Targeted Rural Quality Programs

The Health Resources and Services Administration (HRSA) sponsors various quality programs aimed at rural populations. Although smaller in terms of resources than the quality efforts of AHRQ and CMS, these programs likely have a good deal of impact because they are specifically tailored to the needs of rural areas and sensitive to the constraints faced by rural providers. Three HRSA quality programs are discussed: the Rural Hospital Flexibility Grant Program (Flex), the Small Hospital Improvement Program (SHIP), and quality efforts focused on community health centers and rural health clinics. Also discussed are the quality requirements applicable to rural health clinics.

The Medicare Flex program was created in 1997 to provide additional financial support to small rural hospitals designated as critical access hospitals (see Appendix C). As of May 2004, 835 hospitals had been certified as critical access (FMT, 2004; Personal communication, S. Poley, July 7, 2004). HRSA’s grant program provides grants to states to support activities in four areas: helping hospitals convert to critical access status, promoting rural health networks, integrating emergency services, and improving quality. In fiscal year 2004, HRSA awarded approximately $39.7 million in Flex grants to 45 states (Personal communication, J. Riggle, July 2, 2004). More than $4.3 million of this funding was used for quality improvement. One state, Montana, used these funds to create a statewide network among its critical access hospitals to collaborate on ongoing quality improvement activities by linking the network to the regional QIO; the network also supports collaboration on provider education, medical staff credentialing, and public reporting (NACRHHS, 2003).

In a telephone survey of more than 200 critical access hospitals conducted in 2000 and again in 2001, the responding hospitals reported significant increases in quality improvement activities, including continuing education programs for staff, data collection for staff feedback, systems to avoid/ prevent errors, and medical error reporting policies (Moscovice et al., 2002). Many reported a redefinition of quality improvement processes, including greater formalization of policies and procedures and increased emphasis on quality improvement as compared with quality assurance. Many of the respondents reported collaboration with an affiliated hospital (47 percent), a QIO (45 percent), or a state hospital association (32 percent) on quality improvement activities. A more recent survey of a subset of critical access hospitals that had reported sizable improvements in their quality-related activities on earlier surveys revealed that four-fifths had implemented one or



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