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Rural Healthcare Quality

According to the Institute of Medicine (IOM), quality is:

The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

Because quality is directly linked to desired health outcomes, healthcare payers are increasingly using quality measures as a factor in determining provider reimbursements.

The 2001 IOM report, Crossing the Quality Chasm: A New Health System for the 21st Century, (Free, registration required) called for fundamental reform of the U.S. healthcare system to better achieve higher quality standards. This report identified six aims that have been at the heart of U.S. healthcare quality improvement efforts since its release:

  • Safe
  • Effective
  • Patient-centered
  • Timely
  • Efficient
  • Equitable

The 2005 IOM report, Quality Through Collaboration: The Future of Rural Health Care, argued that rural healthcare had largely been on the periphery of national healthcare discussions, saying:

In general, the smaller, poorer, and more isolated a rural community is, the more difficult it is to ensure the availability of high-quality health services.

Some of the challenges rural quality improvement efforts face, identified in a 2015 National Quality Forum (NQF) report, Performance Measurement for Rural Low-Volume Providers, include:

  • Fewer healthcare providers
  • Lack of information technology
  • Many different demands falling on fewer people
  • Limited resources available for quality improvement
  • Serving a more vulnerable population, with poorer health status and behaviors
  • Exclusion from some quality initiatives for providers such as Critical Access Hospitals, Rural Health Clinics, and Federally Qualified Health Centers, which are paid differently

Rural providers also have strengths related to quality, particularly in how rural individuals and organizations pull together for a common goal and make the most of limited resources. A 2011 Rural Monitor article, Rural Health Networks Prove There Is Strength in Numbers, describes how rural health networks help small, rural hospitals share resources to engage in quality improvement projects. A 2014 Centers for Disease Control and Prevention (CDC) report, Implementation of Antibiotic Stewardship Core Elements at Small and Critical Access Hospitals, identifies rural hospitals as often being tight-knit communities where collaboration is the norm, a strength in supporting quality improvement efforts.

Currently, there are efforts underway to better understand the challenges rural providers face in reporting on quality measures and engaging in quality initiatives. The NQF's Measure Applications Partnership (MAP) Rural Health Workgroup is developing a core set of rural-relevant quality measures, based on insights from a multi-stakeholder group. Its May 2018 draft report, MAP 2018: Recommendations for a Core Set of Rural-Relevant Measures for Hospitals and Selected Ambulatory Care Settings and Measuring and Improving Access to Care, describes the measure characteristics appropriate to rural providers as being:

  • NQF-endorsed
  • Cross-cutting, so not condition-specific or procedure-specific
  • Resistant to low case-volume
  • Addressing care transitions

The workgroup is also looking at certain conditions and services that impact rural populations:

  • Mental health
  • Substance abuse
  • Medication reconciliation
  • Diabetes, hypertension, and chronic obstructive pulmonary disease (COPD)
  • Hospital readmissions
  • Perinatal and pediatric conditions and services

Frequently Asked Questions


How is Medicare reimbursement tied to healthcare quality?

The Centers for Medicare & Medicaid Services (CMS) has been shifting payments from volume to value through a range of different quality reporting programs that seek to provide better care for patients, improved population health, and lower cost. These programs are typically phased in over a range of years, beginning with required quality data reporting, then followed by incentives for good performance and/or penalties for poor performance.

Because certain rural healthcare facilities, such as Critical Access Hospitals, Rural Health Clinics, and Federally Qualified Health Centers, are reimbursed differently, they have been excluded from most of the CMS value-based programs. NQF's 2015 report Performance Measurement for Rural Low-Volume Providers, which was mentioned in the introduction, discusses the importance of including rural providers in CMS quality improvement programs.

For facilities such as Critical Access Hospitals and Rural Health Clinics that are not currently required by CMS to report quality data, the expectation is that they will need to do so in the future, as the health system transition from volume-based reimbursement to value-based reimbursement continues. Pilot projects and initiatives to develop appropriate quality measures are needed to help pave the way for relevant quality reporting for these facilities.

