Due to limited resources, low patient volume, small staffs, and inadequate information technology, CAHs face many challenges in implementing quality improvement initiatives. The Flex Monitoring Team conducted a national telephone survey of 72 CAHs, along with two in-depth case studies, to describe key quality improvement initiatives by hospitals actively involved in initiatives with support hospitals and statewide organizations. The study found that many CAHs are successfully implements quality improvement activities, including patient safety initiatives. CAHs are involved with multiple external organizations in these activities, and for the two case study hospitals, administrators made quality improvement a priority for their organizations. Key factors in quality improvement activities include cost-based Medicare reimbursement for funding additional staff, trainings, and equipment, as well as the commitment of hospital leaders and key staff.