Skip to main content

2026 North Dakota Flex Program Newsletter

Items in this issue include:

By the Numbers: 2025-2026 Grant Year

41

Total Educational Activities Offered to North Dakota Critical Access Hospitals (CAHs) and Rural Health Clinics (RHCs)

73

Total Technical Assistance Provided for Medicare Beneficiary Quality Improvement Program (MBQIP)

Critical Access Hospitals Quality Network

Four North Dakota Hospitals Recognized Among Top CAHs

Four Critical Access Hospitals (CAHs) in North Dakota were named to the Top 20 CAHs for 2026, according to the Chartis Center for Rural Health. This leading group of hospitals was selected from the Chartis Center for Rural Health's 2026 Top 100 CAH list, which was released earlier this year. Additionally, one North Dakota CAH was named to the Top 20 in Quality.

This year, North Dakota had the greatest number of CAHs in the Top 20, as compared to other states in the nation. CAHs were presented their awards at the annual National Rural Health Association (NRHA) Rural Health Clinic (RHC) and CAH Conference in Kansas City, Missouri, on September 18.

North Dakota CAHs Recognized in Top 20

Best Practice Recipients – Quality

2026 North Dakota Flex Annual CAH and RHC Meeting

Held on April 14 at the Bismarck State College's National Energy Center of Excellence, this year's Flex annual meeting was the best-attended yet. The full day consisted of topics ranging from building a resilient leadership culture to a panel discussion on opportunities and lessons learned from North Dakota CAHs that conducted financial assessments and productivity analyses. Attendees also heard from the North Dakota Emergency Medical Services Association on regional networking opportunities, and from our state surveyors on the top CAH and RHC deficiencies.

Flex Team Presents at Dakota Conference on Rural Health

From left, Anna Walter, Kari Novak, ArvaDell Sharp, and Anahita Anvari-Clark.

Two abstracts were accepted to be presented at this year's Dakota Conference on Rural Health, held June 3-4 in Grand Forks. Anna Walter and Anahita Anvari-Clark presented on the CAH Quality Network and the RHC Network. They were joined by Kari Novak, clinic manager at Unity Medical Center's Grafton and Park River clinics, and ArvaDell Sharp, quality improvement and care coordinator at Pembina County Memorial Hospital, who shared their perspectives with their respective Networks.

From left, Anna Walter, Montana Halberg, Stephanie Fugleberg, and Kristen Jung.

Anna Walter presented on the success of the Emergency Department Transfer Communication (EDTC) cohort. She was joined by Stephanie Fugleberg, inpatient nurse manager at Sanford Mayville Medical Center; Montana Halberg, RN at Altru Hospital Devils Lake; and Kristen Jung, quality risk manager at West River Health Services in Hettinger. The cohort participants shared their Plan Do Study Act (PDSA) plans and lessons learned.

Flex Team Receives National Award for Quality Improvement

From left, Ann Loges, Anna Walter, and Lorraine Burton.

In July, the Flex team traveled to Washington, D.C. for the annual Flex Reverse Site Visit, hosted by the Federal Office of Rural Health Policy and its program partners.

Over three days, Flex program staff from across the country shared insights, networked, and connected, which helped inspire new ideas and opportunities for the work we do in North Dakota.

From left, Anahita Anvari-Clark, Anna Walter, Thomas Engels and Jody Ward.

Anna Walter co-presented with Rural Quality Improvement Technical Assistance (RQITA) at the National Flex Reverse Site Visit on the structure of the recently completed EDTC cohort.

Also at the meeting, the North Dakota Flex Program received the inaugural Flex Quality Improvement Award, recognizing our work in the Quality Improvement area of our workplan.

New Activity – Quarterly Quality Improvement (QI) Calls

This past year, the Flex team began hosting quarterly calls for QI leaders and staff to provide a space to ask questions and learn from other quality peers around the state. They provided time to learn more about the Medicare Beneficiary Quality Improvement Program (MBQIP) measures and hear how others are improving their reporting and/or outcomes.

