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2025 Fall Flex/CAH Quality Network Newsletter

Items in this issue include:

Critical Access Hospitals Quality Network

Three North Dakota Hospitals Recognized Among Top Critical Access Hospitals

Three Critical Access Hospitals (CAHs) in North Dakota were named to the Top 20 CAHs for 2025, according to the Chartis Center for Rural Health. This elite group of hospitals was selected from the Chartis Center for Rural Health's 2025 top 100 CAH list, which was released earlier this year. Additionally, three CAHs were named to the Top 20 in Quality, and one CAH was named to the Top 20 in Patient Satisfaction, which are best practice designations.

For the first time ever, Towner County Medical Center, in Cando, received all three designations, the first hospital ever to receive triple honors in the same year.

Representatives from the CAHs received the
awards in September at the NRHA conference.

North Dakota CAHs Recognized

Best Practice Recipients – Quality

Best Practice Recipients – Patient Satisfaction

Six North Dakota Hospital CEOs Make Top List

In Becker's Hospital Review, a top list of Critical Access Hospital (CAH) presidents/CEOs to know included six North Dakota leaders.

According to Becker's release, "The leaders featured on this list are driving growth by expanding services, upgrading facilities, and building skilled teams. Despite challenges like the pandemic and nationwide staffing shortages, these executives have implemented resilient strategies to keep their hospitals thriving for the long haul."

The six North Dakota CAH CEOs recognized are:

A total of 118 rural hospital and health system presidents and CEOs were selected for 2025. Delfs and Fischer were also selected as top CEOs in 2024.

"The leadership in a healthcare system sets a tone for the organization and often that tone will spread, not only through the providers and staff of the organization, but also through the community," said Jacob Warren, director at the University of North Dakota Center for Rural Health (CRH). "From managing resources in a thoughtful way, hiring providers and staff that prioritize patient care, and becoming partners in their local communities, we are truly thankful for their contribution to the health of North Dakotans."

Langdon Prairie Health Receives Flex Quality Award

L-R: R. Wayne Reid, Catherine Taylor, Darla
Roder, Michelle Skillings, and Maria
Eisenzimmer accepting the Flex Quality
Reporting Award.

Langdon Prairie Health received the Flex Quality Reporting Award at the 2025 Dakota Conference on Rural and Public Health.

The award is given to a CAH in North Dakota who has developed an Antibiotic Stewardship Program to include all required elements and met the largest number of subcomponent measures.

Antibiotic Stewardship Programs can help clinicians improve clinical outcomes and minimize harms by improving antibiotic prescribing.

Improving Emergency Department Transfer Communication in CAHs

Communication in emergency departments (EDs) is vitally important, especially when a patient transfer takes place. In order to provide timely, accurate, and direct communication from one healthcare facility to another, certain elements need to be communicated and documented, which is called the Emergency Department Transfer Communication (EDTC).

Medicare Beneficiary Quality Improvement Program

EDTC is one of the measures within the Medicare Beneficiary Quality Improvement Program (MBQIP). Nationwide, CAHs are held to quality improvement initiatives, or MBQIP, to improve patient care.

Recently, the North Dakota Flex Program saw challenges many CAHs were facing when it came to MBQIP measures, specifically the EDTC scores, and they developed a program designed to help hospitals raise their score on the measure.

Shared Goals

Five hospitals were invited to be part of a five-year cohort with the short-term goal of reaching 100% in one of the eight EDTC elements they weren't currently meeting. The long-term goal is to reach 100% in all eight elements. And the program has seen success during the first year.

Anna Walter, Flex project coordinator, shared how the cohort has worked together and independently to achieve these goals. "From the time a provider decides a patient needs to be transferred, there are a series of steps that should be taken to ensure the facility the patient is being transferred to has all necessary communication available in a timely manner to continue that patient's care," she said.

Importance of Planning

The members of the group each had to develop a Plan-Do-Study-Act (PDSA), which Walter helped walk them through.

"The group has met quarterly for the first year," said Walter, "which included a lot of peer-to-peer discussions and sharing of resources. The first meeting was to identify challenges or barriers the facilities were experiencing that may be prohibiting them from achieving 100% in all eight EDTC elements. Some common challenges identified included travel staff not being orientated on EDTC and staff not fully documenting everything they did or collected in the medical record."

Walter also met with each facility individually, to look for ways efficiencies could be found, since every ED is different.

