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Alabama Hospital Association

General Information

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


Quality Reporting Requirements

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

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.)