Quality Improvement & Training Program

Pennsylvania Office of Rural Health

Quality Improvement Objectives:

  • Explain the history of quality improvement in health care and MBQIP
  • Define key terms associated with quality improvement
  • Discuss Critical Access Hospital designation
  • Describe key indicators for quality improvement
  • Discuss the importance of quality measurement
  • Identify the four key principles of quality improvement
  • Identify available resources to facilitate quality improvement

Key Terms:

Quality improvement (QI) consists of systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups.

The Institute of Medicine (IOM), a recognized leader and advisor on improving the nation’s health care, defines quality in health care as, “a direct correlation between the level of improved health services and the desired health outcomes of individuals and populations.”

The Institute of Medicine (IOM) outlines six aims for improvement for health care:

Safe: Avoiding injuries to patients

Timely: Reducing waits for both recipients and providers of care

Effective: Providing care based on scientific knowledge

Efficient: Avoiding waste

Equitable: Ensuring that the quality of care does not vary because of characteristics such as gender, ethnicity, socio-economic status, or geographic location

Patient-centered: Providing respectful and responsive care that ensures the patient values guide clinical decisions.

Performance measurement: The regular collection of data to assess whether the correct processes are being performed and desired results are being achieved

The Performance Improvement Measurement System (PIMS) is used to develop grantee baseline measurements, track progress, and develop an evidence base for effective rural health interventions

HCAHPS: aims to provide a standardized survey instrument and data collection methodology for measuring patients’ perspectives on hospital care

MBQIP aims to improve the quality of care provided in critical access hospitals (CAHs) by increasing quality data reporting by CAHs and then driving quality improvement activities based on the data

Critical Access Hospital (CAH) is a designation given to certain rural hospitals by the Centers for Medicare and Medicaid Services (CMS).

This designation was created by Congress in the 1997 Balanced Budget Act in response to a string of hospital closures in the 1980s and early 1990s.

The CAH designation is designed to reduce the financial vulnerability of rural hospitals and improve access to health care by keeping essential services in rural communities. This is accomplished through cost-based Medicare reimbursement and technical assistance services provided to these hospitals ensure financial and operational viability.

The Medicare Rural Hospital Flexibility Program (Flex) was designed to help establish Critical Access Hospital designation.

The prevention of CAH closure or assisting CAHs to identify other viable models to serve the health care needs of their rural communities is an important role for state Flex Programs to play in this shifting health care environment.

Flex Programs also use their grant dollars to: improve networks, improve population health and integrate Emergency Medical Services (EMS); provide benefit to the community; increase performance improvement, financial improvement, and operational improvement; and address quality improvement issues.

The Pennsylvania Critical Access Hospitals’ CEOs made a commitment to participate in the MBQIP program. The CEOs and their Quality Improvement Directors have worked diligently to achieve above-average QI outcomes. As a result of this collaborative effort, Pennsylvania was one of the first four states in the nation to have 100% of the CAHs agree to participate in MBQIP!

History of QI and MBQIP

The Medicare Beneficiary Quality Improvement Project (MBQIP) is a quality improvement activity under the Federal Office of Rural Health Policy’s (FORHP) Medicare Rural Hospital Flexibility (Flex) grant program.

The goal of MBQIP is to improve the quality of care provided in Critical Access Hospitals (CAHs) by increasing data reporting and driving quality improvement activities based on the data.

CAHs have historically been exempt from national quality improvement reporting programs due to challenges related to measuring improvement in low-volume settings and limited resources.

However, some CAHs are not only participating in national quality improvement reporting programs, but are excelling across multiple rural topic areas.

For example, small rural hospitals that participate in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey often outperform prospective payment system (PPS) hospitals on survey scores.
MBQIP allows individual hospitals to review and assess their data, compare their results against other CAHs, and partner with other hospitals on quality improvement initiatives to improve patient outcomes and provide the highest quality care to every patient, every time.

7 Elements of Care Transitions

  • Administrative communication
  • Patient information
  • Vital signs
  • Medication information
  • Physician- or Practitioner-generated information
  • Nurse-generated information
  • Procedures and tests

Emergency Department Transfer Communication (EDTC)

Emergency Department Transfer Communication (EDTC): National Quality Forum-endorsed measures set forth as part of the MBQIP for hospitals to evaluate communication for transitions of care during emergency department transfer.

