Orientation for New Quality Directors — Eight-Part Virtual Series

Tuesday, April 4
Kick off, Science of Improvement and TeamSTEPPS

Participants will learn the science of improvement, including concepts to improve teamwork and communication.

Session Objectives:

• • outline the concepts of a Plan/Do/Check/Act system of improvement
  • explain how to conduct a brief, huddle and debrief

Jessica Stultz, MHA, BSN, R.N., CPPS, CPHQ, LSSGB
Director of Clinical Quality
Missouri Hospital Association
Jefferson City, Mo.

Tuesday, April 11
Substance Use Programming: An Evidence-Based Approach and Safety and Preparedness

While services for the prevention and treatment of substance misuse and substance use disorders traditionally have been delivered separately from other mental health and general health care services, effective integration of prevention, treatment and recovery services across health care systems is key to addressing substance misuse and its consequences. SUDs are strongly intertwined with other medical conditions, making an integrated approach to care essential. Information shared during this presentation will include Missouri and national data on SUD prevalence, including overdoses. Current statewide initiatives and evidence-based practices that are being driven by health care systems will be highlighted.

Session Objectives:

• • examine regional, state and national data that addresses the prevalence of SUD
  • discuss the evidence-based approaches, strategies and treatments that Missouri has integrated to address growing concerns around SUD
  • summarize how an emergency situation impacts your facility, community or region
  • define your role and the role of your organization in an emergency situation that impacts their facility, community or region
  • identify the key resources and support persons in the event of an emergency or for the purpose of moving a safety-related initiative forward

Shawn Billings, M.S.
Vice President of Substance Use Programming
Missouri Hospital Association
Jefferson City, Mo.

Robert Loseman
Vice President of Safety and Preparedness
Missouri Hospital Association
Jefferson City, Mo.

Tuesday, April 18
Quality Reporting: Required, Voluntary and Leading Metrics

This session provides an overview of quality measure reporting requirements and additional resources on quality reporting programs.

Session Objectives:

• • identify key CMS quality reporting requirements and deadlines for IQR, OQR, and IPF programs

Sherry Buschjost
Vice President of Quality Services
Missouri Hospital Association
Jefferson City, Mo.

Tuesday, April 25
Risk

Risk managers leverage the links between risk management and patient safety. Threats to patient safety are a key element of risks that health care organizations need to consider, and they must implement risk-mitigating techniques. By fostering a culture where health care providers are empowered to speak up, risk managers can use incident reports and other sources of information to manage risk, influence key decision-makers, and ultimately impact patient safety and quality care.

Session Objectives:

• • define risk and risk management related to health care quality
  • describe the process for risk management decision-making
  • identify mitigation strategies for health care risk management and patient safety

Laura Hirschinger, MSN, R.N., AHN-BC, CPPS
Manager of Risk Management and Patient Safety
Healthcare Services Group
Jefferson City, Mo.

Staci Walters, R.N.
Risk Management
Healthcare Services Group
Jefferson City, Mo.

Tuesday, May 2
Peer Review/Credentialing

The peer review process often is misunderstood and mistaken for the performance improvement process. While closely intertwined and sometimes overlapping, they are two separate processes. There are a number of reasons for credentialing and privileging practitioners, including patient protection, risk management and liability considerations, and it’s required by accrediting bodies.

There are numerous privacy considerations associated with creating original content, reposting/retweeting, or responding to patient or community comments. Attendees will learn how to use social media effectively while maintaining compliance with HIPAA.

Session Objectives:

• • list the difference between peer review and performance improvement
  • explain the importance of credentialing and privileging

Michael Murphy
Quality/Safety Committee Director
Missouri Baptist Hospital
St. Louis, Mo.

Tuesday, May 9
PFE/Equity

Session I: PFE
12:35 to 1:15 p.m.

This session will highlight the importance of engaging patients at the bedside and improving patient outcomes, which begins with quality improvement work in the conference room. MHA PFAC members will provide an overview and examples of how to engage Patient Family Advisors in process improvement work to affect the quality, safety and experience of care.

Session I Objectives:

• • discuss practical approaches to engage both Patient Family Advisors, QI and patient safety teams
  • identify common challenges for engaging patients and families as meaningful partners in safety and QI, and strategies to overcome them

Liz Kruvand
Patient Experience Specialist
SSM Health Cardinal Glennon Children’s Hospital
St. Louis, Mo.

