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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. 96% of Kansas CAHs have participated in public reporting of quality metrics.  

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.

The next Quality Corner Call is scheduled for noon on January 13, 2022 . The brochure with more details will be posted soon.  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:


Star Ratings:

Overall Hospital Quality Star Ratings on Hospital Compare: Overview for Flex Programs and Rural Stakeholders 


QAPI Resources:

Hospital QAPI Worksheet – Public

Quality Review Blank Example

QAPI Gap tool

Sample Documents from Coffey County Health System

Sample Document from Nemaha Valley Community Hospital

National Example of QI Orientation



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

Instructions for Running HCAHPS Summary Report

Summary – HCAHPS Best Practices in CAHs 


Patient and Family Engagement:

COVID-19 and Patient- and Family-Centered Care Frequently Asked Questions 

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


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),


Other Resources:

Quality 101:  Quality Improvement Resources

MBQIP Basics Training Recording and Slides – October 1, 2021

MBQIP Overview Webinar

MBQIP Measures Fact Sheet

Paul Moore’s Video – Confused about MBQIP?

IHI Quality Improvement Essentials Toolkit

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

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

Quality Improvement Basics by Stratis Health

2021 BLANK SHIP and MBQIP Quality Information

MBQIP Data Abstraction Deadlines for FY21-22


Quality Ideas by Department: