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.
New MBQIP Measures
The Federal Office of Rural Health Policy has added new measures in the Medicare Beneficiary Quality Improvement Project. The measures and the implementation timeline were presented in a webinar on July 11, 2024. Follow the links below for more information.
- New MBQIP Measures Webinar Recording
- New MBQIP Measures Webinar Slides
- CAH_Quality_Infrastructure_Measure_Specifications.pdf (flexmonitoring.org)
- Data-Submission-Guide_Hybrid-HospitalWide-Readmission_508.pdf (telligen.com)
- Data-Submission-Guide_Screening-for-SDOH_508.pdf (telligen.com)
- Data-Submission-Guide_Screen-Positive-Rate-SDOH_508.pdf (telligen.com)
- Data-Submission-Guide_Hospital-Commitment-to-Health-Equity_508.pdf (telligen.com)
- Data-Submission-Guide_SafeUseofOpioids_508.pdf (telligen.com)
- MBQIP 2025 Information Guide
- CAH Quality Infrastructure Specifications 2025
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:
- May 6, 2025 RECORDING and SLIDES
- April 8, 2025 RECORDING and SLIDES
- February 11, 2025 RECORDING and SLIDES
- November 14, 2024 RECORDING and SLIDES
- October 15, 2024 Heartbeats Behind the Headlines RECORDING and SLIDES
- August 14, 2024 Measures Under Consideration (MUC) and Trends for the Future RECORDING and SLIDES
- April 18, 2024 CAH Quality Assessment Results and Resources RECORDING and SLIDES
- February 6, 2024 Emergency Room Transfer Communication RECORDING and SLIDES
- January 10, 2024 Refresh, Replenish and Refocus in 2024 (no recording available) and SLIDES
- Healthy Habits Handout – to be printed before viewing
- Take Care of Yourself Handout – to be printed before viewing
QAPI Resources:
Sample Documents from Kansas CAHs
- Quick PIP Template
- Example Quick PIP
- Quality Data Reporting Dashboard Base
- Example-Completed Quality Reporting Dashboard
- Quality Department Duties
National Example of QI Orientation
Patient and Family Engagement:
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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Other Resources:
- HCP Influenza Summary Tasks and Tips April 2022
- MBQIP Basics Training Recording and Slides – November 9, 2023
- IHI Quality Improvement Essentials Toolkit
- Quality Improvement Implementation Guide and Toolkit for Critical Access Hospitals
- Critical Access Hospital eCQM Resource List
- Quality Improvement Measure Summaries for MBQIP
- Quality Improvement Basics by Stratis Health
- Healthworks and KHA Events July 24 to Dec 24
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 BROCHURE - March 27, 2025
- Run a Report in the new QualityNet system
- Complete Population and Sampling in the new QualityNet system
- How to complete OP-22 in HQR – updated March2024
- Upload Chart Abstracted Cases in the new QualityNet system
- Exporting Abstraction from CART
- Correcting Rejected Cases
- Check CART Version
Abstracting in HQR (step by step instructions)
HQR/QualityNet Training Series
The Centers for Medicare & Medicaid Services (CMS) would like to announce that instructional support videos (28) are now available to help you navigate through Hospital Quality Reporting (HQR). You may access these videos from the HQR playlist using the following LINK.
Emergency Department Transfer Communication Resources:
Quality Corner Call 2-6-24
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