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Quality Improvement

The Quality Improvement section under the MI Flex Program is driven by the Michigan Critical Access Hospital Quality Network (MICAH QN).

MICAH QN Mission Statement

As a premier system of quality, the Michigan Critical Access Hospital Quality Network (MICAH QN) will be a model in developing processes that demonstrate the high quality service provided by CAHs. MICAH QN will identify opportunities for change that lead to continued improvement in the health status of the population we serve.

MICAH QN Vision Statement

MICAH QN will be known as the statewide and national leader in the measurement of healthcare quality for Critical Access Hospitals (CAHs).


  • Improve the health of our communities by working together to expand our professional and financial resources.
  • Develop a process to measure quality standards.
  • Establish a common database for benchmarking by collecting data and identifying best practices that each CAH can use in their individual process improvement plan.
  • Demonstrate the value of CAHs to our communities.
  • Demonstrate commitment and unification as a collaborative body to regulatory agencies and political concerns regarding health care quality in Michigan CAHs

MICAH QN Strategies:

In 2015, and 2018 the MICAH QN underwent a strategic planning process to align their priorities with the National Quality Strategy. The following three strategies were adopted:

Strategy Group # 1 - Making Care Safer by Reducing Harm Caused in the Delivery of Care.

Strategy Group #2 - Data Management and Analysis

Strategy Group #3 – Promoting Effective Communication and Coordination of Care.

MICAH QN Resources

MICAH QN Meeting Materials

May 20th, 2022


Strategy Group #1 (Making Care Safer by Reducing the Harm Caused in the Delivery of Care)

Strategy Group #2 Data Management and Analysis

Strategy Group #3 Effective Communication and Coordination of Care

Facilitated Discussion Resources:

February 18th, 2022

November 11th, 2021

August 21st, 2021

May 21st, 2021

February 19th, 2021

The Medicare Beneficiary Quality Improvement Project

The Medicare Beneficiary Quality Improvement Project (MBQIP) is a quality improvement activity under the Medicare Rural Hospital Flexibility (Flex) grant program. The goal of MBQIP is to improve the quality of care provided in small, rural Critical Access Hospitals (CAHs). This is being done by increasing the voluntary quality data reporting by CAHs, and then driving quality improvement activities based on the data. This project provides an opportunity for individual hospitals to look at their own data, measure their outcomes against other CAHs and partner with other hospitals in the state around quality improvement initiatives to improve outcomes and provide the highest quality care to each and every one of their patients.

As with all activities related to quality improvement in MI CAHs, the MICAH QN has driven the MQBIP effort.

Current MBQIP Measures

Additional Resources regarding the current phase of MBQIP

Submission of Metrics

Most of the metrics are submitted via the CART tool, or a vendor (i.e. Quantros) with the exception of the following:

OP-27 must be submitted via NHSN thus each CAH should be registered with NHSN and able to submit data.

  • Click here for a webinar recording and slides providing an overview of the Healthcare Professional Flu measure (OP-27), including how to sign up for an account through the National Safety Healthcare Network (NHSN), the measure submission process and available quality improvement support. For a step-by-step webinar recording to showcase how CAHs can obtain NHSN accounts as well as activate the Healthcare Personnel Vaccination Module for successful submission of OP-27. The webinar will also touch on collaboration opportunities for QIN-QIOs and state Flex Coordinators in order to maximize data submission and quality improvement support for CAHs.
  • Click here for a FAQ document compiled by the Quality Innovation Network

OP-22 must be submitted to QualityNet via secure log-in.

