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Quality & Safety Update | May 2023


Jessica Stultz

Jessica Stultz

Director of Clinical Quality



Quality & Safety Update


  • Disease Management
  • Process Improvement
  • Quality and Safety
  • Regulatory
  • Substance Use Disorder


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 Provides Resources To Help Hospitals Navigate The End Of COVID-19 PHE

Staff Contact: Kara Amann-Kale or Keri Barclay

The COVID-19 PHE ended May 11 as the federal government concluded the emergency phase of the pandemic. MHA compiled the following resources to assist member hospitals during this transition and will continue to update the website with relevant information.

  • MHA developed forms to assist hospitals with drafting after-action reports and improvement plans for the COVID-19 pandemic response.
  • The CDC updated its COVID-19 infection control guidance and no longer will produce the community transmission metric. Moving forward, masking guidelines should be a facility-determined, risk-based assessment accounting for relevant stakeholder input and local metrics. The testing requirement for nursing home admissions also should be based on facility discretion.
  • CMS plans to end the COVID-19 vaccine requirement for staff and contractors in CMS-certified health care facilities. Additional details will be forthcoming related to this rule change.
  • While supplies last, DHSS will continue to make available personal protective equipment and COVID-19 antigen tests by request, and the federal government will continue to provide COVID-19 vaccines and some therapeutics, including Paxlovid and Lagevrio. Distribution will be transitioned to the commercial market at a later date.
  • The CDC announced in April upcoming changes to the COVID-19 Hospital Data Reporting Guidance to reflect a reduction in the required number of reported data elements and updated the cadence required for submission from daily to once per week. Hospitals are asked to continue reporting under the current requirements until the changes take effect in NHSN Sunday, June 11. AHA published a Special Bulletin with additional details.
  • MHA published a list outlining when specific waivers associated with the PHE will end. CMS issued a memo to state surveyors identifying the regulatory requirements that will be reinstated with the end of the PHE.
  • The FDA released FAQs explaining what happens to EUAs when a PHE ends.
  • MHA updated its regulatory and licensure guidance on the state and federal waiver processes that were affected by the end of federal declarations. While hospitals can request a variance of regulations included in 19 CSR 30-20.015, they will need to ensure the variance request would not conflict with either state or federal requirements.

MHA, Partners Publish Overdose Education And Naloxone Distribution Program Guidance

MHA, Partners Publish Overdose Education And Naloxone Distribution Program Guidance

Staff Contact: Shawn Billings

A recent analysis of Missouri hospital community health needs assessments identifies mental health and substance use as the top two areas impacting Missouri communities. Considering the high prevalence of unmet substance use disorder needs among emergency department patients and the increasing frequency of drug-related ED visits, ED practitioners are uniquely positioned to prevent opioid overdose deaths.

Recognizing the action needed to save lives, MHA and partnering organizations — DMH, DHSS and UMSL’s Addiction Science Team — developed Overdose Education and Naloxone Distribution (OEND) Program Guidance to support hospitals with establishing this simple and cost-effective harm reduction intervention for community members at risk for an opioid overdose.

Engaged Leadership Is Critical To Successful QAPI Program

Staff Contact: Jessica Stultz

Quality Assurance Performance Improvement Conditions of Participation deficiencies are the third most frequently cited of the 24 CoPs for Medicare-certified hospitals. The QAPI CoP requires a hospital to “maintain and demonstrate evidence of its QAPI program for review by CMS, as well as the governing body oversight of the program in an effort to deliver safe, quality patient care and prevent adverse events and patient harm.” A component of the successful execution of a hospital QAPI program requires engagement by the hospital’s governing body. Board oversight in the development and ongoing planning of a hospital’s QAPI activities is essential and includes the following.

  • review the QAPI program periodically
  • develop a plan to implement and maintain the QAPI program
  • review progress of QAPI projects
  • determine annual QAPI projects
  • evaluate implemented improvement actions
  • establish clear expectations for safety and communicate hospitalwide
  • allocate adequate resources for QAPI program requirements

Learn more in CMS’ recently released guidance, and join us at this year’s Leadership Forum to hear from Dr. Steve Berkowitz about the critical role of leadership in clinical quality improvement.

health care worker against workplace violence

MHA Requests Workplace Violence Data

To quantify the prevalence of workplace violence incidents occurring within Missouri hospitals, MHA relaunched a data collection initiative to inform advocacy efforts and member technical assistance. Designated safety and security leaders received an Excel-based collection tool with a request to submit standardized measures three times annually to

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MHA Updates Quality Reporting Guides

MHA updated the acute care, critical access hospital and specialty services quality reporting guides to reflect requirements effective with Jan. 1, 2023, dates of service. The guides support hospitals with reporting quality measures through various reporting programs. Access the guides for direct sources of information and to stay up-to-date on measure specifics.

Kids jumping rope outside

MHA, HIDI Refresh Key Data Sources

The Missouri ZIP Health Rankings data included on the exploreMOhealth CHNA platform and data driving public-facing Health Equity Dashboards were updated in April to include hospital claims through FFY 2022 and the latest information from the U.S. Census Bureau.

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DHSS Launches “Tobacco Is Changing”

Tobacco companies are creating new “tobacco-free” products with synthetic nicotine, labeling them as “clean” to market to youth. To educate parents, DHSS launched a statewide campaign in partnership with numerous organizations, including MHA. The website describes different candy-flavored tobacco products and includes a robust media toolkit.


June 6 | Orientation for Infection Prevention Professionals

  • 1 to 2:30 p.m. | Seven-part virtual series + bonus sessions | Register

June 22-23 | 2023 MHA Leadership Forum

  • Adams Pointe Conference Center, Blue Springs, Mo. | Register

September 12-14 | Settings of Care Conference: Fostering Innovation Through Clinical and Operational Collaboration

  • Stoney Creek, 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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