stethoscope on table


Quality & Safety Update — July/August 2021


Jessica Stultz

Jessica Stultz

Director of Clinical Quality



Quality & Safety Update


  • 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.

COVID-19 Update

For COVID-19 Updates, please visit the MHA COVID-19 web page.

To receive regular COVID-19 updates from MHA in your inbox, fill out the online form.

QSR Data Insight

QSR Data Insight

Staff Contact: Mat Reidhead

The presence of multimorbid physical and behavioral disorders is a significant driver of adverse patient outcomes, excess utilization and costs. During fiscal years 2019 and 2020, nearly 2.7 million individual Missourians experienced an inpatient hospitalization and/or emergency department visit at one or more Missouri hospitals. Among them, nearly half (49.2%) did not experience a diagnosis for a physical chronic condition or a behavioral health disorder. Unfortunately, the other half of patients were diagnosed with one or more conditions, resulting in a graded dose response with hospital utilization and cost. Among them:

  • 32.6% were diagnosed with one or more physical chronic conditions but no behavioral disorders,
  • 4.7% were diagnosed with one or more behavioral disorders but no physical chronic conditions, and
  • 13.4% were diagnosed with one or more of each.

During the two-year study period, the 1.3 million patients without a physical or behavioral condition diagnosis experienced 1.6 hospital encounters and incurred $8,433 in associated charges on average. By contrast, 2,380 patients experienced five or more physical and behavioral condition diagnoses. These patients had 24 inpatient and/or ED visits, and $350,629 in associated charges on average.

Using data to identify and intervene with patients at risk of excess hospital utilization, health spending, and avoidable morbidity and mortality is an effective strategy in population health management and moderating pervasive health disparities. MHA’s Quality, Safety and Research teams are working closely with the Hospital Industry Data Institute to develop solutions designed to identify at-risk patients using emerging technology, such as HIDI’s analytic workbench and Admit Discharge Transfer alerts via Collective Medical. As these solutions mature, QSR is working to develop hospital access to risk-stratified, analytics-ready curated databases specific to your individual patients or customized patient panels.


Save the Date for the Infection Preventionist Orientation: Kickoff is Sept. 7

Staff Contact: Jessica Stultz

This orientation program will prepare new infection prevention health care professionals to be facilitators and resources for surveillance, prevention and control of infections. It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance, analyzing disease data, and identifying and resolving problems. It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs, product selection and evaluation. This event allows participants to engage in case study activities and applications of user-friendly tools to enhance their infection prevention programs and goals. This program will have an in-person kickoff in Columbia, Mo., on Tuesday, Sept. 7, and will consist of weekly virtual sessions from Tuesday, Sept. 14, through Tuesday, Oct. 26. Please watch your email for application links.


Lean Six Sigma Black Belt and Green Belt Applications Open

Staff Contact: Jessica Stultz

MHA is partnering with A3 Healthcare to offer lean belt opportunities to a select number of applicants from Missouri hospitals to increase the knowledge, capacity and capability to support organizations. Selected applicants will have the opportunity to pursue and achieve green or black belt certifications based on their knowledge and experience. Lean Six Sigma certifications create foundational (green) and advanced (black) applied knowledge for managing efficient and effective performance improvement – a critical infrastructure requirement in today’s health care environment.

The green belt application is open to all those interested. The black belt application is open to all those with a current A3 Healthcare green belt. Applications will be accepted until Tuesday, Aug. 17. The green belt project is $1,000 per two-person team, and the black belt project is $1,000 per student. Also, if the student does not have access to a license for Minitab statistical software, a requirement of the project, this can be purchased through A3 Healthcare for $545. Attendees will be awarded on Wednesday, Aug. 18. Subsequent signed participation agreements and invoices must be returned by Tuesday, Aug. 31.