DeeJo Miller
Program Manager, Patient and Family Engagement
Children’s Mercy Kansas City
Kansas City, Mo.

Session II: Equity
1:15 to 1:45 p.m.

This session will highlight the importance of the accurate collection of Race, Ethnicity and Language (REal) data. It also will address the importance of using standardized tools to collect social determinants of health data and the importance of using closed-loop referral platforms. Lastly, it will show the importance of clinical-community linkages and how the community health needs assessment can be used alongside the available clinical and nonclinical data to improve the health of individuals, communities and the population served.

Session II Objectives:

• • outline the importance of segmenting quality outcomes data by Race, Ethnicity and Language as part of your strategy to promote health equity
  • explain the importance of collecting both clinical and nonclinical data as a strategy to promote health for individuals and communities

Stephen Njenga, MPH, MHA, CPHQ, CPPS, LSSYB
Director of Quality Measurement and Population Health Improvement
Missouri Hospital Association
Jefferson City, Mo.

Tuesday, May 16
Survey and QAPI

This session provides an overview of hospital regulatory readiness for new quality directors, including suggestions on how to prepare for a regulatory survey and elements to consider. This includes the hospital’s QAPI plan, and how to access and interpret the Centers for Medicare & Medicaid Services’ Conditions of Participation.

Session Objectives:

• • identify suggested elements to include in the hospital’s QAPI plan

Hirshell Parker, MHA, BSN, LSSBB
Executive Director of Quality and Risk Management
Ste. Genevieve County Memorial Hospital
Ste. Genevieve, Mo.

Tuesday, May 23
Quality/Finance

The presentation will cover the mandatory pay-for-performance programs for Inpatient Prospective Payment Systems and home health agencies. Information will be provided about reports that are distributed by MHA, including how they may be helpful with understanding the programs and how it affects hospitals.

Session Objectives:

• • examine how the mandatory Medicare pay-for-performance programs are tied to hospital payments

Andrew Wheeler
Vice President of Federal Finance
Missouri Hospital Association
Jefferson City, Mo.

Shawn Billings, M.S., currently serves as the vice president of substance use programming for the Missouri Hospital Association. Previously, Billings was employed as a Treatment Court Administrator for the Missouri state courts. He has more than 15 years of experience managing local, state and federally funded programs to enhance and expand behavioral health treatment services for high-risk and high-need populations in both rural and urban settings. Throughout his career, he also has served as a federal grant peer reviewer, adjunct faculty at Drury University and as an Alderman in the City of Battlefield, Mo.

Sherry Buschjost joined the Missouri Hospital Association team in 2005 and now serves as the vice president of quality services. Buschjost’s role is to provide technical assistance to hospitals regarding inpatient, outpatient and psychiatric measures. She has 11 years of management experience as a core measure vendor assisting hospitals with the collection, reporting and analysis of critical quality data. Additionally, Buschjost monitors compliance of state and federal grants. Before joining MHA, Buschjost’s professional background includes more than 20 years of experience in a hospital setting.

Laura Hirschinger, MSN, R.N., AHN-BC, CPPS, has served HSG as a risk management consultant since October 2017. She began her career as a registered nurse in 1996. Her clinical nursing experience is in a variety of nursing specialties, including medical-surgical, neonatal intensive care, pain management and palliative care. She also has more than 10 years of experience in hospital leadership roles. Hirschinger has co-authored several academic articles on the topics of second-victim response and peer-support teams. She has presented her research findings at conferences and hospitals throughout the U.S. Hirschinger graduated with a Master of Science in nursing with a focus in holistic nursing from the Jewish Hospital College of Nursing and Allied Health at Washington University in St. Louis. She has been a Certified Professional in Patient Safety since 2015.

Liz Kruvand received her bachelor’s degree in pharmacology from the University of Bath, UK. Her degree included a year working in Novartis Pharma AG in Basel Switzerland, which began a period of travel in the U.S. and Europe honing her research skills. Her work included studying molecular genetics at Albert Einstein College of Medicine in N.Y. and RNA expression mapping at the Max Planck Institute of Immunobiology and Epigenetics in Freiburg, Germany.

