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March 2019
In This Issue
Quality Updates
HIIN Updates
Safety & Preparedness Updates
MoAHQ Update
Quality Reporting News
Upcoming Events
MHA Quality & Safety Showcase

MHA Quality & Safety ShowcaseThe 2019 MHA Quality & Safety Showcase was held Tuesday, Feb. 12, in Columbia, Mo. Throughout the day, 26 quality improvement projects were showcased from 17 different member hospitals. Presentations were heard from the 2018 Aim for Excellence award winners, participants in both the readmissions reduction/care transitions and sepsis immersion projects, and the first cohort of Lean Six Sigma project participants. The day ended with a graduation ceremony presenting the Lean Six Sigma first cohort participants with their green belt certificates.

2019 Visionary Leadership Award

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.

Quality Updates
Missouri Maternal Child Learning and Action Network Launched
In recognition of the need to focus efforts statewide to influence maternal and infant morbidity and mortality, the Missouri Maternal Child Learning and Action Network officially launched in December 2018. The MC LAN serves as an opportunity to learn, take action and leverage peer networks to improve the health outcomes of women, children and families. The network consists of approximately 45 clinicians and associated stakeholders with demographic representation across the state. The MC LAN is actively engaged in developing plans for data management, clinician and patient outreach strategy, and education projects and support.

Engage EVS Staff to Reduce Infections
It is important that environmental services technicians understand how essential their work is in protecting the health of patients, families, co-workers and themselves. Through funding provided by CDC, HRET and APIC, subject matter experts created educational tools, available in both English and Spanish, for EVS technicians to master basic infection prevention and control information on their own.

Topics covering basic principles of infection control for EVS technicians; keeping EVS team members, patients and caregivers safe; chemical safety for EVS; and surface cleaning and disinfection procedures in EVS are included in the list of resources available. Learning tools include videos, infographics and checklists, which are downloadable and free of charge for use in your facility.

HIIN Updates

Congratulations to HIIN-Participating Hospitals 
Two Missouri HIIN-participating hospitals were selected to present their work at the 2019 AHA Rural Health Care Leadership Conference in early February. The conference brought together top thinkers in the field, and offered proven strategies for accelerating performance excellence and improving the sustainability of rural hospitals.

Congratulations to Cox Medical Center Branson and Ste. Genevieve County Memorial Hospital on the recognition of your success!

Top Performing Critical Access Hospitals in ALL EDTC Composite Scores
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 an area of focus. ED transfer communication measures allow CAHs to show 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.

As of the fourth quarter of 2018, the following CAHs achieved 100 percent compliance in the ALL EDTC composite score, putting them in the top performers list of CAHs in Missouri and the nation.
  1. Carroll County Memorial Hospital
  2. Ellett Memorial Hospital
  3. Cox Monett Hospital
  4. Ray County Memorial Hospital
  5. Harrison County Community Hospital
  6. Ste. Genevieve County Memorial Hospital
  7. Lafayette Regional Health Center
  8. Pike County Memorial Hospital
  9. Mercy Hospital St. Francis
  10. Mercy Hospital Lincoln
  11. Perry County Memorial Hospital
  12. Putnam County Memorial Hospital
Since Jan. 1, 2015, the ALL EDTC composite score for all Missouri hospitals improved by 30 percent, as shown by the chart below.

FLEX MBQIP Benchmark Graph  

Safety & Preparedness Updates
CMS Issues Emergency Preparedness Updates
The Centers for Medicare & Medicaid Services released a Quality, Safety & Oversight Memo (QSO-19-06-ALL) outlining updates, which eventually will be reflected in Appendix Z in the Standard Operations Manual. The revisions include adding emerging infectious diseases to the definition of all-hazards approach, new Home Health Agency citations, and clarifications under alternate source power and emergency standby systems. The new guidelines are effective immediately.

The Department of Health and Senior Services Bureau of Home Care developed a checklist of the emergency preparedness changes affecting home care, as well as a checklist outlining the final changes to the interpretive guidelines affecting home health under Appendix B.

