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Alabama Hospital Association

General Information

This page provides information on a number of quality-related topics.


October 29, 2019 Quality Forum session - CMS Quality Initiatives– Dr. Michelle Schreiber, Director of the Quality Measurement and Value-Based Incentives Group at CMS, Powerpoint, Video link to session

October 29, 2019 Quality Forum session - Deep Dive into Documentation –Stefanie Ledbetter, BSN, MSHI, Director of Business Analytics, Clinical Decision Support and Clinical Documentation Integrity for East Alabama Medical Center; Lucy Walton, BSN, MSN, Manager, Clinical Documentation Integrity; Michelle O’Grady, RN, CCS, Manager of Inpatient & Outpatient Coding Education for East Alabama Medical Center, provided a live demonstration of how their team digs into coding and documentation that can impact HACs and readmissions penalties. Debra Holmes, RN, BSN, CCDS, Director of Case Management, Quality, Social Services and CDI for Northeast Alabama Regional Medical Center; and Sherri Stroud, RN, C, MSN, Director of Quality and Risk Management for Springhill Medical Center, shared coding/documentation lessons learned from their site visit to EAMC. CDI reference websites, Feedback from site visit to EAMC from Debra Holmes, IP selected discharges by date range, Video link to session

October 29, 2019 Quality Forum session - New BCBS Readmission Program – Heather Quinn, Provider Network Consultant, gave an overview of the hospital 30-day readmission program to begin Jan. 1, 2020. Powerpoint, Video link to session

October 29, 2019 Quality Forum session - AQAF 12th Scope of Work Update- Dr. Wes Smith, CEO, AQAF, Powerpoint

October 29, 2019 Quality Forum session  - Care Transitions– Panelists shared their efforts to ensure better handoffs, both within the hospital and with post-acute providers. This panel included: Michelle Allen, RN, MSN, ACM, Director of Case Management and Care Transitions for Springhill Medical Center; Kate Akridge, LBSW, Complex Case Manager for Thomas Hospital; and Heather Bennett, RN, BSN, Director Case Management, CDI, Infection Control and Education for Coosa Valley Medical Center. Michelle Allen's Powerpoint, Kate Akridge's Powerpoint, Heather Bennett's Powerpoint, Video link to session

July 11, 2019 Excel Class for Clinicians - Instructors Alicia Dunkin and Stefanie Ledbetter

Quality Reporting Requirements

CMS requirements - updated Nov. 2018 Summary of various reporting requirements (NHSN, Joint Commission,etc.)

April 9, 2019 - Building a Culture of High Reliability – Joycelyn Craighead, RN, MSPH, CPHQ Huntsville Hospital, will share their journey to high reliability tools and processes to ensure the right care at the right time for every patient. 

April 9, 2019 Quality Forum - Hospital Star Ratings – Continuing Lessons Learned on Coding and DocumentationVideo link. Panel members will share what they have learned about the importance of accurate and complete documentation and coding. These are important factors that impact Star Ratings and the claims-based measures that comprise the rating.  Members include: Stefanie Ledbetter, RN, BSN, MSHI, Business Analytics, Clinical Decision Support, Clinical Documentation Integrity, EAMC, Betty Grubb, RN, Chief Quality Officer, Crestwood Medical Center,  and Joan Wilder, MSHI, RHIA, CPC, Certified ICD-10 Trainer for Shelton State Community College. No slides were used in this presentation. Guidelines for Achieving a Compliant Query Practice (2019 Update), AHIMA Inpatient Query Toolkit (2018 Copyright) Requires AHIMA Membership/Subscription, CMS 2019 ICD-10-CM Coding Downloads [See Section II. Selection of Principal Diagnosis for UHDDS reference on principal diagnosis. See Section III. Reporting Additional Diagnoses for general rules for other additional diagnoses] AlaHA's Hospital Checklist for improving documenting and coding.

April 9, 2019 Quality Forum - ED Throughput – Panel members will share their best practices and lessons learned in ensuring better ED throughput: Andy Vann, MD, FACEP, ER Physician for Gadsden Regional Medical Center, (Slide deck) Meredith Lutz, BS, MPH, MBA, Quality Director, UAB Medical West, (Slide deck)Terri Snider, MSN, RN, Director of ER Services for DCH, and Donal Conway, MD, Chair of ER Medicine for DCH (Slide deckVideo link.

