiscal legislative sessions have begun in February of evennumbered years, but Act 545 of 2019 requires that fiscal legislative sessions begin in April in presidential election years and in February in gubernatorial election years. The April start date isn’t the only noteworthy feature of this year’s fiscal session. All eyes are on the appropriations bills of the “Big Six” state agencies – Corrections, Education, Higher Education, Health, Human Services, and Public Safety – because the budgets of those agencies account for the largest share of Arkansas state tax collections and expenditures. (And with delays in tax collection due to postponement of Tax Day until July 15, the situation becomes more complicated.) Arkansas hospitals pay special attention to the appropriation of the Department of Human Services – more specifically, that of the Division of Medical Services – which designates funds to pay providers for care rendered to Medicaid beneficiaries. In addition to appropriating funds for

hospital services, physician services, rural health clinics, nursing facility services, home health services, developmental disabilities services, services for Arkansans with behavioral health needs, care for pregnant women and newborns, prescription drugs, and more, it is also the appropriation that houses the Medicaid Expansion program, now enacted as Arkansas Works. Its predecessor, of course, is the Health Care Independence Act, commonly known as the Arkansas Private Option, which began as an 1115 waiver program in 2014 and

...States that did not create ... a Medicaid Expansion program see significantly more rural hospital closures than Arkansas and other states that [did]...

ended in 2016. (Note: Act 1 of the Second Extraordinary Session of 2016 created Arkansas Works with a program start date of January 1, 2017. The Arkansas Private Option ended on December 31, 2016.) The Medicaid Expansion program allows childless Arkansans between the ages of 19 and 65 who earn less than 138% of the federal poverty level (which, for 2020, means an annual income of less than $17,236 for an individual or $35,535 for a household of four) and adult parents or caretakers with incomes between 17% and 138% of the federal poverty level to have access to medical care. For hospitals in Arkansas, costs for uncompensated care – health care services provided to patients for which there is no payment or reimbursement – were reduced by 44% in the Expansion’s first three years. It is no secret that the states that did not create or implement a Medicaid Expansion program are seeing significantly more rural hospital closures than Arkansas and the other states that took advantage of the federal opportunity (Figure 1). That’s one of the big reasons that the Arkansas Hospital Association has fought so diligently to keep the program – even as the program has undergone changes that reduce the overall number of eligible beneficiaries (Figure 2). Hospitals not only care for patients who need our services; they are also a major part of a community's healthy economy.

ARKANSAS HOSPITALS | SPRING 2020 45

Medicaid Expansion States and Rural Hospital Closures, 2014 - 2020

FIGURE 1 Medicaid Expansion helps protect against hospital closures, as shown by this map. The states designated in green are those that adopted Medicaid Expansion. Those in gray did not. Note the smaller number of closures in Medicaid Expansion states, compared with those where the program was not expanded.

When a hospital closes in Arkansas, it's a proverbial "double whammy" of negative community impact. Anytime the Arkansas legislature is in session, it has a lot of power over the Medicaid Expansion program. The Arkansas Hospital Association’s advocacy efforts for approval of the Medicaid appropriation are critical in both the regular sessions and the fiscal sessions. In both instances, the appropriation bill must reach a three-quarters affirmative vote threshold. In regular sessions, the enabling legislation may be tweaked with only a majority vote. In fiscal sessions, any bill considered a non-appropriation bill has an additional requirement that two-thirds of each chamber must vote affirmatively before it can be introduced. Arkansas’s governor and legislature created the Arkansas Private Option in

