more clinical guidelines or protocols; two-thirds had enhanced improvement training for staff; and as a group these hospitals had implemented a wide range of quality improvement activities (e.g., projects focused on pneumonia, congestive heart failure, acute myocardial infarction, or stroke, as well as patient safety initiatives) (Moscovice et al., 1997).

In fiscal years 2002 and 2003, the SHIP program provided about $15 million each year to rural hospitals to support quality improvement projects and transitional efforts related to the new Medicare Prospective Payment System and the Health Insurance Portability and Accountability Act (NACRHHS, 2003). A total of 1,400 hospitals received small grants of less than $10,000 each in fiscal year 2002, and 28 percent of these hospitals used some or all of these funds for quality improvement.

The approximately 3,500 clinics participating in the rural health clinic program (discussed in Appendix C) must satisfy the requirements of CMS’s quality assessment and performance improvement program (Balanced Budget Act of 1997, Public Law 105-133, Section 4205(b)). That program requires that rural health clinics evaluate clinical effectiveness (appropriateness, prevention), access to care (availability and accessibility, cultural competency, emergency interventions), patient satisfaction, and utilization of clinical services. A 2000 study of 40 rural health clinics in 10 different states found that the clinics’ activities and capabilities varied widely, and few were prepared for implementation of the CMS program (Knott and Travers, 2002). The clinics indicated that technical assistance and staff training in all aspects of quality assurance would be needed to implement the program, along with more time and resources.

HRSA also provides support and technical assistance to the approximately 840 community health centers, a little more than one-half of which are located in rural areas (Personal communication, R. C. Lee, May 28, 2004). Technical assistance focuses on chronic care management, disease registries, the application of evidence-based practice guidelines, and quality measurement and improvement. Many community health centers have also been involved in a 6-year health disparities collaborative focused on diabetes (Chin et al., 2004).

Accreditation and Certification Programs

Accreditation and certification programs have played an important role in encouraging and facilitating the development of quality improvement programs and processes in the hospital sector. As a condition of participating in



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