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Michigan Center for Rural Health > Programs > Hospital Programs > Critical Access Hospitals > Quality Improvement >

MICAH QN

Michigan Critical Access Hospital Quality Network

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  • Community Health Workers
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  • MCRH Resource Snapshot
  • National Rural Resources
  • Newsletter Archive
  • Remote Patient Monitoring for Rural Michigan Hospitals
  • Rural Maternal Health Environmental Scan

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  • CAH Conference
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(517) 355-7979

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Michigan State University 909 Wilson Rd. Rm B-218 East Lansing, MI 48824

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SPARTANS WILL|© Michigan State University|

MICAH Michigan Critical Access Hospital Quality Network Logo

Quarterly Meetings

2026 Schedule

February 20: Virtual | 8:30-11:30am

May 7: In- Person | 8:30-11:30am

August 21: Virtual | 8:30-11:30am

November 12: In-Person | 8:00-11:00am

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The MICAH QN is a formal, 501 c3, with member representation from all 35 CAHs in Michigan. The MI Flex Program facilitates all quality improvement programming in the CAHs through the MI CAH Quality Network.

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.

Vision Statement

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

Purpose

- 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 ByLaws | MBQIP All Measure Document | MI CAH Quality Dashboard | BCBSM 2026-2027 PG5 P4P Program Guide

Meeting Notes 2026
May
  • Agenda
  • Strategy Group #1 - Making Care Safer by Reducing the Harm Caused in the Delivery of Care
    • Peer Highlight: Munson Healthcare - Priositizing SUD/OUD
    • SUD/OUD Breakout Discussions (by ED volume)
  • Partner Updates
    • Superior Health Quality Alliance Update
  • Strategy Group #2 – Data Management & Analysis              
    • MI CAH Scorecard Showcase: Aspirus Stoplight Report
    • Medicare Beneficiary Quality Improvement Program (MBQIP) Data Update
  • Master PowerPoint

February
  • Agenda
  • Strategy Group #1 – Making Care Safer by Reducing the Harm Caused in the Delivery of Care   
    • National Pediatric Readiness Project (NPRP) – State of MI Update
  • Partner Updates
    • Superior Health Quality Alliance Update
    • BCBS PG5 Update – Looking Forward to Program Year 2026          
  • Strategy Group #2 – Data Management & Analysis              
    • National Rural Rating System presentation
  • MICAH QN Core Measures/MBQIP report out
  • Master PowerPoint
  • Master PowerPoint
Meeting Notes 2025
 
November
  • Agenda
  • Master PowerPoint
  • Strategy Group #3 - CAH Priorities - What You Need to Know Now Resources
  • Transitions of Care Roundtables
     
    • Discussion #1 - Inpatient to Community Care Partner (SNF, LTC, etc.)
    • Discussion #2 - Inpatient/ED Discharge with PCP Follow-Up
    • Discussion #3 - Inpatient/ED Discharge to Behavioral Health Resources
  • Strategy Group #2 Data Management and Analysis
  • MICAH QN Quality Data Review
  • Breakout Group Discussions
     
    • Staffing and Staffing Models
    • Capacity and Bed Availability
    • Throughput and Process Efficiency
    • Patient Characteristics and Acuity
    • Community and External Factors
  • Strategy Group #1 Update
     
    • Peer Presentation: Success Cause Analysis - OSF Escanaba

August
  • Agenda
  • Master PowerPoint
  • Strategy Group #3 - CAH Priorities – What You Need to Know Resources
    • Aspire Rural Health System Provider Communication Best Practice Sharing - Doctor/Provider Communication
    • Press Ganey Solution Starter – Provider Communication
  • Strategy Group #2 - Data Management and Analysis
    • 2023 State Report (MBQIP Top 10 Methodology)
    • MBQIP Update – Current State of MI CAH Performance
    • Utilizing MBQIP to Drive Change – OP-18B Lean Project Success Story
  • Strategy Group #1 - Making Care Safer by Reducing the Harm Caused in the Delivery of Care
    • ProMedica Charles and Virginia Hickman Hospital - Sepsis Presentation
  • Superior Health Quality Alliance Update
    • One-Pager

February 
  • Agenda
  • Master PowerPoint
  • Strategy Group #3
    • Information Sprints – What MICAH QN Leaders Need to Know NOW!
  • Strategy Group #2
    • Data Management and Analysis
    • MICAH QN All Measures Spreadsheet
  • Strategy Group #1
    • Making Care Safer by Reducing the Harm Caused in the Delivery of Care – focus on where the group is heading for 2025
  • BCBS PG5 Update (coming soon!)
  • iMPROve Health Update (coming soon!)

