VAHQ Summer 2018

A Message from the President.

Happy Summer to the VAHQ Membership!

We hope that you are enjoying the summer with your colleagues, family and friends.
What a great first half of the year have had with the VAHQ! We heard from you that educational opportunities are important to you. Therefore we worked to re-start the VAHQ educational webinars and successfully hosted our first one (free of charge after this suggestion came from a member) on June 20th! You will find more info on the webinars in the newsletter.

Here are a few notes, reminders and dates to remember:

  • We will be hosting two CPHQ prep courses this year. The first will be in Ashburn, Virginia at Ashby Ponds on July 24-25, 2018. Please see our website ( for more information- registration is quickly increasing! The second will be in October in Richmond – more to come!
  • We heard your feedback regarding the VAHQ Annual Conference and will be arranging for virtual attend-ance at the NAHQ Annual Conference (November 5-7, 2018). We will be arranging for viewing sites in Northern and Central Virginia and are excited that we will be able to attend a national conference that is packed full of dynamic speakers without going too far from home and at a discounted rate.
  • Make sure to check out our website ( and follow us on Facebook and LinkedIn (more infor-mation on the newsletter). Our team has done a stellar job of making sure these resources are helpful and of value to the membership. If you have feedback on how to make them better, please share it!
  • We will hold summer networking events. Please share any ideas you may have!
  • Membership! So far this year we have had 23 renewals and 7 new members join the VAHQ. In order to ensure that our membership is strong and dynamic and that we may contribute positively to the quality community in the Commonwealth, we are always interested in recruiting new members. Please pass along contact information for anyone you would like to see as a VAHQ member.
  • NEW! VAHQ Email – We are excited to share that the VAHQ Board is in the process of obtaining VAHQ email addresses. We look forward to sharing them and to providing this VAHQ-specific means of com-munication with our membership. Email me anytime at!

We look forward to a busy summer. Please feel free to reach out to me or any other VAHQ Board Member if you have questions, ideas, or concerns.

Elizabeth Mikula
2018 VAHQ President

Featured Board Members

Tanya Scott

Tanya is a nurse with over 21 years of experience in various aspects of nursing and healthcare including Medical/Surgical; Pre-Admissions/Same Day Sur-gery; PACU; Community Health; and Preventive Medicine. In March 2016 Tanya began working at the Richmond VAMC in the Quality Department where she is currently the Mental Health Service Line Quality liaison. She is thrilled to be able to serve fellow veterans and to be able to work at the facility that has given her such excellent care since she got out of the service. She has been a member of VAHQ and NAHQ since 2005. She is the proud parent of 1 biological and 1 step-daughter; 1 step-son; 2 dogs; and 4 cats. She is obsessed with anything purple.

Carla Thomas

Carla Thomas is a well-known partner and leader among Virginia’s care transi-tions initiatives. As Health Quality Innovators’ (HQI’s) Director of Care Tran-sitions for the Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) contract, Carla oversees a team that supports commu-nity coalitions working to reduce hospitalizations in Maryland and Virginia. She is a graduate of Slippery Rock University in Pennsylvania where her mas-ter’s degree led to extensive Alzheimer’s program development for a large nursing home corporation. Her 15 years of quality improvement leadership at HQI includes improvement initiatives for nursing homes, hospitals and care transitions. Carla is a certified professional in healthcare quality and a trainer in TeamSTEPPS and coalition-building.

Betsi Hurd–

I have been a RN for 41 years. Clinical experience has been critical care and med-surg. I have been a CNE, Nursing Supervisor, Director of Critical Care, Director of Medical and Orthopedic Unit. In the last ten years I have focused on Quality. I have been a CPHQ for 15 years. I was a data analyst and Admin-istrative Director of Quality Outcomes for Bon Secours. Currently I am the Administrator for Personal Care Services with Hope In-Home Care, LLC with six offices across Virginia. I wanted to learn about the home care side of healthcare and to facilitate a better transition from the hospital to home and to maintain the client in the community in hopes of decreasing hospital admis-sions.

VAHQ Educational Webinars are Back!

VAHQ recently hosted the first webinar of 2018. Robin Arnicar RN, ASN presented key points on antibiotic stewardship. Participants of this insightful webinar were awarded 1 CEU through NAHQ and let’s not forget to mention that registration was free! Historically, VAHQ has charged a small fee for webinars but throughout the remainder of the year VAHQ will host several more webinars that are free of charge.

Robin’s key points included:

  • Antibiotic stewardship reduces antibiotic resistance
  • 30-50% of antibiotic use in hospitals is unnecessary or inappropriat
  • Nearly 50% of antibiotics in nursing homes are given longer than necessary
  • Bacteria cause 2 million illnesses and 23,000 deaths annually
  • A step-wise approach to developing and implementing an Antibiotic Stew-ardship Program is critical to its success. The program needs leadership commitment, accountability, drug expertise, action, tracking, reporting and education to be successful.

