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.

MHA Realignment — Quality, Safety and Research Department Update

Staff Contact: Leslie Porth

Staff of the Hospital Industry Data Institute and MHA’s Strategic Quality Initiatives Department have been conducting timely and valuable research on a variety of subjects for many years. The demand for research and increased data — due to COVID-19 and other topics — continues to grow. To enhance research efforts, MHA has realigned to bring the work of SQI and HIDI staff together.

Due to this realignment, we are adding additional subject matter expertise and renaming the SQI Department to reflect the true scope of its efforts. The SQI Department now will be called the Quality, Safety and Research Department. As part of this organizational move, Mat Reidhead, vice president of research and analytics, and Josh Grotzinger, director of research and analytics, will transfer from HIDI to the QSR Department. Mat and Josh’s move to the QSR Department will enhance research across the enterprise, supporting all operating departments and companies.

We are excited about these new changes and believe they will help us better serve our hospital members by enhancing and growing our work in several important areas.

Maternal-Child Health

Staff Contacts: Alison Williams or Kelsey Hussey

Missouri AIM Informs Perinatal SUD Web-Based Resource

The Missouri Alliance for Innovation on Maternal Health — a partnership between the Missouri Department of Health and Senior Services and MHA, in collaboration with the MO HealthNet Division’s Maternal/Fetal/Infant Subcommittee for Substance Use Disorder and The Uplift Connection powered by Missouri Foundation for Health — collaborated to identify and create a public-facing perinatal SUD resource and service listing available throughout Missouri.

In this effort, these entities have collaborated on a survey collection tool for those providing perinatal SUD services, and have asked key stakeholders and partnering organizations to participate and/or disseminate the survey to as many appropriate providers as possible. The results of this survey will establish a much-needed directory of resources for providers and mothers alike. This resource will create a robust set of shared resources that ultimately will improve care coordination and promote improved health outcomes for mothers, infants and families.

Three-Part Training Series Available

MHA and Mid-America Addiction Technology Transfer Center Network are offering a three-part training series, “Embracing Pregnant & Parenting Families Challenged with Substance Use Disorder.” Session topics will include the following.

• SUD 101 & neurobiology of addiction
• parenting & addiction
• evidence-based treatment for pregnant women with oud
• stigma & implicit bias
• working toward becoming a stigma-free provider, with a focus on language
• being recovery-oriented & person-centered

Training dates will take place Wednesday, May 26; Wednesday, June 2; and Wednesday, June 9. Each session will begin at 11:30 a.m. and end at 1 p.m.

Opioid Use Disorder

Staff Contact: Shawn Billings

MHA, DHSS Host NAS Summit

MHA and the Missouri Department of Health and Senior Services hosted the 2nd Annual Neonatal Abstinence Syndrome Summit on Feb. 23. The virtual Summit hosted 185 stakeholders who received national and statewide updates on NAS surveillance and changes in reporting criteria. Participants also learned about implementation strategies for Eat, Sleep, Console, an evidence-based functional assessment tool used to provide care and support for infants exposed to opioids during pregnancy.

During the Summit, participants learned how socioeconomic, epigenetics and trauma can impact the labor, birth and postpartum experience, and recognized the important role health care providers present to positively influence the health of women, their children and communities. Additionally, those in attendance were able to identify the importance of recognizing the lived experience of patients with substance use disorder as a valuable component to identify when providing care.

Population Health Updates

Staff Contacts: Stephen Njenga

MHA Releases 2020 Population Health Assessment Survey Results

As the health care landscape continues to shift from volume to value, hospitals and health systems are implementing innovative care redesign strategies to improve care delivery and lower costs. MHA recently completed its 2020 Population Health Assessment Survey — an important step in helping hospitals and health systems evaluate their progress in transitioning to a value-based environment.

The survey covered nine domains — leadership, patients/community, workforce, finance, data and technology, operations, legal/regulatory, outcomes and policy/advocacy — and when comparing the 2020 and 2017 survey results, each domain improved. However, work remains in hospitals’ population health journey. Key future focus areas include adopting innovative strategies that seek to improve access to care, data collection and analysis, technology, and health outcomes for individuals and populations.

Survey results — summarized statewide and by hospital type — are available in MHA’s Population Health Assessment. Individualized reports were shared with each participating hospital or health system. These survey results will inform MHA’s population health strategy, and ensure the necessary tools and resources to support hospitals throughout their population health journey are provided.

FLEX MBQIP Updates

Staff Contacts: Sherry Buschjost or Stephen Njenga

MHA Recognizes Top Performing CAHs

While emergency care is important in all hospitals, the emergency department particularly is important in critical access hospitals where the distance to urban tertiary care centers makes the effective triage, stabilization and transfer of patients an area of focus. ED transfer communication measures allow CAHs to show how well they carry out their important stabilize-and-transfer role for rural residents. This measure is required of hospitals participating in the FLEX MBQIP program in Missouri and throughout the nation.

