Advancing Quality & Patient Safety, a podcast by the New Mexico Hospital Association
By NM Hospital Association
Advancing Quality & Patient Safety, a podcast by the New Mexico Hospital Association. This podcast highlights member hospital efforts in the fields of quality & patient safety and features insights from clinical experts across our state. This podcast serves the purpose of facilitating shared learning and collaboration across NMHA member hospitals.
Episode 20 of Advancing Quality & Patient Safety: Team Approach to Reducing CDI. This episode features an interview with Kerry Bolin, MSN, NEA-BC, CPHQ, who is the VP Patient Safety and Quality, at Gerald Champion Regional Medical Center in Alamogordo, New Mexico.
Kerry shares with us the wide approach they took to reducing CDI in their hospital including process improvements in antimicrobial stewardship, lab stewardship, & environmental cleaning to ensure safe care for every patient.
Lastly, Kerry shares with us her insight on leading an initiative that involves multiple disciplines & clinical departments.
Episode 19 features an interview with Lacey Robinson, Infection Prevention & Employee Health nurse at Miners' Colfax Medical Center in Raton, New Mexico.
Lacey was recently involved with leading a hospital wide initiative that improved their healthcare personnel flu vaccination rates from 67% last flu season to almost 100% this year.
Lacey shares with us creative ideas and solutions to this challenging topic that supports staff and maintains a positive culture of safety.
Lacey also shares with us insights around being a new IP, and how important it is to develop relationships and collaborate with physician leaders and administration.
Today's episode features an interview with Rennie Mariscal, Physician Practice Administrator & Director of Case Management and Amanda Pryor, Interim Director of Case Management from Gila Regional Medical Center (Silver City, NM).
They shared their efforts and successes with a comprehensive care transitions program that included multidisciplinary collaboration and community partnerships.
Episode 18 of Advancing Quality & Patient Safety: Partnering to Reduce Hospital Readmissions. This episode features an interview with Wendi Hulett, Chief Nurse Executive at Lincoln County Medical Center in Ruidoso, New Mexico. LCMC was the winner of the top rural/critical access and overall top hospital categories for the 2019 NMHA Quest for Excellence Awards.
Wendi shares with us data-driven approaches the hospital has taken to drive key interventions with reducing hospital readmissions to as low as 2.2%. She shares with us the multidisciplinary approaches taken at the hospital, along with partnerships established with local EMS to conduct home visits post hospital discharge.
Lastly, Wendi shares with the important modifications they made to their in-hospital questionnaire, to help them gain a better patient and family perspective.
Episode 17 features an interview with Megan VanNatta, Director of Compliance, Christina Salazar Director of Nursing, & Jennifer Risley Director of Therapy with the national recognized inpatient rehabilitation facility, The Rehabilitation Hospital of Southern New Mexico. This hospital was the winner of the NMHA's Quest for Excellence Award in 2019 as the top specialty hospital.
The leadership team shares with us a program recently developed at the hospital to service spinal cord injury survivors with successful reintegration into their community. The interdisciplinary team at the hospital adopted validated clinical practice guidelines, along with standardized care management processes to help spinal cord injury patients regain functional independence and return to their daily activities.
We learn from the hospital the importance of partnering with patients and families from day one of the hospital stay, setting shared goals with them, and most notably, always asking the patient what is most important them. Lastly, we highlight the hospital’s commitment to patients post-discharge with programs they have developed such as community support groups.
Episode 16 of Advancing Quality & Patient Safety features an interview with Kelly Garland, Quality Coordinator, & Erin Martin, Chief Quality Officer, at MountainView Regional Medical Center in Las Cruces.
Kelly & Erin share with us a multidisciplinary huddle that occurs in their hospital. What sets this huddle apart from most is its focus on documentation accuracy and coding in real-time. We learn from MountainView the importance of the message “ if isn’t codable documentation, it didn’t happen.”
They also share with us the widespread learning that occurs in their hospital with real-time root cause analysis at the unit level combined with unit led improvements in clinical care processes.
