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Oregon Office of Rural Health

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Program Area: Support for Quality Improvement

During fiscal year (FY) 2018, the Oregon Office of Rural Health (ORH) continues to prioritize improved reporting by Critical Access Hospitals (CAHs) under the Medicare Beneficiary Quality Improvement Project (MBQIP) program, while also engaging CAHs to emphasize quality improvement activities.    

For the third consecutive year, ORH continues to identify MBQIP Top Performing Hospitals under each of the MBQIP domains. Each year, CAHs who have consistently reported and whose rates fall at or above the national average in each given domain are recognized. In addition, we award one CAH as an Overall Top Performer (for all MBQIP domains) and one CAH that is Most Improved. Quality Officers are given recognition throughout the state and at the Annual Oregon Rural Health Conference and awarded $5,000 to implement a quality improvement project at their facility. They have the following year to implement their quality improvement project and as a final reporting requirement, they showcase their project and results via a poster board presentation that is displayed at the following years Annual Oregon Rural Health Conference.

Oregon continues to support CAHs on improving the patient experience by offering continued programming for Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) improvements. ORH has taken a stepped approach over the past three years by offering:

  • Annual scholarships to the Healthcare Service Excellence Conference for CAH executives
  • Free access to the HCAHPS Breakthrough Leadership Webinar Series (a 13-month series targeted at hospital leaders)
  • Onsite assessments of CAHs to evaluate the hospital patient and employee experience

For FY 2018, ORH is offering a one-year subscription to three CAHs for the Everyone’s a Caregiver Application (app) which provides over 130 on-demand training activities targeted towards nurses, providers, frontline staff, department managers, and executive level leadership. The app allows for CAHs to implement training opportunities for all levels of staff in various increments ranging from short 3-5-minute videos, to 45-60-minute videos for department meetings lunch-and-learns. CAHs can: track the training by person or department; require specific training modules as part of improvement activities; use training videos for new employee onboarding.

ORH works with a CAH Quality Officer each year to publish our Critical Access Hospital Quality Reporting Manual. This is a resource for existing Quality Officers and staff as well as a user-friendly “go-to” guide for new quality employees.  This manual offers an overview of all quality reporting programs, reporting requirements and reporting instructions. The guide also provides tips on sharing data across the CAH facility using sample dashboards, the ORH MBQIP Benchmarking reports (available via Tableau Online to participating CAHs). The guide is distributed annually to CAHs and anytime new staff are hired; it is shared on the ORH website and with quality partners around Oregon. 

Program Area: Support for Financial and Operational Improvement

For FY 2018, ORH is employing the following to target strategic financial and operational improvement:

  • Continued use of CAH financial indicator and service line analysis and reporting from the Oregon Association of Hospitals and Health Systems
  • Execution of a Provider-Based Rural Health Clinic (PBRHC) Financial and Operational Needs Assessment survey
  • In-depth follow-up, based on CAH 2017 Rural and Frontier Listening Tour, to complete a feasibility study and initiate a nurse mentor pilot program for select CAHs

Increased technical support will be provided to CAH-owned PBRHCs for activities to help strengthen their financial and operational baselines. An example is a Practice Innovation Grant, aimed to support improved operations, patient care, patient satisfaction, or quality tracking and/or reporting. 

A Financial and Operational Assessment of CAH-owned PBRHCs is underway to help target program activities. ORH will utilize assessment data to provide programming for PBRHCs, such as Medicaid cost-report support, coding and billing training, and emergency preparedness training.

Based on challenges discussed during the 2017 Rural and Frontier Listening Tour, the Oregon Center for Nursing (OCN) has been contracted to study the feasibility of implementing a mentoring program for nurses in Oregon CAHs and provide recommendations for pilot sites. This work will include: survey design, implementation and analysis, pilot site visits, and a final recommendations report.

Program Area: Support for Population Health Management and Emergency Medical Services Integration 

In order to provide customized, current analysis and reporting on community and service area health, ORH’s Data/GIS Analyst purchases 12 datasets annually and acquires without cost more than two dozen others. The resulting ORH Primary Care Database contains the most comprehensive demographic and health status information for all rural areas in Oregon at the zip code level. This data is the source of the six-page Primary Care Service Area profiles, which have the latest zip code and county-level information on demographics, socioeconomics, vital statistics, maternity characteristics, mortality, health risk factors, providers, and primary care supply and demand numbers for all rural communities in Oregon. A sample of the current Service Area Profile and instructions for how to request customized profiles is available online. 

ORH produces the Areas of Unmet Health Care Needs (AUHCN) in Rural Oregon Report and the CAH Community Benefit Reporting Highlights annually. Both are available on the ORH website.

Each year ORH analyzes the most recently available Community Benefit spend and reporting data (FY 2016) by Oregon’s CAHs. Three operational areas for improvement were identified:

  • Most of the CAHs appeared to be under-reporting, specifically in areas such as overhead and indirect costs for community benefit programs and subsidized health services
  • Many CAHs financial assistance policies lack the detail required by the IRS, typically in regard to publishing a plain-language summary and providing a basis for calculating amounts charged
  • Some tax district hospitals (which are exempt from the IRS 990 Schedule H reporting) that are also 501c3 may not be meeting 501r requirements
  • More detail can be found in the report which is available on the ORH website
  • Based on the surveyed success of FY 2017 work, ORH is working with the Oregon Health Authority's (OHA) Emergency Medical Services (EMS) and Trauma Division to:
    • Continue support for trauma simulation training for CAHs, including strengthened curriculum for teams to integrate new skillsets and strategies into measurable protocol improvements
    • Increased support for rural EMS Medical Director training and education
    • Support from the Flex EMS Sustainability supplement will enable ORH and OHA EMS and Trauma to use licensure and operational data to identify and complete collaborative site assessments for top performing and struggling rural EMS agencies. Assessment data will be used to inform strategic planning at the state level

Please provide information about Collaboration/Shared Services

The ORH, in partnership with the Oregon Association of Hospitals and Health Systems, annually publishes a report to break out community benefit reporting highlights for Oregon’s 25 CAHs. The Oregon Health Authority publishes all non-profit Hospital Community Benefit data annually. This report describes community benefit reporting requirements, including the federal requirements for 501(c)(3) hospitals.

Please provide information about any efforts to assist CAHs/communities and partner organizations in the transition to value-based care.

The ORH provides various educational opportunities which include transition to value-based care at the Oregon Rural Health Conference each fall. 

Please provide information about network activities in your state to support Flex Program activities.

THe ORH is an active member of the Oregon Partners in Healthcare Quality workgroup that meets quarterly to share and collaborate on the activities that each organization is offering to providers across Oregon, including CAHs and rural clinics. Regular participants of this workgroup include, but are not limited to: ORH, Health Insight of Oregon (QIO / HIIN) who recently merged with Qualis Health, the Oregon Health Authority Public Health, and Health Information Exchange (HIE) Division.

Please describe how your state Flex Program has enhanced its use of data in the past year.

ORH, in response to a mandate from the Oregon Legislature, developed the Areas of Unmet Healthcare Needs (AUHCN) report in 1998 to measure medical under-service in rural areas. It is published annually. Last year, ORH convened a stakeholder group to revise the report to better align with an integrated health care model. The report includes nine variables that measure access to primary care, including physical, mental ,and oral health care (for more on the variables used, see page 12 of the report). This year, secondary work location patient care full-time equivalents (FTEs) for physicians, physician assistants, nurse practitioners, psychiatrists, dentists, and marriage and family therapists were added to improve workforce accuracy.

The report provides a total unmet need score for each primary service care area in Oregon. An area's score can be compared to other service areas as well as to overall scores for the state, all urban, all rural and all frontier areas. Additionally, if a score is low, it identifies which of the nine variables are negatively impacting the service area. The report can be used to quantify how well communities are able to access physical, mental, and oral primary health care.

The Oregon Office of Rural Health offers an MBQIP Benchmarking program that allows CAHs to access their own MBQIP data in various formats and compare their data to that of their peers. The program is cloud-based, allowing CAHs to access their data at any time via Tableau Online. Examples of the multitude of available reports CAHs can access are:

  • Side-by-side data comparison with other CAHs
  • Dashboard reports
  • Current and historical data

Do you have any hospitals interested in converting to CAH status?:


Program Statistics

Type of Organization University
Staffing 3.5 FTEs
Number of CAHs 25
Website URL Organization Website

Flex Program Staff

Sarah Andersen
Director of Field Services

Began in September 2019

Stacie Rothwell
Program Manager, Rural Health Outcomes, Oregon
(503) 494-7416

Specialty Areas / Background

Provides subject matter expertise, evidence-based support and technical assistance to rural Oregon hospitals, clinics and community stakeholders on quality improvement and improving health outcomes.

Program Manager since September 2015

This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UB1RH24206, Information Services to Rural Hospital Flexibility Program Grantees, $1,100,000 (0% financed with nongovernmental sources). This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.