The Quality Payment Program (QPP) is a CMS program that rewards Medicare clinicians providing high quality, high value care with increased payments. Two tracks are available:

  • The Merit-based Incentive Payment System (MIPS) is aimed at clinicians that meet a low volume threshold. It measures quality, improvement activities, advancing care information, and cost.
  • Alternative Payment Models (APMs) are payment approaches that provide additional incentive payments for high-quality and cost-efficient care.

To learn about support for rural providers related to QPP, see What programs, resources, and technical assistance are available to support quality improvement efforts in rural healthcare facilities?

The CMS Promoting Interoperability Program, formerly the Medicare Electronic Health Record (EHR) Incentive Program, requires that Critical Access Hospitals and other eligible hospitals report electronic clinical quality measures (eCQMs) to demonstrate meaningful use of electronic health record technology. A Critical Access Hospital eCQM Resource List is available to help CAHs meet these reporting requirements. See the Critical Access Hospital Payment Adjustment and Hardship Exception Tipsheet for information on how these requirements impact reimbursement.


Which Medicare quality reporting or monitoring programs apply to rural facilities?

The quality reporting requirements vary for different types of healthcare facilities. Regardless of what is specifically required, facilities often have the option to voluntarily report quality data, which can help potential patients make assessments about the care provided when using Hospital Compare, Nursing Home Compare, Physician Compare, and similar resources.

Rural Prospective Payment System (PPS) Hospitals

Hospitals paid through the prospective payment system (PPS) are required to report quality measures to CMS through the Hospital Inpatient Quality Reporting Program (IQR) and Hospital Outpatient Quality Reporting Program (OQR) in order to maximize their reimbursement. PPS hospitals are subject to penalties and bonus payments from CMS in relation to the Hospital Value-Based Purchasing Program (VBP), and subject to penalties through the Hospital Acquired Conditions Reduction Program (HACRP) and the Hospital Readmissions Reduction Program (HRRP). Rural PPS hospitals participate in Hospital Value-Based Purchasing if they meet the minimum number of cases and measures, and are also included in the HACRP and HRRP program if they meet minimum case thresholds.

Critical Access Hospitals

Critical Access Hospitals (CAHs) are not required by CMS to participate in the Inpatient or Outpatient reporting program, nor are they eligible for the Hospital Value-Based Purchasing, Hospital Acquired Conditions Reduction Program, or the Hospital Readmissions Reduction Program. CAHs are encouraged to voluntarily report to CMS but it does not affect their reimbursement.

The Medicare Rural Hospital Flexibility (Flex) Grant Program, designed to support Critical Access Hospitals and funded by the Federal Office of Rural Health Policy, encourages quality and performance improvement activities. The Medicare Beneficiary Quality Improvement Project (MBQIP) is a special project of the Flex Program and supports CAH quality reporting as a means to help improve quality of care. Participating hospitals voluntarily share quality data to drive quality improvements based on those data. MBQIP consists of measures in four domains: patient safety/inpatient, patient engagement, care transitions, and outpatient.

There are also a number of additional quality initiatives that involve CAHs. For an overview of each initiative and a list of measures and how they relate to the different initiatives, see the National Quality Reporting Crosswalk for CAHs from the National Rural Health Resource Center and Stratis Health.

Several CAHs have been recognized by FORHP and the National Rural Health Resource Center for their quality improvement efforts:

Rural Health Clinics

Rural Health Clinics (RHCs) were excluded from many Medicare quality programs such as the Physician Quality Reporting System (PQRS).The CMS Conditions of Participation for RHCs includes an annual program evaluation requirement, which is the only current quality requirement for RHCs. The evaluation must look at appropriate utilization of clinic services and whether established clinic policies were followed. The requirement may be met by having a quality assessment and performance improvement (QAPI) program in place. For more on the RHC program evaluation requirements, as well as background information on quality improvement and RHCs, see RHC Technical Assistance Educational Series Module 5: RHC Performance Measurement and Quality Improvement from the National Organization of State Offices of Rural Health.

