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November 2018
In This Issue
HIIN Updates
Quality Updates
Safety & Preparedness Updates
MoAHQ Update
Quality Reporting News
Upcoming Events
96th Annual Convention & Trade ShowMHA hosted its 96th Annual Convention & Trade Show on Nov. 7-9 in Osage Beach, Mo. The event featured the following speakers: Tim Hague, R.N., “Parkinson’s and Perseverance: The Amazing Race;” Doc Hendley, “Digging for Hope: Turning Wine to Water and Other Modern Day Miracles;” Natalie Stavas, M.D., “Running Towards Chaos;” and Capt. Chesley “Sully” Sullenberger, “208 Seconds: A Lifetime of Lessons.” Eleven of MHA’s personal membership groups enjoyed the opportunity to receive education and network with their peers on industry trends, challenges and solutions. A major highlight of the event was the induction of MHA’s new board chair, Steve Edwards, CEO of CoxHealth. Additionally, several hospitals and leaders were recognized for their significant contributions to health care in Missouri, including winners of the Aim for Excellence awards – Perry County Memorial Hospital, Mercy and CoxHealth.
HIIN Updates
The MHA HIIN team awarded 70 hospitals with Milestone 8 stipends, totaling $84,325. The stipends were earned by hospitals who were up-to-date on reporting data and demonstrated a high level of performance within the HIIN project. Congratulations!

Additionally, the MHA HIIN team is excited to announce that the contract modification to continue the HRET HIIN work until at least March 27, 2019, has been received. Within the contract, there are measure updates that will be identified as the contracts are negotiated and signed. Please stay tuned for notices and updates as they become official.

The next HIIN Huddle is at 2 p.m., Tuesday, Nov. 27, and registration is available online.

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 an application packet, 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

HRET HIIN Spotlight — CenterPointe Hospital
From the Field: Ask for Safe Care, Ask for Clean Hands

HIIN quality improvement fellow, Elizabeth Hensley-Birky with CenterPointe Hospital in St. Charles, Mo., focused her quality improvement fellowship project on increasing hand hygiene compliance in the acute care unit. The aim was to increase health care workers’ hand hygiene compliance to 90 percent by
Dec. 31, 2018. The hospital’s change ideas include the following.

  • Expand hand hygiene monitors from infection control to other departments, including nursing supervisors, administrators and pharmacists.
  • Re-educate staff and patients on the importance of hand hygiene.
  • Implement the World Health Organization's My 5 Moments for Hand Hygiene approach.
  • Place signage on carts that read, "Ask me if I washed my hands," and posters on patient rooms that say, "Ask for safe care, ask for clean hands," as a reminder for patients to confirm that health care staff have washed their hands.
The quality improvement project started in January 2018, and by May 2018, the hospital had increased hand hygiene compliance from 30 percent to 78 percent. Congratulations to Elizabeth and her team on their success toward increasing hand hygiene compliance!

Key takeaways:
  • Observing staff helps with compliance, but it is not enough to provide sustainable improvement.
  • Focus on one change idea at a time to see success, then gradually act upon other ideas.
  • Education itself is not enough for staff; it is important to show the impact through data.
Quality Updates
UP Intervention Sprints
MHA is excited to welcome the following hospitals into the Script UP Sprint.
Barnes-Jewish Hospital
Bates County Memorial Hospital
Bothwell Regional Health Center
Cass Regional Medical Center
Cedar County Memorial Hospital
Cox Barton County Hospital
Excelsior Springs 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 St. Louis
St. Alexius Hospital
Wright Memorial Hospital

The Script UP Interventions focus on how too many, too few or incorrect medications, including antibiotics, can lead to adverse drug events. These adverse drug events may result in longer, more intense hospital stays and readmissions. Through the Script UP Sprint, 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:
Soap UP: Wednesday, Nov. 28, 2018
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 projects
  • 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.

Patient Family Advisory Council Update 
MHA’s Statewide Patient and Family Advisory Council is making strides for patient and family engagement through their statewide PFAC challenge. A key outcome for the council is to promote a statewide culture of health, integrating the patient and family perspective. The PFAC challenge tasks each Missouri hospital with identifying at least one nonemployee patient or family member to serve on at least one committee within the organization by July 2019.

As of July 2018, 19 percent of Missouri hospitals who responded to the survey assessing the level of patient and family engagement were meeting the challenge metric, which is an increase from 11 percent reported in December 2017. Missouri hospitals are surveyed quarterly, with the next survey scheduled for later this month.
Patient and Family Engagement Roadmap
MHA encourages all hospitals to accept the challenge and achieve this critical PFE goal! The Patient and Family Engagement Roadmap is intended to be used as a strategic guide to help hospitals increase patient and family engagement within their organization.

Please visit the MHA PFAC web page to learn more about the council, access the PFAC survey schedule and find other relevant resources.

Regional Meetings
FLEX MBQIP Regional Meeting Attendees - Festus, Mo.Three FLEX Medicare Beneficiary Quality Improvement Project regional meetings were held across the state in October. Harrison County Community Hospital, Mercy Hospitals Aurora and Cassville, and Salem Memorial District Hospital each presented on how they are using best practices and innovative strategies to achieve the goals of the MBQIP program. Throughout the last few months, several critical access hospitals received national recognition for excellence in quality and patient experience.
ED Transfer Communication Measure Highlights
Through the third quarter of 2018, 94 percent of Missouri CAHs were actively reporting their Emergency Department Transfer Communication measures. While emergency care is important in all hospitals, the ED serves as a critical access point for care in rural areas. Achieving effective triage, stabilization and transfer of patients with the necessary and appropriate information to the next care provider is vital. EDTC measures demonstrate the capability of CAHs to effectively carry out the important stabilize-transfer role for the rural residents they serve.

