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April 2019
In This Issue
HIIN Updates
Safety & Preparedness Updates
Quality Reporting News
Upcoming Events
MHA Awards

MHA Visionary Leadership Award2019 Visionary Leadership Award Call for Applications
MHA is accepting applications for the 2019 Visionary Leadership Award. Recognizing outstanding achievements in clinical and health outcomes, this award will be presented at MHA’s annual convention to one hospital or health system chief executive.

All applications and materials for the 2019 Visionary Leadership Award must be received electronically by 5 p.m. Friday, May 3.

MHA Aim for Excellence Award2019 Aim for Excellence Award Call for Applications
MHA is accepting applications for the 2019 Aim for Excellence Award. Hospitals are encouraged to submit an application highlighting a project that reduces harm, improves health outcomes or improves health status within their community.

The deadline to submit an application is 5 p.m. Monday, May 6. For more information and FAQs, visit MHA's website. Also available online is the 2018 Compendium and 2018 award recipient videos.

HIIN Updates

HIIN Option Year 
Currently, the Centers for Medicare & Medicaid Services is reorganizing all of its quality and safety contracts, including “hospital improvement,” through the new 12th Scope of Work that began in February. During the transition, CMS provided a verbal commitment to continue the current HIIN work through at least Thursday, June 27, while finalizing a longer extension of the current contract and in preparation for a new contract in 2020. Participating hospitals can expect updated project dashboards, programming updates and staff contracts in April.

MHA will continue to work with the American Hospital Association’s Health Research and Educational Trust throughout the transition. MHA will ensure uninterrupted data collection and reporting, as well as technical support, to continue advancing improvement and to satisfy CMS’ compliance for hospitals of 50 beds or more to actively engage in quality and safety initiatives.

Concurrently, MHA is actively designing a new, comprehensive hospital quality and safety improvement program for members and partners to be deployed under CMS’ 12th SOW. This plan will focus on data-driven improvement techniques, cohort-based improvement sprints, innovative partnerships and increasing reliable performance. Opportunities to increase organizational capacity and capability will continue, as well.

Congratulations to Milestone Recipients! 
The MHA HIIN team congratulates the following HIIN-participating hospitals for meeting the HIIN extension milestone requirements.

  • CenterPointe Hospital
  • Cox Monett Hospital
  • Fitzgibbon Hospital
  • Golden Valley Memorial Hospital
  • Lafayette Regional Health Center
  • Landmark Hospital of Joplin
  • Long-Term Acute Care Hospital, Mosaic Life Care of St. Joseph
  • Mercy Hospital South
  • Mercy Rehabilitation Hospital Springfield
  • Missouri Delta Medical Center
  • Pike County Memorial Hospital
  • Ranken Jordan Pediatric Bridge
  • Royal Oaks Hospital
  • Saint Francis Medical Center
  • Saint Luke's East Hospital
  • Saint Luke's Hospital of Kansas City
  • Saint Luke's North Hospital — Barry Road
  • Ste. Genevieve County Memorial Hospital
  • Sullivan County Memorial Hospital
  • Washington County Memorial Hospital

Thank you for continued HIINgagement!

Regional Meetings
Three FLEX Medicare Beneficiary Quality Improvement Project regional meetings were held across the state in March. Hermann Area District Hospital and Wright Memorial Hospital each presented on their use of best practices and innovative strategies to achieve the goals of the MBQIP program.
FLEX MBQIP regional meeting attendees — Festus, Mo.
Regional Meeting Attendees — Festus, Mo. 
Throughout the last year, Iron County Memorial Hospital focused on improving quality with significant emphasis placed on Emergency Department Consumer Assessment of Healthcare Providers and Systems scores. Through these efforts, they increased scores by an average of 30 percent from first quarter 2018 to fourth quarter2018. According to the current Telligen reports, two Missouri CAHs received a five star rating on Hospital Consumer Assessment of Healthcare Providers and Systems.
Emergency Department Transfer Communications Measures Highlights
Through the fourth quarter of 2018, 94 percent of Missouri CAHs were actively reporting the Emergency Department Transfer Communications 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’s EDTC results through second quarter 2018.
  • 540% increase in EDTC reporting since first quarter 2015
  • 100% improvement across all EDTC measures in CY 2018 compared to CY 2015
  • 30% improvement in all seven EDTC measures, including the “ALL EDTC” score
  • 11.86% improvement in “ALL EDTC” composite score
  • 12 CAHs are in the top 10% of best performing CAHs in the nation for the “ALL EDTC” (achieving 100% in all measures)
Notable Improvements in Outpatient Measures
Compared to the first quarter 2015 baseline, there have been the following improvements through second quarter 2018.
Quality Measure Percent Improvement
OP-2: Fibrinolytic therapy received within 30 minutes 128%
OP-3: Median time to transfer for acute coronary intervention 8%
OP-5: Median time to ECG 42%
OP-18: Median time from ED arrival to ED departure for discharged ED 4%
HCP/OP-27: Influenza vaccination coverage among
health care personnel
IMM-2: Influenza immunization – 4Q2016-1Q2018 2.2%
Increased reporting has enabled organizations to make valid and reliable decisions across the EDTC, outpatient, patient safety and patient experience measures. Sharing best practices during the regional meetings, statewide meeting, coaching support and peer-to-peer mentoring have been key strategies leading to these notable improvements.
Safety & Preparedness Updates
PIO Workshop
PIO WorkshopIn March, public information officers in the health care setting had an opportunity to attend a Public Information Officer Workshop to develop techniques and skills when serving in a hospital, joint information center, health coalition or incident command system. The course focused on effectively communicating during high-concern, high-risk and high-stress issues, as well as obtaining media and crisis communications skills. Those attending included PIOs, public relations and marketing professionals, and staff responsible for messaging during incidents that affect operations.