A February 2016 policy brief from the Maine Rural Health Research Center, Pilot Testing a Rural Health Clinic Quality Measurement Reporting System, discusses the feasibility of implementing an RHC quality measurement and benchmarking (QM/BM) system, based on a pilot study. The project first identified a set of quality measures relevant to RHCs, and then a group of RHCs from across the country reported on those measures. The brief documents both the barriers and benefits RHCs experienced, as well as opportunities to improve quality reporting for RHCs in the future.

Federally Qualified Health Centers

Federally Qualified Health Centers (FQHCs) are largely excluded from Medicare reporting programs, but have quality reporting requirements as part of the Health Center Program. Participation in the federal Health Center Program requires an ongoing quality improvement/assurance (QI/QA) program. The QI/QA program must address quality and utilization of services, patient satisfaction, and patient safety. Health Centers also submit quality measures as part of the Uniform Data Set (UDS) program. To learn more about UDS quality measures and how they align with CMS quality reporting programs, see the Uniform Data Set (UDS) Measure Crosswalk to Other Quality Reporting Programs. For more information on quality initiatives related for FQHCs, see Health Center Quality Improvement.


What are the challenges that rural providers face for quality reporting?

The May 2018 draft report from the MAP Rural Health Workgroup, MAP 2018: Recommendations for a Core Set of Rural-Relevant Measures for Hospitals and Selected Ambulatory Care Settings and Measuring and Improving Access to Care, identifies the following measurement challenges rural providers face:

  • Limited experience with performance measurement and reporting because they are not eligible for most current CMS quality programs even though many participate voluntarily
  • Challenges with claims-based performance measures due to low patient volumes and data limitations for rural providers who do not receive claims-based reimbursement and so may not include comprehensive data on their claims
  • Limited time, staff, and financial resources available for quality improvement activities

Rural providers lack the economies of scale that allow larger health systems, and rural facilities that are part of larger systems, to address quality reporting requirements. They have fewer staff members to spread around the additional work and are less likely to be able to dedicate a specific staff member or team to focus on quality initiatives. Even the time needed to train staff on new requirements takes away from other tasks. Rural facilities may also lack the technical resources to insert new processes and data collection in their existing health information technology (HIT) systems to meet changing requirements. The top quality reporting challenges in an RHC pilot study, as reported in Pilot Testing a Rural Health Clinic Quality Measurement Reporting System, included challenges related to extracting data from the electronic health record and from paper records, and availability of staff time to collect and report measures.


What do we know about rural facilities and quality of care?

Rural-specific research on quality can be challenging to find due to low volumes, as well as the fact that reporting is voluntary for many types of rural facilities. However, some organizations focus on analysis of rural-specific quality data.

The Flex Monitoring Team, for example, is funded by the Federal Office of Rural Health Policy (FORHP) to analyze and evaluate the Medicare Rural Hospital Flexibility Grant Program. It produces annual quality reports for each of the 45 states participating in the Flex Program. State-level reports released in 2017 (reporting 2015 data) and 2018 (reporting 2016 data) include voluntarily reported data by Critical Access Hospitals (CAHs) across the country and compare CAH reporting and results by state across a variety of inpatient and outpatient quality measures. Two national summary reports, Hospital Compare Quality Measure Results for CAHs, 2016 and Patients’ Experiences in CAHs: HCAHPS Results, 2016, are also available.

FORHP also supports a number of rural health research centers that conduct a variety of research, including studies of rural healthcare quality. The Rural Health Research Gateway is funded by FORHP to disseminate the publications developed by the rural health research centers. Research specific to rural health quality can be found on the Rural Health Research Gateway’s Quality topic page.

A number of studies highlight positive quality outcomes in rural settings, including a 2016 JAMA article, Association of Hospital Critical Access Status with Surgical Outcomes and Expenditures Among Medicare Beneficiaries, and a 2017 Journal of Rural Health article, Surgical Patient Safety Outcomes in Critical Access Hospitals: How Do They Compare?