Kruvand’s journey began with the premature birth of her daughter, Maya. She was born three months premature at 2 pounds 2 ounces, and she spent three months being cared for in the NICU at St. Louis Children’s Hospital. As a result of her experiences in the NICU, she was with St. Louis Children’s Hospital since 2010 initially volunteering, and in 2014 she became the coordinator of the Family Partner Program. In the summer of 2021, Kruvand moved to become the patient experience specialist at SSM Health Cardinal Glennon Children’s Hospital continuing her work fostering patient and family-centered care. Kruvand’s experiences with her daughter and health care systems have been truly life-changing. Leaving a career in biological research, she has become a leading family advocate and expert in providing the family voice, as well as partnering with numerous clinicians and researchers to ensure patient and family centeredness.

Robert Loseman has worked in the health care industry for more than 20 years. He currently serves as the vice president of safety and preparedness at the Missouri Hospital Association. His previous career, which encompassed two health care systems with multiple hospitals and clinics, included leadership oversight over food services, environmental services, telecommunications, safety, building operations and maintenance, life safety, and security.

Loseman is a Certified Healthcare Emergency Professional and is a skilled and seasoned security, safety and emergency preparedness professional who has vast experience in managing everyday operations of a multitude of health care departments and emergency situations. He previously served as past co-chair of Missouri’s central region Emergency Healthcare Coalition for five years. He has trained at FEMA’s Center for Domestic Preparedness and holds professional memberships with the International Association of Healthcare Safety and Security, ASIS International, and the National Fire Protection Agency. Additionally, he has presented nationally on workplace violence prevention and control measures. He received his Bachelor in Fine Arts from Truman State University and a Master of Science in management and leadership from Western Governors University.

After DeeJo Miller’s daughter’s cancer diagnosis in 2004, her focus shifted to helping families who enter the health care system with their children. She was hired by Children’s Mercy Kansas City as a “parent on staff” in 2008 to utilize her experiences and collaborate with staff by serving as a voice for the families. Having spent more than 300 days inpatient with her daughter who received a bone marrow transplant, allowed her to maintain the point of view of families. She brings this perspective to her role as a Program Manager in the Patient & Family Engagement department. Miller provides leadership to the organization to advance PFCC principles, concepts and culture. She offers direction and expertise in planning, decision-making and organizational changes related to patient and family engagement. Additionally, she manages more than 200 Patient Family Advisors and 19 PFACs, and relies on her firsthand experience to inspire a PFCC culture and influence the quality, safety and experience of care at Children’s Mercy.

Michael Murphy, M.D., graduated Cum Laude with a bachelor of arts in English from Yale University in 1979, from Medical School University of Virginia in 1983 and from General Surgery University of Virginia in 1988. He was a fellow of cardiac surgery at the Texas Heart Institute in Houston from 1988 to 1990. Dr. Murphy was a cardiothoracic surgeon at Missouri Baptist Medical Center from 1990 to 2021 and also served as Quality/Safety Committee Director from 2018 to 2023.

Dr. Murphy’s philosophy in case-based review in 10 separate peer committees is that we are not looking to sanction but rather to learn from our misses and near misses in a Just Culture framework. We emphasize professionalism, ownership and agency of the medical staff in a culture of constant improvement.

Stephen Njenga, MPH, MHA, CPHQ, CPPS, LSSYB, is the director of quality measurement and population health improvement at the Missouri Hospital Association. He has worked in public health and health care for the last 17 years. Njenga coordinated the quality, population health and innovative model areas of the Medicare Rural Hospital Flexibility Program that serves all of Missouri’s critical access hospitals. He was a national recipient of the 2018 MBQIP Spirit Award for Innovation and Collaboration in the FLEX program. Through his leadership, the Missouri FLEX quality program received the 2016 national award for exemplary quality performance improvement on Emergency Department Transfer Communication measures. In his health care career, he has worked in the following areas: accreditation, quality management, patient safety, performance improvement and measurement, medical staff services, population and community health, and HIPAA privacy. He has a dual Bachelor of Science in biology and psychology from Drury University, a Master in Public Health with specialization in epidemiology, and a second Master in Healthcare Administration, both from Missouri State University. He is a Certified Professional in Healthcare Quality, Certified Professional in Patient Safety and Certified in Lean Six Sigma Yellow Belt. He serves in the National Rural Health Resource Center – Technical Assistance Support Center Advisory Board, Missouri Institute for Community Health Governing Board, #HealthierMO Executive Committee, Statewide Community Health Worker Advisory Committee, Missouri Diabetes Council and DHSS Public Health System Partners Group.