The audience also had the opportunity to hear from local PIO Yvette Williams, Director of Corporate Communications with CoxHealth Springfield, who recently experienced the tragic Branson Duck Boat Incident and shared their own lessons learned.

HCAHPS Survey – Question Removal
CMS plans to remove the three pain communication questions from the HCAHPS survey, effective October 2019. Read the federal information collection notice.
3rd Annual Summit for Acute & Post-Acute Care Providers
The Summit for Acute & Post-Acute Care Providers: Insights and Perspectives on Care Coordination and Value-Based Payment is a unique one-day event that convenes payers, providers and suppliers to absorb thought leadership, and to network with policy/strategy/operations influencers and decision-makers. At the summit, ideas are exchanged, opportunities are examined, bridges are built and collaboration emerges.

The summit takes place Wednesday, May 8, in St. Louis and includes the following topics.
  • Making Care more Affordable and Accessible
  • Changing Behaviors to Improve Health
  • Care Collaboration and Value-Based Care
  • Disruptive Forces in the Health Care Industry
  • Health Care Consumer Perspectives
See the most up-to-date information regarding this upcoming summit!
Missouri STR/SOR Offers Free Buprenorphine Waiver Training
The Missouri Opioid State Targeted Response and Missouri State Opioid Response, along with the Missouri Coalition for Community Behavioral Healthcare, is offering a free Buprenorphine waiver training. The first four hours of the course will be in person, and the last four hours will be individual online work. The in-person training will take place from 8:30 a.m. to 12:30 p.m. Saturday, May 25, in Kansas City, Mo. Online registration is available.

This coursework will go toward APN or PA 24 hours of training. Once completed, finish the other 16 hours of work to get your certificate. For additional information, contact Emily Conde at, or 573/634-4626, ext. 103.
Save the Date: 2019 MHA Quality and Safety Convening
The 2019 MHA Quality and Safety Convening is for anyone committed to and passionate about improving health care quality and safety for patients, families and those who work in a health care setting. Patients and families are uniquely positioned to provide the best perspective and work in partnership with health care across the continuum to achieve the triple aim of better care, better health and lower costs. However, the quadruple aim includes the addition of increasing the health care worker’s joy in work. Developing a reliable, resilient workforce has never been more important. How can we create synergy among patients, families and health care workers to optimize and balance the needs and experiences of all involved? This convening serves as an opportunity to further explore and discuss the critical issues that contribute to the overall health care experience by all stakeholders and advance toward achieving the quadruple aim.

The 2019 MHA Quality and Safety Convening will take place Thursday, July 25. Registration and additional details will be available soon.
HAI Projects from MU Nursing Outreach
The University of Missouri Nursing Outreach has an updated website. The new site features a health care-associated infections page, which hosts a collection of more than 100 learning resources, including the latest references regarding best practices, video clips, online tools and practice kits. Webinar-based online courses also are available on the site. A flyer has been developed to assist with site navigation.

Don’t miss a thing! Follow MU Nursing Outreach on Instagram @mu_nursing_outreach.
New MHA Resources Promote Safe Care Environments
Healing Happens HereEncompassed in every hospital’s mission is the need to ensure safe, appropriate and high-quality care for patients. Since 2016, MHA has been curating resources through the S.A.F.E.R. Initiative to assist hospitals in creating safe care environments. The initiative provides a platform for interactions between patients and families, hospital staff, and members of the community, designed to improve safety.

In recognition of the recent National Patient Safety Awareness Week, MHA released patient-facing resources using the theme Healing Happens Here. The new resources can be co-branded for use throughout the hospital.

These resources have been crafted to avoid misinterpretation that could deter patients from seeking needed care in hospitals’ emergency departments. Additional guidance about hospitals' responsibilities under the Emergency Medical Treatment and Active Labor Act is available.

If you have questions about Healing Happens Here or the S.A.F.E.R. Initiative, please contact Jackie Gatz at or 573/893-3700, ext. 1330.
Quality Works Logo
Quality Works® Expands Services
Quality Works® expanded its services to include expertise in facilitating and leading clinical quality, population health, safety collaborations and performance improvement education. These offerings include the following. For more information, contact Sherry Buschjost at
CMS Posts Resources For CY 2019 eCQM Reporting Period
Read more.
CMS Releases 4Q2018 Submission Checklists
Read more.

More news can be found in MHA Today.
Upcoming Events

Orientation for New Infection Prevention Professionals
Columbia College  Jefferson City Campus
Jefferson City, Mo.


2019 MHA Quality and Safety Convening
Columbia College  Jefferson City Campus
Jefferson City, Mo.


Orientation for New Quality Improvement Directors
Columbia College  Jefferson City Campus
Jefferson City, Mo.

Upcoming Virtual Events

The Opioid Crisis Series Part III: 
Addressing the Opioid Epidemic Through a
Recovery-Oriented System of Care
10 a.m.


FLEX — Population Health Webinar
10 a.m.


Emergency Preparedness
Program Update Webinar
11 a.m.

For additional MHA events, visit the MHA calendar.

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