MBQIP Data Reporting Reminders

Upcoming deadlines:

  • October 14 – Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Q2 2026 data
  • November 2 – EDTC (Q3 2026)
  • November 2 – OP-18 (Q2 2026)
  • November 20 – CAH Quality Infrastructure and Assessment

For questions or technical assistance, please contact:

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

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

Rural Health Clinic Network

Strengthening Chronic Care Management Across Rural North Dakota

The Chronic Care Management (CCM) cohort helped five participating Rural Health Clinics (RHCs) strengthen and expand their CCM programs by developing standardized workflows for patient identification, referrals, enrollment, care planning, documentation, billing, and reimbursement. Across the cohort, organizations increased active enrollment, strengthened provider and interdisciplinary engagement, and improved processes to support the long-term sustainability of care management services. Several organizations also demonstrated positive patient outcomes, including improved medication management, better chronic disease self-management, and reductions in unnecessary healthcare utilization.

By the end of the project, participating organizations had moved beyond initial implementation challenges and established stronger infrastructure, performance monitoring, and processes to support continued growth and quality improvement in CCM. Throughout the next grant cycle, Flex will continue to work with a subject matter expert to provide ongoing technical assistance to stabilize and mature the participating RHCs' CCM programs.

RHC Financial and Operational Benchmarking: Turning Trends into Action

In April, North Dakota RHC leadership and clinic managers came together to attend a full-day workshop in Bismarck to review updated financial and operational benchmarking data and best practices. A subject matter expert worked to re-evaluate the current benchmarking system and identify indicators that best meet the action-oriented needs of our state's RHCs. Using the most current Medicare Cost Report data, the analysis compared current performance with previous years to identify multi-year trends and noteworthy performance at the individual clinic level.

The workshop provided an opportunity for RHCs to network, review the findings, discuss financial and operational best practices related to the indicators and benchmarks, and learn from one another. The sessions focused on practical, actionable strategies that RHCs can use to strengthen their financial and operational performance.

Financial/Operational Improvement

Year Two of North Dakota Behavioral Health Cohort Completed

Four Critical Access Hospitals (CAHs) have completed year two of a three-year project related to creating, improving, and/or expanding a behavioral health program at their hospital. They continue to work with a subject matter expert to develop knowledge and skills to address the identified behavioral health gaps in their community. Year two focused on strengthening community partnerships, and year three will conclude with topics around sustainability.

Thank you to the following participants:

CAH Productivity/Financial Assessments

Sakakawea Medical Center, in Hazen, and First Care Health Center, in Park River, were selected to partner with Eide Bailly to participate in a comprehensive productivity analysis. Additionally, Northwood Deaconess Health Center, in Northwood, and Jacobson Memorial Hospital, in Elgin, were selected to complete an individual financial and operational assessment, both designed to identify opportunities for improvement and long-term sustainability.

The participating hospitals provided data for benchmarking against state and regional rural hospital peers, received customized reports highlighting key priorities and actionable recommendations, and engaged in follow-up coaching over a six-month period to support implementation of identified improvements. The participating CAHs also shared their experiences as part of a panel discussion during the 2026 North Dakota Flex CAH and RHC Annual Meeting, which helped other rural hospitals learn from their successes and challenges.

North Dakota CAHs Received Funds to Implement F/O Projects

Six CAHs received funding during the 2025-2026 grant year to assist with financial/operational (F/O) improvement projects. They include:

Emergency Medical Services Improvement

CAH and EMS Region Meetings

Four region meetings were held in the past year. Facilitated by the North Dakota Emergency Medical Services Association (NDEMSA) regional advisors, these Critical Access Hospital (CAH) and EMS collaboration meetings give hospital leadership, ambulance services, and NDEMSA advisors a recurring forum to share operational challenges and work through them together rather than in isolation. They also serve as a practical channel for spreading solutions that are already working in one area to other communities facing the same gaps.