Upcoming Webinars:

  • Thursday, July 31, 2018 from 12p -1p. Anissa Cole will tell us about Life Net
  • Wednesday, August 15th from 1p-2p Richmond Health Department will present a webinar is on TB management
  • Wednesday August 22nd from 12p-1p Michelle Comeaux will speak about High Reliability/Regulatory Readiness
  • Wednesday, September 19 from 12p-1p Melissa Gasker will speak about LTAC/SNF/ALF

Mark your calendars and check the VAHQ website for registration details!

We have added two more great reasons as we continue our list of TOP 10 Reasons why you should be a VAHQ Member
7. It pays to be a member!
Members are entitled to reduced registration fees for educational events held by VAHQ. Members have received a $50 reduced annual education confer-ence registration in the past years as well as reduced webinar fees. Our educa-tional events are a great way to obtain CEUs and you can buy a new pair of shoes with the money you saved using the member discount!

6. Enhance your resume!
There is no arguing that membership in an association such as VAHQ demon-strates that you are committed to keeping up to date in your Quality profes-sion. Looking to strengthen your leadership experience? Becoming a VAHQ board member develops team management and coaching skills in addition to broadening your network of quality professionals.

Education Update

CPHE Review Course - July 24 and 25, 2018 - Ashburn, VA

This interactive two-day course is designed to support those planning to take the Certified Professional in Healthcare Quality® (CPHQ) Certification Exam-ination. Based on the current CPHQ content outline, this course engages par-ticipants in a review of the examination material and offers valuable tips on how to best prepare for test day. Participants should begin this course with functional knowledge in areas identified on the CPHQ content online. Com-pletion of this course does not guarantee a passing score on the examination.

Price: $369 for NAHQ Members, $449 for Non-members

The course begins at 8:00 AM and concludes at 4:30 PM on both days. The course fee includes breakfast and lunch on both days and electronic access to handout materials for one year. This course is being held in collaboration with Virginia Healthcare Quality Association.

Visit or to register.


Annual Conference Save the Date Details to Follow

Mark your calendars, we have big plans for the annual conference this year! We have heard from you that a dynamic line-up of nationally recognized speakers is important to you. In addition, we have heard from many of you that you would be interested in attending the NAHQ Annual Conference virtually. Therefore, we plan to virtually connect with the NAHQ Annual Conference (November 5-7, 2018) via wo lo-cations, one in Northern Virginia and one in Central Virginia. This opportunity offers you the opportunity to network with VAHQ mem-bers, earn CEUs, and attend the national conference at a greatly dis-counted rate. More to come .. we are excited!

Resource Roundup

HCAHPS: Patients' Perspectives of Care Survey

By the Health Care Industry Committee

How does HCAHPS work?

The Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS, pro-nounced “H-caps”) survey was developed collaboratively by Centers for Medicare and Medi-caid Services (CMS) and the Agency for Healthcare Research & Quality (ARHQ). The survey aims to produce data about patient experience of care that allows for objective and meaningful comparisons of hospitals. The questions address topics that are important to consumers, create new incentives for hospitals to improve quality of care, and enhance provider accountability in health care by increasing transparency of the quality care. Included as a component of the Val-ue-Based Purchasing program, CMS uses provider HCAHPS survey results to positively or negatively adjust individual hospitals’ Medicare reimbursement.

Why is the HCAHPS survey a key issue for providers?

The HCAHPS survey measures patient experience. HCAHPS survey scores are an indication of the level of service provided by an organization, contribute to its reputation, and have reimbursement implications for providers. Traditionally, consumers have “consumed” and not “shopped” for health care services. However, more consumers are moving or being forced to move to high deductible healthplans. As a result of this increased financial commitment, patients are more engaged in their health care decisions. Experi-ence is one of the many ways consumers are weighing their options. Under Value-Based Purchasing (VBP), HCAHPS accounts for 30% of the TPS in FY 2015 and 25% in FY 2016 and FY 2017.
The Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS, pronounced “H-caps”) survey was developed collaboratively by Centers for Medicare and Medicaid Services (CMS) and the Agency for Healthcare Research & Quality (ARHQ). The survey aims to produce data about patient experience of care that allows for objective and meaningful comparisons of hospitals. The questions ad-dress topics that are important to consumers, create new incentives for hospitals to improve quality of care, and enhance provider accountability in health care by increasing transparency of the quality care. Included as a component of the Value-Based Purchasing program, CMS uses provider HCAHPS survey results to positively or negatively adjust individual hospitals’ Medicare reimbursement.