EDTC MBQIP MEASURES the 4 EDTC Quality Domains

  • Patient Safety
  • Outpatient Care
  • Patient Engagement
  • Care Transitions

Patient Safety

Patient safety measures are used to gauge how well a hospital provides care to its patients.

MBQIP measures are based on scientific evidence and can reflect guidelines, standards of care, practice parameters, and patient perceptions.

Medical information from patient records and/or HCAHPS survey responses are converted into rates or percentages that allow facilities to assess their performance.

Outpatient Care

The CMS outpatient measures evaluate the regularity with which a health care provider administers the outpatient treatment known to provide the best results for most patients with a particular condition.

Patient Engagement

Studies have demonstrated measurable benefits to providing patient-centered care with a positive impact on patient satisfaction, length of stay, and cost per case.

By improving communication with patients, whether via providers at the bedside or institutionally through committees focused on systemic changes in patient care, patient outcomes can, and will, improve.

Broad improvement efforts focusing on patient-centered care, organizational culture, communication strategies, and staff engagement and satisfaction are critical for comprehensive improvement.

Care Transitions

Care transitions refer to the movement of patients from one health care provider or setting to another.

For patients living with serious and complex illnesses, transitions in setting of care are prone to errors. For example, one in five patients discharged from the hospital to home experience an adverse event within three weeks of discharge.

The current rate for hospital readmissions among Medicare beneficiaries within 30 days of discharge is nearly 20%, contributing to lower patient satisfaction and rising health care costs.

Four Key Principles in Quality Improvement

  • Quality improvement work as systems and processes
  • Focus on patients
  • Focus on being part of the team
  • Focus on use of the data

QI Work as Systems and Processes

“To make improvements, an organization needs to understand its own delivery system and key processes.”

Focus on Patients

An important measure of quality is the extent to which patients’ needs and expectations are met. Services that are designed to meet the needs and expectations of patients and their community include:

  • Systems that affect patient access
  • Care provision that is evidence-based
  • Patient safety
  • Support for patient engagement
  • Coordination of care with other parts of the larger health care system
  • Cultural competence, including assessing health literacy of patients, patient- centered communication, and linguistically-appropriate care

Focus on Being Part of the Team

At its core, QI is a team process. Under the right circumstances, a team harnesses the knowledge, skills, experience, and perspectives of different individuals within the team to make lasting improvements. A team approach is most effective when:

  • The process or system is complex
  • No one person in an organization knows all the dimensions of an issue
  • The process involves more than one discipline or work area
  • Solutions require creativity
  • Staff commitment and buy-in are needed

Focus on Use of the data

Data are the cornerstone of QI. They are used to describe how well current systems are working; what happens when changes are applied, and to document successful performance. Using data:

  • Separates what is thought to be happening from what is really happening
  • Establishes a baseline (Starting with a low score is acceptable)
  • Reduces placement of ineffective solutions
  • Allows monitoring of procedural changes to ensure that improvements are sustained
  • Indicates whether changes lead to improvements
  • Allows comparisons of performance across sites

The Importance of Quality Improvement




Health Resources and Services Administration. (2011, April). Quality Improvement. Retrieved March 15, 2017, from https://www.hrsa.gov/quality/toolbox/508pdfs/qualityimprovement.pdf

Stratis Health. (n.d.). Quality Improvement Implementation Guide and Toolkit for Critical Access Hospitals. Retrieved March 15, 2017, from https://www.ruralcenter.org/tasc/resources/quality-improvement-implementation-guide-and-toolkit-critical-access-hospitals

Gerhardt, G. et al., “Data Shows Reduction in Medicare Hospital Readmission Rates During 2012,” Medicare & Medicaid Research Review 3 (2013), accessed April 1, 2015, doi: 10.5600/mmrr.003.02.b01

Health Resources and Services Administration [HRSA]. (2011, April). The HRSA Quality Toolkit. Retrieved March 15, 2017, from https://www.hrsa.gov/quality/toolbox/508pdfs/introductionandoverview.pdf