This study examined QI activities supported by the Flex Program in nine states, assessed the role of the State Flex Programs in developing and supporting QI activities, and explored the effect of these initiatives on CAH QI efforts.

Key Findings:

• The Flex Program has been instrumental in funding and providing leadership for the development of CAH quality improvement initiatives.
• Collaborative shared learning strategies have been central to the success of Flex Program QI programs.
• Scaling QI program activities to the capacity and resources of CAHs is critical to success.
• Administrative, clinical, and board leadership and buy-in are also critical to the success of CAH QI initiatives.
• Despite widespread support for these QI initiatives, there is limited hard evidence on their impact.
• Overlap between the quality measures in Hospital Compare and those used by state and multi-state QI reporting and benchmarking programs offers the opportunity for developing a common set of “rural relevant” hospital quality measures.