stethoscope on table


Quality & Safety Update — January/February 2022


Jessica Stultz

Jessica Stultz

Director of Clinical Quality



Quality & Safety Update


  • Maternal Health
  • Opioids
  • Patient Engagement
  • Population Health
  • Quality and 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.

MHA Announces New Senior Vice President of Quality, Safety and Research

MHA is pleased to announce that Jackie Gatz, MHA’s Vice President of Safety and Preparedness, has accepted the position of Senior Vice President of Quality, Safety and Research effective Jan. 2.

Jackie has served in a variety of emergency preparedness and safety roles since 2005 and has been a member of the MHA team since 2008. She is highly regarded by Missouri’s hospitals for her dedication to their needs, her responsiveness to urgent and emergent issues, and especially her leadership throughout the COVID-19 pandemic. Her selection from among a number of highly qualified candidates was strongly endorsed by leaders within MHA and our partner institutions.

We look forward to working with Jackie as we continue our efforts to improve the health status of Missourians.


MHA Announces 2022 Awards Call for Submissions

Staff Contact: Jackie Gatz

MHA is offering its annual, prestigious awards to recognize the sustained improvements of its member hospitals. All awards will be presented during MHA’s 100th Annual Convention in November.

Aim for Excellence Award

The Aim for Excellence Award recognizes Missouri hospitals’ innovation and outcomes related to the Triple Aim approach. Utilizing this approach, hospitals can improve the individual experience of care and the health of populations, and reduce per capita costs of care.
Application Deadline: 5 p.m. Friday, May 6

Visionary Leadership Award

The Visionary Leadership Award recognizes outstanding achievements in clinical and health outcomes and will be awarded to a hospital or health system chief executive whose organization has demonstrated sustained improvements.
Nomination Deadline: 5 p.m. Friday, May 6



Exceptional People. Extraordinary Stories.

Staff Contact: Mary Becker

Exceptional People. Extraordinary Stories.

To celebrate 100 years of helping hospitals, MHA is soliciting 100 stories of individuals representing our hospitals. Every health care worker has an important story to tell. We want to share these extraordinary stories — not only from front-line caregivers, but everyone from plant engineers to phlebotomists, and auxilians to administrators. Each person contributes to the essential work done every day.

Use our online submission form to submit your story or submit one on behalf of another person. MHA will share these stories throughout the year and will share them collectively as we wrap up our centennial celebration at MHA’s Annual Convention in November.

Maternal-Child Health

Staff Contacts: Alison Williams

Missouri AIM Announces CPPPSUD Collaborative

More than 25 hospitals across Missouri are participating in the Missouri Alliance for Innovation on Maternal Health Care for Pregnant and Postpartum People with Substance Use Disorder patient safety bundle collaborative to reduce severe maternal morbidity and mortality from SUD across the care continuum and phases of pregnancy and postpartum.

MHA created a toolkit for the Missouri AIM CPPPSUD collaborative to support and guide participants through patient safety bundle implementation. The toolkit includes a summary of the issue with Missouri specifics, links to professional resources and the patient safety bundle elements. All stakeholders interested in supporting the reduction of perinatal SUD are encouraged to access this new resource.


Webinars Available for Embracing Pregnant & Parenting Families Challenged with SUD

  • The Brain, Substance Use Disorders and Parenting: A Health Care Professional’s Guide to Universal Screening Practices (May 26, 2021) — Recording | Slides
  • Pregnant and Parenting Families with SUD: Evidence-Based Treatment, Neonatal Opioid Withdrawal and Supporting the Infant-Parent Relationship (June 2, 2021) — Recording | Slides
  • Stigma, Language & Implicit Bias: Moving Toward Becoming a Stigma-Free Provider (June 9, 2021) — Recording | Slides 

Opioid Use Disorder

Staff Contact: Shawn Billings

Opioid SOR 2.0 Offers MAT Waiver Training

As opioid overdose deaths continue to increase, MHA works to educate providers on upcoming MAT waiver training opportunities to better serve patients with opioid use disorder. The training, provided by Opioid SOR 2.0 in partnership with the Missouri Behavioral Health Council, assists physicians, nurse practitioners and physician assistants who wish to apply for a waiver to prescribe buprenorphine. Participants complete four hours of live training, followed by four hours of individual online work. Several dates are available throughout 2022

This training allows providers to prescribe buprenorphine to more than 30 patients in their practice settings. Providers wishing to work with less than 30 clients can apply for a waiver immediately by completing a Notice of Intent.

Clinical Quality

Staff Contact: Jessica Stultz

MHA Offers Opportunities for Health Care Quality Professionals

Health care is continually evolving, and as health care professionals, we know learning never stops. MHA provides several opportunities to facilitate learning, including Lean Six Sigma belt certifications, orientations for infection prevention professionals, orientations for quality directors and more.