Looking Ahead: September 1, 2026 – August 31, 2027

CAH Quality Network

  • Save the Date for the 2027 North Dakota Flex Annual CAH and RHC Meetings – The annual meeting will be held April 13. This will be followed April 14 with two separate educational workshops, one related to Conditions of Participation (CoPs) and one on Year Five RHC Financial and Operational Benchmarking and Best Practices.
  • Mini Education Series on Quality Improvement (QI) topics – We will be hosting virtual mini-education sessions related to quality measures and improvement strategies. Keep an eye out for calendar invites and topics.
  • Targeted QI Support – The Flex program will continue to review MBQIP data reports to identify lower-performing measures and provide targeted quality improvement support to Critical Access Hospitals (CAHs).

RHC Network

  • Save the date for the Virtual Practice Manager Workshop – Scheduled to be held November 17 and 19.
  • Chronic Care Management Cohort – Five RHCs will continue to receive support from a subject matter expert (SME) to ensure a strong foundation for the Chronic Care Management (CCM) program they have developed. Additional funding will be available for two more RHCs to develop a CCM program within their clinic with support from a SME.
  • Year five RHC Financial and Operational Benchmarking and Best Practices Workshop – Scheduled for April 14, 2027, in Bismarck, following the 2027 North Dakota Flex Annual CAH and RHC Meetings.

Financial and Operational Improvement

  • CAH Billing and Coding Bootcamp – We will be hosting a Virtual CAH Billing and Coding Bootcamp on January 26-27, 2027. The two-day webinar will cover what revenue cycle and coding/billing staff in CAHs need to know related to documentation, professional and facility coding, and medical billing processes.
  • North Dakota CAH Subcontract Program – Flex funding will be available through a request for proposal (RFP) process for CAH financial/operational improvement areas. All North Dakota CAHs and their CAH-owned RHCs are eligible to apply.

EMS Improvement

  • These activities are Flex-funded through a subcontract with NDEMSA:
    • CAH and EMS regional meetings
    • EMS management and leadership training
    • Train-the-trainer suicide prevention training for EMS personnel

Additional Resources

Email Listservs

Did you know we have Director of Nursing (DON), Quality Improvement (QI), and Rural Health Clinic (RHC) Manager email listservs? This tool allows you to email questions, policy requests, or ask for other feedback directly to your peers using the listservs.

Important reminders on using the listservs:

  • When replying to a question or request, the replies go to everyone on the list! This is intentional, as the purpose of the listserv is to share and gain resources among our peers in the state.
  • If you have a question that may be sensitive and you want to share anonymously, you can send it to Anna or Anahita, and we will reach out to get responses.
  • Please ensure there is no protected health information included with your question, response, or any resources you share.

Flex Virtual Library

The Flex Virtual Library is a free, password-protected platform where you can access recordings of previous educational webinars related to Conditions of Participation (CoP), CoP state survey sharing calls, MBQIP, and more.

Email Anahita Anvari-Clark, clinical project coordinator, for your facility's log-in information and how to access the library.

Are You New to Your Role or Organization?

Please email either Anna Walter or Anahita Anvari-Clark for a one-hour orientation on the Flex Program, the CAH Quality Network, and MBQIP Program.

If you are a new RHC manager, please contact Anna Walter, project coordinator, for a one-hour orientation on the RHC Network.

Upcoming Meetings

  • October 7 – Patient and Visitor Illegal Substances in the Emergency Department
  • October 8 – DON Networking Meeting – CAH Quality Network
  • October 20 – Clinic Manager Meeting – ND RHC Network
  • October 29 – CoP Education: Physical Plant/Life Safety – Nash Consulting*
  • November 5 – ND CAH Antibiotic Stewardship Learning Collaborative
  • November 12 – DON Networking Meeting – CAH Quality Network
  • November 17 – Virtual Practice Manager Workshop*
  • November 19 – Virtual Practice Manager Workshop*
  • December 8 – ND RHC Network Advisory Committee Meeting
  • December 10 – ND CAH Quality Network Statewide Meeting
  • December 15 – Clinic Manager Meeting – ND RHC Network
  • December 16 – QI Networking Meeting – ND CAH Quality Network
  • December 17 – DON Networking Meeting – CAH Quality Network
  • December 17 – Mini QI Education Webinar*

*Calendar invites will be sent once vendor contracts are completed.