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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:

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 noon on Tuesday, November 13 on Best Practices for CAHs.  Click HERE for the brochure.  Click HERE to register.

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

  • April 12, 2018 Antibiotic Stewardship and Resistance RECORDING and SLIDES
  • May 16, 2018 Emergency Department Transfer Communication RECORDING and SLIDES
  • July 11, 2018 Antibiotic Stewardship and Resistance, Part II RECORDING and SLIDES
  • August 14, 2018 Understanding Telligen MBQIP Reports RECORDING and SLIDES
  • October 9, 2018 Ask the Expert RECORDING and SLIDES
  • November 13, 2018 Best Practices for CAHs SLIDES– the recording is not available
  • January 9, 2019 RECORDING and SLIDES
  • February 20, 2019 RECORDING and SLIDES
  • April 17, 2019 RECORDING and SLIDES

Additional Resources:

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

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?

IHI Quality Improvement EssentialsToolkit

PfP-Strategic-Vision-Roadmap-508 102017

Summary – HCAHPS Best Practices in CAHs 

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