"The PDSA allowed the facility to work toward a specific area of improvement. Once those were completed, we also worked on process mapping the EDTC process within their facility. This is a visual way to understand the different steps that take place in an ED once a patient transfer begins, similar to a flow chart. This has been a great tool for them to share with all ED employees the inconsistencies that were identified in their current workflow and what changes needed to be made in order to improve the process and communication."

Seeing Success

The second year will include continuing to monitor the scores and see if any additional follow-up is needed. After that, more monitoring will take place and Walter is hopeful the scores will continue to increase.

"We have already seen short-term success with the members of the cohort. All five facilities saw improvement in their EDTC scores, and four of the five reached their short-term goal of 100% in at least one element. This has been a great model and way for Flex to identify how additional support can make a difference in Quality measures."

North Dakota CAH Quality Network Statewide Virtual Meeting: Key Highlights

The North Dakota CAH Quality Network statewide virtual meeting, held on August 5, 2025, marked a shift in format. For the first time, the meeting was consolidated into a single session, rather than the usual two half-day meetings split between east and west. All six tertiary hospitals presented together in one meeting, offering valuable insights and updates to CAHs across the state.

Presentations from CRH, state partners such as Quality Health Associates and the Center for Collaboration and Advancement in Pharmacy at North Dakota State University, and the six tertiary hospitals in North Dakota, covered key topics and initiatives such as EDTC, Antibiotic Stewardship Program, antibiotic use, going catheter-free, Hospital at Home program, and more.

If you missed the meeting, the recording is available on the Flex Virtual Library. Please contact Anahita Anvari-Clark for your login details.

The next statewide meeting will be held virtually on December 3, 2025, from 9:00 am to 12:00 pm Central.

Flex Virtual Library Changes

Due to new federal accessibility requirements, we will no longer post inaccessible policies or presentation slides to the Flex Virtual Library. All materials on University of North Dakota websites must meet accessibility standards by April 2026.

  • You can continue to share policies through the DON, QI, and RHC Network listservs.
  • CRH staff slides will be made accessible and posted to the Virtual Library.
  • Education slides by subject matter experts will only be shared if accessible or can be requested directly from the speaker. We are working with our vendors to ensure their slides meet requirements by April 2026.
  • Recordings will continue to be posted as they already meet accessibility standards.

For more information on the new rule, view Fact Sheet: New Rule on the Accessibility of Web Content and Mobile Apps.

We regret any inconvenience. Thank you for your patience and understanding as we adjust to this new process. If you have any questions, you can contact Anahita Anvari-Clark.

Regulatory Updates

Centers for Medicare & Medicaid Services recently published memos summarizing the Medicare rules and regulations for CAHs.

  • QSO-26-01-ALL – Contingency Plans – State Survey and Certification Activities in the Event of Federal Government Shutdown (Posted 10-1-2025)
  • QSO-25-27-RHC – Rural Health Clinic (RHC) Changes in Regulations for Primary Care Services and Laboratory Requirements (Posted 9-26-2025)
  • QSO-23-15-CLIA REVISED– REVISED Clinical Laboratory Improvement Amendments of 1988 (CLIA) Post-Public Health Emergency Guidance (Posted 9-23-2025)

MBQIP Data Reporting Reminders and Resources

Upcoming Submission Deadlines:

  • November 21, 2025 – CAH Quality Infrastructure Assessment
  • January 7, 2026 – Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
  • January 31, 2026 – Emergency Department Transfer Communication (EDTC)
  • February 1, 2026 – Median Time from ED Arrival to ED Departure for Discharged ED Patients-(OP-18)

Remember: The encounter period for HCP/IMM-3 (Influenza Vaccination Coverage Among Healthcare Personnel) began on October 1. Ensure that your facility has a process in place to record flu vaccinations, including those that decline the vaccine. You can find excellent resources at the National Healthcare Safety Network, including instructions on how to complete the Healthcare Personnel Influenza Summary Form.

For questions or technical assistance please contact:

Anna Walter for EDTC, OP-18, OP-22, CAH Quality Infrastructure Assessment

Anahita Anvari-Clark for HCAHPS, Antibiotic Stewardship, HCP/IMM-3, Safe Use of Opioids, Hybrid Hospital-Wide Readmission

Rural Health Clinic Network

North Dakota RHC Representatives Advocate at NARHC Policy Summit

Two North Dakota RHC representatives traveled to Washington, D.C. in June to attend the National Association of Rural Health Clinics (NARHC) Policy Summit, where they joined fellow rural health advocates from across the country to shape and influence policy affecting rural healthcare.

