stethoscope on table


Quality & Safety Update — September 2022


Jessica Stultz

Jessica Stultz

Director of Clinical Quality



Quality & Safety Update


  • Maternal Health
  • Opioids
  • Patient Engagement
  • Patient Safety
  • Population Health
  • Preparedness and Response
  • Quality and Safety
  • Safety


quality and safety

The Quality & Safety Update provides health care professionals with up-to-date information on current quality improvement projects, resources and quality reporting. The newsletter also highlights announcements and upcoming events that could benefit your organization.

Compass Honor

MHA Recognizes Inaugural 2022 Compass Honor

Sponsored by the Statewide Patient and Family Advisory Council, MHA introduced an annual recognition, the Compass Honor, which recognizes a Missouri hospital for outstanding efforts in effectively partnering with their PFAC. Through public recognition, this honor will encourage and inspire hospitals to adopt practices, learn collectively and improve their PFACs.

The “compass” in Compass Honor signifies that with each direction we turn, we find partners in care.

  • North symbolizes patients as our true north.
  • South symbolizes caregivers and family.
  • East symbolizes health care providers.
  • West symbolizes support staff.

Applications for the compass honor were accepted and scored by the Statewide PFAC. Although all applications were exceptional and the work taking placing within Missouri hospitals is inspirational, a winner had to be selected.

PFAC poster

We are proud to announce that the inaugural 2022 MHA Statewide PFAC Compass Honor is awarded to the PFAC of University Health.

University Health’s PFAC made several contributions to their organization. Below are a few examples.

  • communication revisions improved billing practice strategies
  • improvement charters now include the “voice of the patient” section
  • physicians, residents, medical students, social workers, and nurses are educated on patient advocacy and respect for the patient voice in decision-making
  • helped define exceptional patient experience
  • installed cultural food equity and an on-site food pantry
  • made accommodations to the discharge lounge
  • developed a badge to recognize and support family caregivers
  • revised its patient and visitor web page
  • refined appointment reminder text messages

Also being recognized are honorable mentions North Kansas City Hospital and University of Missouri Healthcare.

Maternal-Child Health

Staff Contacts: Alison Williams

MC LAN Hosts Information to Action Convening

The Maternal-Child Learning and Action Network, Missouri’s Perinatal Quality Collaborative, hosted a virtual event, “Information to Action Convening: Infant Health Equity in the NICU/Well-Baby Nursery,” on Aug. 19.

This convening offered a platform to discuss health equity gaps and opportunities within the NICU/WBN setting of care. Participants heard from experts, including patients and family members, on the background and significance of the issue and the impact on health care, experience and outcomes. A panel of patients and family members shared their experiences, providing significant insight into actions and difference-makers. The convening closed with a panel discussing solutions, innovative ideas and current actions serving to mitigate health disparities. A recording of the event is available online.

The Uplift Connection Hosts Annual Maternal and Infant Health Convening

Every year, Missouri’s community partners gather to make real-world change and build connections to better serve women and infants. The annual Maternal and Infant Health Convening is a core part of The Uplift Connection’s purpose to serve as a hub, convene thought leaders, build awareness of regional and local efforts, and connect maternal and infant stakeholders and work across the state. This year, the event takes place Tuesday, Sept. 27, and Wednesday, Sept. 28, in St. Louis. Online registration is available.

Opioid Use Disorder

Staff Contact: Shawn Billings

988 Becomes National Suicide and Crisis Lifeline

In July, 988 became the national three-digit phone number for all mental health, substance use and suicide crises. Additional details about the lifeline are available on the Missouri Department of Mental Health’s website.

MHA held a webinar to provide information on current and future implementation plans, including how hospitals can support implementation efforts.

Clinical Quality

Staff Contact: Jessica Stultz

CMS Releases Quality Reporting Manuals

Now available on QualityNet are quality reporting manuals effective with Jan. 1, 2023, dates of service.

LSS Green Belt Pod Sessions Available

Earlier this year, MHA sponsored hospital members in their pursuit of obtaining Lean Six Sigma Green Belt Certifications. The graduates recorded short pod sessions that summarize their projects and answer questions about their experience. The pod sessions are available on MHA’s website. Please feel free to share this information with others in your organization.

PFAC Webinar Recordings Available

The Statewide PFAC hosted a three-part webinar series, “Healing Happens Here: A Patient’s Perspective,” which identifies ways to collaborate with patients and families using evidence-based practices to improve the health care experience for all. Webinar recordings are available online.

Population Health

Staff Contact: Stephen Njenga

CHNA Education Series Presentations and Recordings Now Available

MHA hosted a complimentary six-part Community Health Needs Assessment webinar series to assist hospitals with understanding the unique needs of their communities and the patients they serve. Topics discussed include community benefit requirements, resources available to conduct CHNAs, an overview of social determinants of health and more. Presentations and recordings for each session are available on MHA’s website.

