The Rural Quality Improvement Technical Assistance (RQITA) Resource Center was created to help rural healthcare organizations overcome challenges and improve healthcare and quality of care using data, measurement and improvement activities. Through RQITA support, Telligen aims to assist small rural and critical access hospitals in improving health outcomes in rural communities across the United States. RQITA Resource Center staff provide technical assistance for rural healthcare organizations to expand capacity in quality improvement and ensure success in future models based on high-quality, high-value patient care.
The RQITA Resource Center supports the Federal Office of Rural Health Policy (FORHP) at the Health Resources and Services Administration (HRSA) programs Medicare Beneficiary Quality Improvement Project (MBQIP) and the Small Health Care Provider Quality Improvement Program.
Telligen supports small, rural healthcare organizations by:
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- Expanding capacity to use data for quality improvement
- Providing technical assistance to improve the use of health information technology and related quality measurement and improvement efforts
- Supporting implementation of quality measures, measure reporting and rural-relevant measures
- Identifying and disseminating evidence-based strategies for quality improvement
Key Resources and Tools
Quality Improvement Tools and Templates
Measure Specific Resources
RQITA Monthly Newsletter
Request Techincal Assistance
Meet the Team
Key Resources and Tools
MBQIP Measures
Explore essential resources for MBQIP, including new measures for MBQIP 2025.
Data Reporting
Utilize these links to research and learn about various tools and resources relevant to data reporting for MBQIP measures.
- Monthly MBQIP Data Submission Deadlines
- CMS Abstraction & Reporting Tool (Outpatient)
- CAH Quality Infrastructure Measure Specifications
- Emergency Department Transfer Communication Specification Manual
- Hospital Inpatient Specifications Manuals | CMS
- Hospital Outpatient Specifications Manuals | CMS
- Hospital Quality Reporting (HQR) Data Reporting Tutorials | CMS
- QualityNet Training & Guides | CMS
- QualityNet Support | CMS
- Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
- HCAHPS Overview: Vendor Directory | National Rural Health Resource Center
- HCP Flu Vaccination | HPS | NHSN | CDC
- Patient Safety Component and Add/Find Annual Surveys | CDC
Quality Improvement Tools and Templates
Quality Improvement Workbook
This workbook provides valuable resources to support your team’s quality improvement efforts, including an interactive timeline, quality improvement goal statement template and ways to track progress during your organization’s quality improvement journey.
Plan-Do-Study-Act Tools
Here you will find tools and resources for implementing the Plan-Do-Study-Act cycle. Discover templates, diagrams and guides to facilitating improvement initiatives.
TeamSTEPPS
The TeamSTEPPS program by the Agency for Healthcare Research and Quality (AHRQ) aims to improve patient safety through enhanced communication and teamwork among healthcare providers. Here you will find a pocket guide and comprehensive program overview.
Medical Errors
This article discusses medical errors and provides patients 20 tips on how they can keep themselves safe. It highlights the importance of patient involvement in their care, bringing medications to doctor visits, and being aware of any known allergies they might have.
Measure Specific Resources
Patient Safety
Adverse Drug Events
Here you can find resources such as change pathway and trigger tools dedicated to optimizing glycemic control, managing opioid use and implementing effective anticoagulation therapy.
Glycemic Control
Opioids
Anticoagulation Therapy
Antibiotic Stewardship
These links lead you to CDC and AHA resource recommendations for implementing effective antibiotic stewardship programs in a variety of healthcare settings including small and critical access hospitals.