Brock Sherva, CEO of Northwood Deaconess Health Center – which operates RHCs in Larimore, Northwood, and Binford – and Dustin Hager, PA-C and COO of Heart of America Medical Center – which operates RHCs in Dunseith, Rugby, and Maddock – attended the summit on behalf of North Dakota RHCs. They were also joined by Anna Walter and Rebecca Quinn from CRH.

The summit's first day focused on key policy briefings and updates, including presentations from the Federal Office of Rural Health Policy and the NARHC policy team, as well as preparation sessions for congressional meetings.

L-R: Brock Sherva, Ryan Kenyon, Anna Walter, Rebecca Quinn, and Dustin
Hager outside of Senator Kevin Cramer's office.

On the second day, Sherva and Hager, along with CRH's Walter and Quinn, met with staff from the offices of North Dakota's congressional delegation. These meetings provided an opportunity to educate lawmakers' aides about the critical services RHCs deliver and the unique challenges they face across rural North Dakota. U.S. Senator John Hoeven also made a brief appearance during the meetings to show support.

Thank you to Brock and Dustin for representing North Dakota's RHCs and advocating for continued improvements in rural healthcare policy and funding. Their leadership and engagement are vital to ensuring access to quality care for our rural communities.

Financial/Operational Improvement Update

CAH Cost Reporting Program Completed

This summer the North Dakota Flex Program filled a need for many CAHs by sponsoring a cost report strategy/compliance review. Nearly one third of the 37 North Dakota CAHs submitted an application to be selected for this opportunity, which only had four spots available, showing a growing need in the state.

CAHs submit a cost report annually to Medicare, detailing the costs incurred in delivering services to patients over the past year. The cost report strategy/compliance review activity provided an in-depth review of the CAHs current cost report to identify any risks, opportunities, and optimization of Medicare reimbursement. Eide Bailly facilitated the activity.

The program included:

  • A review of current reporting elections/strategies to identify risks and opportunities to improve data collection, correct errors in reporting, and considerations for requesting/electing alternative methodologies for reporting and allocating of costs.
  • A review of organizational services and structures to determine if there are opportunities to make changes in organizational operations that would allow for enhanced reimbursement opportunities in the cost report.

Megan Rath, CFO of South Central Health out of Wishek, shared the impact the activity had on the hospital. "The cost report review was such a great experience for South Central Health. Our session with Eide Bailly helped us better understand our compliance risks, identify opportunities for improvement, and ensure we're staying compliant with current regulations. The guidance we received will strengthen our financial planning and ultimately support our ability to continue providing high-quality care in our community."

St. Luke's Medical Center, in Crosby, also participated in the activity. "The review was a great opportunity for St. Luke's Medical Center," shared CEO Jody Nelson. "It helped us take a closer look at how we report our costs and showed us some ways to improve and make sure we're getting the reimbursement we're eligible for. Opportunities like this make a big difference for small hospitals like St. Luke's."

"The North Dakota Flex Program was happy we were able to offer this opportunity for several CAHs," said Anna Walter, project coordinator at CRH, "to help them ensure regulatory accuracy, maximize reimbursements, and strengthen financial decision-making."

Funding Opportunity – 2025 North Dakota CAH Subcontract Program

The North Dakota Flex Program will have upcoming funding available to support North Dakota CAHs through CAH Financial/Operational Improvement Area of Choice. This funding is intended to allow CAHs to self-identify a financial or operational area for improvement and intervention. Activities that will be considered are: coding and billing chart audit, chargemaster review, chargemaster scrub, 340B external audit, revenue cycle management, service line assessment, etc. When available, funding information and the online application can be found at Flex Funding Programs.

Important dates:

  • Release date: December 8, 2025
  • Technical Assistance Meeting: December 18, 2025, 2:00 pm Central
  • Application due date: January 9, 2026
  • Award notification date: January 23, 2026
  • Award completion deadline: August 31, 2026

Small Hospital Improvement Program (SHIP)

The SHIP funding year runs June 1, 2025, through May 31, 2026. The SHIP Funding Priority Area this year is consistently reporting MBQIP measures.