Summary of HCAHPS Survey Results

Average “Top Box" Score for Hospitals
July 2017 (October 2015 to September 2016 Discharges)
Quietness of Hospital—52%
Communication About Medicines—63%
Pain Management—71%
Communication with Nurses—74%
Cleanliness of Hospital—73%
Communication with Doctors—82%
Discharge Information—87%

The survey asks for patient feedback in several areas, including communication with nurses and doctors, the responsiveness of hospital staff, the cleanliness and quietness of the hospital environment, pain man-agement, communication about medicines, discharge information, among others. A random sample of discharged adult patients across medical conditions are asked to answer 27 questions pertaining to their most recent hospital stay. Patients taking the survey must be 18 years or older and have had atleast one overnight stay in the hospital as an inpatient, but are not required to be Medicare beneficiaries. The ques-tions are administered to patients by mail, telephone, mail with telephone follow-up, or interactive voice recognition. Hospitals submit collected data to CMS for analysis. The Patient Experience Domain Score for each hospital is determined by summing the hospital’s HCAHPS Base Score (0-80) and HCAHPS Consistency Score (0-20). CMS publicly reports HCAHPS scores on its Hospital Compare website.

Healthcare Quality Foundation (HQF) Certification Grant
Deadline: July 31, 2018

Each year, HQF awards grants to individuals looking to enhance their profes-sional development by earning the Certified Professional in Healthcare Quali-ty® (CPHQ) certification. The HQF Certification Grant is awarded two times annually (in January and July) and provides financial assistance to healthcare quality professionals preparing for the CPHQ exam.

Healthcare Quality Foundation (HQF) Certification Grant
Deadline: July 31, 2018

Each year, NAHQ recognizes three members who have shown loyalty, passion, and enthusiasm for the organization and the healthcare quality profession. Indi-viduals may nominate their peers or submit a self-nomination. Award recipients will be notified in late August and will receive complimentary registration to NAHQ Next, taking place November 5-7, 2018, in Minneapolis, MN.

Health Literacy and Older Adults

From Centering on Excellence: A Virginia Quality and Patient Safety Newsletter


The VHHA Center for Healthcare Excellence is leading several performance improvement initiatives in the Commonwealth. The Center has received funding to support Virginia’s hospitals as they work to improve health outcomes for patients.

The Virginia NICU Early Intervention (EI) Collaborative:

Thirty-three (33) Virginia Neonatal Intensive Care Units (NICU) are participating in a grant-funded initi-ative through the Virginia Board for People with Disabilities called the Virginia NICU Early Intervention Collaborative to improve the quantity and quality of referrals to Early Intervention services for infants cared for in hospitals. Early Intervention is a community-based program that provides services to infants and toddlers, from birth to three years of age, who have developmental delays or disabilities. Some babies that have been in the NICU may need help learning skills typically acquired in the first three years of life such as crawling, walking, communicating, playing, eating, and dressing. Early Intervention providers in the community work with families post-discharge in their homes to develop or enhance these skills.

The Collaborative has developed resources in response to gaps identified during the investigation phase of the project. While this work has been led by participating hospitals, all Virginia hospitals are encouraged to access the public-facing VA NICU EI Collaborative website to learn more about Early Intervention, use the Referral Guidance Form, education modules, and the On Your Way Skill Building Worksheets for Families and Caregivers. Later this month, a Collaborative-developed "Virginia Best Practice Protocol" document will be posted to the website as a resource for hospitals regarding recommended practices for improving care coordination for infants served in NICUs.

Stopping Sepsis in Virginia Hospitals and Nursing Homes

The Stopping Sepsis program with the VHHA Center for Healthcare Excellence and Health Quality Inno-vators (HQI) is in the final months of a nearly two-year project that concludes in September 2018. Thirty-three (33) of our hospitals have been participating to improve sepsis bundle compliance and mortality outcomes data. The project team hosted two webinars in March and May this quarter. These collaborative presentations were offered to hospitals and nursing homes in the Sepsis Special Innovation Pro-ject. Handouts can be found on HQI’s Resource Center website here. The project team continues to bring hospitals and nursing homes together for in-person events, and on networking calls.

VHHA Center of Healthcare Excellence joins HRET to Offer AHRQ’s ICU Safety Program to Virginia ICUs

The Virginia Hospital Research & Education Foundation (VHREF) and the Center for Healthcare Excel-lence have been awarded grant funding to convene Virginia hospitals in a 12-month improvement initia-tive designed specifically for adult Intensive Care Units (ICU) to lower central line associated bloodstream infection (CLABSI) and catheter associated urinary tract infection (CAUTI) rates. Along with our national partner, the American Hospital Association’s Health Research & Education Trust, hospitals have been invited to participate in the project funded by the Agency for Healthcare Research and Quality (AHRQ). The AHRQ Safety Program for ICUs: Preventing CLABSI and CAUTI is being conducted in col-laboration with the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS). The program began April 30 with 12 Virginia hospitals enrolling 20 individual adult ICUs. This effort will employ resources that have been developed as part of earlier national efforts to apply the Comprehensive Unit-based Safety Program (CUSP) to eliminate CLABSIs and CAUTIs. Participants will gather and apply lessons learned regarding effective implementation of quality improvement efforts in the ICU setting. To learn more about the AHRQ ICU Safety Program visit

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