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December 2018
In This Issue
HIIN Updates
Quality Updates
Safety & Preparedness Updates
Quality Reporting News
Upcoming Events
The population health program at Hannibal Regional Healthcare System was instituted to assist with chronic disease management and promotion of wellness. To achieve the Triple Aim, population health team members coordinate care across the continuum of care to ensure appropriate utilization of resources through education and counseling. They provide care navigation and follow-up to ensure patients have the appropriate appointments with providers and obtain their medications. The team also supports medication education and provides assistance with learning to follow a healthier lifestyle. In May 2013, a grant funded by the Missouri Foundation for Health was introduced to include members of the community, particularly super-users of the emergency department. Targeted diagnoses included diabetes, hypertension and hyperlipidemia.
Data for three super-users of the ED is shown. From 2013 to 2015, ED utilization and inpatient admissions for each super-user dropped by 54 percent, 80 percent and 38 percent, respectively; overall utilization decreased by
61 percent.

Cost savings dropped dramatically for each super-user, with the largest drop being for patient #2 who saw a decrease of $738,384, or 95 percent.

One such utilizer was pleased to share her success story with us. At the time she joined the program, the patient was 47 years old, overweight, sedentary and a smoker. She lived with her parents and rarely left her home. She was diabetic with high blood pressure and high cholesterol. After an ED visit for abdominal pain, she underwent surgery and was discharged after seven days.

“Five days later, I was readmitted. I got up one morning to take my blood sugar. The reading was in the 50s. I took all of my medication and returned to bed. My mother checked on me later to find me confused and trying to remove the staples and buttons on my belly. 911 was called, and I was taken to the hospital. My blood sugar on arrival was 29. I was never told not to take my medicine if my blood sugar was low.”

The patient was referred to the program by the hospitalist coordinator who was concerned that the patient was not knowledgeable about her conditions and was at-risk for further readmissions. The accountable care/population health nurse provided coordination of care, helping increase the patient’s knowledge about the medical conditions and changing the behaviors that were causing or exacerbating them.

“I am very thankful for this program! My accountable care nurse has been my cheerleader, and friend to me and my family. She taught me recovery didn’t mean depriving myself of the things I love, it means tweaking them to make better choices.”

The patient subsequently lost more than 100 pounds. She has learned to use a pill organizer to ensure she takes her medications properly, and she checks her blood sugar, weight and blood pressure daily, and follows a daily exercise regimen.

“Without this program I wouldn’t be alive today!”

The program continues to thrive, evidenced by the addition of three nurses to the accountable care/population health team.

HIIN Updates
As the Hospital Improvement Innovation Network project rolls into its extension period and continues to support improvements made across the state in harm and readmissions reduction, the extension plan has been finalized and was shared during the HIIN Huddle webinar on Nov. 27. As outlined in the plan, the HIIN team will continue to provide data reports, support, educational opportunities, stipends, capacity building and resources. The extension brings a stronger focus on patient and family engagement and disparities; therefore, hospitals will be surveyed frequently during the project to recognize and give credit for advancements to achieving milestones for PFE and health equity metrics. In addition, MHA plans to provide access to educational programs and resources to help hospitals reach contract milestones.
Lean Six Sigma Recruitment
After great success with the initial Lean Six Sigma Green Belt Project, MHA is pleased to announce a second cohort. This project is offered exclusively to HIIN hospitals.

Lean Six Sigma is a performance improvement platform with roots originating in the production and manufacturing industry. Its methodology builds upon a five-step process — Define-Measure-Analyze-Improve-Control — with an intense focus on the removal of errors, defects or “waste,” described as any step, motion or resource that does not add value to the process.

The second cohort will be hosted in Jefferson City and is limited to 23 projects requiring a two-person hospital-based team. At the end of the eight-month intensive project, participants are awarded Green Belt Certification. This is a unique opportunity to not only receive education regarding the DMAIC process, but also to implement the tools and techniques learned while receiving technical assistance throughout the program.

