New Project Targets CAH Quality Measures and Reporting

by Candi Helseth

A new project supported by the Office of Rural Health Policy (ORHP) is helping Critical Access Hospitals (CAHs) improve patient care quality and operations, and more accurately report rural health care quality. The Flex Medicare Beneficiary Quality Improvement Project (MBQIP), rolled out in September, will target Flex funding support to CAHs that voluntarily engage in quality improvement (QI) projects meeting its guidelines.

Improving quality has always been one of the primary goals for CAHs participating in the ORHP Medicare Rural Hospital Flexibility Program (Flex), which was begun in 1997 under a federal program to strengthen rural health care. ORHP Senior Health Policy Advisor Paul Moore said the three-phase MBQIP targets those CAHs that haven’t been implementing rural-relevant quality measures or aren’t reporting QI results. CAHs comprise 66 percent of all rural hospitals.

“The first phase initiatives focus on rural appropriate care management protocols,” said Kristin Martinsen, ORHP Hospital-State Flex Division Director. “Congestive heart failure and pneumonia management were our first choices because these diagnoses make up a large part of inpatient admissions in rural hospitals.”

In addition to continuing QI initiatives on Phase 1 measures, MBQIP’s second phase calls for adoption of measurement and reporting for outpatient care along with patient satisfaction, Martinsen said.

“Outpatient procedures are a natural focus because CAHs tend to have a higher volume of outpatient services than inpatient,” she explained. “Patient safety and reducing hospital readmissions are also focuses in the second phase, which begins in September 2012.”

In Phase 3, beginning in September 2013, CAHs will begin measuring and reporting on efforts to reduce medication errors and improve outcomes for patients being transferred to other facilities.

Moore said the third phase offers the best opportunity for CAH QI improvements because adverse drug events or improper medication management is the primary cause of harm in hospitals nationwide. A pharmacist is on-site for less than 40 hours a week in more than one-third of small rural hospitals so the third phase calls for a pharmacist’s review of medication orders within 24 hours. Because many CAH patients are transferred to tertiary centers for surgery or other advanced care not typically offered at CAHs, it is imperative that CAHs conduct transfers using proven, successful measures. Moore said the third phase was slated for 2013 to give participating CAHs ample planning time for the additional resources that will be required.

“We are focusing on improving CAHs through measurement, reporting and targeting proven improvement strategies,” he stressed. “We are trying to proceed in a manner that allows them to see the value in participating as they go.”

More than one-third of the 45 states enrolled in Flex already have established QI committees, programs and benchmarks to evaluate success. Martinsen works directly with state offices of rural health, which provide Flex assistance to their state’s CAHs. The National Rural Health Resource Center manages support and education services through the Flex-funded Technical Assistance and Services Center (TASC).

MBQIP is designed to help CAHs measure QI successes and report results to CMS Hospital Compare or another vendor, Martinsen said. (CAHs are not required to report.) “The trends have shown over time that Hospital Compare outcomes have improved on those measures where we do see reporting,” Martinsen said.

About 70 percent of CAHs in state Flex programs choose to voluntarily report to CMS Hospital Compare on at least one quality-related measure. Reporting has been a source of contention among CAHs, Moore said, due to concerns that reporting systems are based on urban hospital research and fails to account for the differences between rural and urban hospital resources, services and patient volumes.

Quality of Care and Patient Outcomes in Critical Access Rural Hospitals, a report released this year by the Journal of the American Medical Association (JAMA), also calls for CAHs to collect and report data. The JAMA article states that little is known about CAHs’ quality of care or patient outcomes in these geographically isolated hospitals. Moore added that getting CAHs to report results in a timely manner will result in development of reporting statistics that more accurately reflect rural health care quality.

“There are bright spots all across the country where CAHs are doing great things,” he said. “What we’re looking to do now is to fill in the gaps and make it consistent among all providers. The CAHs that are already doing quality projects and tracking them have proven that quality can be improved. Now it’s a matter of disseminating those practices and getting them out into areas where it isn’t being done. On a brighter note, I am happy to tell you that, according to the Flex Monitoring team report, rural hospitals do better than their urban counterparts when it comes to HCAHPS (Hospital Care Quality Information from the Consumer Perspective) patient satisfaction. And links to reimbursement in the future will most likely have a patient-centered focus.”

CAHs already engaged in QI projects relative to MBQIP’s first phase can still join in the second or third phases. To learn more about MBQIP and/or to sign up for it, watch this video, or email Paul Moore,, or Kristin Martensen,

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