The priority area must be addressed before working on additional SHIP eligible activities. This information is reflected in each CAH's subaward paperwork in the Scope of Work section. As the SHIP year progresses, continue working on your selected activities. If you encounter a barrier to implementing a selected activity, reach out to Nicole Threadgold as soon as possible to discuss options.

SHIP reporting continues to include: a mid-year check-in to see how CAH-selected activities are progressing; a final report to see progress of implemented activities; and reimbursement request once expenses are incurred. Look for communications regarding the mid-year check-in to be sent in December.

Workforce

2025 Recruitment for Retention Academy

The 2025 3RNET Recruitment for Retention Academy is available at no cost to all of our North Dakota healthcare facilities! This 6-part webinar series began October 7 and will continue through December 16. If you missed the first few sessions, don't worry. All sessions are available to watch as part of your registration. CRH is sponsoring our state's attendance to save you $500 PER REGISTRATION.

Register for the 3RNET Recruitment for Retention Academy. Enter your info and click "add to cart". It will say $500, but don't worry. On the next page, you will be able to add a coupon code CRH25 to remove the fee. Follow prompts for information, and you'll be all set.

3RNET PLUS TOOLS

If you are a user of 3RNET and are looking for a more efficient way to track candidate interactions, consider upgrading to a 3RNET PLUS TOOLS account.

3RNET PLUS TOOLS can keep you organized and streamline your recruitment process. Begin your free 30-day trial by upgrading your account. Reach out if you need any help navigating this process.

3RNET Refreshers Available

3RNET is a free and valuable resource available to rural and underserved communities across the state. If you haven't logged in lately, or feel like you could use a refresher on how best to use this site, reach out to Stacy and schedule a 30-minute refresher.

3RNET is your place for:

  • Free job postings
  • Direct referrals of candidates to your account (matching your job openings)
  • Promotion of open jobs at job fairs and presentations that Stacy attends
  • Recruitment and retention resources that are useful for new or seasoned recruitment professionals

Be sure to use your account to its fullest potential, and log in today.

2025 Primary Care Week

Primary Care Week Community Meet and Greet CRH and the American Medical Student Association hosted the 2025 Primary Care Week at the University of North Dakota (UND) School of Medicine & Health Sciences the week of October 27 to 31. This annual event includes a full week of sessions to help students understand more about primary care professions. Sessions include a panel of primary care residents, a student-lead conversation about summer opportunities, and the Community Meet and Greet event to connect students with healthcare facilities from the state and region.

State Office of Rural Health

Threadgold Named Regional Representative for National Organization

Nicole Threadgold, director of the North Dakota State Office of Rural Health (SORH) at CRH, has been named a regional representative for the National Organization of State Offices of Rural Health (NOSORH) for Region E. She was elected by the participants at the Region E Partnership meeting. NOSORH assists SORHs in their efforts to improve access to, and the quality of, healthcare for nearly 61 million rural Americans, and has five regions, covering all 50 states.

"I am excited to serve in this new capacity," said Threadgold, "and look forward to continuing Region E's strong representation while supporting NOSORH's important work to improve health in rural America."

Threadgold, alongside co-regional representative Sharon Weber, of Wyoming, will be a primary point of contact within Region E, sharing regular updates about NOSORH activities and relevant rural health information. She will also serve on the planning committee for the regional meeting and take the lead in welcoming new state office directors, helping to introduce them to the organization. NOSORH relies on regional reps to encourage engagement in NOSORH committees and activities across their region.

Region E consists of North Dakota, Alaska, Colorado, Idaho, Montana, Oregon, South Dakota, Utah, Washington, and Wyoming.

"Nicole brings a deep passion for rural health and a strong track record of collaboration, leadership, and service to rural communities," said Ashley Moretz, of the Utah Office of Primary Care and Rural Health, and the NOSORH president-elect.

2025-2026 Scrubs Camp Grant Recipients Announced

The Rural Collaborative Opportunities for Occupational Learning in Health (R-COOL-Health) Scrubs Camp grant recipients for the 2025-2026 cycle have been awarded. Scrubs Camps are one-day camps held in rural communities that are organized through a partnership among a local healthcare facility, an economic or job development authority, and a school. Scrubs Camps target students in grades 5-12 to introduce them to careers in healthcare in fun, interactive ways.

2025-2026 Grant Awardees:

The Scrubs Camps will be held between September 2, 2025, and April 30, 2026. The twelve camps that will be hosted in the coming months will reach over 140 communities and approximately 1,370 students around North Dakota.