Hirshell Parker is the Executive Director of Quality and Risk Management at Ste. Genevieve County Memorial Hospital where he has been employed for the past two decades serving in leadership roles. Parker is a registered nurse and holds a Master of Healthcare Administration, a Bachelor of Science in nursing and is a Lean Six Sigma Blackbelt. Parker is a past MoAHQ president and currently serves on the board. A vast majority of his time is spent focusing on organizationwide performance improvement projects aligning with a pursuit of top decile safety and quality while maintaining compliance with regulatory standards. Fostering the idea of organizational learning and integration, Parker recently achieved the goal of becoming a Baldrige Quality site examiner. He enjoys teaching, knowledge sharing and learning from his peers.

Jessica Stultz, MHA, BSN, R.N., CPPS, CPHQ, LSSGB, became a registered nurse in 2007. She currently serves as the director of clinical quality at the Missouri Hospital Association. In this role, she specializes in assisting hospitals with improving patient outcomes through process improvement, data collection, teamwork and communication, and project management. She began her nursing career in a surgery/trauma/burn intensive care unit and was part of a charter team to open a specialized burn and wound ICU where she was a nursing supervisor for five years. Stultz obtained her master’s degree in health administration and secured a position as a medical-surgical unit manager. In 2014, Stultz joined MHA and has worked specifically in quality — leading, managing and executing grants and contracts as she assists hospitals to improve processes, leading to better patient outcomes. Stultz is a Certified Professional in Healthcare Quality, Certified Professional in Patient Safety and holds a Lean Six Sigma Green Belt. Stultz also is a TeamSTEPPS Master Trainer. Stultz is the MHA liaison for the Missouri Association of Healthcare Quality Professional Membership Group.

Staci Walters, MSN, R.N., CNL, CPPS, has served HSG as a risk management consultant since 2019. Her background includes more than 25 years as a registered nurse. Her clinical nursing experience includes a variety of nursing specialties, including medical-surgical, trauma and emergency, and sexual assault nurse examiner. Her leadership roles were as assistant manager of an emergency department, performance improvement specialist and manager of patient safety. Walters graduated with a Master of Science in nursing with a focus in clinical nurse leadership from Central Methodist University in 2014. She has been a Certified Professional in Patient Safety since 2015.

Andrew Wheeler serves as the vice president of federal finance at the Missouri Hospital Association, specializing in federal advocacy, Medicare payment and policy, and regulatory compliance. He has more than 16 years of experience in the hospital setting, working in hospital operations, finance and strategic planning. He has 10 years with MHA, advocating, educating and assisting hospitals with current issues. Wheeler is a certified health care financial professional and a fellow of the Healthcare Financial Management Association.

Participants must attend the program in its entirety and complete an evaluation to receive a certificate of completion and continuing education contact hours.

Credit Designation Quality Professionals 

Quality Professionals —This program has been approved by the National Association for Healthcare Quality for a maximum of 1.0 CPHQ continuing education credits for this event.

Requirements for Credit:

• Attend/participate in the educational activity and review all course materials.
• Complete the CE Declaration form online by 11:59 p.m. ET June 23, 2023 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.

Disclaimer
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.

Please note that your registration request will be submitted to the organizer for approval. Upon approval, virtual instructional materials and access information will be sent to the email address indicated on the registration form. The registration fee is for one individual attendee and one connection. Each additional connection will be charged a separate registration fee.

If you have special needs addressed by the Americans With Disabilities Act, please contact the Missouri Hospital Association.

MHA Health Institute
P.O. Box 60
Jefferson City, MO 65102
Phone: 573-893-3700
Fax: 573-893-2809

For cancellations received in writing before the established deadline date, the registrant will receive a full refund — minus a $50* processing fee per registrant. After the deadline date, no refunds will be granted. Registrants not in attendance will be responsible for the full registration fee. Substitutions are encouraged. We reserve the right to cancel this program because of insufficient registration.

*Unless otherwise specified in the program details.