stethoscope on table


Quality & Safety Update — March/April 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.

MHA Recognizes National Public Health Week, Updates Health Equity Dashboards

Health equity dashboards

National Public Health Week takes place each year during the first full week of April. This year’s theme, “Public Health is Where You Are,” reinforced the importance of having the right infrastructure to promote health and well-being for everyone, irrespective of social determinants of health.

This year during NPHW, the MHA Health Equity Dashboards were refreshed to include data through fiscal year 2021. Additionally, new indicators on maternal and child health were added, as well as a new module exploring the association between health and social vulnerability.

MHA staff also participated in recent interviews to discuss public health. Stephen Njenga, director of quality measurement and population improvement, discussed population health and SDOH in the Telehealth Unmuted podcast with Heartland Telehealth Resource Center. And, DHSS featured Kara Amann-Kale, director of hospital preparedness programs, in a YouTube video highlighting NPHW.


Submission Deadlines Draw Near for 2022 MHA Awards

It’s not too late to qualify for recognition at MHA’s 100th Annual Convention in November! Submissions for MHA’s most prestigious annual awards honoring the accomplishments of its member hospitals are due Friday, May 6.

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

Maternal-Child Health

Staff Contacts: Alison Williams

New Guide Available for Serving Pregnant and Parenting Persons Affected by SUD

New Guide Available for Serving Pregnant and Parenting Persons Affected by SUD

MHA, in partnership with the Mid-America Addiction Technology Transfer Center, Region 7, released a new guidance document and professional development opportunity, “Optimizing Care of the Mother-Baby Dyad Affected by SUD: A Guide for Health Care and Social Service Professionals Serving Pregnant and Parenting Persons.”

The guide includes links to on-demand webinars and materials for use to increase awareness and understanding of addiction as a chronic disease, care delivery changes required to better serve this population, and how to become a stigma-free provider.

Organizations are encouraged to use these resources for staff professional development and to encourage ongoing conversations on how to reduce stigma and implicit bias for perinatal patients diagnosed with SUD and co-morbid mental health conditions.

Opioid Use Disorder

Staff Contact: Shawn Billings

Missouri AG Announces Opioid Settlement

In February 2022, the Missouri Attorney General’s Office announced a term sheet and settlement with several opioid distributors (McKesson, Amerisource Bergen and Cardinal Health), and Johnson & Johnson, which could total just under half a billion dollars to be spent directly on opioid abatement and treatment. This money will aid those suffering from substance use disorder and provide needed resources to treatment centers and other support systems across the state.

  • In August of 2020, the Missouri legislature passed RSMo 196.1050, which specifically requires 100% of opioid settlement monies be directed at the epidemic.
  • Expenditures that qualify as opioid remediation include naloxone or other FDA-approved drugs to reverse opioid overdoses, medication-assisted treatment, education programs, outpatient counseling and therapy, housing, transportation, job placement/training, child care, treatment for neonatal abstinence syndrome and more.
  • The portion of Missouri settlement funds will be deployed in an opioid abatement and treatment fund overseen by the Missouri departments of Mental Health, Social Services, Health and Senior Services, Public Safety, Corrections, and the Office of State Courts Administrator.

Enhancing and Expanding Missouri’s Bridge Model: Engaging Patients in Care Coordination

In March 2018, MHA — in partnership with the Behavioral Health Network, Missouri Department of Mental Health, Missouri Institute of Mental Health and many other state agencies — identified other Missouri communities disproportionately affected by opioid overdose deaths to replicate EPICC programming.

In terms of reach, EPICC programming now is offered in the central, eastern, southwest and western regions of the state — more than 13,000 community members diagnosed with OUD have been served. In response to an emerging threat with the increased prevalence of methamphetamine use and ongoing challenges with alcohol use disorder, EPICC eligibility criteria was expanded in November 2021 beyond opioids to include alcohol and stimulant use disorder. Additionally, MHA currently is working with Lake Regional Hospital and Central Ozarks Medical Center to launch programming at Lake of the Ozarks with a tentative launch date of July 2022.

Clinical Quality

Staff Contact: Jessica Stultz

MHA Offers Quality Director Orientation

In June, MHA staff will kick off an eight-week, virtual new quality director orientation. This orientation supports staff new to this role within the past 18 months by advancing their knowledge and technical skill set, and providing access to critical resources. Topics covered will include quality measurement and financial implications, risk management and compliance, team leadership, communication skill-building, safety, survey readiness, and more.

