Building on national efforts to develop Emergency Medical Services (EMS) performance measures, the Flex Monitoring Team sought to identify measures relevant to the rural communities and hospitals supported by the Flex Program. By conducting a literature search to review research on performance measures used by key EMS organizations, and by impaneling a group of EMS experts to identify and rate rural-relevant EMS performance measures, this study established 17 performance measures to support EMS services in rural communities. The measures monitor the capacity of local agencies to collect and report quality and financial data, use the data to improve agency performance, and train rural EMS employees in emergent protocols for all age groups. With these measures, the Federal Office for Rural Health Policy can further its goal of better focusing State Flex Program activity to improve its impact on the performance of rural EMS services in the areas of financial viability, quality improvement, and local/regional health system performance.