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. 95% of Kansas CAHs have participated in public reporting of quality metrics.  

Congratulations to our 18 Quality 101 Graduates!  These Quality Managers studied for two days, learning how to establish a quality program in their facilities, how to identify areas that need assistance, and what resources Kansas has to assist them.  Our thanks to all the presenting partners:  Kansas Healthcare Collaborative, University of Kansas Care Collaborative, Kansas Hospital Education and Research Foundation, Kansas Foundation for Medical Care, Kansas Hospital Association, and Kansas Association of Quality and Risk Managers.








Available Help Desk:

Quality Health Indicators (QHi), Stuart Moore,, (785) 233-7436


Quality Corner Calls:

Quality Corner Calls are offered by the Kansas Department of Health and Environment and the Kansas Hospital Education and Research Foundation and focus on quality improvement activities consistent with the Medicare Rural Hospital Flexibility Grant Program.

The next Quality Corner Call is scheduled for August 18, 2020, and it will be on the topic of “Age-Friendly Health System.”  Click HERE for the brochure.  Click HERE to register for the webinar.

Click on the links below to listen to the recordings and view the slides of previous Quality Corner Calls:

  • July 9, 2020 Immunizations:  Helping Communities Stay Healthy RECORDING and SLIDES
  • May 6, 2020 Changes in Quality Reporting due to COVID-19 RECORDING and SLIDES
  • April 17, 2020 Engaging Patients and Families During Social Distancing RECORDING and SLIDES
  • October 9, 2019 Best Practices in CAHs RECORDING and SLIDES
  • August 14, 2019 Tackling the Challenges in the Quality Department RECORDING and SLIDES
  • July 17, 2019 Palliative Care in Critical Access Hospitals RECORDING and SLIDES
  • May 15, 2019 Antibiotic Stewardship and Resistance RECORDING and SLIDES
  • April 17, 2019 Patient Experience: Making a Difference RECORDING and SLIDES
  • February 20, 2019 QHi, Quality Health Indicators RECORDING and SLIDES
  • January 9, 2019 Electronic Clinical Quality Measures (eCQMs) RECORDING and SLIDES



Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Overview: Vendor Directory

Instructions for Running HCAHPS Summary Report

Summary – HCAHPS Best Practices in CAHs 



NHSN Patient Safety Component Data Entry

National Healthcare Safety Network (NHSN),


QAPI Program Resources:

Sample Documents from Coffey County Health System

Sample Document from Nemaha Valley Community Hospital

National Example of QI Orientation

Other Resources:

Paul Moore’s Video – Confused about MBQIP?

IHI Quality Improvement Essentials Toolkit

Patient and Family Engagement PfP-Strategic-Vision-Roadmap-508 102017

Quality Improvement Implementation Guide and Toolkit for Critical Access Hospitals

Medicare Beneficiary Quality Improvement Project (MBQIP) Quality Reporting Guide

Critical Access Hospital eCQM Resource List

Quality Improvement Measure Summaries for MBQIP

Implementation of Antibiotic Stewardship Core Elements at Small and Critical Access Hospitals

MBQIP Data Submission Deadlines for FY19-20

Quality Improvement Basics:  A Collection of Helpful Resources for Rural Health Care Organizations 

Quality Improvement Basics by Stratis Health

SHIP and MBQIP Quality Information


Quality Ideas by Department: