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January 2019
In This Issue
Reimagine Rural Health
Quality Updates
HIIN Updates
Safety & Preparedness Updates
MoAHQ Update
Quality Reporting News
Upcoming Events
Reimagine Rural Health

Reimagine Rural HealthIn early December, Gov. Mike Parson held a rural health summit in Bolivar, Mo., that addressed a multitude of issues that are of great magnitude for rural Missourians. A number of the issues touched on expanded opportunities to improve rural health policy and delivery. As a result, MHA is launching an initiative, “Reimagine Rural Health,” that explores 10 rural health issues that were raised at the summit and proposes policy options that should be considered to address them.

Our goal is to work with the Parson administration and other stakeholders to develop programs and policies that help Reimagine Rural Health in Missouri to provide a strong and sustainable health care system well into the future.

10 Rural Health Issues

  1. Expand Access to Behavioral Health Services
  2. Expand Access to Primary Care Providers
  3. Increase Access to Care for Substance Use Disorder
  4. Ensure Access to Quality Health Care
  5. Allow and Encourage Innovative Payment Models
  6. Collaborate to Identify and Address Social Determinants of Health
  7. Expand Telehealth and Telemedicine
  8. Advocate for Improved Infrastructure
  9. Support Emergency Services
  10. Empower Partnerships

We hope you will join us in sharing this information throughout your social networks and communities. Follow us on Facebook and Twitter. And, let us know your ideas to #ReimagineRuralHealth.

Quality Updates

Citizen’s Memorial Hospital Receives 2018 Missouri Quality Award 
Citizens Memorial Hospital/Citizens Memorial Health Care Foundation was recognized with the 2018 Missouri Quality Award administered by the Midwest Excellence Institute. The Missouri Quality Award is the highest level of recognition for business excellence in Missouri and is given to elite organizations based on leadership, strategy, customer engagement, strategic planning, workforce engagement and operations.

This is the third time CMH has won the award — also having earned the distinction in 2014 and 2010. CMH is the only organization in southwest Missouri to have won the award.

The CMH Missouri quality writing team includes: 1st Row – Donna Shelby, Renee Meyer, Heather Finnell, Donald J. Babb, DeAnna Hedger, Kim Tatum and Tamera Heitz-Peek. 2nd Row – Chuck Mauck, Dr. Ron Evans, Lesa Stock, Valerie Noblitt, Tracie Walker, Beverly Derrickson, Debbie McQuay and Jeremy MacLaughlin. 3rd Row – Karen Stockdale, Jarrett Finnell, Jeffrey Miller, Mike Calhoun, Tim Francka, Kim Eggleston and Gary Fulbright.

MHA Convenes Missouri's Maternal-Child Learning and Action Network 
Following increased scrutiny of the rate of maternal mortality nationally, and specifically in Missouri, MHA and the Missouri Department of Health and Senior Services collaborated to formalize a slate of clinical and stakeholder subject matter experts to convene and identify required actions. The Missouri Maternal-Child Learning and Action Network will focus on both maternal and infant morbidity and mortality. The initial meeting, held on Dec. 3 at MHA, served to understand current activities and initiatives throughout the state, identify key steps to formalize actions and fiscal support of quality improvement activities, and identify initial data sets for project focus. Core team members have been expanded to include the Missouri Department of Social Services, the March of Dimes, and a representative from the Council on Patient Safety in Women’s Healthcare and the Alliance for Innovation in Maternal Health. MHA will provide further updates on the LAN’s activities and initiatives. Please contact Alison Williams at with any questions.

MHA's Statewide Patient and Family Advisory Council Makes Progress for PFE 
MHA’s Statewide PFAC convened on Friday, Nov. 30, to complete foundational work, begin planning 2019 patient and family engagement statewide goals/strategies, and inaugurate two new council co-chairs. The PFAC was established the summer of 2017 to contribute to the development and implementation of health care initiatives and policy, while applying the unique feedback and insight of the patient and family to improve care delivery. The council currently is comprised of 26 members, including clinical/hospital staff, a physician, patients, family members and community members. Laurie Hines and Patti Bradley accepted co-chair elections for the 2018-2020 term.

The council has been working diligently to establish its foundation and begin its work supporting Missouri hospitals in patient and family engagement. Below is a brief summary of the council’s work throughout the past 18 months.

  • defined the council mission
  • identified key actions and objectives for the first 18-24 months
  • adopted 12 metrics to measure PFE in Missouri hospitals
  • created a council member orientation manual
  • created a PFAC/PFE resource web page
  • created a PFE roadmap with resources for Missouri’s hospitals
In 2019, the council plans to enhance the support provided to Missouri hospitals by:
  • creating and distributing a PFAC toolkit that includes a starter checklist and PFAC leadership PowerPoint
  • recording and publishing PFE vlogs and blogs
  • creating and distributing a statewide PFAC dashboard
  • continued resources and support for Missouri hospitals to meet the Statewide PFAC challenge
PFAC EngagementMHA’s Statewide PFAC challenges every hospital in the state of Missouri to identify at least one nonemployee patient or family member serving on at least one committee within the organization by July 2019. Of Missouri hospitals that responded to a survey assessing their level of patient and family engagement, only
25 percent are meeting the challenge metric as of December 2018. The next quarterly survey will take place this month. We encourage all hospitals to accept the challenge to achieve this critical PFE goal!
PFAC Council
PFAC council members in attendance
at the Nov. 30 in-person meeting.

PFAC Co-Chairs
Laurie Hines and Patti Bradley,
2018-2020 council co-chairs.

UP Intervention Sprints
MHA is excited to welcome the following hospitals into the Get UP Sprint.
Bates County Memorial Hospital
Bothwell Regional Health Center
Cass Regional Medical Center
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
Pike County Memorial Hospital
Pinnacle Regional Hospital
Salem Memorial District Hospital
Southeast Hospital
St. Alexius Hospital
Wright Memorial Hospital

Get UP Improvement SprintThe 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 facilitate the review of current policies, assess the need for change, address barriers and consider implementation of a plan to control “drift” from goals.

MHA is offering the complimentary sprints to all member hospitals. The enrollment deadline for the Wake UP Sprint is Wednesday, Feb. 20.

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 Friday, Feb. 8.
HIIN Updates
MHA HIIN hospitals are halfway through the year two extension, which ends March 2019. During the extension, hospitals are focused to achieve and sustain improvements, clinical outcomes, patient and family engagement, and disparity and equity measures. MHA HIIN hospitals have an opportunity to earn a stipend as part of the upcoming milestone. The upcoming due date for hospitals’ data through December is Tuesday, Jan. 22.

MHA is using “sprints” and unique training opportunities to support participating hospitals to meet milestone objectives. These include access to the PFE resources and ongoing survey of the 12 identified state PFE metrics; a new training for registration staff to improve accurate collection of race, ethnicity and language data; the UP Sprints; and the launch of the second cohort of the Lean Six Sigma Green Belt project. Information on each of these opportunities follows.

Improving REaL Data Collection - Training Opportunity
MHA is collaborating with the University of Missouri’s Center for Health Policy to offer an on-demand training, primarily geared toward hospital registration staff. This project is designed to give registration/admission staff the knowledge, skill and resources needed to obtain race, ethnicity and language data during the admission process. REaL data is vital as a foundational patient data component. Along with better collection of social determinants of health data, this additional information will assist hospitals and health care providers in increasing the ability to more efficiently target effective resources for specific patient populations.

In addition to completing three modules, participants will be required to complete pre- and post-knowledge assessments, as well as competencies, after each module. More information and registration links will be sent to MHA HIIN leads when available.

Lean Six Sigma Green Belt Project
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. We are excited to welcome the following hospitals into the project.
Carroll County Memorial Hospital
Excelsior Springs Hospital
Fitzgibbon Hospital
Freeman Health System
Hannibal Regional Healthcare System
Ozarks Medical Center
Pemiscot Memorial Health Systems
Pinnacle Regional Hospital
Ranken Jordan Pediatric Bridge Hospital
Southeast Hospital

The second cohort will be hosted in Jefferson City. At the end of the eight-month intensive project, participants are awarded Green Belt Certification. Through this unique opportunity, participants not only receive the education around the five-step Define-Measure-Analyze-Improve-Control process, but also will implement the tools and techniques learned while receiving technical assistance throughout the program.

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. MHA commends your dedication to improve care in the communities you serve!
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
FEMA Releases Preptalk On Health Care Emergency Preparedness And Response
The Federal Emergency Management Agency and its emergency management partner organizations released a video of Dr. Sheri Fink’s PrepTalk, “Triage, Ethics And Operations: Healthcare Emergency Preparedness and Response,” from the third PrepTalk symposium event on Sept. 6, 2018.

In her PrepTalk, Dr. Fink shares two real-world case studies that demonstrate the value of situational awareness, the complexities of prioritizing limited resources and the importance of ensuring systems can effectively support operational decisions. “How we allocate the resources that we have in disasters; how we choose who gets the resources … is going to affect the outcome,” said Dr. Fink.