Missouri Hospitals Experience Blood Product Shortages

Staff Contact: Jessica Stultz

Last month, the American Red Cross issued a blood shortage notice and encouraged hospitals to follow the recommended strategies for managing a shortage and to actively employ conservation practices. MHA recently queried its hospitals to gauge the blood product shortage, and initial results found that there currently are hospitals experiencing shortages requiring them to alter or delay patient care. Several others are experiencing a shortage, and a multitude are anticipating a shortage soon. This query will continue periodically, as needed, until the supply can be maintained. MHA encourages hospitals to review the Red Cross recommendations, collaborate with those in your region, encourage your community members to donate blood and assist them in getting vaccinated against COVID-19.

Safety & Preparedness

Staff Contact: Jackie Gatz

COVID-19 Vaccine Guidance & Updates

MHA continues to support hospitals as they play a vital role in COVID-19 vaccine administration. As vaccinators shifted from mass vaccination models to offering convenient vaccine opportunities, many hospitals continue to create vaccine opportunities for patients through administration during emergency department visits, prior to inpatient discharge and in clinic settings. The Centers for Disease Control and Prevention recently released guidance for offering COVID-19 vaccines in these settings.

The Missouri Department of Health and Senior Services began COVID-19 vaccinator quality assurance visits on July 1 to provide hospital awareness of the forthcoming COVID-19 vaccinator audits. These in-person visits by DHSS  staff are at the direction of the CDC. MHA staff coordinated with DHSS Bureau of Immunization staff to develop an FAQs document to assist members as they prepared for these visits.

Maternal-Child Health

Staff Contacts: Alison Williams

Second AIM Collaborative: Care of the Obstetric Patient with Substance Use Disorder

MHA is pleased to announce its second Alliance for Innovation on Maternal Health Collaborative: Care of the Obstetric Patient with Substance Use Disorder. This collaborative is scheduled to launch in late August/early September. The collaborative is open to hospitals with and without birthing units, as well as clinics caring for and serving perinatal populations.

The collaborative will follow AIM’s framework of Readiness, Recognition & Prevention, Response, and Reporting/System Learning. This bundle, along with all future AIM bundles, will add a fifth “R” for Respectful Care, which focuses on health equity, racial disparities, and stigma and bias. The initial scope of work for collaborative participants will be on the readiness phase, and then will transition through the other bundle phases throughout the collaborative timeline. Organizations interested in joining should contact Alison Williams.


Severe Hypertension in Pregnancy Collaborative Wraps Up

The Alliance for Innovation on Maternal Health Severe Hypertension in Pregnancy Collaborative held its final team meeting on Friday, June 25. Collaborative teams from across Missouri have been working for more than a year on improving the timely treatment of medication administration for patients with severe range hypertension. These teams have implemented specific evidence-based practice standards across their birthing units, emergency departments or prenatal clinics. Teams worked to involve departments where pregnant or postpartum patients would be seen, including EDs and obstetrics clinics, working to streamline processes to ensure all pregnant and postpartum women receive the same standard of care, specifically related to medication administration of fewer than 60 minutes for patients experiencing severe range hypertension. Overall, 27 teams received MO AIM Star designations for their efforts related to this collaborative. End-of-project outcomes include the following.

  • Average percent of SHP bundle completion: 91%
  • Average percent of structure measures complete: 90%
  • Average percent of team performance improvement measures complete: 93%
  • Improvement/(Decline) of HTN-P4 rate from baseline: 11.32%


2021 Maternal and Infant Health Convening

MHA is delighted to again be partnering with The Uplift Connection to offer the 2021 Maternal and Infant Health Convening on Tuesday, Sept.  28. The convening will be held virtually. Additional information and registration details are available on The Uplift Connection’s website.

Opioid Use Disorder

Staff Contact: Shawn Billings

St. Louis County PDMP Continues Until Statewide Program Begins

On June 7, Gov. Parson signed Senate Bill 63 into law, allowing Missouri to establish a statewide prescription drug monitoring program. While the legislation will go into effect in August 2021, there are various benchmarks that need to be met to create a fully operational program. The St. Louis County PDMP will continue to operate until a statewide program is available and fully operational. Dispensers in participating jurisdictions should continue to report Schedule II-IV controlled substance dispensations. Participating jurisdictions will need to renew user agreements with St. Louis County to continue participating until the statewide program is available.