The following are key highlights of Missouri CAH EDTC results through Q2 2018.
  • 540 percent increase in EDTC reporting since Q1 2015
  • 100 percent improvement across all EDTC measures in CY 2018 compared to CY 2017
  • 23.97 percent improvement in all seven EDTC measures, including the “ALL EDTC” score
  • 8.97 percent improvement in the “ALL EDTC” composite score
  • nine CAHs are in the top 10 percent of best performing CAHs in the nation for the “ALL EDTC” composite score (achieving 100 percent in all measures)
Notable Improvements in Outpatient Measures
Compared to the Q1 2015 baseline, the following improvements have been made through Q2 2018.

Notable Improvements in Outpatient Measures

Increased reporting has enabled organizations to make valid and reliable decisions across the EDTC, outpatient, patient safety and patient experience measures. Sharing best practices through the statewide and regional meetings, coaching support, and peer-to-peer mentoring are key strategies leading to these notable improvements.
Safety & Preparedness Updates
Ebola Webinar
Missouri Department of Health & Senior Services presented a webinar discussing an overview of the state response plan that is intended to be used as general education and as a reminder for front-line health care facilities to continue to identify and isolate suspect patients, as well as 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.
New MHA Preparedness Report
Attendees of MHA’s Annual Emergency Preparedness and Safety Conference received a new MHA report, “Missouri Hospital Preparedness: Identified Threats and Focus Areas.” The report outlines the threats and risks affecting Missouri hospitals and draws attention to three crucial areas: patient surge, infrastructure resiliency and resource management. Although Health Care Security and Safety Week recently concluded, MHA’s work in this area will continue.
CMS Extends Timeline for Publication of Final Rule on Discharge Planning
The Centers for Medicare & Medicaid Services announced it is extending the timeline for publication of the final rule on revisions to the discharge planning requirements for hospitals, CAHs and home health agencies to Nov. 3, 2019. The agency cites significant policy issues that need to be resolved to address concerns raised by public comments and assurance of appropriate coordination with other government agencies, specifically, collaboration with the Office of the National Coordinator for Health Information Technology. Final rules generally are required to be published within three years of the publication of the proposed rule, which would have been Nov. 3, 2018.
Upcoming Webinar: Community Paramedics — Their Role in Value-Based Care
MHA is excited to facilitate an upcoming webinar for participants to learn about the growing role of community paramedics in managing populations. Community paramedics are EMS practitioners who are trained and trusted medical professionals, available 24/7 in nearly every community around the nation. CMS and managed care payers are taking steps to engage these professionals in effective care transitions. The webinar will cover the following topics.
  • broadening the understanding of community paramedics
  • community paramedic programs in Missouri and their measuring impact
  • the future of community paramedics in driving care transitions
The webinar will take place at 11 a.m. Wednesday, Dec. 12. Registration is required.

Webinar presenters include Mark Alexander, administrative director of Pre-Hospital Services for CoxHealth, who is responsible for the financial and operational oversight of the Emergency Medical System owned by CoxHealth, and David Lewis, assistant chief for the St. Charles County Ambulance District, who serves as the District’s chief strategy officer for its Mobile Integrated Health Program in which advanced practice paramedic skills are leveraged to address community health care gaps.

MoAHQ Update by Missy Sutton, MoAHQ President
Missy Sutton, MoAQH PresidentThe Missouri Association of Healthcare Quality has a brand new website. MoAHQ members can access the member login by using “moahq” as the username (all lowercase) and entering your password. The new website contains quick links to the member directory, board of directors, job notices, and other resources and quality links. If you currently are not a member and are interested in joining, there is a quick link on the website to join the organization.

MoAHQ has been working hard to recruit new district representatives to serve on the board by updating the current district representatives’ role and applying strong recruitment efforts from current board membership. Listed below are the new district representatives for 2018-2019. Their main goal will be to increase MoAHQ membership and share strategies and resources to assist with current quality initiatives within their districts. We are excited to have this new team of leaders helping to share and shape quality efforts throughout our state. Please feel free to contact the district representatives below if you have ideas for future MoAHQ initiatives.

District 1: Angie Snyder
District 2: Sarah James and Dorothy Andrae
District 3: Linde Merrow and Jodie Sapaugh
District 4: Debbie Nihill and Elaina Osterbur
District 5: David Winnett
District 6: Jenifer Civy and Lynn Rasnick

To learn more, visit our updated website at, or contact me at
New! Behavioral Health and Rehabilitation Resource Release
HRET HIIN released two new resources highlighting effective practices, or practices that leading behavioral health and rehabilitation organizations have employed to provide safe, high-quality care. The practices were collected from freestanding hospitals, long-term care facilities, and subject matter experts across the nation. Payer mixes, patient populations and geographies are diverse, making the practices and case studies implementable by a broad spectrum of facility types.

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 Updates Inpatient and Outpatient CART
Read more.
2019 Reporting Period eCQM Flows Now Available
Read more.
CMS Updates Claims Detail Reports For OP-35 and OP-36
Read more.
Addendum to National Hospital Inpatient Quality Measures Specifications Manual Released
Read more.
TJC Releases Specifications Manual Addendum 2018B1
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 Conference Center
Blue Springs, Mo.

Upcoming Virtual Events

HIIN Huddle Webinar: November
2 p.m.


Community Paramedics Webinar
11 a.m.

For additional MHA events, visit the MHA calendar.

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