Skip to main content

2021 Spring Flex/CAH Quality Network Newsletter

We are excited to introduce our new twice-yearly newsletter! Items in this issue include:

Meet Our Team

  • Ashley Folarin joined the Center for Rural Health (CRH) in November 2020 as a project assistant with the Flex program and Project ECHO.
  • Nicole Threadgold is the CRH's new project coordinator as of December 2020 for Flex and the Small Rural Hospital Improvement Program and will be helping with the CHNA process.
  • Anna Walter joined CRH in March 2021 and is a project coordinator for the Rural Health Clinic Network.
  • Jody Ward is the new program director as of 2020, previously she was the senior project coordinator from 2008-2020.

Financial/Operation Improvement

The CRH Flex program is assuming the role of completing the annual North Dakota CAH Financial Analysis report previously completed by Darrold Bertsch. Due to the pandemic and its financial impact, the next financial analysis will be completed in the fall of 2022. If there are any financial measures that would be meaningful in the meantime, please reach out to Project Coordinator Nicole Threadgold via email or call (701) 330-3264.

Quality Improvement

An updated 2021 Conditions of Participation checklist will be ready to send out to all CAHs this spring. Each CAH will receive two booklets via mail and an electronic copy will be housed in the CAH Quality Network Virtual Library.


Workforce needs in North Dakota remain a focus for rural and underserved areas, as well as urban areas. The CRH’s workforce specialist assists in the connection of healthcare workforce to rural and underserved areas in the state. Through a website called 3RNet, the workforce specialist can enable a connection between facilities with healthcare workforce job vacancies, and healthcare professionals seeking work. The website is a national job board focused on rural recruitment and retention. Rural and underserved healthcare facilities in the state of North Dakota have the ability to post their job vacancies for free on this site, and receive referrals of candidates through the website, who are actively seeking work. Posting open jobs to the website also allows the workforce specialist to further promote these vacancies through general candidate communication, job fairs, and presentations to health degree programs throughout the state. To learn more about how you can increase your job vacancy exposure, please reach out to Stacy Kusler.

Medicare Beneficiary Quality Improvement Program (MBQIP) Data Reporting Reminders & Resources

  • Quality Improvement Measure Summaries for MBQIP, August 2020.
  • Interpreting MBQIP Hospital Data Reports for Quality Improvement, March 2021.
    This guide is intended to help CAH staff use MBQIP Hospital Data Reports to support quality improvement efforts and improve patient care.
  • Ask Robyn – Quarterly open office hours calls for data abstractors
    Tuesday, April 13, 2:00 – 3:00 pm Central
    Sometimes it just helps to talk to someone. Quality Reporting Specialist Robyn Carlson will be offering open office hour calls to discuss your MBQIP abstraction questions. Sessions are free of charge, but registration is required. For more information about the Ask Robyn calls, contact Robyn Carlson,
  • Webinar Recording: Hospital Outpatient Quality Program update, February 24.
    This webinar has step-by-step information on accessing and using HARP.
  • 2021 Data Reporting Reminders: (dates are subject to change)
    • April 30
      • Domain/Measure: Care Transitions/EDTC
      • Reporting Period: Q1 2021
      • Reporting Channel: RED Cap
    • May 1
      • Domain/Measure: Outpatient/Population & Sampling
      • Reporting Period: Q4 2020
      • Reporting Channel: Quality Net via HARP account
    • May 1
      • Domain/Measure: Outpatient/ OP-2, OP-3 and OP-18
      • Reporting Period: Q4 2020
      • Reporting Channel: Quality Net via CART
    • May 14
      • Domain/Measure: Patient Safety/ HCP/IMM-3 (flu)
      • Reporting Period: October 1, 2020 to March 31, 2021
      • Reporting Channel: NHSN
    • May 15
      • Domain/Measure: Outpatient/OP-22
      • Reporting Period: Calendar Year 2020
      • Reporting Channel: Quality Net via HARP account
    • June – No MBQIP core measures due this month
    • July 1
      • Domain/Measure: Patient Engagement/HCAHPS
      • Reporting Period: Q1 2021
      • Reporting Channel: Quality Net or by your vendor
    • July 31
      • Domain/Measure: Care Transitions/EDTC
      • Reporting Period: Q2 2021
      • Reporting Channel: RED Cap
    • August 1
      • Domain/Measure: Outpatient/Population & Sampling
      • Reporting Period: Q1 2021
      • Reporting Channel: Quality Net via HARP account
    • August 1
      • Domain/Measure: Outpatient/ OP-2, OP-3 and OP-18
      • Reporting Period: Q1 2021
      • Reporting Channel: Quality Net via CART
    • September – No MBQIP core measures due this month

Upcoming Meetings

Check out the shared calendar for more information.