October 16, 2018 Quality Forum  - Video of entire Forum (see individual sessions below)

Updates on CMS Quality Reporting for Hospitals and Physicians – Akin Demehin, MPH, Director of Policy, American Hospital Association Powerpoint Slides, Video link for session

Understanding Star Ratings and Learning How to Improve on Claims-based Measures – Overview from Akin Demehin on the methodology behind the ratings. Powerpoint Slides Hospital Speakers: Stefanie Ledbetter, RN, BSN, MSHI, Business Analytics, Clinical Decision Support, Clinical Documentation Integrity, EAMC, and Nicki Ware, RN, BSN, MBA, Executive Director of Quality at EAMC Handout - Hospital Checklist for Claim-based Measures, Video link for session

Appropriate Imaging – Jim Duncan, MD, PhD, FSIR, Professor of Radiology, Vice Chair for Quality and Safety, Washington University School of Medicine Powerpoint Slides, Video link for session


Tools from the Excel Class for Clinicians  Instructors: Stefanie Ledbetter and Rosemary Blackmon. 


April 3, 2018 Quality Forum 

  • Improving Clinical Documentation - (video link) Dr. Kathleen Bowen (EdiPhy Advisors) and Jennifer Bratz (Baptist Medical Center South) Powerpoint
  • Mitigating Ligature Risk - (video link) Debra McGuire (Brookwood Health System) Powerpoint


October 3, 2017 Quality Forum  Value Based Purchasing Update - Keith Granger, CHS Regional President and Market CEO for Alabama, covers the importance of quality measurement to patient's care and to a hospital's bottom line. Watch the video here. Click here for the slides.

Medication safety toolkit - information for providers and consumers

Archived Education (webinars, power points, etc.)

Sickle Cell Webinar (listen to the recording)- The webinar starts at minute 13:50. Slide Deck - Patients with Sickle Cell Disease (SCD) create special demands and require understanding on the part of hospital professionals. Only a small percentage of patients with SCD truly are multi-visit-patients (MVPs). If hospital personnel get fatigued and label patients with SCD as drug seekers the path to a healthier life is blocked. This webinar uncovers tips you can use to prevent readmissions, improve your opioid prescribing, and engage the patient/family to provide better education and self-management skills. Three HRET/HIIN Subject Matter Experts will lead this webinar for our Alabama hospitals. Pat Teske, MHA, RN, Subject Matter Expert for readmissions, Steve Tremain, MD, Physician Improvement Advisor, Patient Safety Consultant, Subject Matter Expert for ADEs, and Martha Hayward, IHI Lead, PFE Subject Matter Expert.

Quality Residency Class Materials from 2018 Class - Included on this page are all of the slides, tools, guidelines, and tools shared from various hospitals participating in the class. Topics include: Orientation Guides, Key Components of Hospital Quality Programs, Quality Improvement Methods/Tools, Excel Classes/How to use Data, Patient Safety, Culture of Safety, Safety Data Analysis, Trigger Tools, Introduction to Infection Prevention, Improving Documentation and Coding to support quality outcomes, Leadership, Change, Teams/Communication Strategies,Triple Aim Topics, Patient Experience, Care Transitions, and Case Management.

2018 IP Boot Camp - Included on this page are all of the slides, tools, guidelines, and tools shared from various hospitals participating in the class. Topics include: Epidemiology 101, Prevention of Transmission, HAI Prioritiy focus on CDI, The Enviroment and Why it matters, The Surveyors are in the Lobby!, HAI with focus on CLABSI, NHSN Basics, Microbiology 101 (Kristin Reeves), ADPH validations and TAP reports (Melanie Chervony), Culture of Culturing, Garcia articles (for cost of inappropriate culturing - Blood Cultures, Blood Culutre Contamination costs, Urine culture costs),Twelve Deadly Diseases, Speaking Points for Flu, Antibiogram - example from EAMC, Cleaning in the world of IPs, Cleaning Accountability Guide, AC Teams (Lisa McAuley), Data - How do you have your Data tell your Story, How to Wear Multiple Hats in a Small Hospital - (Cathy Hodge and Katie Hopper),  Antibiotic Stewardship, Articles for bringing front-line nurseses into the ABS program,  Cdiff - Examples of diarrhea decisions tree.

New overview for IPs - from the Colorado Hospital Association

Quality/IP Basics - job descriptions and other resources for new quality directors and infection preventionists

Other Resources (policies, checklists, articles, etc.)