 

Meeting Notes 2024
November
  • Agenda
  • Welcome PowerPoint
  • Strategy Group #3 – CAH Priorities!
    • Update – Focus on Aging (PowerPoint) (coming soon!)
    • AHA Podcast on The Work of Action Communities in Age-Friendly Health Systems
    • FY 2025 Final IPPS Rule (Age-Friendly Information starts on Slide 12)
    • FY 2025 IPPS Press Release
    • Geriatric Emergency Department – McKenzie Health System
  • Strategy Group #2 – Data Management and Analysis
    • MBQIP – The “Why”, the Current State of Top 10 Performance, and MBQIP Deadline Reminders (coming soon!)
    • MICAH QN Core Measure Report Out
    • Corewell Health CAH Scorecard Showcase
    • Decreasing 30 Day Readmissions – My Michigan Health
  • Strategy Group #1 – Making Care Safer by Reducing the Harm Caused in the Delivery of Care | Sepsis in Small Rural Hospitals – Best Practices
    • Michigan Hospital Medicine Safety Consortium Slides
    • Aspirus Health Slides 

August
  • Agenda
  • Accreditation Resources
    • DNV Survey Prep
    • DNV GL Healthcare - Survey Document Request List
    • Ancillary Unit Department Sweep Checklist
    • Non-Clinical Department Sweep Checklist
    • Patient Care Department Sweep Checklist
  • Strategy Group #3 – CAH Priorities – What you need to know now!
    • Community Health Worker 101 Presentation
  • Strategy Group #2 Data Management and Analysis
    • MI CAH Peer Showcase – Scheurer’s Contaminated UA Study
  • MICAH QN Data Report Out
    • 4Q 2023 MICAH Group Quarterly Reports & 2Q 2024 EDTC X
    • Critical Access Hospital CMS PowerPoint
    • MBQIP SDOH Presentation
  • Strategy Group #1 – Reducing Harm Caused in the Delivery of Care
    • MyVoice Back to Basics Education Front Line Teams – MyMichigan Health

May
  • Agenda
  • Strategy Group #3 – CAH Priorities – What you Need to Know Now!
    • Discussion Groups: Hospital Commitment to Health Equity & SDOH Screening
  • Strategy Group #2 Data Management and Analysis
    • Q4 2023 MBQIP Data (including Q1 2024 MBQIP EDTC Data, and HCAHPs)
    • MBQIP All Measure Document
    • National CAH Quality Assessment – MI Highlights
  • MI CAH Scorecard Showcase  
    • Munson Healthcare
    • Audit Workbook Template
    • Reworking the Quality Meeting to Ensure Robust Discussion (Mackinac Straits Health System)
  • Strategy Group #1 – Reducing Harm Caused in the Delivery of Care
    • Breakout Discussions on Increasing Safety Event Reporting focused on the topics; “The Why”, Collection Tools, and Closing the Loop with Team Members.
  • Partner Updates
    • iMPROVE Health Update – Governors Award of Excellence

