Global Measures
View the global measures report of your hospital.
Reports
The Global Measures Quality Reports present each Critical Access Hospital’s self‑assessment across the eight core elements of quality infrastructure—leadership, strategy, workforce engagement, culture of continuous improvement (behavior & systems), patient/community engagement, meaningful data collection, and data‑driven improvement. Hospitals receive one point per element (0‑8 total), giving a concise snapshot of capacity and helping states target technical assistance where it will have the greatest impact.
Using Comparison Data for Global Measures
Global Measures Quality Reports provide facility‑level and aggregate results to illuminate strengths and gaps in quality infrastructure. Each report includes the following comparison groups:
- All reporting CAHs in your state (column CAH State Current Quarter)
- All reporting CAHs nationally (column CAH National Current Quarter)
- Top‑decile benchmark for robust quality infrastructures (column 90th Percentile)
While averages highlight the mid‑range, hospitals should aim to achieve all eight elements—and reach or exceed the 90th‑percentile benchmark—to build a resilient, organization‑wide foundation for continuous quality improvement.
Measure Information
Core elements
- Leadership Responsibility & Accountability
- Quality Embedded within the Organization’s Strategic Plan
- Workforce Engagement & Ownership
- Culture of Continuous Improvement through Behavior
- Culture of Continuous Improvement through Systems
- Engagement of Patients, Partners, and Community
- Collecting Meaningful and Accurate Data
- Using Data to Improve Quality
Measure Rationale
This measure will provide state and national comparison information to assess your CAH infrastructure, QI processes, and areas of improvement for each facility. Using this measure, SFPs can plan quality activities to improve CAH quality infrastructure. Data will provide timely, accurate, and useful CAH quality-related information to help inform state-level technical assistance for CAH improvement activities. This measure will provide hospital and state- specific information to help inform the future of MBQIP and national technical assistance and data analytic needs. The intention is to identify areas of need in quality infrastructure and capacity in order to implement continuous processes.
Population and Definitions
The unit of measurement is an individual CAH. This structural measure captures assessment data from individual CAHs as they reflect on the infrastructure capacity specific to their facility.
Answers for the measure should reflect the current point in time unless otherwise specified (e.g., if a question asks about a quarterly or an annual process, is that process in place at the current point in time). CAHs should attest to the information only where they completely meet the description in the question response(s) for the correlating criteria and elements.
Calculations
Hospital score can be a total of zero (0) to eight (8) points (one point for each element, must meet each of element’s criteria to receive credit).