Models for Quality Improvement in CAHs: The Role of State Flex Programs (Briefing Paper #25)

Document Type

Briefing Paper

Publication Date



MRHRC, Flex, Medicare Rural Hospital Flexibility Program


A central goal of the Flex Program, as defined in the original and reauthorizing legislation, is to help Critical Access Hospitals (CAHs) develop and sustain effective quality improvement (QI) programs. This study examined the range of multi-CAH QI and performance measurement reporting initiatives supported by the Flex Program in nine states, assessed the role of State Flex Programs in developing and supporting these initiatives, and explored their impact on the QI programs of CAHs.

Key Findings:

  • State Flex Program funding was frequently the primary, if not sole, source of funding to support these efforts.
  • Collaboration and shared learning are common Flex Program strategies underlying state QI initiatives.
  • Quality measurement and reporting is a challenge due to a lack of agreement on common measures across state QI and benchmarking systems and a common belief that Hospital Compare measures are not “rurally relevant” (i.e., specific to the needs of CAHs).
  • Administrative, clinical, and board leadership and buy-in were consistently identified as crucial to the success and sustainability of CAH-level QI initiatives.
  • States reported that the scope of their QI has to be scaled to the available resources and capacity of CAHs to avoid QI fatigue among CAH staff.
  • There is limited hard evidence on the impact of the QI initiatives adopted by State Flex Programs; much of the “evidence” supporting these initiatives is anecdotal or based on postconference or webinar evaluations.


With funding from the federal Office of Rural Health Policy (PHS Grant No. U27RH01080), the Rural Health Research Centers at the Universities of Minnesota, North Carolina, and Southern Maine are cooperatively conducting a performance monitoring project for the Medicare Rural Hospital Flexibility Program (Flex Program).

Funding Organization

Office of Rural Health Policy

Grant Number

PHS Grant No. U27RH01080

bp25.pdf (294 kB)
Models for Quality Improvement in CAHs: The Role of State Flex Programs (Briefing Paper #25)