Fundamental differences in how healthcare is provided between rural and urban settings, as well as socioeconomic and cultural differences of the populations served, make it challenging to compare healthcare quality. Understanding these differences is one of the greatest challenges to comparing quality outcomes.

These differences were highlighted by formal responses to a 2013 JAMA article, Mortality Rates for Medicare Beneficiaries Admitted to Critical Access and Non–Critical Access Hospitals, 2002-2010. The article garnered formal response by the Flex Monitoring Team and two informal responses by Dr. Wayne Myers in the Daily Yonder and the Rural Monitor.

As summarized in the Flex Monitoring Team response, understanding the rural context is key:

Researchers who analyze rural health policy issues need to understand the rural health care environment. If not, their research has the potential to harm rather than help rural hospitals and health care professionals in providing high-quality care for their patients.

Key differences highlighted in the responses to the article include:

  • Differences in volume and services
    Rural healthcare facilities see a much smaller volume of patients than their urban counterparts, making it a challenge to compare quality between the two types of facilities. With a small sample size for any one procedure or treatment, quality data can be skewed, leaving a high probability of misinterpretation. Due to their small size and remote nature, CAHs often don't offer the advanced procedures available at larger urban facilities. For example, few rural hospitals provide cardiac catheterization; they instead focus on stabilization and transfer of patients in need of such services.
  • Differences in patient demographics and choices
    Patients have a choice in how they receive care and their preferences can directly contribute to quality outcomes. A patient may choose to be treated near their home at a rural facility, knowingly forgoing a higher level care which could be provided at a larger facility. In some instances, rural patients may use rural hospitals as a proxy for hospice services so they can be near their home and family at the end of their life.
  • Differences in transfer rates
    Small rural hospitals transfer patients at higher rates than larger facilities, especially for some serious medical conditions such as emergency cardiac care, according to Which Medicare Patients Are Transferred from Rural Emergency Departments? Outcomes of rural hospitals may vary depending on whether transferred patients are excluded, assigned to the initial hospital, or to the receiving hospital.

What programs, resources, and technical assistance are available to support quality improvement efforts in rural healthcare facilities?

A wide range of resources, funding programs, and initiatives are available to help rural healthcare providers develop quality improvement programs.

State Flex Programs

The Medicare Rural Hospital Flexibility (Flex) Program funds State Flex Programs that provide support to Critical Access Hospitals related to quality and performance improvement. In particular, Flex Program staff can help CAHs understand and meet Medicare Beneficiary Quality Improvement Project (MBQIP) requirements.

Small Health Care Provider Quality Improvement Program

The Small Health Care Provider Quality Improvement Grant Program (SHCPQI) is a FORHP-funded program that provides support to rural primary care providers for planning and implementation of quality improvement activities. A February 2016 Rural Monitor article, Small Health Care Provider Quality Improvement Grant: A Cultural Shift in Quality for Providers, provides an overview of the program and highlights SHCPQI projects in Colorado, New Hampshire, North Carolina, and Oregon. Two additional SHCPQI programs are featured in RHIhub's Rural Health Models and Innovations:

Rural Health Networks

Rural health networks, such as statewide CAH quality networks, can voluntarily organize themselves to work collaboratively to improve healthcare quality. Quality networks share useful information such as best practices to achieve quality outcomes and encourage data reporting by members. Member organizations often submit quality data to be analyzed and benchmarked against network, state, and national aggregates to inform quality improvement efforts at each member facility.