- Antibiotic Stewardship Change Pathway
- Antibiotic Stewardship Core Elements at Small and Critical Access Hospitals
- Core Elements of Hospital Antibiotic Stewardship Programs | Antibiotic Use | CDC
- Priorities for Hospital Core Element Implementation | Antibiotic Use | CDC
- Current Report | Antibiotic Use | CDC
- Antimicrobial Stewardship (ahaphysicianforum.org)
- Annual Surveys, Locations & Monthly Reporting | PSC | NHSN | CDC
- Improving Antibiotic Stewardship Use, Current Report | CDC
CDC AUR Measure
Your hospital may be eligible for reporting the Antimicrobial Use and Resistance (AUR) Measure. FORHP and CDC co-hosted a webinar for CAHs about CAH eligibility and reporting criteria. This is a GREAT resource to get up to speed on the Antimicrobial Use and Resistance (AUR) Measure within the Centers for Medicare and Medicaid Services (CMS) Promoting Interoperability Program and using the National Healthcare Safety Network (NHSN) Antimicrobial Use (AU) data for action in critical access hospitals. Watch the webinar here.
For additional information on the AUR measure visit the NHSN website.
Any hospital could and should connect with their state HAI/AR program. These programs are part of the state health department. Every state has a link to their program here and can help hospitals with reporting. Find your state program.
eCQMs
Utilize these eCQI Resource Center links to find comprehensive resources and guidance on electronic Clinical Quality Measures. Here you will find a eCQM 101 guide, practical steps for getting started with eCQMs and information regarding QRDA quality measure data reporting.
Falls
Resources coming soon!
Healthcare-Associated Infections (HAI)
Here you will find resources and guidelines for infection prevention related to MDRO, CLABSI, CAUTI, and surgical site infections. You will have access to educational materials, orientation checklist and root cause analysis tools for combatting these infections.
- Multi-drug Resistant Organisms – Infection Prevention Back to Basics: Multi-Drug Resistant Organisms (MDROs)
- Infection Prevention Orientation Checklist
- CDI Root Cause Analysis Tool – Multi-Drug-Resistant-Organisms-MDRO-Template
- MDRO Line List Template coming soon.
- CLABSI resource coming soon.
- CAUTI resource coming soon.
- Surgical Site Infections resource coming soon.
Patient Safety Culture Survey
Resources coming soon!
Perinatal Care
Resources coming soon!
Safe Use of Opioids Concurrent Prescribing
These resources provide detailed information about the eCQM measure CMS0506v6. It includes measure specifications, data elements and implementation guidance necessary for reporting this measure. Additionally, there are resources to help with getting started with eCQMs and the Quality Reporting Document Architecture.
Vaccinations
ere you will find vaccination related resources including Vax Hub, immunization toolkits, data collection forms and instructions, trainings and submission tips.
- Visit Telligen’s Vax Hub for on-demand tools, resources and learning modules related to influenza, pneumonia, COVID-19 and RSV vaccines.
- Download Telligen’s Influenza and Pneumococcal Immunization Toolkit
- CDC Healthcare Personnel Flu Vaccination data collection forms and instructions
- CDC Healthcare Personnel Flu Vaccination trainings
- NHSN Submission Tips
- NHSN Healthcare Personnel Flu Vaccination (CDC)
Patient Experience
HCAHPS
Here you will find HCAHPS related resources including general overviews of the HCAHPS survey, the Medicare Care Compare website and a vendor directory guide.
Emergency Department Patient Experience
Resources coming soon!
Care Coordination
Claims-Based Measures
Readmissions
This tool will help develop an individualized, multidisciplinary program with goals, process and outcome measures aimed at preventing hospital readmissions and reducing multi-admission patient utilization.
Complications
Hospital Return Days
Discharge Planning
These resources will direct you to AHRQ resources and tools to improve discharge and transitions of care and reduce readmisssions, including the RED Toolkit.
Hybrid Hospital-Wide Readmissions
Here you will find resources and information regarding the Hybrid Hospital-Wide Readmissions Measure.
Medication Reconciliation
The change pathway tool is a topic-specific, step-by-step guide to quality improvement. The change pathway is created using evidence-based practice resources and guidelines. Key quality improvement activities such as formulating an aim statement, conducting a root cause analysis and identifying interventions are included in each guide. Interventions are outlined as beginner, intermediate and expert so that you may explore opportunities for improvement that meet your needs.
