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2019 Annual Quality Report: Missouri Hospitals — Aiming for Excellence





  • Care Coordination
  • Disease Management
  • Patient Safety
  • Process Improvement
  • Quality and Safety


care coordination disease management patient safety process improvement quality and safety

Improving care and improving health is essential to Missouri’s hospitals, health systems and clinicians. Each day, health care professionals and hospital executives work tirelessly to provide clinical expertise and leadership to reduce or prevent costly chronic diseases, maximize outcomes, and improve health across the life span of Missouri patients.

The performance data on 19 metrics tracked by Missouri hospitals summarize the progress and trends on specific quality measures related to hospital infections, patient safety and readmissions. The period between baseline data and the comparison year is five years for infection and safety measures, and three years for readmissions measures. MHA staff support a culture of shared responsibility that holds organizations accountable for the systems they design, while promoting an open and honest reporting environment.

For an overview of the progress and trends of specific quality measures related to infections, readmissions and improving safety:


To view performance on several clinical measures tracked by Missouri’s rural hospitals:



Healthcare-associated infections are acquired by patients while receiving medical treatment or surgical care. Modern medical care involves various invasive devices and procedures that increase the risk for infection and can complicate recovery. The HAIs included in this report are surgical site infections, postoperative sepsis, methicillin-resistant Staphylococcus aureus, central line-associated bloodstream infections, catheter-associated urinary tract infections and Clostridioides difficile infections.

Evidence-based medicine, along with a focus on an individualized plan of care for the patient that includes a review of risk factors, can improve care and outcomes. Engaging patients and their families on risk factors and best-in-class clinical standards may lead to positive clinical outcomes.

Infection Dashboards


Hospital readmissions serve as a key measure for the quality of patient care. MHA is focused on decreasing preventable readmission within 30 days of discharge. The data in this report track all-cause, acute myocardial infarction, coronary artery bypass graft, congestive heart failure, chronic obstructive pulmonary disease, hip/knee, pneumonia and stroke readmissions.

Patients are readmitted within 30 days for a myriad of reasons, some of which include common health conditions such as CHF, septicemia, pneumonia, COPD and cardiac dysrhythmias. The patient is at risk as they move between the acute care setting to home or other locations. Multidisciplinary care teams, including patients and their families, hospital staff, and post-discharge providers and caregivers, can help reduce the risk of readmission through ongoing two-way communication.

Readmissions Dashboards


The simplest definition of patient safety is the prevention of errors and adverse effects associated with health care. Health systems, doctors and nurses can improve patient safety by engaging patients and their families, following evidence-based protocols/procedures, learning from opportunities, and effectively communicating with the health care team.

Missouri hospitals are addressing four main categories of safety: injuries from falls and trauma, postoperative pulmonary embolism or deep vein thrombosis, rate of pressure ulcers at stage 3+, and unexpected deaths during a hospital stay.

Improving Safety Dashboards

This progress report is based on data from January 2014 to January 2019 for infection and safety measures, and December 2015 to November 2018 for readmissions measures. The sources are claims and National Healthcare Safety Network data that is processed by the Hospital Industry Data Institute, the data company of the Missouri Hospital Association.

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