Safety & Preparedness

Staff Contact: Robert Loseman, Jr.

MHA To Begin Collecting Workplace Violence Data

Violent behavior demonstrated in the health care environment threatens the safety of staff, patients and visitors, and organizations should have a reporting mechanism in place for when an event occurs. Reports of aggression should be reviewed, evaluated and addressed appropriately. Collectively, such reports generate data on when, where and who is most likely to be involved in such incidents and may provide insight into proactive approaches to mitigate future risk. It is important that health care personnel have access to a widely communicated and no fault/harm reporting platform to document aggressive, combative and/or suspicious behavior within their organization.

In Missouri, there is no mandated statewide tracking or data aggregation system for workplace violence. This fall, MHA will be relaunching workplace violence data collection efforts and encourages hospitals to participate. Information-gathering will be focused on occurrences within the emergency services setting of care initially, including the number of occurrences induced by patients, visitors, those with law enforcement engagement, persons with a mental health diagnosis and/or individuals with documented history of past aggression.

The review and analysis of these data will be used to guide programming and help direct resources. In addition, it will aid in advocacy efforts to prevent burdensome mandatory requirements and inform policymakers on ways to support safe care environments. Additional details, including how to participate, will be released this fall.

MHA Maintains COVID-19 Resource Request Process

The new BA.4 and BA.5 variants have led to a surge in COVID-19 cases across the state. As hospitals continue to respond to the COVID-19 pandemic, MHA maintains a resource request document that outlines support available to hospitals and the associated request process.

Monkeypox Resources Available

The current global monkeypox outbreak continues. To date, there have been 25 reported cases in Missouri. To support hospitals, MHA has added several resources, including situational awareness, clinical guidance, laboratory resources, infection control and more, to its website.

MoAHQ logo

MoAHQ Update

MOAHQ is excited to open applications for the 2022 Director of Quality Professional Award.

When you take a moment to think about the quality champion in your hospital, does someone stand out? It is time they received statewide recognition for their work. The Distinguished Quality Professional Award recognizes a professional in quality management who has demonstrated exceptional skills in quality improvement. This award is designed to honor a professional who has exhibited extraordinary skills in the following areas of health care quality: leadership, expertise and knowledge of quality principles, contributions to the health care quality profession, and being a role model for other quality professionals. Anyone is eligible, and nominees are not limited to members of MOAHQ.

The award winner will be honored during the MoAHQ Annual Quality Summit on Friday, Nov. 11. MoAHQ and MHA encourage you to submit a nomination for the Distinguished Quality Professional Award by Friday, Sept. 9.

During the 2022 MoAHQ Quality Summit, project presentations also will presented. MoAHQ invites you to submit an abstract for an opportunity to present your improvement work. Health care professionals across the state put in countless hours to improve the quality of care provided to our patients. We are pleased to offer this platform for you to virtually spotlight your work. Project presentations are open to everyone, and if your project is accepted, you may attend the members-only summit. For more information about how to submit your abstract, email Elaina Osterbur at


Updated Infection Prevention and Control of Monkeypox

Human-to-human transmission of monkeypox virus occurs by direct contact with lesion material or from exposure to respiratory secretions. Reports of human-to-human transmission describe close contact with an infectious person. Transmission in health care settings has been rarely described. To learn more, visit the CDC website.

New ASPR TRACIE Tool Available

ASPR TRACIE designed a new interactive tool to assist hospital emergency planners and supply chain staff to estimate supplies that may be needed during various emergencies based on hospital characteristics, including pharmaceutical, burn, trauma and PPE supplies.

Discount Code Available for APIC Membership

To save $30 on APIC membership, complete the online membership form using discount code MOHA2022 on the last page of the application before the payment screen.

The offer only is valid online and applies to APIC Full/Active or New IP Membership (U.S. only). It does not apply to APIC products or programs, is not valid on previous orders and cannot be combined with other promotions. Individual membership is nontransferable. The offer expires Dec. 31, 2022.


Sept. 27 | MHA: Do As I Say, Not As I Do: Normalizing Mental Health Help-Seeking In Health Care

Sept. 27-28 | The Uplift Connection: Maternal and Infant Health Convening

Oct. 5-6 | MHA: Charge Nurse Leadership Development

Oct. 18 | MHA: Orientation for Infection Prevention Professionals — Virtual Series

On-Demand Education

The MHA Health Institute offers cost-effective learning opportunities to both members and nonmembers to help them understand and address emerging issues, learn and share best practices, and comply with legal and regulatory requirements. Learn more.

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