Here are two rural health networks with a quality focus featured in Network Spotlights from the National Rural Health Resource Center's Rural Health Innovations:

This rural health network program shared by the National Cooperative of Health Networks in RHIhub's Rural Health Models and Innovations also focuses on quality:

Quality Improvement Organizations

Quality Improvement Organizations (QIOs) are independent organizations that work on behalf of CMS to improve healthcare quality. QIOs work with healthcare facilities and providers to improve healthcare delivery to ensure quality care, especially for underserved communities. QIOs also make sure Medicare payment is made for only medically necessary services and investigate complaints made by beneficiaries concerning quality of care. The work of QIOs is state-focused under regionalized contracts. Two Beneficiary and Family Centered Care-QIOs (BFCC-QIOs) manage all beneficiary complaints and appeals. Fourteen Quality Innovation Networks (QIN-QIOs) help healthcare providers with quality initiatives, with access to evidence-based improvement strategies and support for peer-to-peer learning via Learning and Action Networks. Learn more about how to Partner with a QIO and locate your QIO.

Hospital Improvement Innovation Networks

CMS's Hospital Improvement Innovation Networks (HIINs) focus on harm reduction in the Medicare program, working at the national, regional, state, and hospital system level. HIINs help hospitals implement best practices to improve the quality of care in the Medicare program. They develop learning collaboratives, provide technical assistance related to quality measurement, provide training, and more.

Practice Transformation Networks

Practice Transformation Networks (PTNs) are peer-based learning networks that coach, mentor, and assist clinicians in developing core competencies specific to practice transformation. PTNs are part of the CMS Transforming Clinical Practice Initiative, which supports clinician practices in sharing and developing comprehensive quality improvement strategies.

Quality Payment Program's Support for Small, Underserved, and Rural Practices

The Quality Payment Program (QPP), which was mentioned earlier, is a CMS program that awards increased payments to Medicare clinicians providing high quality, high value care. Support for Small, Underserved, and Rural Practices provides free customized QPP technical assistance to practices with 15 or fewer clinicians, with priority for practices located in rural and underserved areas. QPP Help and Support offers additional resources to understand the QPP, including videos, online courses, and more.

QIN-QIOs and PTNs also provide QPP technical assistance and are often the organizations that provide QPP support to rural providers.

Additional QPP resources focused on rural practices:


How can the use of rural-relevant quality measures help us understand and improve rural quality of care?

The NQF's MAP Rural Health Workgroup, as mentioned earlier in this guide, is developing a core set of rural-relevant quality measures that are, among other things, resistant to low case-volume and address topics of particular importance to rural areas. By focusing on measures that rural facilities can collect in a manner that is valid and reliable, they are giving rural facilities a tool both to improve their performance and to demonstrate that performance to payers. At a time when the healthcare system is transitioning to pay for value, it is important that rural facilities can show the value they provide, using measures that take into account the particular circumstances they face.


How are rural facilities working to implement antibiotic stewardship?

Antibiotic stewardship programs seek to improve antibiotic use at healthcare facilities. According to the CDC's Overview and Evidence to Support Appropriate Antibiotic Use, this can help improve quality of care through better treatment and patient outcomes and reduced antibiotic resistance.

A March 2017 Rural Monitor article, Strategies for Superbugs: Antibiotic Stewardship for Rural Hospitals, provides an overview of antibiotic stewardship (AS) issues in rural areas. It features AS programs at Critical Access Hospitals (CAHs) in Idaho and Colorado and a health system AS program in Utah that includes 11 small hospitals and 5 CAHs. The work of the Colorado CAH is also featured in Antibiotic Stewardship Program (ASP) Case Study: Critical Access Hospital - Southwest Health System, from the Health Research & Education Trust. The QIN-QIO serving Alaska, Mountain-Pacific Quality Health, and its AS work are featured in QIOs in Action: Promoting Antimicrobial Stewardship in Rural Alaska.

Resources have been developed to help rural facilities develop AS programs, including:

In addition, several Flex programs shared information on AS work in their states at a July 2018 Flex Program Reverse Site Visit meeting:

Critical Access Hospitals participating in MBQIP will be required to fully implement an AS program by 2022. This will be measured through the CDC's National Healthcare Safety Network Annual Facility Survey, which includes questions on antibiotic stewardship in its Patient Safety Component. For more information, see National Healthcare Safety Network Annual Facility Survey for CAHs, a February 2018 FORHP/CDC webinar.