DHSS Releases Updated Buprenorphine Guidelines

The Missouri Department of Health and Human Services released new buprenorphine practice guidelines in April 2021. Such guidelines exempt eligible health care providers from federal certification requirements related to training, counseling and other ancillary services typically needed to treat opioid use disorder patients with buprenorphine. Providers now will be able to treat as many as 30 OUD patients without having the Data X waiver. To get evidence-based treatment to more Missourians, MHA has worked with its partners to increase their awareness of the new guidelines and to connect health care providers to resources for obtaining a notice of intent, which still is required through the Substance Abuse and Mental Health Services Administration.


Staff Contacts: Sherry Buschjost or Stephen Njenga

CAHs Earn LSS Yellow Belt Certification

The FLEX program offered all critical access hospitals an opportunity to participate in a LEAN Six Sigma Yellow Belt Certification Program. The program began June 2 and included a six-part online learning module series that equipped leaders with skills to solve challenges amidst a rapidly changing COVID-19 health care environment.

A total of 98 participants registered for the LSS project, representing 32 hospitals. Following each online course, the participants completed a skills assessment, which required a passing grade. Once successful completion of all six skills assessments, participants received LSS Yellow Belt Certification.


MoAHQ Update

We are called to be lifelong learners. One can make a strong argument that continuous learning is a minimum requirement for a health care professional, especially in quality. After all, we are charged with ensuring safety and robust outcomes for each life in which we are accountable. As such, much learning can occur by networking with others who have similar goals and objectives. I recently had the opportunity to attend a Quality Assurance and Performance Improvement workshop with several other critical access hospital leaders. The experiences exchanged, conversation and fellowship truly was refreshing. Roundtable discussions led the charge of best practices and sharing of practical ideas that we could take back to our home organizations. The activities of the day once again made me realize how greatly we need to network. Regardless of the type of health care facility or educational institution, we have so much to share with one another. Together, we can make a difference and move the “quality needle” in our own organizations and across Missouri.

Holding true to the idea of learning, MoAHQ is well-positioned to serve as the preeminent vehicle to meet the needs of quality professionals across the state. MoAHQ’s efforts foster engagement through evidence-based idea-sharing and opportunities to exchange experiences. We have made several changes since the beginning of the year to offer networking and learning experiences to our members. Beginning in January, we have been offering bimonthly full membership meetings. At these meetings, the 2020 MHA Convention MoAHQ poster presenters have taken a turn sharing their projects in more detail and engaging in question-answer sessions with members. We truly have had remarkable presentations and look forward to the projects to be shared at this year’s MHA Convention.

MoAHQ is planning a busy fall to connect with members. Stay tuned to MHA communications for 2021 Distinguished Quality Professional award applications, and the opportunity to submit a poster abstract to present at the 2021 MHA Convention. Over time, we too expect and look forward to other opportunities to network this year. We look forward to seeing you soon.

Never stop learning because life never stops teaching. MoAHQ invites you to membership if you would like the opportunity to learn more about quality and connect with a group whose sole focus is on health care quality. Visit the MoAHQ website to learn more.

Hirshell Parker, MHA, BSN, R.N., LSSGB
MoAHQ President
Executive Director of Quality and Risk Management
Ste. Genevieve County Memorial Hospital



Are you a patient advocate or patient representative within the reach of MHA? If so, then the Heart of America Chapter for Healthcare Consumer Advocacy is the group for you! We are a group of health care professionals who want to network with other patient advocates/representatives. Our goals this year are to build our membership and create more interest in HACHCA, while also learning from each other. We held a virtual event on June 22 to introduce additional people to HACHCA. We had great conversations and discussions, made some networking connections, shared resources, and even awarded “door prizes” to some attendees. Our next event is being planned as an in-person social hour on Wednesday, Sept. 15. Details are being finalized, but if you are interested in joining us and becoming a member of HACHCA, you can register at Please contact Becky Moburg at for questions about HACHCA.

