One of the first steps in the transition to value-based reimbursement models is often related to quality reporting and the ability to demonstrate quality, efficiency and strong patient experience. Despite the challenges, many rural communities are stepping up to the opportunities of delivery system reform. Although considered voluntary by CMS, nearly 90% of CAHs nationwide participate in public reporting of at least some quality metrics. 100% of Kansas CAHs participate in public reporting of quality metrics.
MBQIP Resources:
- New MBQIP Measures Webinar Recording
- New MBQIP Measures Webinar Slides
- MBQIP 2025 Information Guide
- CAH Quality Infrastructure Specifications 2025
- FMT MBQIP Report CAH User Guide
- RQITA Measure Specific Resources
- RQITA MBQIP Navigator
- MBQIP Minnesota Quality Reporting Guide
- MBQIP Basics RECORDING and SLIDES Nov. 8, 2024
Quality Improvement Resources:
- MBQIP Basics Training Recording and Slides – November 9, 2023
- IHI Quality Improvement Essentials Toolkit
- RQITA QI Workbook
- Quality Improvement Basics by Stratis Health
- RQITA QI Tools and Templates
- Quality Improvement in Focus
- QI Toolkit
Quality Improvement Engagement Resources:
- Getting There Guide
- Conversation with Jack King, “How Hospital Boards Can Support Quality and Patient Safety”
- Getting Started Kit: Governance Leadership “Boards on Board”
- KHA Board's Guide to Quality
Additional Resources:
- QI Resources for Rural Health Organizations
- How to Make a Run Chart
- Summer is Coming
- Critical Access Hospital eCQM Resource List
Required Orientation & Education and Training Guides:
Quality Corner Calls:
Quality Corner Calls are offered by the Kansas Department of Health and Environment and Healthworks and focus on quality improvement activities consistent with the Medicare Rural Hospital Flexibility Grant Program.
Click on the links below to listen to the recordings and view the slides of previous Quality Corner Calls:
Quality Scholarships:
KRHOP will be offering up to $600 of preparation cost for taking The Certified Professional in Healthcare Quality certification through the National Association for Healthcare Quality.
Questions can be directed to
QA/PI Plan Resources:
- Hospital QAPI Worksheet – Public
- Quality Review Blank Example
- QAPI Gap tool
- Managing Your QAPI Program
- Example-Completed Quality Reporting Dashboard
- 89QAPI Plan Sample
- QAPI Networking Group Resources
PDSA and PIP Resources:
HCAHPS:
- FMT HCAHPS Toolkit
- Hospital Quality Star Rating (HCAHPS)
- Improving HCAHPS Huron Whitepaper
- Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Overview: Vendor Directory
Patient and Family Engagement Resources:
Social Drivers of Health Resources:
Antibiotic Stewardship and NHSN:
- Implementation of Antibiotic Stewardship Core Elements at Small and Critical Access Hospitals
- NHSN Patient Safety Component Data Entry
- National Healthcare Safety Network (NHSN),
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Quality Ideas by Department:
- Anesthesia
- Billing
- Cardiac Rehabilitation
- Cardiopulmonary
- Central Supply
- Dietary
- Emergency Department
- Home Care
- Housekeeping
- Human Resources
- Infection Control
- Laboratory
- Maintenance
- Materials Management
- Medical Records
- Nursing
- Obstetrics
- Operating Room
- PACU
- Pharmacy
- Physician Clinic
- Radiology
- Rehabilitation
- Safety
- Social Services-Discharge Planning
- Super Committees – Streamlining Committee Activities
MBQIP Data Abstraction Resources:
Kansas-specific Training
- Abstraction Training RECORDING and SLIDES - March 27, 2025
- How to complete OP-22 in HQR – updated March 2024
Abstracting in HQR (step by step instructions)
Emergency Department Transfer Communication Resources:
EDTC and Abstraction Training RECORDING and SLIDES - March 27, 2025
Stratis Health Resources
- Data Specification Manual
- EDTC Measure Frequently Asked Questions
- Data Specifications Manual Training Video
- Data Collection Tool (Download the tool at the link under "Data collection resources" tab)
- Data Collection Tool Training Video
Sample Documents from Kansas CAHs
Important Websites: