Critical Access Hospital Quality Improvement Program

** NC Healthcare Foundation grant-funded program**


The Medicare Rural Hospital Flexibility (FLEX) Program was established by the Balanced Budget Act (BBA) of 1997 in the creation of critical access hospitals (CAHs). CAH designation allows the hospital to be reimbursed on a reasonable cost basis for inpatient and outpatient services provided to Medicare patients (including lab and qualifying ambulance services) and, in some states, Medicaid patients.

Flex funding encourages the development of cooperative systems of care in rural areas, joining together CAHs, emergency medical service (EMS) providers, clinics, and health practitioners to increase efficiencies and improve the quality and safety in patient care. The Flex Program requires states to develop rural health plans and funds their efforts to implement community-level outreach. The Flex Program includes support for the following five program areas:

  • CAH Quality Improvement (required)
  • CAH Operational and Financial Improvement (required)
  • CAH Population Health Improvement (optional)
  • Rural Emergency Medical Services (EMS) Improvement (optional)
  • Rural Innovative Model Development (optional)
  • CAH Designation (required if requested)

Through the FLEX Program, the North Carolina Healthcare Association (NCHA) in partnership with the NC Office of Rural Health, is assisting hospitals in assessing current performance, identifying gaps, and developing improvement plans to address identified opportunities for the Medicare Beneficiary Quality Improvement Program (MBQIP) core measures for inpatient, outpatient, care transitions, and patient experience measures. The patient experience measures are inclusive of metrics from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores.

Training on basic quality improvement, data tracking and reporting with access to best practices and subject matter experts will help to establish a foundation for sustainable improvement.  The action period for this collaborative is August 2020 through August 2021.

Upcoming Events

Please check our site frequently for changes in event scheduling.  Educational opportunities relevant to rural health and communities will be shared via FLEX program lead email communications list.

Quarterly Webinar Office Hour Calls

  • January 28, 2021, 11:00am – 12:00pm
  • April 22, 2021, 11:00am – 12:00pm | Join the meeting by clicking here. Meeting ID: 99443465370 Passcode: 007813
  • July 22, 2021, 11:00am – 12:00pm | Join the meeting by clicking here. Meeting ID: 94396986848 Passcode: 237307
August 27, 2021 – CAH Virtual Statewide Meeting


March 2 + March 4, 2021 – CAH Virtual Statewide Meeting

March 2 – Presentations
March 2 – Recording

March 4 – Presentations
March 4 – Recording

August 26-27, 2020 – CAH Virtual Statewide Meeting

Agenda (PDF)

August 26 Presentations:

NC DHHS ORH Hospital Program Updates (PDF)
Opening Keynote: COVID-19 “The New Normal” Highlights Old Woes: Addressing Racial Equity in Quality Care (PDF)
Recording – Opening Keynote (YouTube)
Break-Out 1: Understanding MBQIP Through Equity Lens in COVID-19 Response: Best Practices in Hospital Communications in the “New Normal” (PDF)
Break-Out 2: Opportunities for REaL Data Collection: Improving Accuracy (PDF)
BO2 Handout – Data Collection Resources v21 (PDF)
BO2 Handout – HSAG HIIN Strategies for Equitable Care (PDF)
BO2 Handout – IfDHE REaL Data Resource (PDF)
Critical Access Hospital Community Profiles – Demo Reference Slides (PDF)
Swing Bed Quality and Growth Opportunities (PDF)
North Carolina Swing Bed Directory (PDF)
North Carolina ORH 2020 and 2021 FLEX Program Updates (PDF)

August 27 Presentations:

NC ORH Program Updates (PDF)
Critical Access Hospital Market Updates (PDF)
Market Updates Resource Article – HFMA Accounting for CARES Act Program (PDF)
CAH Update – Managed Care (PDF)
NC CAH LAN Performance Benchmarking (PDF)
The Case for Value-Based Care: Envisioning the Future of Population Health Management (PDF)
Closing Keynote: A Pathway for Rural Health to Thrive in a Post-COVID-19 World (PDF)
Recording – Closing Keynote (YouTube)
NC ORH 2020 & 2021 FLEX Program Updates (PDF)

February 18-19, 2020 – FLEX Statewide Meeting: Profiles in Innovation

Agenda (PDF)

Feb 18 Presentations:

ORH Program Updates (PDF)
Quality & Patient Safety: Patient Safety Organizations & The Critical Access Hospitals (PDF)
Growing Better Health Outcomes Together in North Carolina (PDF)
NC Community Action Agencies Map (PDF)
CAH Swing Bed Program Development and Benchmarking (PDF)
Hospital Spotlight: Pender Hospital (PDF)
CAH Profiles: Using Data to Drive Rapid Improvement Projects (PDF)
Keynote: The He(art) of Meaningful Stakeholder Engagement (PDF)

Feb 19 Presentations

Welcome & Introductions: NC ORH Updates (PDF)
NC Medicaid Reform: Impact on CAHs (PDF)
New Market & Healthcare Updates (PDF)
Part I: Practice Management Optimization and Alignment (PDF)
Performance Improvement Projects: St. Luke’s Hospital Culture Initiative Case (PDF)
Part II: Practice Management Optimization and Alignment (PDF)
Financial, Operational, and Departmental Productivity Benchmarks (PDF)

November 20 & 21, 2019 – Regional CAH Meeting at Ashe Memorial & St. Luke’s Hospital

Agenda (PDF)

August 22-23, 2019 – CAH Learning & Action Network Meeting

Agenda (PDF)

August 22 Slides:

ORH Updates Slides  (PDF)
Quality and Patient Safety Performance Improvement Slides (PDF)
National and State Legislative and Policy Issues Slides (PDF)
Siler City FM Residency Site & Chatham Maternity Care Center Slides (PDF)
Rural Grants and Project Updates Slides (PDF)
Optimizing Your Swing Bed Program: Design and Growth Strategies Slides (PDF)
Workplace Violence Slides (PDF)
Mission Focused Medicine in Rural America Slides (PDF)
Quality and Patient Safety Technology: NC Health Connex Slides (PDF)
Designing for Improvement and Innovation: Brainstorming & Action Planning Slides (PDF)

August 23 Slides:

Market Updates and CAH Sharing Slides (PDF)
Market Updates Slides (PDF)
Rural Primary Care Slides (PDF)
State Scorecard – Stroudwater Handout (PDF)
North Carolina Swing Bed Portal Data Slides (PDF)
FirstHealth Montgomery Memorial Hospital Flex Grant Project Slides (PDF)
Cannon Memorial Hospital Project Update Slides (PDF)
Alleghany Memorial Hospital Renovation & MOB Slides (PDF)
St. Luke’s Hospital Culture Assessment to Drive Engagement and Performance Improvement Slides (PDF)
Financial and Operational Best Practices Slides (PDF)

May 22, 2019 – Regional CAH Meeting at Dosher Memorial Hospital

Agenda (PDF)
NCHF Presentation (PDF)
NC ORH Presentation (PDF)

Feb. 14, 2019 – February Quality Collaborative Quarterly Meeting

Slides Main Presentation (PDF)
Diversion Toolkit (PDF)
Healthcare Worker Diversion Prevention Toolkit (webpage)
Webinar: An Introduction to the Coalition for Model Opioid Practices in Health Systems’ Diversion Prevention Toolkit – February 15, 2019 (PSO Members Only page)
Opioid Stewardship

Nov. 1, 2018 – November Quality Collaborative Quarterly Meeting

Slides Main Presentation
MBQIP Abstraction Overview

Aug. 23, 2018 – August Quality Collaborative Quarterly Meeting

Slides Main Presentation
Quality Improvement Measure Summaries
Behavioral Health Healthcare Worker Diversion Toolkit
IVC Bill Handout
Two Antibiotic Stewardship Program

Feb. 22, 2018 – February Quality Collaborative Quarterly Meeting

Slides Mission Health iRound for Patient Experience
Slides Pender Memorial Daily Multidisciplinary Bedside Rounding
Slides Vidant Health Sitter Program 
Slides Wake Forest Baptist Health Success Story: Improving Pneumonia 30-Day Mortality Rates