Currently, 25 hospital-based health care professionals are obtaining a Lean Six Sigma belt certification. Of this group, 23 are working to earn their green belt, and two are completing the black belt program. Due to the overwhelming interest and exceptional feedback we received, MHA is offering another belt certification cohort to students in 2023.

Last fall, MHA offered an orientation course for new infection prevention professionals, and again, due to the tremendous interest, we plan to offer this on an annual basis. Throughout the course, students were provided with networking opportunities, resource navigation, basic infection prevention knowledge, mentors and access to subject matter experts.

In 2022, we are offering a revised quality director orientation. Much like the orientation for infection prevention professionals, this orientation helps health care providers fill their toolbox with knowledge, resources and networking connections to help them be successful in their careers. This course will begin in June and offer a weekly webinar for eight weeks. Registration information will be sent out in the coming weeks.

Patient and Family Advisory Council

Staff Contact: Jessica Stultz

Coming Soon: Compass Honor

Missouri’s Patient and Family Advisory Council soon will begin accepting applications for a new accolade – the Compass Honor Recognition. This award will publicly recognize a hospital for outstanding effort with their PFAC. Through public recognition, this honor will encourage and inspire hospitals to adopt and improve their own PFACs. After careful consideration, the Missouri PFAC chose to name the award “The Compass Honor,” because “compass” incorporates the idea that with each direction we turn, we find partners in care.

  • North symbolizes patients as our true north star for service.
  • South symbolizes caregivers and family.
  • East symbolizes health care providers.
  • West symbolizes hospital staff.

Stay tuned for more information on the Compass Honor as we will be rolling out applications soon.


Daisy Award Best Practice

Does your facility offer the Daisy Award for your nursing staff? SSM Health Cardinal Glennon offers an innovative process for patients and families to submit Daisy Award nominations. Using a QR code scanned by a smart device, nominators are taken directly to an online submission site. This removes the need to collect paper, mail in or turn in submission forms. The QR can be printed on discharge papers and business cards, placed on web pages and screen savers, and more.

Population Health

Staff Contact: Stephen Njenga

CHNA Guidance and Implementation Strategy

MHA Offers CHNA Resources

MHA recently published the Community Health Needs Assessment Guidance and Implementation Strategy document to provide hospitals with the information necessary to complete this important process. Along with incorporating the most recent regulatory requirements from the Internal Revenue Service, the guide also offers several tools and resources that hospitals can utilize when conducting a CHNA.

In addition, MHA offers several resources to assist with the CHNA process.

  • The guide, “Engaging Your Community: A Guide for Nonprofit Hospitals,” assists nonprofit hospitals in maximizing the provision and promotion of charitable programs and services. It describes numerous activities that enhance a nonprofit hospital’s tax-exempt status and provides guidance on creating a community benefit report to publicize investments in the community.
  • The professional staff in Quality Works can provide a number of services to assist hospitals in conducting and implementing their CHNAs.
  • The exploreMOhealth website offers both county- and ZIP code-level data. It is the key to diagnosing and addressing some of our region’s most pressing health issues, thus helping hospitals and other organizations further their missions to improve individual, community and population health. This project is a collaboration between the Hospital Industry Data Institute, the Washington University School of Medicine and BJC HealthCare.
  • MHA offers a suite of four equity-centered dashboards that provide previously unavailable granularity in health outcomes, health factors and social determinants of health for finite population segments and geographic areas in Missouri. Hospitals and other organizations can use this data and information to advance their health equity journey.


MoAHQ Update: New MoAHQ President Looks Forward to the New Year

We are now two years into the COVID-19 pandemic, and we are constantly learning to reprioritize personally and professionally. Our Missouri Association for Healthcare Quality Board is committed to engaging our members in helping us do just that. Despite the challenges we face across the nation, our membership group has the benefits of networking, education, best practice sharing, career development and much more. There is much to share in the world of quality across the state, and we plan to further expand our outreach to bring great speakers and presenters to our membership group this year. We will continue to highlight accomplishments and presentations, as well as current happenings in our MHA Quality & Safety newsletter.

MoAHQ 2022 Goals:

  1. Increase engagement from members and district representatives. An MHA district map is available.
  2. Expand education and presentations beyond quality topics.
  3. Redefine the roles of district representatives and fill open districts 2, 5 and 6 with representation.
  4. Increase student engagement across all districts.

We look forward to the MHA’s Annual Convention in November, as well as naming another Distinguished Quality Professional Award recipient. We will update all members as additional details are available.

Thank you,
Brandy Beilsmith, MSN, R.N., CPHQ
MoAHQ President


MHA Today


Did you know the quality reporting requirement on COVID-19 vaccination of employees in the Inpatient Prospective Payment System does not apply to a critical access hospitals unless they already voluntarily report on the quality measures required in the rule for acute hospitals? Learn more.


April 28: From Staff Nurse to Charge Nurse: Putting the Right Tools in Your Toolbox

  • Courtyard by Marriott, Columbia, Mo. | Register


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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