February
  • Agenda
  • Welcome PowerPoint
  • Strategy Group #2 - Data Management and Analysis
    • Q3 2023 MICAH QN Core Measures Data, and Q4 2023 MBQIP EDTC Data
    • MICAH QN HCAHPs Report Out
    • MICAH QN Gap Analysis – Areas of Opportunity with Data & Performance
    • MI CAH Scorecard Showcase – Scheurer Health
  • Strategy Group #3 – CAH Priorities – What you Need to Know Now!
    • MI CAH CNHA Overview
    • Corewell Health – Leveraging the Joint Commission Health Equity Standards to Improve Care
  • Partner Updates
    • iMPROVE Health Update – Governors Award of Excellence
Strategy Group 1
Fall Prevention Resources
  • AHRQ Fall Prevention Toolkit
  • Peer Group 5 Storyboards surrounding Fall Prevention - BCBS P4P Program
  • Universal Fall Precaution Policy Example
Fall Definition Resources
  • NQF 0202 Falls with Injury
  • NQF 0101 Falls Screening, Risk Assessment and Plan of Care to Prevent Future Falls
  • GLPP Hospital Improvement Innovation Network Encyclopedia of Measures and FAQ - MHA Community Site
Debriefing Resources
  • Example debriefing document (Kalkaska)
Resiliency Resources
  • Joint Commission - Resilience and Resilience Engineering in Health Care
Strategy Group 2
General Resources
  • MBQIP All Measure Document
  • Additional Measures used by MICAH QN
  • Creating a Random Sample in Excel (Guide put together by SG #2)
  • CMS Star Ratings - Presentation by Stratis Health
    • Slide Deck
  • How to Create a Random Sample in Excel
  • How To…Create a Random Data Sample in Excel
  • February MBQIP Monthly - Random Sampling on Page 3
Scorecard Showcases:
  • Aspirus Health
  • Sparrow Health System
  • SCH ED-Blank MI CAH Scorecard Showcase
  • Sparrow Clinton Hospital Examples
    • EVS | Radiology | Med Surg
  • Aspirus Health COPD Scorecard
  • Corewell Health CAH Scorecard Showcase
Resources Related to BCBS PG5 Programming
  • Conditions of Participation (CoP) for Admissions Discharge and Transfer (ADT) Notifications Master Education provided by the Michigan Health Information Network (MiHIN)
  • Note: Please see this resource as well (Conditions of Participation (CoP) for Admissions Discharge and Transfer (ADT) Notifications Master Document)
  • BCBS PG5 P4P - HIE/ADT Education
Strategy Group 3
General Resources
  • Communication Tools - RELATE
    • Information for Staff Training | Card
  • Engaging Members through the MICAH QN Book Club. Previous books include, In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope, Who Move my Cheese, and, Leadership Secrets of Santa Clause.
  • Reducing COPD Readmissions by Engaging Patients and Families in their Care and Promoting Effective Communication and Coordination of Care
    • Presentation
Leader Rounding Resources
  • Leader Rounding Sheet
  • Leader Rounding Script
  • Extent to Which you Felt Ready to Be Discharged
  • Instructions Given on How to Care for Yourself at Home
  • Speed of Discharge Process After Told You Could Go Home
  • Discharge Planning Checklist
Care Transitions Solution Starters
  • Medication Understanding Solution Starter
  • Medication Review Worksheet
  • Resource - Care Transitions: Staff Took my Preferences into Account
  • Resource - Patient and Family Discharge Checklist
  • Trail of Your Care Scripting
    • Example brochure
Educational Series 2026
May
  • State Connecting Data, Improving Care - How MiHIN Supports CAHs RM
    • Powerpoint | Video
March
  • State Plan on Aging and Aging Network Overview
    • Powerpoint | Video | MI Options Resource
February
  • MDHHS Stroke STEMI UPDATE
    • Powerpoint | Video
January   
  • Swing Beds : What, When, Why and How
    • Powerpoint | Video
Educational Series 2025
July
  • Enhancing Rural Care: Bridging Gaps in Quality Through Proactive Physical Therapy and Fall Prevention
    • PowerPoint | Video
March
  • MDHHS – Systems of Care Stroke and STEMI Updates
    • PowerPoint | Video 
February
  • AHA – Rural Health Care Outcomes Accelerator Program
    • Presentation | Video
January
  • I-REACH Rural Veteran Health Care
    • Presentation | Video
Educational Series 2024
October
  • October MI-211 Webinar
    • Presentation | Video
September
  • HMS MCRH Antimicrobial Stewardship Webinar
    • HMS Antimicrobial Use Guidance and Toolkit
    • Presentation | Video
August
  • MiHIN Overview and Updates
    • Presentation | Video
July
  • Michigan Value Collaborative Overview and Updates
    • Video | No Presentation Provided
  • Transforming Rural Healthcare through Remote Patient Monitoring (RPM)
    • Presentation | Video
June
  • Blue Cross Blue Shield Peer Group 5 P4P Overview
    • Peer Group 5 Hospital Pay for Performance (P4P) Program Overview
      • Video | No Presentation provided
April
  • Understanding Stroke and STEMI Administrative Rules and Updates
    • MDHHS - Updates for the Stroke and STEMI Systems
      • Presentation | Video
March
  • Bridging the Gap between EMS and Hospitals (regulations and relationships)
    • Patient Movement Subcommittee
    • MICAH QN EMS Presentation | Video
February
  • Strategies to Enhance HCAHPS Response Rates
    • Presentation | Video 
January
  • Working Quality Improvement into Contracts
    • CHW Contract Quality Metric Process
    • Metrics for Contract Evaluations
    • Working Quality Improvement Into Contracts
      • Video

Michigan Critical Access Hospital Quality Network Executive Committee

  • Mariah Hesse, University of MI Health System Sparrow Clinton and Carson, Chief Nursing Officer - President (Officer)
  • Jen Anderson, University of MI Health System, Quality | Community Hospital Lead PI Specialist - Vice-President (Officer)
  • Christi Salo, Munising Memorial Hospital, Chief Nursing Officer - Treasurer (Officer)
  • Barb Wainright, Corewell Health, Quality Improvement Specialist, Lead Quality, Safety & Experience - Secretary (Officer)
  • Heather Schragg, Eaton Rapids Medical Center, Director of Quality, Risk Management, Medical Staff Services - Strategy Group #3 Leader
  • Kena Nicholson, Schoolcraft Memorial Hospital, Quality Coordinator - Strategy Group #2 Leader
  • Tiffany Friar, University of MI Health System Sparrow Eaton and Ionia, Chief Nursing Officer - Strategy Group #1 Leader
  • Christine Bissonette, Kalkaska Memorial Hospital, Service Line Director, Acute Care Services - Member
  • Todd Peltola, Baraga Community Hospital, Director of Quality and Risk - Member
  • Darcy Donnelly, Aspirus Keweenaw, Director of Nursing - Member
  • Julia Harbuck-Valley, Scheurer Health, Quality Manager – Member
  • Kimberly Shiner, Director of Compliance, Quality & Risk Management, Schoolcraft Memorial Hospital – Member
  • Jennifer Duke, Patient Safety Quality Specialist, MyMichigan Health System – Member

 

Questions? Contact

Amanda Saint Martin

Hospital Programs Manager

amanda.saintmartin@affiliate.msu.edu