Follow the camps on Facebook at R COOL Health Scrubs Programs to see all the great activities they will be hosting with the students!

Community Health Needs Assessments at CRH

CRH has a long-standing history of conducting Community Health Needs Assessments (CHNAs). CRH has the experienced staff and resources to guide you throughout the assessment process.

Your dedicated CRH CHNA lead and assistant are actively involved in all 11 steps of your CHNA process. Together with expert data and communications teams, they:

  • Prepare and submit UND Institutional Review Board documents for approval. This ensures the CHNA survey process is conducted in an ethical way protecting the rights and welfare of those participating in the survey.
  • Create a customized survey tailored to discover your community's health needs.
  • Organize and facilitate two community meetings (in-person) and 6-10 key informant interviews (in-person or virtual if needed).
  • Analyze your unique survey results, county-level health information, key informant and focus group data.
  • Create your final CHNA report, incorporating updated primary and secondary data and prioritized needs.

Coordination of all items throughout the 11-step process are facilitated via exclusive access to CRH's online eToolkit. The eToolkit is a central repository or tools and resources integral to conducting a successful CHNA. It is the primary communication tool between your CRH CHNA team and your facility's CHNA liaisons. Did you also know there is bonus eToolkit content to assist your liaisons in CHNA Implementation Planning? For more information contact Holly Long.

2026 Dakota Conference on Rural Health

The 2026 Dakota Conference on Rural Health returns to Grand Forks, North Dakota June 3-4 at the Alerus Center.

The Dakota Conference provides an opportunity for hundreds of healthcare professionals, educators, and students to share strategies for building and sustaining healthy communities in North Dakota. The conference is being re-imagined for 2026 – look for a revised format to include your favorite keynote and breakout sessions, the legislative panel, poster presentations, and the awards banquet. Registration, calls for proposals, and much more will be open starting in November.

National Rural Health Day

National Rural Health Day is November 20! There are many opportunities for organizations to celebrate the Power of Rural. How will you celebrate on November 20?

Blue Cross Blue Shield of North Dakota Caring Foundation Rural Health Grants Program

Rural Health grants focus on transforming the health and well-being of rural North Dakotans and address the social drivers of health affecting its communities so we can build a better future of opportunity, access, and full potential for all.

The program targets the following primary focus areas:

  • Economic stability
  • Education access and quality
  • Healthcare access and quality
  • Neighborhood and built environment
  • Social and community context

View the Rural Health Grants Program project page for application information. Deadline to submit is November 14, 2025. For more information contact Holly Long.

Upcoming Meetings

Looking for a particular meeting? Visit the North Dakota Healthcare Partners Events Calendar and search our upcoming events for more information and to register then add to your calendar.

Upcoming Flex Program/North Dakota CAH Quality Network/RHC Network Meetings

  • November 12 – ABS Data and Education
  • November 13 – DON Networking Meeting
  • November 18 – CfC Education Webinar – Creating an Internal Compliance Program – Health Services Associates (HSA)
  • December 9 – CCM Webinar Series #2: Designing for Success: How to Construct a Compliant and Sustainable CCM Program
  • December 11 – DON Networking Meeting
  • December 16 – Clinic Manager Meeting, North Dakota RHC Network
  • December 17 – CCM Webinar Series #2: Designing for Success: How to Construct a Compliant and Sustainable CCM Program
  • December 18 – CfC State Survey Sharing Meeting - North Dakota RHC Network

Save the Date!

Photos & Presentations

Staff of the North Dakota Flex team were asked to present on various topics are recent state and national conferences.

  • Flex Program Director Jody Ward (at left in photo) participated in a panel discussion titled Charting the Course: Strategic Planning Action for Your State's Flex Program at the 2025 Flex Program Reverse Site Visit in Washington, D.C. Other panelists included Scott Daniels from Hawaii and Bob Duehmig of Oregon.

Did You Know?

The Flex program offers a variety of tools and resources.

Virtual Library:

  • 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

Email Anahita Anvari-Clark at anahita.anvariclark@UND.edu for login information.

Are You New to Your Role or Organization?

Please email Anna Walter at anna.walter@UND.edu or Anahita Anvari-Clark at anahita.anvariclark@UND.edu for an orientation on the North Dakota Flex Program, MBQIP Program, the North Dakota CAH Quality Network, and the North Dakota RHC Network.