As of the first quarter of 2021, the following CAHs achieved 100% compliance in the ALL EDTC composite score, putting them in the top performers’ list of CAHs in Missouri and the nation.

1. Cox Barton County
2. Carroll County Memorial Hospital
3. Cass Regional Medical Center
4. Ellett Memorial Hospital
5. Harrison County Community Hospital
6. Iron County Hospital
7. Lafayette Regional Health Center
8. Mercy Hospital Carthage
9. Mosaic Medical Center – Albany
10. Perry County Memorial Hospital
11. St. Genevieve County Memorial Hospital
12. Washington County Memorial Hospital

Announcements

CMS Exceptions

The Centers for Medicare & Medicaid Services announced in March 2020 they were granting exceptions from reporting requirements and extensions for clinicians and providers participating in Medicare quality reporting programs with respect to upcoming measure reporting and data submission for those programs. The extent of those exceptions are available, and it includes most of Q1 and Q2 2020. CMS can grant waivers or extensions to hospitals that have not requested them when CMS determines that an extraordinary circumstance affects an entire region or locale. That is the authority they used to grant the exceptions for part of Q42019, and Q1 and Q2 2020. If a hospital submitted data during that time, but COVID-19 negatively impacted their results, they could request an Extraordinary Circumstance Exception, otherwise, it counts. For the rest of the time that CMS did not specifically exclude, the hospital would have to submit an ECE.

MHA Today

• 3/19: CMS Alerts Users Action May Be Needed To Receive Reports Through Managed File Transfer
• 3/29: TJC Announces Updates To Home Health And Hospice Requirements
• 3/31: CMS Releases Claims Detail Reports For Outpatient Imaging Efficiency Measures
• 3/31: Missouri AIM Launches Survey To Inform Perinatal SUD Web-Based Resource
• 4/2: MO HealthNet Updates Pharmacy Manual Related To PDMP Verification Requirements
• 4/5: MHA Hosts 11th Annual Behavioral Health Summit
• 4/12: HHS Announces Measures To Improve Maternal Health During Black Maternal Health Week

Resources

Hospital Quality Reporting Guides

MHA updated the acute care, critical access hospital and specialty services quality reporting guides to reflect requirements effective with Jan. 1, 2021, dates of service. The guides support hospitals with reporting quality measures through various reporting programs. Download the updated guides to access direct sources of information and to stay up-to-date on measure specifics.

Well-being Playbook 2.0

The American Hospital Association’s Physician Alliance released the Well-being Playbook 2.0, a new resource that builds on its 2019 playbook to help hospital and health system leaders support their teams during the COVID-19 pandemic. The update includes curated resources specific to COVID-19 on suicide prevention, operationalizing peer support, and a guide to walk leaders through well-being program development and execution.

April Was National Minority Health Month

Throughout National Minority Health Month, MHA shared information, resources and education through its various media outlets, including the COVID-19 Update, MHA Today and on social media. This year, the U.S. Department of Health and Human Services Office of Minority Health focused on the disproportionate impact the COVID-19 pandemic is having on racial and ethnic minorities and underscored the need for these vulnerable communities to get vaccinated as more vaccines become available. COVID-19 vaccination is an important tool to help us get back to normal, prevent the spread of COVID-19 and bring an end to the pandemic.

This year’s theme for National Minority Health Month is #VaccineReady, which empowers communities to get the facts and share accurate vaccine information, participate in clinical trials, get vaccinated when vaccine is available, and practice COVID-19 safety measures. OMH offers additional details and resources on its website.

NHSN 2021 Q1 Newsletter

The National Healthcare Safety Network released its 2021 Q1 Newsletter, which features training videos, information on the launch of the Dialysis Patient COVID-19 Vaccination Module, updates from the Antimicrobial Use and Resistance Module, and more.

COVID-19: Spread the Science, NOT the Virus

Spread the Science, NOT the Virus Safety Series is a new offering from Jefferson’s College of Population Health and the states’ hospital associations. During planning and response to COVID-19, hospitals were first and foremost attuned to keeping patients as safe as possible. With a novel virus, unknown and untested treatments, and unpredictable impacts of the virus on different patients, the hospitals had to establish processes and practices that would save the most lives and prevent the most harm while patients were under their care. Sessions will continue until June. Previous sessions are available in the library. More information is available on the website.

Upcoming Virtual Events

Social Determinants of Health — Four-Part Virtual Series

• April 27: Introduction to Social Determinants of Health
• May 18: Best Practice Strategies for Collecting SDOH/ICD-10 Z-code Data
• June 8: Using Technology to Connect Patients and Resources
• June 29: Telehealth/Telemedicine

Register on or before Monday, June 28. Each session will be recorded and available to registered attendees after the session.

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.