Infection Prevention Orientation Returns

MHA’s eight-week, virtual orientation for new infection prevention professionals again will be offered this fall. This series provides networking opportunities, resource navigation, basic infection prevention knowledge, and access to mentors and subject matter experts. 100% of past attendees have shared that they are more confident in their role after completing this extremely valuable orientation. Additional details will be available soon.

Lean Six Sigma Cohort Continues Training

In partnership with A3 Healthcare, MHA continues to offer members Lean Six Sigma green and black belt certification training. Cohort #5 will conclude this spring and includes 27 hospital-based health care professionals — five black belts and 22 green belts. Cohort #6 includes 28 hospital-based health care professionals, with 26 in the green belt and two in the black belt program. The response, interest and exceptional feedback MHA has received regarding this member training has been overwhelmingly positive. At the completion of the programs, the belt students complete a project summary and compendiums are shared.

Patient and Family Advisory Council

Staff Contact: Jessica Stultz

Apply for the Compass Honor

MHA’s Patient and Family Advisory Council is calling for applications for its inaugural Compass Honor by Wednesday, June 1. Established to recognize exemplary progress as a hospital-based PFAC, the chosen hospital will be presented with a trophy and press kit during an upcoming MHA event later this summer. Through public recognition, this honor aims to encourage and inspire hospitals to adopt PFAC best practices and advance the health care experience for patients and providers.

Healing Happens Here: A Patient’s Perspective Webinar Series

In June, the MHA PFAC is hosting a three-part webinar series, “Healing Happens Here: A Patient’s Perspective.” Building on MHA’s previous Healing Happens Here Toolkit, which focused on safety/security and workplace violence. Alternately, this series will help caregivers collaborate with patients and families by using evidence-based practices to improve the health care experience for all.

Join these resource-rich informative sessions to learn simple ways to make an impact at the bedside. Each session is scheduled for 45 minutes, and registration is available at the respective links.

Population Health

Staff Contact: Stephen Njenga

MHA Announces CHNA Six-Part Webinar Series

Nonprofit hospitals are mandated to conduct a community health needs assessment every three years and adopt an implementation strategy to meet the community health needs identified in the assessment. To support hospitals with these efforts, MHA is offering a six-part CHNA webinar series where attendees will learn about the regulatory requirements to ensure compliance, and receive new tools and resources that will help them complete the CHNA process.

Safety & Preparedness

Staff Contact: Kara Amann-Kale

Monitoring Hospital Visitor Policies

Throughout the COVID-19 response, hospitals have navigated changing visitor policies in response to community spread and case surges. In February, CMS determined that federal guidance on visitor restrictions no longer was necessary, and many hospitals are planning and implementing new policies related to the reintroduction of visitors.

To support hospitals, MHA hosted a hospital visitation policy and practice webinar, and future technical assistance will be forthcoming. We encourage hospitals to reach out with concerns and feedback to help support the development of this programming.

Shifting Focus to Endemic Management

MHA preparedness staff are focused on helping hospitals transition from acute pandemic response to endemic management of COVID-19 in the care environment, following an announcement by the state of Missouri and CDC’s transition to COVID-19 community levels.

Programming currently is being developed to support this transition, including quarterly webinars on relevant hot topics. The first webinar was held on staffing and change management. Future webinar topics include deferred maintenance, workforce resiliency and respiratory protection programs. Registration details will be shared closer to event dates.

MoAHQ Update

MoAHQ has great speakers lined up for 2022 as we work to further expand our presentation topics. Moving forward, we also have started adding regulatory updates from any members with recent survey activity to enhance readiness across the organizations. We also are focusing on student development and ensuring our presentations are beneficial for student members with a future in health care.

Planning is underway for MHA’s 100th Annual Convention in November. We will provide program updates as soon as MHA has finalized plans for this year.

MoAHQ has been working to recruit a new district representative to serve on the board in District 5 where there is a vacancy. District 2 has a new representative as of March. The board is revising the Operating Guidelines and reviewing the district representatives’ role to ensure we have good support and networking across the state. Listed below are the current district representatives for 2022. Their main goal is to increase MoAHQ membership, and share strategies and resources to assist with current quality initiatives within their districts. Please feel free to contact the district representatives if you have ideas for future MoAHQ initiatives.

To learn more, you may contact me at

Thank you,

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


April 20 | SA: After the Hospital: Longer-Term Impacts of Pediatric Sepsis

May 12 | CHA: 2022 NHSN Basic Training Webinar

June 2 | MHA: Quality Assessment and Performance Improvement Program

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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