What are some other examples of how rural facilities are addressing healthcare quality?

A wide range of rural projects have been developed to address healthcare quality. Many have been highlighted throughout this guide related to specific programs.

Additional examples include:

More examples are included in the Models & Innovations section of this guide and in Other Case Studies and Collections of Program Examples: Healthcare quality.


How are Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes (PCMHs) impacting quality in rural areas?

Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes (PCMHs) are two noteworthy service delivery models that aim to improve healthcare quality through a value-based, rather than volume-based, strategy. Both models aim to improve outcomes by more closely coordinating care among providers and facilities to improve quality outcomes.

ACOs are groups of physicians, facilities and other healthcare providers who voluntarily enter into a partnership to provide coordinated care with incentives for quality and efficiency. As an incentive to provide high quality care, CMS and some commercial payers will share cost savings with the ACO. The ACO Investment Model was an ACO initiative established by CMS in 2015 that continued in 2016 to encourage participation among rural providers. This model was developed in response to concerns over small and rural providers lacking the adequate resources to establish the necessary infrastructure for successfully implementing a population care management program. According to Medicare Shared Savings Program: Fast Facts, a January 2018 CMS publication, 421 Critical Access Hospitals and 1,210 Rural Health Clinics were part of a Medicare Shared Savings Program (an ACO) in 2018.

The patient-centered medical home (PCMH) is a model for providing patient care that is comprehensive, patient-centered, coordinated, accessible, and high quality. This model emphasizes a long-term relationship between the patient and a team of professionals, led by the patient's physician, which works to provide and coordinate care. Despite challenges to implementing the PCMH model in rural areas, optimism exists for its ability to achieve financial savings and reach quality improvement targets in rural areas, according to Rural Health Clinic Readiness for Patient-Centered Medical Home Recognition: Preparing for the Evolving Healthcare Marketplace. Learn how the PCMH approach supports quality efforts in this description of the Patient Centered Medical Home Practicum in Primary Home, a program pairing college students majoring in healthcare management with rural primary care practices in order to improve service quality and patient experience.


How can the use of telehealth and health information technology (HIT) impact the quality of care delivered in rural areas?

Telehealth and HIT are technology-based tools that can improve care and care coordination in rural communities. These technologies can play a significant role in improving quality of care in rural communities.

Telehealth: Mapping the Evidence for Patient Outcomes from Systematic Reviews, a 2016 Agency for Healthcare Research and Quality (AHRQ) brief, reports that telehealth is effective in helping patients with chronic conditions through remote patient monitoring and communication and counseling and is also effective in the provision of psychotherapy. A 2013 AHRQ report, Findings and Lessons from the Improving Quality Through Clinician Use of Health IT Grant Initiative, identifies ways that HIT can help improve quality of care by supporting:

  • Clinician and patient decision-making, for example providing guidance related to medication management
  • Clinical workflow, for example reminder systems for clinicians
  • Care coordination, such as a notification system to alert primary care providers about patient discharges from the hospital

Telehealth can both improve the care rural patients receive by providing access to specialty care and help rural primary care providers through case-based learning and mentorship from specialists, via programs like Project ECHO.

Because of its role in reporting on quality measures, HIT is often listed as a challenge for rural facilities implementing quality initiatives. However, the expansion of electronic health records (EHR) and the sharing of EHR data through health information exchanges can be particularly useful to rural facilities that may have patients transitioning to and from urban hospitals. Clinical quality and safety is a major focus of HIT efforts. CMS and the Office of the National Coordinator for Health Information Technology provide a range of information and educational resources related to electronic clinical quality measures (eCQMs) in the eCQI (Electronic Clinical Quality Improvement) Resource Center including information on Eligible Hospital / Critical Access Hospital eCQMs.

For more information, see RHIhub's topic guides on Telehealth Use in Rural Healthcare and Health Information Technology in Rural Healthcare.


Last Reviewed: 8/16/2018