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February 2019
In This Issue
Quality Updates
HIIN Updates
Safety & Preparedness Updates
MoAHQ Update
Quality Reporting News
Upcoming Events
2019 Aim for Excellence Award

The Missouri Hospital Association 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.

2018 Aim for Excellence Award Winners
Perry County Memorial Hospital | Perryville
Critical Access and
Rural Hospital

CoxHealth | Springfield
Small and Large
Metropolitan Hospital

Mercy | St. Louis
Care Collaborative or
Health System

Pictured: Debbie Hayden, Director of Occupational Therapy; Janice Lundy, Director of Social Work and Geriatric Care Management; and Patrick Carron, President and CEO
Pictured: Steve Edwards, President and CEO; Becky Watts, Administrative Director of Cardiovascular Services; Trina Hargis, Nurse Manager; and Jeff Hawkins, Vice President of Clinical Services

Pictured: Fran Hixson, Director of Clinical Quality, and Peter Brawer, Ph.D., Vice President of Clinical Quality and Patient Safety

Quality Updates
UP Intervention Sprints
Get UP Improvement SprintThe Get UP Improvement Sprint is underway. The Get UP Intervention focuses on mobilizing patients. Early progressive mobility preserves muscle strength, reduces delirium, improves lower extremity circulation and lung capacity, and reduces length of stay, allowing patients to return to optimal function more quickly. Through the Get 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.

MHA is offering the complimentary sprints to all member hospitals – don’t miss out on the remaining UP Intervention Sprint! The enrollment deadline for the Wake UP Sprint is Wednesday, Feb. 20. For more information or to register, please contact Amanda Keilholz. Recorded webinars for the Script UP and Soap UP sprints now are available on MHA's website.

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 Friday, Feb. 8.
HIIN Updates

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
  • Osage Beach Center for Cognitive Disorders
  • Pike County Memorial Hospital
  • Sullivan County Memorial Hospital
These organizations have shown incredible dedication to improving safety and quality. MHA commends your dedication to improve care in the communities you serve!

Two Missouri Hospitals to be Recognized at AHA Rural Health Care Leadership Conference 
The American Hospital Association's 2019 Rural Health Care Leadership Conference brings together top practitioners and thinkers to share strategies and resources for accelerating the shift to a more integrated and sustainable rural health system. The conference will examine the most significant operational, financial and environmental challenges and present innovative approaches that will enable participants to transform their organization's care delivery model and business practices.

Congratulations to Cox Medical Center Branson and Ste. Genevieve County Memorial Hospital for being two out of only 10 scholarship awardees selected by HRET! Both facilities will attend and present their storyboards at the conference in Phoenix, Ariz. in early February.

Cox Medical Center Branson Cox Medical Center Branson submitted their storyboard application on hospital onset C. difficile. In 2017, with the hospital’s onset of C. difficile SIR consistently greater than one, a goal was set to reduce their SIR to less than 0.9. Diagnostic stewardship in the form of a “Charge Nurse Hard Stop” was implemented, and as a result of this intervention, an improvement of 70 percent not only was achieved in a single quarter, but also has been sustained. Having access to resources provided through HIIN empowered their team members to make innovative and quality-focused interventions.

Ste. Genevieve County Memorial Hospital Ste. Genevieve County Memorial Hospital submitted their storyboard application on falls. The hospital identified, through use of a root cause analysis, that there was a systemic lack of fall risk recognition and communication of risk precautions within the organization. With an average of 29 falls annually systemwide from 2014-2017, a goal was set to achieve a 40 percent reduction in all falls and a 90 percent increase in inpatient nursing compliance with fall risk precautions by 2018 with implementation of a fall prevention bundle. As a result, a 66 percent reduction in falls was achieved systemwide with a 93 percent increase in staff compliance with a fall risk bundle. MHA HIIN provided support, guidance and technical assistance through tools and evidence-based practice as measures were employed to reduce falls.