  • Click here for Quality Net Training Videos. This webpage houses videos on the following topics:
    • QualityNet Secure Portal: New User Enrollment Training: The audience for this session is health care providers and support contractors who need to access the QualityNet Secure portal. The training covers preparing for first-time login, logging in for the first time (proofing and credentialing process), logging into the QualityNet Secure Portal and logging out of the QualityNet Secure Portal
    • Hospital Quality Reporting Notice of Participation: This video provides instructions on the Hospital Quality Reporting Notice of Participation (NOP) pledge data entry application. Although it is not necessary for critical access hospitals (CAHs) to complete the inpatient or outpatient notice of participation (NOP) in order to participate in the Medicare Beneficiary Quality Improvement Project (MBQIP), the NOPs must be completed in order for data submitted to QualityNet to appear on Hospital Compare
    • Outpatient Quality Reporting Web- Based Measures: This video demonstrates important features and key steps for submitting outpatient web-based measures via the QualityNet Secure Portal’s Web-Based Data Collection Tool. Measures submitted through this tool include MBQIP required measure OP-22 and MBQIP additional measure OP-25. New users will want to watch the beginning of the video which demonstrates where to find the application for reporting outpatient measures. The video provides step-by-step instruction for submitting measure OP-22 starting at the 10:44 mark
  • Click here to access the following resources on the Quality Net Website. Navigate to the section titled Quick Start Guides.
    • Quality Net Account Holders
    • Non- Quality Net Account Holders
    • QuailtyNet Secure Portal Registration
    • QualityNet Secure Portal User Gui

The EDTC metrics must be submitted to Crystal Barter via fax, or email. Aggregate information for each metric will be generated via the Stratis Health Tool Summary Report Form. For more information on the EDTC metric, click here.

Additional Resources Related to MBQIP and Quality Improvement in the CAH Setting

  • MBQIP Monthly - MBQIP Monthly is a monthly e-newsletter that provides critical access hospitals (CAHs) with information and support for quality reporting and improvement and highlights current information about the Medicare Beneficiary Quality Improvement Project (MBQIP).
  • Quality Improvement Basics: A Collection of Helpful Resources for Rural Health Organizations.
  • Quality Improvement Implementation Guide and Toolkit for Critical Access Hospitals
  • This guide and toolkit offers strategies and resources to help critical access hospital (CAH) staff organize and support efforts to implement best practices for quality improvement. It includes:
    • A quality improvement implementation model for small, rural hospital settings
    • A 10-step guide to leading quality improvement efforts
    • Summaries of key national quality initiatives that align with the priorities of the Medicare Beneficiary Quality Improvement Project (MBQIP)
    • Best practices for improvement for current MBQIP measures
    • A simple, Excel-based tool to assist CAHs with tracking and displaying real time data for MBQIP and other quality and patient safety measures to support internal improvement efforts.
  • This recorded training series is for critical access hospital (CAH) staff with responsibility for data collection of Centers for Medicare and Medicaid Services (CMS) Inpatient and Outpatient quality measures. Pick individual topics that you have questions about or listen to the full series for a comprehensive overview of the process to identify each measure population and abstract the required data elements.

    Individual topics include:

    • Locating CMS Specifications Manuals (13-minute video)
    • Locating CART (CMS Abstraction Reporting Tool) (9-minute video)
    • Outpatient AMI Measures (OP1 - OP5) (23-minute video)
    • Outpatient Chest Pain Measures (OP4 - OP5) (20-minute video)
    • ED Throughput Measures (OP18, OP20, OP22) (19-minute video)
    • Outpatient Pain Management Measure (OP21) (12-minute video)
    • Inpatient Influenza Vaccination Measure (IMM-2) (18-minute video)
    • Inpatient Emergency Department (ED) Measures (ED-1, -2) (18-minute video)

BCBS Peer Group 5 Pay-for-Performance Program

NHSN Resources

The National Healthcare Safety Network (NHSN) released new and updated training materials. Below is a brief summary:

  • Self-paced online courses: Virtual training courses for the Patient Safety Component (PSC) and Outpatient Procedure Component provide instructional slides with detailed graphics and examples.
  • Quick learns: Quick learns are short educational experiences that define a specific part of a protocol or deliver approaches for data analysis within the NHSN Application.
  • 2020 update for training videos and slides: Although there were no extensive changes made to the NHSN PSC protocols for 2020, NHSN wants to note differences between the training content provided in 2019 and the current 2020 protocols. Therefore, PDF documents detailing changes to the information presented in the 2019 videos and slides have been posted alongside the 2019 videos and slide PDFs on the website.

Members with questions about NHSN training materials may contact


Crystal Barter
Director of Performance Improvement
Michigan Center for Rural Health
909 Fee Road
B-218 West Fee Hall
Michigan State University
East Lansing, MI 48824
Direct Line: 517-432-0006