To achieve the six quality aims, rural communities must establish comprehensive quality improvement programs. Since the release of the Quality Chasm report, a great deal of national and local attention has been focused on enhancing the health care sector’s quality improvement capabilities. Because of their small scale and low operating margins, rural providers have found it difficult to make such investments.

Although many of the elements of an effective quality improvement infrastructure will be the same for rural and urban areas, some customization is needed for rural areas. For example, when care processes in rural and urban areas differ because of differences in the mix of available services (e.g., urban areas have more ready access to tertiary-level care), rural-specific comparative data on some aspects of the care process (e.g., emergency care, stabilization, and transfer services for acute myocardial infarction patients) are most useful for quality improvement purposes.

For the most part, current quality improvement programs and tools available at the national and local levels focus on the personal health care system. To assist rural communities in their efforts to promote both personal and population health, further thought should be given to how best to adapt quality improvement knowledge and tools (e.g., evidence-based reports, practice guidelines, standardized performance measure sets) to support an integrated approach to decision making. Rural communities must also have the flexibility and assistance needed to develop quality improvement programs likely to have the greatest impact in a rural context. In some areas, for example, a communitywide or even regional quality improvement program is likely to be preferable to having each provider setting develop its own approach. To this end, the Department of Health and Human Services needs to develop a coordinated and tailored approach to meeting the needs of rural communities.

Recommendation 2. The Department of Health and Human Services should establish a Rural Quality Initiative to coordinate and accelerate efforts to measure and improve the quality of personal and population health care programs in rural areas. This initiative should be coordinated by the Health Resources and Services Administration’s Office of Rural Health Policy, with guidance from a Rural Quality Advisory Panel consisting of experts from the private sector and state and local governments having knowledge and experience in rural health care quality measurement and improvement.

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