New FLEX MBQIP Contact
Effective Jan. 1, 2019, Sherry Buschjost, Vice President of Quality Services, will be the administrative contact for the Medicare Rural Hospital Flexibility Program at MHA. Sherry can be reached at or 573/893-3700, ext. 1369. Jim Mikes will continue as your finance and operations contact and Stephen Njenga as your quality and population health contact.
Regional Meetings Scheduled
FLEX MBQIP regional meetings have been set for 2019. See upcoming events section to register.
Safety & Preparedness Updates
Workplace Violence 
Through the S.A.F.E.R. Initiative, MHA continues to prioritize efforts to reduce the prevalence of violence in the workplace. In addition to a workplace safety policy repository to validate existing approaches and recognize best practices, MHA will be collecting statewide workplace violence data to identify themes and provide benchmarks to members. Using the Hospital Industry Data Institute’s quality portal, hospitals will have the opportunity to submit first quarter 2019 data in early April. A recent memo to security directors and selected chief operating officers further outlines the initiative. If additional staff beyond current quality portal users is necessary to submit the data, MHA staff will provide training and enable access to HIDI’s quality portal. Questions may be directed to Jackie Gatz, Vice President of Safety and Preparedness, at
Public Information Officer Workshop for Health Care Providers
MHA is providing a workshop on Tuesday, March 5, at The Broadway Hotel in Columbia, Mo., to prepare public information officers in health care settings to communicate more effectively with high-concern, high-risk and high-stress issues.

Topics will include the role of the PIO in a hospital, joint information center, health care coalition and incident command system; high-concern, high-risk and high-stress communication tools, templates and skills; message mapping and message development techniques; and basic, intermediate and advanced media and crisis communications skills.

Dr. Vincent Covello, Director of the Center for Risk Communication in New York, will provide the training. Dr. Covello is a nationally and internationally recognized trainer, researcher, consultant and expert in communications in high-concern, high-risk and high-stress situations. His recent assignments include trainings, workshops and consultations related to communications about active shooter situations, terrorist bombings, cyber-security incidents, organizational change, accidents, hospital emergencies, occupational safety, vaccine safety, waste disposal, air quality, water security, fires, operational disruptions, major budget cuts, hurricanes, earthquakes, tornadoes, Ebola and Zika.

There is no registration fee to attend; however, early registration is encouraged. The course is being offered statewide, and seats will be filled on a first-come, first-served basis for the first 45 registrants. Clock hours may be applied toward CHEP certification. See upcoming events section to register.

Survey Readiness: Environment of Care and Life Safety Standards Including Behavioral Health Environmental Risks
MHA is offering a one-day program on Tuesday, April 9 at Camden on the Lake in Lake Ozark, Mo., to provide information for individuals who are responsible for managing the Environment of Care and Life Safety program and understanding The Joint Commission survey methodology and recent changes to the standards. Information will be provided to implement a practical, continuously compliant program for health care facilities to achieve maximum performance while effectively preparing for unscheduled TJC and CMS surveys. While TJC and CMS requirements are the basis for curriculum development, there is value in the content and discussion for all hospitals, regardless of the accrediting body.

Attendees also will receive specific guidance on the most serious deficiencies that are commonly cited in surveys. Behavioral health environmental risks have become a significant survey focus and will be reviewed during this program to include risk assessment strategies.

There is no registration fee to attend; however, early registration is encouraged as this course is being offered statewide, and seats will be filled on a first-come, first-served basis for the first 60 registrants. Clock hours may be applied toward CHEP certification. See upcoming events section to register.

A block of rooms has been reserved at Camden on the Lake. Individuals will need to make reservations directly by calling the hotel at 888/365-5620 and requesting the MHA room rate of $128 plus tax. The cutoff to make a reservation is Friday, March 8.
Show-Me ECHO Webinar Series
The Missouri Telehealth Network’s Show-Me ECHO announced that it will be holding a series of webinars regarding challenges in rural obstetrics, high-risk OB partnerships and neonatal abstinence syndrome.

