Orientation for New Quality Improvement Directors — A Virtual Speaker Series

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Start Time:12:00 AM
End Time:12:00 AM
Contact Information
Additional Information

This educational activity is jointly provided by AXIS Medical Education and MHA Health Institute.
AxisLogo_4ColorProcess MHA Health Institute Logo

Supported by Missouri Association for Healthcare Quality.

Register on or before Tuesday, Aug. 11.

MHA member — $295 for the entire series
Nonmember — $395 for the entire series

Each session will begin at 9.a.m. and will be offered every other Tuesday starting on Tuesday, Aug. 18, with the exception of the last session on Tuesday, Nov. 17, to avoid the week of Thanksgiving.

Handout links will be sent only to individuals who are registered for this event. CEUs are available only for those who register and attend all sessions of the live event; no CEUs are available for partial attendance or for attending the recordings.

This series is being offered at a reduced registration fee to MHA-member hospitals thanks to a generous contribution from the MHA Management Services Corporation. This series also is eligible for use of the MHA Health Institute coupon. Note: Coupons were mailed to MHA-member hospital CEOs in December 2019.


This speaker series is for anyone new to a hospital-based quality director or quality department role within the past 12 to 18 months. Supervisors and leaders interested in gaining a greater understanding of the quality and safety workflow in a hospital also are encouraged to attend.

Key topics covered include the critical tie between quality and finance, understanding regulatory requirements and survey preparation, an overview of quality measure reporting requirements, analyzing and using data to promote process improvement, the culture of safety tenets, and leading and managing improvement teams. Additionally, participants will be given an overview of hospital safety, population health, and patient and family engagement. This is a novice level, orientation-based program to equip those new to quality roles with the base knowledge and skill set necessary to perform job requirements.


Upon completion of the program, participants will be able to:

  • review key quality reporting requirements, deadlines and resources
  • discuss voluntary quality and safety programs and reporting
  • discuss how quality reporting and improvement efforts will impact the Medicare pay-for-performance systems
  • discuss how to develop and manage quality improvement dashboards
  • review how appropriate use of data can drive change organizationally
  • review characteristics of strong quality leaders
  • identify federal and state regulatory and legislative changes that will impact quality compliance and improvement in hospitals
  • review survey and certification management and response plans
  • discuss the key components of a culture of safety, high reliability organization principles, TeamSTEPPS and Lean Six Sigma concepts
  • review key tenets of hospital-based risk management and compliance
  • discuss the role of leadership and quality in developing a culture of safety
  • discuss strategy development to strengthen cultures of safety
  • review definitions and application of the community health needs assessments, REal and SDOH data collection
  • discuss MHA’s multidisciplinary strategy to reduce workplace violence within hospitals
  • review the requirements and available resources to develop all-hazard hospital preparedness programs to facilitate an effective response to incidents resulting in patient surge or impacting operations
  • review evidence-based practices to engage patients and family members in their care, as well as recommended options to formally engage them


Tuesday, Aug. 18

9 to 9:30 a.m. — Welcome/Introduction/Ice Breakers
Alison Williams, MBA-HCM, BSN, R.N.

Vice President of Clinical Quality Improvement
Missouri Hospital Association
Jefferson City

9:30 to 10:30 a.m. — Quality/Finance Link
Andrew B. Wheeler, MBA, FHFMA

Vice President of Federal Finance
Missouri Hospital Association
Jefferson City

Tuesday, Sept. 1

9 to 10:15 a.m. — Quality Reporting
Sherry L. Buschjost

Vice President of Quality Services
MHA Management Services Corporation
Jefferson City

Tuesday, Sept. 15

9 to 10:15 a.m. — Risk Management and Compliance
Laura Hirschinger, MSN, R.N., AHN-BC

Risk Management/Claim Consultant

Staci Walters
Risk Management and Claim Consultant
Healthcare Services Group
Jefferson City

Tuesday, Sept. 29

9 to 10:30 a.m. — Health Equity, Community Connection and Trauma-Informed Care
Stephen N. Njenga, MPH, MHA, CPHQ

Director of Performance Measurement Compliance
Missouri Hospital Association
Jefferson City

Tuesday, Oct. 13

9 to 10 a.m. — Regulation and Legislation Overview
Sarah M. Willson, MBA, BSM, CHPCA

Vice President of Clinical and Regulatory Affairs
Missouri Hospital Association
Jefferson City

10 to 11:30 a.m. — Cultures of Safety and Patient Family Engagement
Alison Williams, MBA-HCM, BSN, R.N.