Training is appropriate for health care executives, physicians, managers, supervisors or directors. Hospitals may submit more than one project and team application. Applications will be accepted through Friday, Nov. 30. For additional information or to register, please contact Amanda Keilholz at


“The Lean Six Sigma program was extremely informative! The health care industry needs a strong movement of standard operating procedures to provide better patient safety. This program introduced some great strategies to better determine the cause of issues, so we can be more productive and successful in resolving them.” — Ste. Genevieve County Memorial Hospital

“The Lean Six Sigma course was very beneficial for the success of our future and ongoing projects within our organization. I really felt that the course explained how to make a project successful by introducing different analytical tools and going through the steps of how to figure out whether a project was worth the resources.” — Liberty Hospital

Zero Heroes 
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported. These organizations have either achieved and/or sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals.

  • Cox Barton County Hospital
  • Carroll County Memorial Hospital
  • Ellett Memorial Hospital
  • Harrison County Community Hospital
  • Iron County Medical Center
  • Mercy Hospital Carthage
  • Osage Beach Center for Cognitive Disorders
  • Sullivan County Memorial Hospital
These organizations have shown incredible dedication to improving safety and quality. Again, congratulations! MHA commends your dedication to improve care in the communities you serve!
Quality Updates
UP Intervention Sprints
MHA is excited to welcome the following hospitals into the Soap UP Sprint.
Bates County Memorial Hospital
Bothwell Regional Health Center
Cass Regional Medical Center
Cedar County Memorial Hospital
Citizens Memorial Hospital
Excelsior Springs Hospital
Fitzgibbon Hospital
Freeman Health System
Golden Valley Memorial Healthcare
Hannibal Regional Healthcare System
Harrison County Community Hospital
Hedrick Medical Center

Iron County Medical Center
John J Pershing VA Medical Center
Kansas City VA Medical Center
Kindred Hospital Northland
Landmark Hospital of Columbia
Madison Medical Center
Mercy Hospital Aurora
Mercy Hospital Cassville
Mercy Hospital Lincoln
North Kansas City Hospital
St. Alexius Hospital
Wright Memorial Hospital

The Soap UP Interventions focus on hand hygiene. Hand hygiene is the single most effective way to reduce the transmission of healthcare-acquired infections. Through the Soap UP Sprint, these hospitals will have the opportunity to take part in interactive discussions with a national subject matter expert. Additionally, the sprint will provoke thought around reviewing current policies, assessing the need for change, addressing barriers and implementing a plan to control drift.

Don’t miss out on the remaining UP Intervention Sprints! MHA is offering the complimentary sprints to all member hospitals. Enrollment for each of the sprints closes the Wednesday prior to the beginning of the sprint. The deadlines are listed below.

Sprint: Enrollment Deadline:
Get UP: Wednesday, Jan. 16, 2019
Wake UP: Wednesday, Feb. 20, 2019

Please review the program information for additional details on the remaining UP Intervention Sprints.

MHA Quality & Safety Showcase 
The MHA Quality & Safety Showcase will take place on Tuesday, Feb. 12, at the Courtyard by Marriott in Columbia, Mo. Providing a platform for shared learning and networking, Missouri hospitals will highlight their work to improve the quality of care and safety, and encourage rapid adoption of proven practices. The day will kick off with keynote speaker Erin Zeringue of A3 Healthcare who will discuss the importance of Lean Six Sigma in health care. The Showcase also will feature presentations from the following.

  • MHA’s Lean Six Sigma Green Belt Project participants
  • Readmissions Reduction/Care Transition and Sepsis Intervention Immersion project participants
  • MHA’s 2018 Aim for Excellence Award winners
To take part in this great opportunity to network with and learn from Missouri hospitals, register by Feb. 8, 2019.
Top Performing CAHs in ALL EDTC Composite Score
While emergency care is important in all hospitals, the emergency department is particularly important in critical access hospitals where the distance to urban tertiary care centers makes the effective triage, stabilization and transfer of patients — with the necessary and appropriate information — of life or death importance. ED transfer communication measures allow acute care safety net facilities to demonstrate how well they carry out their important stabilize-and-transfer role for rural residents. This measure is required of hospitals participating in the FLEX MBQIP program in Missouri and across the nation.