MountainView Regional Medical Center, the winner of the 2019 NMHA Quest for Excellence Top General Acute Care Hospital, exemplifies the importance of physician leadership, nurse-driven improvements, and a culture of safety to improve documentation & clinical care.
Episode 15 of Advancing Quality & Patient Safety features an interview with Paula Bustillos, the Quality Program Coordinator with UNM Sandoval Regional Medical Center on the topic of hospital certification programs.
Paula shares insights and guidance on the hospital certification process and uses recent examples as she led her hospital through the Bariatric Surgery Certification.
She teaches us the similarities & differences with hospital certification & accreditation, the team you need to assemble when pursuing certification, data abstraction & metrics, and how to engage and facilitate standardization to evidence-based practice.
Episode 14 of Advancing Quality & Patient Safety features an interview with Dr. Robert Underwood, Chief Medical Officer at San Juan Regional Medical Center.
Dr. Underwood is in the process of writing a book on physician leadership, and he shares with us key insights and lessons from his book.
Dr. Underwood covers the topics how to identify good potential leaders at your organization, distinguishing between formal & informal leaders, and how to develop and apply a leadership philosophy when leading teams at your hospital.
Episode 13 of Advancing Quality & Patient Safety: Leading Large-Scale Performance Improvement. This episode features an interview with Marie Cleary- Fishman , AHA's VP for Clinical Quality. Marie will also be speaking at NMHA's 2019 Annual Meeting during the Quality Awards Ceremony.
Marie talks with us about transitions quality leaders need to make when leading large-scale improvement project, whether it is spreading improvement across a hospital or multiple hospitals.
Marie shares insights on various change management strategies, data analysis, and engaging stakeholders at all levels when facilitating improvement.
Lastly, Marie shares lesson learned from her career in quality and stories about important mentors shes had along the way.
Episode 12 of Advancing Quality & Patient Safety: Solutions for Nursing Leader Burnout. This episode features an interview with Sharon Radcliffe, the Chief Nursing Officer at Los Alamos Medical Center.
Sharon is in process of completing her Doctor of Nursing Practice degree, and part of that involves a doctoral thesis capstone project. Sharon chose to research nurse leaders across the country on the topic burnout.
She shares results of that research and gives ideas and solutions around this popular topic in healthcare.
Sharon also importance of continuous learning as a health care leader, and why pursuing the advanced degree in nursing as helped further her passion for nursing leadership.
Episode 11 of Advancing Quality & Patient Safety: Process Design to Improve Patient Outcomes and Employee Satisfaction. This episode features an interview with Doug Johnson, Director of Quality, at Lovelace Medical Center.
Doug is a RN by background and a Lean Six Sigma Black Belt, while having extensive experience in process improvement.
Doug teaches about the principles of process design, methodologies it aligns with, and tools used to apply it.
He shares with us recent success of utilizing process design at Lovelace Medical Center, specifically with care management, that has resulted in improved patient outcomes while significantly improving employee satisfaction.
Episode 10 of Advancing Quality & Patient Safety features an interview with Christina Campos, the hospital administrator for Guadalupe County Hospital. This hospital was recently crowned as a top 20 rural hospital in the country. Christina gives us insights and stories around their journey to this top ranking.
We learn from Christina about the hospital’s approach to quality improvement and how their focus on quality is preparing them for the emerging changes into value-based care and population health. Christina teaches about the importance of community partnerships for hospitals, and how Guadalupe County has taken a proactive approach to leading efforts in ensuring a healthy and thriving population.
Lastly, Christina shares with us her details around her servant leadership approach in leading a hospital, and why mentorship is crucial to the professional development of a leader.
Episode 9 features a conversation with Wendi Hulett, Chief Nurse Executive, from Lincoln County Medical Center. Wendi shares with us key practices and efforts surrounding the hospital's success in reducing patient falls. This success led to their receipt of the 2018 Quest for Excellence recognition at the NMHA Quality Awards and a case study developed by AHA.