Katie Norwood, LMSW
Patient Advocate
AdventHealth Shawnee Mission


MHA Today


OSHA Issues Emergency Temporary Standard To Protect Health Care Workers From COVID-19

The U.S. Department of Labor’s Occupational Safety and Health Administration issued a news release announcing it will issue an emergency temporary standard to protect health care workers from contracting COVID-19. The standard focuses on health care workers most likely to have contact with someone infected with the virus. OSHA announced the new standard alongside new general industry guidance, both of which are aligned with Centers for Disease Control and Prevention guidance.

The emergency temporary standard establishes new requirements for settings where employees provide health care or health care support services, including skilled nursing homes and home health care, with some exemptions for health care providers who screen patients who may have COVID-19. OSHA will update the standard, if necessary, to align with CDC guidelines and changes in the pandemic.


CMS Releases Revised Emergency Preparedness Guidance

The Centers for Medicare & Medicaid Services released revised guidance related to emergency preparedness testing and training for inpatient providers. CMS is extending the one-year testing exemption, which only applies to the next required full-scale exercise (not the exercise of choice), based on the facility’s 12-month exercise cycle and only if a facility currently still is operating under its activated emergency plan. The cycle is determined by the facility. The guidance is effective immediately.


ANA COVID-19 Webinars Available On-Demand

ANA offers free on-demand COVID-19 webinars to assist front-line staff with evidence-based practices. There are 11 timely and high-priority opportunities to choose from, and many offer CEs for completion.

  • Managing Patients with Long-Term Effects of COVID-19: Nursing Priorities and Interventions
  • Boosting Vaccine Confidence in Minority Populations
  • Effective Tools for Practicing Self-Compassion and Self Care in the Time of COVID-19
  • How to Protect Yourself: Use and Re-Use of PPE
  • The State of COVID-19 Vaccine Development: What You Need to Know
  • Caring for COVID-19 Patients: Disease Progression and Nursing Interventions You Need to Know
  • COVID-19 in Non-Acute Care Settings: Hard-Earned Lessons from Two APRNs on the Frontlines
  • How You Can Have a Direct Impact on Reducing the Devastating Racial Disparities of COVID-19
  • How to Survive the Pandemic with An Unbroken Spirit: Actions to Take Right Now to Stay Strong and Focused
  • How to Respond to Ethical Challenges and Moral Distress during the COVID-19 Pandemic
  • Ventilator Management: Essential Skills for Non-ICU Nurses


CDC Issues Guidance for Treating “Long-COVID” Patients

The Centers for Disease Control and Prevention released much-anticipated guidance for physicians treating patients struggling with lingering and complicated problems after COVID-19, often called “long COVID.” The guidance offers initial recommendations for physicians treating patients who are experiencing illness at least four weeks after an acute infection of the virus that causes COVID-19. The interim guidance acknowledges much is unknown about post-COVID-19 conditions, although the National Institutes of Health launched a research effort to learn more.


TJC Releases New Workplace Violence Standards

The Joint Commission announced new and revised workplace violence standards for hospitals and critical access hospitals effective Jan. 1, 2022. The new and revised standards include defining workplace violence, leadership oversight, post-incident strategies and more. A Compendium of Resources is available to assist hospitals with compliance.


Additional Resources:


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 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. Register by Friday, Sept. 10, to receive your event swag before the event.


Critical Care for Non-ICU Clinicians

This webcast series engages a panel of critical care experts who address questions from non-ICU clinicians caring for critically ill patients during the COVID-19 pandemic. Participants are encouraged to ask about any related topics at the time of registration or during the live session. Share this with a friend or colleague who could benefit. Previous webcast recordings are available. The next events take place at 5 p.m. CDT Wednesday, Aug. 11, and Wednesday, Sept. 8.


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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