imply the same solution. As discussed earlier, rural and urban areas vary in their beliefs, customs, practices, and social behaviors, as well as in the availability of human and technological resources. The quality aims are the same—to provide care that is safe, effective, patient-centered, timely, efficient, and equitable—but the means of achieving these aims may differ.

In addressing the quality challenge, rural communities must build on their strengths. Ironically, these strengths stem directly from the major weakness of delivering care in rural areas—the scarcity of resources and providers. In rural communities where the need for services far exceeds the available supply, providers may be more willing and able to work together and with their patients and communities to develop a community health system that best meets the needs of individual patients and the entire population.

This chapter first sets forth the key components of a health care quality improvement program, and suggests how these components apply in particular to the rural context. The second section reviews the current state of quality improvement efforts in rural areas. The final section presents conclusions and recommendations.


The quality infrastructure needed to support quality improvement involves both national and regional/local components. Successful efforts require leadership, cultural change in organizations, and human resources and technical support. In particular, to achieve the six quality aims cited above (and in Chapter 1), rural communities must establish comprehensive quality improvement programs that include five key components (see Box 3-1). It is important to emphasize that all of these components must be supported by information and communications technology (ICT), including electronic health records (EHRs) and web-based communication.

Knowledge of the Science of Quality and Safety Improvement

Quality improvement is an ongoing process that draws on a multidisciplinary knowledge base (i.e., statistics, epidemiology, engineering, human factors analysis) and employs many tools (e.g., control charts, root-cause analysis of adverse events) to identify and understand shortcomings and redesign care processes. Knowledge of the science of quality and safety im-

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