High-Risk OB Partnership for Excellence (HOPE) ECHO
  • Launch date: Tuesday, Feb. 5
  • Noon to 1 p.m. — 1st and 3rd Tuesday
Neonatal Abstinence Syndrome (NAS) ECHO
  • Launch date: Thursday, Feb. 7
  • Noon to 1 p.m. — 1st and 3rd Thursday
Challenges in Rural Obstetrics — Women and Neonates (CROWN) ECHO
  • Launch date: Thursday, Feb. 28
  • Noon to 1 p.m. — 2nd and 4th Thursday
Registration and additional information for all ECHOs can be found at
A Focus on Opioid Stewardship Programs
by Sarah James, MoAHQ District 3 Representative
Sarah James, MoAQH District 3 RepresentativeOpioids have been in the forefront of the news for several years due to the death toll it continues to have in the U.S. On average, the opioid epidemic claims a life every 12 minutes.

The key to implementation of an opioid stewardship program includes involving a multidisciplinary approach; engaging the community; and seeking out federal, state and local resources. Some resources include the CDC Opioid Resource Center, MHA’s Opioid Initiative, Missouri Opioid State Targeted Response, and Engaging Patients in Care Coordination Outreach (EPICC), which connects opioid-dependent patients with recovery coaches to walk them through the process of accessing treatment options in the St. Louis and Columbia areas and is currently expanding to the Kansas City metro area.

Many health systems have implemented multifaceted approaches to combating this epidemic. Opioid stewardship was a new requirement by The Joint Commission as of 2018. Saint Luke’s Health System in the Kansas City metropolitan area implemented a multidisciplinary Opioid Stewardship Program in March 2018. The program is comprised of pharmacists; physician representatives from emergency medicine, internal medicine, pain management, primary care and surgery; nursing staff; and risk management, IT and quality professionals.

Some of the quality initiatives that have been implemented include the following.
  • morphine equivalent daily dose (MEDD) calculations for each opioid prescription – Epic EMR
  • cumulative MEDD calculations for specified timeframes
  • provider access to St. Louis County PDMP and Kansas PDMP
  • provider access to support websites, such as state and local substance abuse resources (SAMHSA), CDC Guidelines, medication disposal sites and opioid risk assessment tools (ORT, SOAPP-R, COMM)
  • systemwide education in the form of semiannual publications on system opioid resources
  • Grand Rounds education provided to health system practitioners presented by MHA
  • neonatal abstinence syndrome policy — Eat, Sleep, Console assessments
  • quality metrics — chart review each time naloxone is administered for admitted patients post-opioid administration
  • quality metrics — emergency medicine should not prescribe > three days of opioid prescriptions
  • intranet web page for systemwide opioid education and resources
  • participation in national Vizient Opioid Collaborative and BJCC Opioid Collaborative
Learn more at the 2nd Annual MHA Opioid Summit: Addressing Perinatal and Neonatal Clinical Care Issues on Wednesday, Feb. 27, in Blue Springs, Mo.

For any questions related to this article, please contact Sarah James.

To learn more or join MoAHQ, visit our website at
Assessing and Identifying Suicide Risk
Suicide is the 10th leading cause of death in the U.S. and the second leading cause of death for individuals aged 10-34. Suicidal crises require clinicians to make a judgment regarding the degree of risk for suicide within the health care environment. Risk assessment findings inform the development of a safety plan and guide subsequent treatment planning. MHA developed clinician education regarding health care-based suicide prevention and ligature-resistant environments.
CMS Seeks Comments On Follow-Up After Psychiatric Hospitalization Measure
Read more.
CMS Updates IPFQR Program Resources
Read more.
CMS Announces New Resources For eCQM Development
Read more.
CMS And TJC Release Guidance For Reporting Diagnostic Study Performed Results Data In 2018 QRDA I Reports
Read more.
TJC Announces eCQM Expert To Expert Webinar
Read more.
CMS Selects Random Sample For IQR Program Validation
Read more.

More news can be found in MHA Today.
Upcoming Events

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
The Broadway Hotel
Columbia, Mo.


Survey Readiness: Environment of Care and
Life Safety Standards
Camden on the Lake
Lake Ozark, Mo.

Spring 2019 MBQIP Regional Meetings

Springfield, Mo.
Hilton Garden Inn


Chillicothe, Mo.
Comfort Inn & Suites


Festus, Mo.
Holiday Inn Express & Suites

Upcoming Virtual Events

1st Quarter Emergency Preparedness
Program Update Webinar
11 a.m.

For additional MHA events, visit the MHA calendar.

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