According to the Institute of Medicine (IOM, now the Health
and Medicine Division of the National Academies of Sciences, Engineering, and Medicine), 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, 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
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)
Measurement for Rural Low-Volume Providers, include:
Fewer healthcare providers
Lack of information technology
Fewer staff available to meet many different demands
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 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 2018 report, A Core Set of
Rural-Relevant Measures and Measuring and Improving Access to Care: 2018 Recommendations from the MAP Rural
Health Workgroup, identified the following criteria for measure selection:
- 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-based to
value-based care through a range of different quality reporting programs
that seek to provide better care for patients, improve population health, and lower cost. These programs are
typically phased in over time, 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 than PPS hospitals, they have been excluded from
most of the CMS
value-based programs. NQF's 2015 report, Performance Measurement
for Rural Low-Volume Providers, 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's
transition 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.
Advanced Alternative Payment Models (Advanced 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
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 Scoring,
Payment Adjustment, and Hardship Information for details on how these
requirements impact reimbursement. Additional resources on this topic are available in the eCQI Resource
Which quality reporting or monitoring programs apply to rural facilities?
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 beyond what is
required, which can help
potential patients make assessments about the care provided when using Medicare’s Care Compare tool and similar
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 the Hospital VBP if they meet
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 quality
reporting programs, nor are they eligible for the Hospital VBP, HACRP, or HRRP. CAHs are allowed to voluntarily
report to CMS and are encouraged to do so through a variety of initiatives, but it does not affect their
The Medicare Rural Hospital Flexibility (Flex) 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 Flex Program project that 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. The Medicare
Beneficiary Quality Improvement Project (MBQIP) Quality Reporting Guide, developed by Stratis Health,
offers Flex Coordinators, CAH staff, and others who are working with MBQIP information to better understand the
measure reporting process. MBQIP consists of measures in four domains: patient
safety/inpatient, patient engagement, care transitions, and outpatient.
Several CAHs have been recognized by FORHP
and the National Rural Health Resource Center for their quality
improvement efforts. These hospitals include, but are not limited to:
Regional Hospital, Ellenville, New York
City Hospital, Boulder City, Nevada
Holy Family Hospital, Estherville, Iowa
Shepherd Medical Center, Hermiston, Oregon
Chowan Hospital, Edenton, North Carolina
Holy Cross Hospital, Nogales, Arizona
Valley Hospital, Gunnison, Utah
Rural Health Clinics
Rural Health Clinics (RHCs) are excluded from many Medicare quality programs such as the Merit-Based Incentive
Payment System (MIPS). For more information about RHCs and MIPS, see RHIhub’s
Rural Health Clinic topic guide. 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 brief
documents both the barriers and benefits RHCs experienced implementing and reporting on a QM/BM system, 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 2021
Uniform Data Set (UDS) Measure Crosswalk to Other Quality Reporting Programs. For more information on
quality initiatives related for FQHCs, see Health Center Quality
What are the challenges that rural providers face for quality reporting?
The August 2018 report from the MAP Rural Health Workgroup, A Core Set of
Rural-Relevant Measures and Measuring and Improving Access to Care: 2018 Recommendations from the MAP Rural
Health Workgroup, identifies the following measurement challenges rural providers face:
Limited experience with performance measurement and reporting because they are not eligible
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
A March 2019 report, Addressing
Low Case-Volume in Healthcare Performance Measurement of Rural Providers, Recommendations from the MAP Rural
Health Technical Expert Panel, further addresses these quality reporting challenges and discusses
recommendations for how measures can be calculated, how data can be used, and different data analysis techniques
that can be utilized by low case-volume providers.
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. For example,
while CMS does not require CAH participation in formal quality reporting and pay-for-performance programs, there
are a number of initiatives focused on engaging CAHs in quality reporting and improvement. These initiatives
often have disparate measures and reporting processes, which can increase reporting burden and complicate CAH
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. Pilot
Rural Health Clinic Quality Measurement Reporting System discusses challenges RHCs faced related to a
pilot quality reporting program. The top quality reporting challenges identified in this study include
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 (Flex)
Program. It produces annual quality reports for each of the 45 states participating in the Flex Program.