Patient Safety Organization
MHA reminds hospitals electing to remain with Vizient PSO after June 2019 that they are required to have an individual agreement signed with Vizient PSO by Friday, March 1. The 2019 Vizient PSO calendar can be found on MHA’s website.
MoAHQ Update by Missy Sutton, MoAHQ President
MoAHQ Distinguished Quallity Professional AwardThe Missouri Association of Healthcare Quality conducted their annual full membership meeting and luncheon in conjunction with the 96th Annual MHA Convention & Trade Show on Nov. 8 at Tan-Tar-A Resort. This year’s full membership meeting and luncheon included presentations from two of the Distinguished Quality Professional Award nominees, Angela Gardner (pictured left) of Mercy Lincoln, and Paulette Powelson (right) of Pike County Memorial Hospital. Dr. Bill Gilbirds (middle), Saint Luke’s Health System, was selected as this year’s winner of the Distinguished Quality Professional Award.

Angela shared with the group Mercy Lincoln’s focus on culture of safety as they strive to become a high reliability organization. With the support of their CEO and engaged staff, this organization has undertaken process improvement initiatives to support this vision.

Paulette focused on Pike County Memorial Hospital’s stroke center project that led to a level III certification. This group designed and developed programs and needed resources to successfully complete this key initiative and provide needed services to their rural community.

Dr. Bill Gilbirds, Chief Medical Officer for Saint Luke's Care, discussed the importance of physician champions in quality improvement initiatives and the importance of a multidisciplinary team, with a focus on changing culture to be successful. He discussed two effective projects to reduce and eliminate C. diff and DVT across Saint Luke’s Health Care system.

After this robust, meaningful discussion, the group adjourned to enjoy the rest of convention and honored Dr. Gilbirds at the awards luncheon on
Friday, Nov. 9.

Pictured from left to right: Missy Sutton, MoAHQ President; Terrie Bauer, MoAHQ President Elect; Dr. Bill Gilbirds, DQP Award Winner; Dr. Julie Hartung, Dr. Gilbirds’ spouse; Toi Wilde, MHA MoAHQ Liaison; Lana Palmquist, MoAHQ Secretary; and Julie L. Quirin, FACHE, Chief Operating Officer, Saint Luke's Health System.
To learn more about MoAHQ, visit or contact MoAHQ President, Missy Sutton. If you would like to join MoAHQ, you can find a membership application here.
Updated Opioid Prescribing Guidelines
Updated opioid prescribing recommendations designed to guide hospital-based physicians’ use have been adopted and released by a coalition of health care policy and advocacy organizations. The revised guidance reflects evolving best practices in the use of opioids for pain management and changes in the law designed to reduce the opioid addiction crisis.

In November 2015, the Missouri Academy of Family Physicians, Missouri Association of Osteopathic Physicians & Surgeons, Missouri College of Emergency Physicians, Missouri Dental Association, Missouri Hospital Association, and Missouri State Medical Association jointly recommended a set of hospital emergency department guidelines to reduce variation in opioid prescribing practices. The new recommended guidelines expand the recommendations and reflect developments in best practices.

Medicare Part D Prescription Opioid Policies 2019: Information for Pharmacists
The Centers for Medicare & Medicaid Services recently released resources for pharmacists regarding upcoming changes to the opioid safety policies, including a new opioid care coordination edit and drug management program (aka "lock-in"). The recently released resources include a quick guide and a PowerPoint. The new opioid policies went into effect on Jan. 1, 2019. It is important to note there will be some variability between plans, so reviewing plan policies and communications also may help with understanding the upcoming changes.

The new policies include improved safety edits when opioid prescriptions are dispensed at the pharmacy, and drug management programs for patients determined to be at-risk for misuse or abuse of opioids or other frequently abused drugs. CMS tailored its approach to help distinct populations of Medicare Part D opioid users.
  • new opioid users (opioid naïve)
  • chronic opioid users
  • users with potentially problematic concurrent medication use
  • high-risk opioid users

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 Releases Addendum to 2019 OQR Specifications Manual
Read more.
CMS Releases Addendum to 2018 OQR Specifications Manual
Read more.
TJC Announces eCQM Expert to Expert Webinar
Read more.
CMS Releases Abstraction Resources
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.


Safety and Regulatory Compliance Program
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

HIIN Huddle Webinar
2 p.m.


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

For additional MHA events, visit the MHA calendar.

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