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CAHs are affected directly and indirectly by the rapidly changing health care payment and delivery environment.  A critical component of the changing health care environment is to accelerate adoption of reimbursement models that reward value, with an emphasis on quality and care coordination. Alternative payment models, such as accountable care organizations, are one key component, with HHS setting targets of 50 percent of Medicare fee-for-service payments through these new models by 2018. However, incentives linked to quality of care metrics also are growing exponentially, with an HHS goal of 90 percent of Medicare FFS payments linked to quality by 2018.

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.  


Available Help Desks:

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

National Healthcare Safety Network (NHSN),, (877) 681-2901

QualityNet,, (866) 288-8912


Quality Corner Calls:

See the post on the home page of this website for details on the periodic Quality Corner Calls.  See QCC Brochure 4-12-18 for details.  Click HERE to register for the webinar.


Additional Resources:

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

MBQIP Data Submission Deadlines – 2017-2018 SHIP

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

MBQIP Data Abstraction Training (Kansas-specific)

MBQIP Data Abstraction Training Series (National)

  • Locating CMS Specifications Manuals (13-minute video)
  • Locating CART (CMS Abstraction Reporting Tool) (9-minute video)
  • Outpatient AMI Measures (OP1 – OP5) (23-minute video)
  • Outpatient Chest Pain Measures (OP4 – OP5) (20-minute video)
  • ED Throughput Measures (OP18, OP20, OP22) (19-minute video)
  • Outpatient Pain Management Measure (OP21) (12-minute video)
  • Inpatient Influenza Vaccination Measure (IMM-2) (18-minute video)
  • Inpatient ED Measures (ED-1, ED-2) (18-minute video)

Paul Moore’s Video – Confused about MBQIP?

Quality Improvement Implementation Guide and Toolkit for Critical Access Hospitals

Medicare Beneficiary Quality Improvement Project (MBQIP) Quality Reporting Guide

NHSN Patient Safety Component Data Entry

Quality Activities by Department