Reports released in 2020
(reporting 2018 data) and 2019
(reporting 2017 data) include voluntarily reported data by Critical Access Hospitals (CAHs) across the
and compare CAH reporting and results across a variety of inpatient and outpatient quality measures.
Two national summary reports, Hospital
Compare Quality Measure Results for CAHs, 2018 and Patients'
CAHs: HCAHPS Results, 2018, 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 of care that could be provided at a larger facility. In some instances, rural patients may use
rural hospitals when hospice services are not available so they can remain near their home and family at the
end of their life.
Differences in transfer rates
According to Which
Medicare Patients Are Transferred from Rural Emergency Departments?, small rural hospitals
transfer patients at higher rates than larger facilities, especially for some serious medical conditions
such as emergency cardiac care. 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
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 on a variety of topics, including 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, CAHs, RHCs, or networks of small
rural 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 three rural health networks with a quality focus featured in Network Spotlights from the
National Rural Health Resource Center's Rural Health Innovations:
Quality Improvement Organizations
Improvement Organizations (QIOs) are independent health quality experts, clinicians, and consumers that
work on behalf of CMS to improve healthcare quality. QIOs work with healthcare facilities and providers to
improve healthcare delivery to ensure high-quality, cost-efficient care. Additionally, QIOs investigate
complaints made by beneficiaries concerning quality of care. The work of QIOs is state-focused and organized
under regional 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 via Learning and Action Networks. Learning and Action Networks grant providers access to
evidence-based improvement strategies and support for peer-to-peer learning. Learn more about how to Partner with a QIO and locate your QIO.
Hospital Improvement Innovation Networks
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. HIINs develop learning collaboratives, provide technical assistance
related to quality measurement, provide training, and more.
Quality Payment Program's Support for Small, Underserved, and Rural Practices
The Quality Payment Program (QPP) 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. 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 Measure Applications
Partnership (MAP) Rural Health Workgroup is developing a core set of rural-relevant quality measures
other things, are 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 (AS) programs seek to improve antibiotic use at healthcare facilities. According to the
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. In September 2019, CMS released a
rule that requires hospitals and CAHs to implement AS programs as a Condition of Participation. However,
interpretive guidelines and survey guidance for providers were not included with this rule.
A March 2017 Rural Monitor article, Strategies for Superbugs:
Antibiotic Stewardship for Rural Hospitals, provides an overview of 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 Southwest Health System Antibiotic
Stewardship Program. Additionally, Antibiotic
Stewardship Implementation: Suggested Strategies from High Performing Critical Access Hospitals, a 2019
report from Stratis Health, highlights AS strategies, barriers, considerations, and lessons learned through
focus group discussions with 34 hospitals across 25 states.
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:
CAHs participating in MBQIP are expected to fully implement an antibiotic stewardship 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:
Pharmacists for Patient Safety Network, a communication network for
rural pharmacists to identify safety concerns and share solutions
Profiles of quality activities at high performing CAHs, featured in “CAHs Can!” articles in the MBQIP Monthly newsletter produced by
Rural Quality Improvement Technical Assistance, a program by Stratis Health.
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
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 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 part of the Medicare Shared Savings Program and 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.
Evaluation of the Accountable Care
Organization Investment Model: Final Report highlights that some AIM
ACOs that reduced total Medicare spending also performed as well or better on quality measures compared to
similar ACOs in
the Medicare Shared Savings Program. According to Medicare Shared Savings
Program Fast Facts, 405 Critical Access Hospitals and 1,397 Rural Health Clinics were part of a Medicare Shared
Savings Program ACO as of January 2021.
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 Care, 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
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. Making the EHR Work: Rural
Healthcare Organizations Use Data Extraction to Improve Patient Care, a 2018 Rural Monitor
article, highlights a variety of ways rural providers are using electronic health records to improve patient
care and outcomes.
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
For more information, see RHIhub's topic guides on Telehealth Use in Rural
Healthcare and Health Information Technology in Rural