Social Drivers of Health
Here you will find resources and information regarding the Screening for Social Drivers of Health Measure used for MBQIP.
- Data Submission Guide for Screening for Social Drivers of Health
- Data Submission Guide for Screen Positive Rate for Social Drivers of Health
- Measure Specifications and FAQs
- How to Submit SDOH Measures
- Social Needs Screening Tool Comparison Table | SIREN (ucsf.edu)
- Guide to Social Needs Screening (aafp.org)
- Rural Health Disparities Overview – Rural Health Information Hub
- National Resource Assistance to Address Social Drivers of Health
- How to Leverage MBQIP Data for Improvements – Social Drivers of Health and Health Equity Webinar
Swing Bed Care
Resources coming soon!
Emergency Department
ED Throughput Measures
Here you will find resources to assist with ED Throughput Measures including a guide for hospitals to improve patient flow and reduce ED crowding, an Emergency Severity Index, Measure Specification Manuals, and Hospital Quality Reporting information.
EDTC
This measure for hospitals to evaluate communication for transitions of care during emergency department (ED) transfers is particularly relevant for critical access hospitals (CAHs) and is included in the Medicare Beneficiary Quality Improvement Project (MBQIP).
Data specifications, data collection resources, and additional information
Chest Pain/AMI
Resources coming soon!
- Aspirin at Arrival
- Median Time to ECG
- Fibrinolytic Therapy
- Median Time to Transfer
Global Measures
CAH Quality Infrastructure
Here you will find resources for Critical Access Hospital quality infrastructure.
Hospital Commitment to Health Equity
Here you will find resources to assist with Hospital Commitment to Health Equity Measures.
Overall Hospital Quality Star Rating
Here you will find resources to assist with the Overall Hospital Quality Star Rating.
Don’t see what you are looking for or needing technical assistance? Click below to enter an online request for the RQITA Resource Center team!
Meet the Team
Meg Nugent, MHA, RN
Alaina Brothersen, MPH
Quality Improvement Lead
Alaina Brothersen has been working in healthcare quality improvement for nine years. She has provided technical assistance for hospitals and rural nursing homes across the country through quality improvement projects in evaluative roles. With a background in public health and program evaluation, she has provided measure development, quality improvement intervention development, technical assistance and evaluations for numerous federal quality programs.
Susan Buchanan, MPH
Principal Investigator
Susan Buchanan is a Director at Telligen with 30 years of experience in quality improvement, health IT and value-based payment models. She has led the charge in many of Telligen’s rural-focused federal programs including the Frontier Community Health Integration Project; Quality Payment Program Small, Underserved, Rural Support program; Transforming Clinical Practice Initiative and Regional Health IT Extension Center. These programs provide technical assistance with performance measurement and improvement interventions.
Ann Loges, BSN, RN
Senior Quality Improvement Facilitator
Ann Loges is a Senior Quality Improvement Facilitator at Telligen with 31 years of nursing experience. Her major accomplishments include leadership in multi-hospital improvement initiatives, EHR implementation responsibilities and hospital strategic planning with ties to point of care goals. Ann has experience in the full spectrum of quality data; from patient level chart abstraction, data reporting and use of data measures to drive improvement. This includes practicing as a Quality Director in a critical assess hospital and offering direct technical assistance to multiple hospitals while collaborating with state and federal partners.
Courtnay Ryan
Senior Quality Improvement Facilitator
Courtnay Ryan has over 20 years of experience in the healthcare industry. At Telligen, she supports long-term care facilities with quality measure reporting, teaches quality improvement methodologies, assists the Learning and Action Network (LAN) QIN-QIO strategy for events and provides technical assistance. Her work in healthcare has spanned across many areas including being a certified nursing assistant, performing administrative duties including ED admissions/discharges, billing and coding and serving as a Quality Improvement Specialist for the Colorado State Office of Rural Health.
This publication is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $640,000 with 0% financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official view of, nor an endorsement, by HRSA, HHS or the U.S. Government. For more information, please visit HRSA.gov.