Aug. 17, 2017 – August Quality Collaborative Quarterly Meeting

Slides CAH Quality Improvement Collaborative Quarterly Meeting
Slides Achieving Health Care Equality for the LGBT Community through Patient Centered Care
Slides St. Luke’s Hospital Virtual Hospitalist Program
Slides Cannon Memorial Hospital HCAHPS and Telemedicine
Slides Murphy Medical Center Behavioral Health Holding Area
Slides Murphy Medical Center Long Bone Pain Improvement
Slides Chatham Hospital HCAHPS Success and Sustainment Using Lean Methodology

October 22, 2020 – CAH Quarterly Webinar
Slides (PDF)
Recording (YouTube)

July 30, 2020 – CAH Quarterly Office Hours Call
Slides (PDF)

May 29, 2020 – CAH Open Hours Office Call
Slides (PDF)
Recording (YouTube)

October 29, 2019 – 2019-2020 CAH Improvement Network Orientation Webinar
Slides (PDF)
Recording (YouTube)

July 14, 2016 — TeamSTEPPS® Series Part II: Lean Concepts and TeamSTEPPS® Tools – Working Together to Improve Quality Outcomes
Slides Lean Concepts and TeamSTEPPS® Tools – Working Together to Improve Quality Outcomes
Video Lean Concepts and TeamSTEPPS® Tools – Working Together to Improve Quality Outcomes

June 9, 2016 — TeamSTEPPS® Series:  Part I 
Slides TeamSTEPPS® Series:  Part I 
Video TeamSTEPPS® Series:  Part I 

May 12, 2016 — Patients as Partners: Operationalizing PFACs and Utilizing PFAs  (QDS)
Slides Patients as Partners: Operationalizing PFACs and Utilizing PFAs
Video Patients as Partners: Operationalizing PFACs and Utilizing PFAs

April 14, 2016 — Seamless Care: Safe Patient Transitions Between Facilities Part II
Slides Seamless Care: Safe Patient Transitions Between Facilities Part II
Action Planning Template 1 
Action Planning Template 2

March 15, 2016 — Using Quality Improvement Tools Webinar
Slides Using Quality Improvement Tools Webinar

March 3, 2016 — Patient Safety: Immunization Measures Webinar
Slides Patient Safety: Immunization Measures Webinar

Jan. 14, 2016 — Seamless Care: Safe Patient Transitions Between Facilities Part 1 
Slides Seamless Care: Safe Patient Transitions Between Facilities Part 1

Critical Access Hospital Rapid Improvement Project

HCAHPS Composite Measure 7 – Care Transitions

Did you know that 20% of patients discharged from the hospital experience an adverse event within 3 weeks? Did you know that within 30 days of discharge, approximately 2.6 million Medicare beneficiaries are re-hospitalized, at a cost of over $26 billion every year? Did you know that medication errors harm 1.5 million people each year in the US at an annual cost of at least $3.5 billion?

These statistics are the result of a complex healthcare system – one key facet being the effectiveness of our transitions of care for patients being discharged.

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a standardized survey instrument and data collection methodology for measuring patients’ perspectives on hospital care. The measure on Care Transitions is HCAHPS Composite 7 measuring the understanding of your care when you left the hospital. The three questions in the survey are:

  • Q23: During this hospital stay, staff took preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left.
  • Q24: When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.
  • Q25: When I left the hospital, I clearly understood the purpose for taking each of my medications.

As of Quarter 4 2016, North Carolina scored 51% for this measure (US score is 52%). To improve this score, the Critical Access Hospital Quality Collaborative launched a Rapid Improvement Project from February 2018-April 2018.

Improving Care Transitions should impact multiple HCAHPS measures through its blend of nurse-patient communication, communication about medication and discharge information elements.

May 4, 2018 — Session #4: A3 Tools Review and Sharing
Slides (PDF)

April 17, 2018 —  Session #3: Right Side of the A3
Slides (PDF)

March 7, 2018  — Session #2: Analyzing the Current State
Slides (PDF)

Observation Sheet Instructions (PDF)
Observation Sheet (PDF)
VSM Sample (PDF)

Feb. 13, 2018 — Session #1: Define Your Scope
Slides (PDF)

Project Scope Template (doc)
Process Scope Template (doc)

Nov. 17, 1017 — HCAHPS Care Transitions Rapid Improvement Project Orientation Webinar
Slides (PDF)

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North Carolina Healthcare Association

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Fax: 919-677-4200

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