Much of the conversation includes insights around the strong patient safety culture that has been established at the hospital. Wendi shares with us their best practices on leadership rounding and patient safety huddles. She teaches us that not only has this strong patient safety culture improved care for patients, but it has facilitated collaboration across their organization and engaged their workforce.
Episode 8 features an interview with the Chief Quality Officer, BranDee Savell, of Nor-Lea Hospital District. Nor-Lea Hospital District recently received the level 4 Zia Award, which is the most prestigious Baldrige recognition at the state level. BranDee educates on the Baldrige Framework, application process, survey process, and how Baldrige aligns with and utilizes many other performance improvement methods. BranDee also shares with us how this framework has not only resulted in improved quality & patient safety outcomes, but also enhancements to the patient experience and improvements in financial outcomes.
Episode 7 features an interview with Cathy Nicholson, Manager of Quality Programs & Penny Beattie, Chief Nursing Officer of Presbyterian Hospital. They share with us a project they led on the topic of patient handoffs from the Emergency Department to inpatient units. They teach us about "warm" handoffs and how its effective with facilitating better teamwork, patient/family engagement, and improving the patient experience.
Episode 6 features an interview with Dr. Greenwood-Ericksen of UNM Hospital & UNM School of Medicine. She talks with us about a recent collaborative effort she led nationally with ACEP (American College of Emergency Physicians) for the formation of the Emergency Quality Network. Within that network, best-practices and tool kits were developed for rural emergency departments and their providers for managing sepsis. Dr. Greenwood-Ericksen also educates us on the CMS Core Measure for sepsis and provides an overview of her research on rural and urban ED's sepsis management performance, recently published in the Journal of Rural Health.
Episode 5 features an interview with Dr. Lara Goitein, who is the Medical Director of Clinician Directed Performance Improvement (CDPI) at CHRISTUS St. Vincent Health System. The CDPI program was recognized last year when CHRISTUS St. Vincent Regional Medical Center received the NMHA Quest for Excellence Award. They were also recognized at IHI's Patient Safety Congress meeting in Boston, MA.
Dr. Goitein shares with us the mission and structure of CDPI, its intersection with the hospital's traditional quality program, and the effect CDPI has had on improving physician engagement, culture of safety, and reducing patient harm.
Episode 4 is Part 2 of the series, "Tips For The New Quality Leader; What I Wish Someone Had Told Me" and features Tony Baird, DSc, MHA, CPHQ, CPPS of Memorial Medical Center in Las Cruces, New Mexico. Tony is the Executive Administrative Director of Medical Staff Services & Clinical Quality at the hospital.
Tony shares with us the role of mentorship and how it has influenced his development as a quality leader. He also shares insights on how to engage senior executives with quality and patient safety initiatives, how to be successful with system-wide improvement projects, and what he sees changing in the healthcare quality landscape.
Episode 3 features an interview with Lisa Thompson, CJCP, CPHRM, CPHQ, TQMC. Lisa is the Chief Quality Officer at Lea Regional Medical Center in Hobbs, New Mexico and has over 30 years of experience in quality leadership.
Lisa shares her insights on how new quality leaders can become successful in their roles. She speaks about key relationships the quality leader must develop and how to influence change across an organization. Lisa also gives some important guidance on the hospital survey process that includes tips on preparation, survey readiness, and survey etiquette.
Episode 2 features an interview with leaders from Cibola General Hospital surrounding their population health centered project on improving flu vaccination rates. Listen today to learn more about their usage of process mapping, PDSA implementation, and strategies to engage multiple hospital departments around a shared vision. Their efforts were recognized with a 2018 NMHA Quest for Excellence award and also recently published by AHA into a case study.
Please reach out to the hospital leaders below for more information on their project.
Ambroshia Mandagaran, Director of Quality and Risk Management;
Glenna Losito, Co-Chief Nursing Officer;
Maria Atencio, Co- Chief Nursing Officer;
Rick Smith, Director of IT;
Randy Mattila, Hospital Pharmacist;