Tuesday, Oct. 27

10 to 11:15 a.m. — QAPI Plan
Tracy Rogers, R.N., MSN, PCCN

Director of Quality
Saint Luke’s Hospital of Kansas City
Kansas City, Mo.

Tuesday, Nov. 10

9 to 11:15 a.m. — Survey and Certification – Preparation, Management and Response Plans
Sarah Yelton, R.N., CPHQ, HACP, LSSGB

Quality Resource Analyst
Saint Luke’s Hospital of Kansas City
Kansas City, Mo.

Tuesday, Nov. 17

9 to 10:15 a.m. — Broader Quality Issues: Safety and Resiliency and Substance Use Disorder
Jackie E. Gatz, MPA, CHEP

Vice President of Safety and Preparedness
Shawn W. Billings, M.S.
Vice President of Substance Use Programming
Missouri Hospital Association
Jefferson City

10:15 to 11 a.m. — Debrief and Wrap-up
Alison Williams, MBA-HCM, BSN, R.N.

Continuing Education

Participants must attend the (live) program in its entirety and complete an evaluation to receive a certificate of completion and continuing education contact hours. (CEUs are not available for the recordings.)

Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by AXIS Medical Education and the MHA Health Institute. AXIS Medical Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Credit Designation

Nursing — AXIS Medical Education designates this continuing nursing education activity for 12.25 contact hours.
Learners are advised that accredited status does not imply endorsement by the provider or ANCC of any commercial products displayed in conjunction with an activity.

Quality Professionals — This program is pending approval by the National Association for Healthcare Quality (NAHQ) to provide CPHQ CE credit.

Requirements for Credit:

  • Attend/participate in the (live) educational activity and review all course materials.
  • Complete the CE Declaration form online by 11:59 p.m. ET Friday, Dec. 4, 2020. Instructions will be provided. If you do not enter the online portal by the above date, you will not be able to retrieve your statement of participation.
  • Upon successful completion of the online form, your statement of completion will be presented to you to print.

AXIS Contact Information
For information about the accreditation of this program please contact AXIS at info@axismeded.org.

Disclosure of Conflicts of Interest
AXIS Medical Education requires instructors, planners, managers and other individuals and their spouse/life partner who are in a position to control the content of this activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly vetted by AXIS for fair balance, scientific objectivity of studies mentioned in the materials or used as the basis for content, and appropriateness of patient care recommendations.

The faculty reported the following financial relationships or relationships they or their spouse/life partner have with commercial interests related to the content of this continuing education activity:

 Name of Faculty or Presenter  Reported Financial Relationship
 Alison Williams, MBA-HCM, BSN, R.N.  Nothing to disclose
 Andy Wheeler, MBA, FHFMA   
 Nothing to disclose
 Sherry Buschjost  Nothing to disclose
 Sarah M. Willson, MBA, BSM, CHPCA  Nothing to disclose
 Stephen N. Njenga, MPH, MHA, CPHQ  Nothing to disclose
 Tracy Rogers, R.N., MSN, PCCN  Nothing to disclose
 Laura Hirschinger, MSN, R.N., AHN-BC  Nothing to disclose
 Staci Walters  Nothing to disclose
 Jackie E. Gatz, MPA, CHEP  Nothing to disclose
 Shawn Billings, M.S.
 Nothing to disclose

The planners and managers reported the following financial relationships or relationships they or their spouse/life partner have with commercial interests related to the content of this continuing education activity:

 Name of Planner/Manager  Reported Financial Relationship
 Rita F. Kay  Nothing to disclose
 Dee Morgillo, M.Ed., CHCP  Nothing to disclose
 Holly M. Hampe, D.Sc., R.N., MHA, MRM  Nothing to disclose

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed in this activity should not be used by clinicians without evaluation of patient conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.