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2013 (Act 1497 of 2013 and its identical companion, Act 1498 of 2013 – ACA § 22-77-2101 et seq). The passage of those Acts that constituted the enabling legislation for the original program required a majority vote: 18 of 35 affirmative votes in the Senate and 51 of 100 affirmative votes in the House of Representatives. The appropriation that enables funding of the program, though, requires a higher, three-quarters threshold: 27 of 35 affirmative votes in the Senate and 75 of 100 affirmative votes in the House of Representatives. In 2013, that appropriation became Act 1496 of 2013 with 77 affirmative votes in the House of Representatives and 28 affirmative votes in the Senate. The vote for the appropriation must take place every year, even if the enabling legislation does not change. With the affirmative vote

threshold so high, it opens the door to political gamesmanship wherein a small number of legislators have the power to withhold their affirmative votes unless and until dramatic changes to the program (or changes, even, to a program or pet project unrelated to Medicaid) are made. In fact, that very thing has happened in previous years (Figure 2). In 2018, when Arkansas Works placed a huge administrative burden on beneficiaries to report their compliance with the program requirement – whether reporting their time on the job, community engagement activities, or their exemptions – Arkansas saw approximately 18,000 people dropped from the Arkansas Works rolls. Uncompensated care rose. U.S. District Judge James Boasberg ruled that the work requirement was inconsistent with Medicaid’s general

purpose of furnishing health care coverage and halted implementation of the reporting requirements. The state appealed, and on February 14, 2020, the federal appellate court upheld Judge Boasberg’s ruling. While the work requirement is no longer in effect, the case is expected to be filed in the Supreme Court of the United States. To add to the complexity of overcoming the affirmative vote threshold in the 2020 fiscal session and the fight over implementation of the work requirement, the 1115 waiver authorizing Arkansas Works is scheduled to end December 31, 2021. That sets up a perfect opportunity for legislators to require dramatic changes in the program that could negatively impact hospitals and Arkansas’s patients. It is clear that changes to the program – which would almost certainly constitute a new state law, a new waiver application, and federal approval for that waiver – will be required in 2021 to enable Arkansans who are currently covered by Arkansas Works to continue to receive health care services from providers who are presently reimbursed by the program for the care they provide. What remains to be seen is whether the members of the General Assembly will insist on placing additional burdens on the program during the fiscal session. While these circumstances are unfolding at the state level, the federal government has also released

guidance for how a state might apply for a Medicaid block grant – a fixed pot of money that the federal government gives to states to provide benefits or services. Specifically, the Centers for Medicare and Medicaid Services (CMS) announced the Healthy Adult Opportunity (HAO) that would allow states to apply for a 1115 waiver to cover services for certain healthy adults. Under the proposal for HAO, adult beneficiaries must be individuals under age 65 who aren’t eligible on the basis of either a disability or their need for long-term care and for whom Medicaid coverage is optional for states, i.e. the Arkansas Works population. Other lowincome adults, children, pregnant women, elderly adults, and people with disabilities will not be directly affected. It is, therefore, no surprise that the Arkansas Hospital Association will maintain laser-like focus on the appropriation for the Division of Medical Services of the Department of Human Services this fiscal session. One thing we know for certain is that big changes are coming, and the Arkansas Hospital Association will be watching, while advocating for the patients, families, and communities we serve.

The Arkansas Hospital Association will maintain laserlike focus on the appropriation for the Division of Medical Services ...

Jodiane Tritt, JD, serves as Executive Vice President of AHA. Melanie Thomasson, MPH, is AHA’s Director of Data.

FIGURE 2: LEGISLATIVE CHANGES

YEAR

CHANGE

2014

• Established health savings accounts. • Implemented cost-sharing for those above 100% FPL. • Limited some transportation services.

2016

• Imposed premiums for those above 100% FPL (NTE 2% of income). • Required job training referrals for unemployed enrollees. • Eliminated 90-day retroactive coverage (halted due to D.C. Circuit Court Case). • Said employer-sponsored coverage must be used if available.

2018

• Added work requirement as condition of eligibility. • Limited eligibility to those with incomes ≤ 100% FPL. • Eliminated employer-sponsored premium assistance programs.

ARKANSAS HOSPITALS | SPRING 2020 47

48 SPRING 2020 | ARKANSAS HOSPITALS

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