The following CAHs achieved 100 percent compliance in the ALL EDTC composite score as of third quarter 2018, placing them in the top performers list of CAHs in Missouri and the nation.
  • Carroll County Memorial Hospital
  • Ellett Memorial Hospital
  • Excelsior Springs Hospital
  • Harrison County Community Hospital
  • Iron County Medical Center
  • Lafayette Regional Health Center
  • Madison Medical Center
  • Mercy Hospital Aurora
  • Mercy Hospital Lincoln
  • Perry County Memorial Hospital
  • Putnam County Memorial Hospital
Safety & Preparedness Updates
Active Shooter Resources Available For Missouri Hospitals
Following the shooting on Nov. 20 at Mercy Hospital in Chicago, MHA staff are reminding members of several resources available on our website to assist staff with mitigation and preparedness efforts. First, armed violent intruder and active shooter planning tools are available with our hazard-specific preparedness resources. Second, in conjunction with our S.A.F.E.R. Initiative, MHA has developed resources to assist member hospitals with mitigating workplace violence through advocacy, reducing regulatory burden, strengthening partnerships and implementing evidence-based strategies through policy development and staff skill building. For more information, contact Jackie Gatz.
DHSS Releases Ebola Webinar
The Department of Health & Senior Services developed a webinar providing an overview of the state’s response plan to Ebola and other highly infectious diseases. The webinar is for general education and a reminder for front-line health care facilities to continue to identify and isolate suspect patients. In addition, the webinar will serve as a companion piece to the Ebola/other highly infectious diseases state response plan itself. The state response plan is located in the EMResource document library.
TJC Announces eCQM Expert to Expert Webinar Series
The Joint Commission, in cooperation with Centers for Medicare & Medicaid Services’ subcontractors, is offering a series of webinars to provide concepts about clinical quality logic expression language. The first webinar in the series is scheduled at 11 a.m. Tuesday, Dec. 11. Topics of discussion include a review of measure logic and common issues related to STK-2, -3 and -6 electronic clinical quality measures. Registration is available.

Quality Works® – Your Go To For Training
Looking for professionals to meet your training needs? Contact the Quality Works® experts to facilitate and lead clinical quality, population health, safety collaboration and performance improvement education. Our offerings include the following.
To learn how professionals may assist your facility, contact Sherry Buschjost at
CMS Announces New Hospital Quality Reporting Next Generation User Interface
In an effort to modernize the Hospital Quality Reporting systems, the Centers for Medicare & Medicaid Services made changes to the preview reports to enable users to make better use of reported data. Upon logging into their QualityNet account, users will see a new HQR Next Generation User Interface. Migration to the new system affects Hospital Compare preview reports. Additional details are available.
TJC Posts Update to Specifications Manual Addendum 2018B1
Read more.
CMS Updates QRDA Category I Conformance Statement Resource for CY 2018 eCQM Reporting
Read more.
CMS Updates eCQI Resource Center
Read more.

More news can be found in MHA Today.
Upcoming Events

Save the Date!
MHA Quality & Safety Showcase

Courtyard by Marriott
Columbia, Mo.


2nd Annual MHA Opioid Summit —
Addressing Perinatal and Neonatal Clinical Care Issues
Courtyard by Marriott Adams Pointe Conference Center
Blue Springs, Mo.


Public Information Officer Training
Blue Springs, Mo.


Safety and Regulatory Compliance Program
Camden on the Lake
Lake Ozark, Mo.

Upcoming Virtual Events

Community Paramedics Webinar
11 a.m.

For additional MHA events, visit the MHA calendar.

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