DHSS Releases Health Update for Ebola Virus Disease
The Missouri Department of Health and Senior Services has been monitoring reports from the Centers for Disease Control and Prevention and the World Health Organization pertaining to the Ebola Virus Disease outbreak declared on Aug. 1, 2018, in the Democratic Republic of the Congo. As reported in WHO’s Disease Outbreak News on Feb. 7, the global risk level for the spread of Ebola from this outbreak remains low. However, the fact that the outbreak is ongoing serves as a reminder to Missouri health care providers to review infection prevention and control procedures as they relate to communicable infections, including EVD. CDC’s Division of Healthcare Quality Promotion shared the information update with state healthcare-associated infection programs to guide preparedness efforts.
When the Unthinkable Happens, Hospitals Offer Hope
When a “Ride the Ducks” boat capsized on Table Rock Lake, the local hospital — Cox Medical Center Branson — sprang into action. As the hours unfolded and the need to provide life-saving care waned, hospital staff held the hands of survivors, prayed with them and provided clothes, medical care and comfort.
Cox Medical Center Branson Duck Boat Video
Rural communities look to their hospital for care, comfort and support in an emergency. Cox Medical Center Branson embraced their patients as part of their community. That is what hospitals do.

Hospitals work to be ready when their communities need them — from everyday emergencies to the unthinkable. Watch their story to see how Cox Medical Center Branson offered hope to its community in the face of tragedy.
2019 Emergency Preparedness Program Update Webinars
In an effort to provide timely and appropriate resources to hospital staff with emergency management responsibilities, MHA will continue to conduct quarterly programmatic updates through 2019. Agenda topics will include, but are not limited to, implementation guidance pertaining to the CMS Final Rule, upcoming education and exercise opportunities, and statewide planning initiatives. These webinars will be recorded and made available on our emergency preparedness web page.

The next update will take place 11 a.m. Thursday, May 23. Registration is required.

CMS Announcement
Please see this announcement from the Centers for Medicare & Medicaid Services regarding MHA.
PFAC Vlog Part 1Statewide PFAC Releases VLOG
The Missouri Statewide Patient Family Advisory Council released the first installment in a new vlog series. Part one covers health care consumers, understanding patient needs and the benefits of informed patients.
2019 Aim for Excellence Award
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.
2019 Community Investment Report2019 Community Investment Report
In 2017, Missouri hospitals provided more than $1.4 billion in uncompensated care and exceeded $3.3 billion in total community benefit. Read the 2019 Community Investment Report, or access hospital-specific data on the Focus on Hospitals website.
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. All in-person trainings will take place from 8:30 a.m. to 12:30 p.m. The following dates are available.
  • Kansas City, Mo. | Register | Saturday, May 25
  • St. Louis, Mo. | Register | Saturday, April 6, or Saturday, Aug. 10
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.
The Opioid Crisis – A Three-Part Webinar Series
A three-part webinar series on the opioid crisis will begin Wednesday, April 3. The one-hour webinars cover the following topics: hospital prevention and response, medication first models, and recovery-oriented systems of care.

Each webinar in the series will take place from 10 to 11 a.m., and registration is required for each. See the links below to register.
Save the Date!
2019 MHA Quality and Safety Convening — Creating Synergy with Patients, Families and Health Care to Achieve the Quadruple Aim
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.
MoAHQ would like to thank Lana Palmquist for serving as its secretary since January 2018. Thanks to Lana’s efforts, MoAHQ membership significantly increased throughout the past year.

Lana has accepted a position with BayCare Health System as the manager of clinical integration in Florida. As she transitions into her new work, MoAHQ would like to say thank you to Lana for all of her efforts and dedication to the MoAHQ Professional Membership Group. Her impressive organizational skills and fun personality have been a great contribution, and we would like to wish her well in her new endeavor.

Sarah James will be taking on the role of the secretary through the rest of 2019 and may be reached at
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 Releases eCQM Case Detail Report
Read more.
TJC Announces Complimentary Integrated Care Certification Workshop
Read more.
TJC Releases Specifications Manual Version 2019A
Read more.
TJC Seeking eCQM Proven Practices Success Stories
Read more.
TJC Updating CY 2019 Chart-Based Measure Selections
Read more.

More news can be found in MHA Today.
Upcoming Events

Spring 2019 FLEX MBQIP Regional Meeting
Holiday Inn Express & Suites
Festus, Mo.


Environment of Care and Life Safety Standards:
Survey Readiness Including
Behavioral Health Environmental Risks

Camden on the Lake
Lake Ozark, Mo.


Orientation for New Infection Prevention Professionals
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 I: 
Hospital Prevention and Response
10 a.m.


The Opioid Crisis Series Part II: 
Opioid Use Disorder – A Medication First Model
10 a.m.


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


Emergency Preparedness
Program Update Webinar
11 a.m.

For additional MHA events, visit the MHA calendar.

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