  • CAH Quality Network Director of Nursing Networking Meetings
    • April 15, 11:00 am Central
    • May 27, 11:00 am Central
    • June 17, 11:00 am Central
    • August 26, 11:00 am Central
    • September 30, 11:00 am Central
  • CAH Quality Network Conditions of Participation Meetings
    • June 9, 10:00 am Central
    • September 9, 10:00 am Central
  • CAH Quality Network Region Meetings
    • Northwest Region – August 9, 9:00 am Central
    • Southwest Region – August 10, 9:00 am Central
    • Southeast Region – August 11, 9:00 am Central
    • Northeast Region – August 12, 9:00 am Central

Upcoming Webinars

These webinars will focus on Conditions of Participation and presented by Laura Dixon. Please save these dates on your calendar – more information will come to your inbox in the coming weeks.

  • Quality Assurance and Performance Improvement (QAPI) Standards and Worksheet for Hospitals – Ensuring Compliance with Conditions of Participation
    April 28, 2:30 - 3:30 pm Central
  • CMS Worksheet for Infection Prevention and Control and Average Sales Price (ASP) Updates
    May 20, 9:00 - 11:00 am Central
  • Discharge Planning: Compliance with CMS Hospital and CAH Conditions of Participation
    June 24, 9:00 - 10:30 am Central
  • Swing Beds Regulations: Complying with the CAH Conditions of Participation
    August 26, 10:00 - 11:00 am Central
  • Informed Consent: Ensuring Compliance with CMS, The Joint Commission (TJC) and Det Norske Veritas (DNV): More than Just a Signature
    September 16, 10:00 - 11:30 am Central

Save the Date – Conferences

  • Critical Access Hospital 2021 Conference hosted by Eide Bailly
    Contact Project Coordinator Nicole Threadgold via email for more details and a registration discount code.
    • Session 1, Day 1
      April 8, 11:00 am – 1:30 pm Central
    • Session 1, Day 2
      April 9, 11:00 am – 1:30 pm Central
    • Session 2, Day 1
      April 15, 11:00 am – 1:30 pm Central
    • Session 2, Day 2
      April 16, 11:00 am – 1:30 pm Central
  • Virtual North Dakota Quality Conference for CAHs and RHCs
    April 28, 12:30 – 4:30 pm Central
    Conference Registration
    The annual quality statewide conference is an opportunity for all CAHs and Rural Health Clinics (RHCs) to come together virtually and discuss pertinent issues regarding patient safety and healthcare quality in North Dakota. You can expect to hear presentations from healthcare quality experts and updates on best practices for both CAHs and RHCs. This meeting is a complement to the North Dakota CAH Quality Network's quarterly regional meetings and will also include content specific to RHCs. All CAHs and RHCs are encouraged to send staff.
  • The Annual Healthcare Service Excellence Conference: Reimagining Healthcare Engagement
    Please consider attending the Healthcare Service Excellence conference focused on Reimagining Healthcare Engagement hosted by Custom Learning Systems on June 8. This conference is aimed toward refreshing the workplace through resilience, agility, and kindness.
    Registration (no longer available) is free with promo code: 68DAKOTA21. Enter the code and hit the Apply button and then click the Order Now button.


Did You Know?

The Flex program offers a variety of tools and resources:

  • Virtual Library
    Contact Jody Ward at for login information.
    • A free online repository of CAH-specific resources
    • A one-stop shop to locate resources, protocols, and best practices related to CAH quality
    • Maintained by the North Dakota CAH Quality Network
  • Shared Calendar
    The North Dakota Healthcare Partners Events Calendar is a simple and streamlined format designed to connect individuals in the healthcare and community service fields to events and educational opportunities from across the state. Our partners are committed to offering high quality on-site and virtual education, and this “one-stop shop” format allows us the opportunity to effectively coordinate events and enhance their visibility.