Quality Integration

Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents the wise choice of many alternatives.” ~William A. Foster

Welcome to the Quality Integration page! We are excited to offer you the latest information, resources in healthcare quality. On this page you will find information for all things Quality related including Organizational Leadership, Patient Safety, Process Improvement, and Hospital Resources to name a few. The intent is to provide a one stop shop so you no longer need to go several websites to gather information instead you can visit the Quality Integration page and find the resources you need. We are excited to be on this journey with you and provide the resources and the support you need to be successful in your role.

SDAHO Quality Integration department vision statement is to be the Leading Experts in Quality which directly supports SDAHO mission of Advancing healthy communities through a unified voice across the health care continuum. The Quality Integration work occurs under the SDAHO Healthcare, Research Education, Trust (HRET) which is a 501c3 non-profit corporation. If you have questions or need assistance, please do not hesitate to the contact the SDAHO Quality team. Our contact information is listed below. Any one of us is happy to assist.

  • Loretta Bryan, Clinical Improvement Consultant, Loretta.Bryan@sdaho.org, 605-789-7531
    • Loretta supports hospitals located South of I-90 and the Black Hills Region
  • Michelle Hofer, Clinical Improvement Consultant, Michelle.Hofer@sdaho.org, 605-789-4995
    • Michelle supports the hospitals located North of I-90 and Southeastern Minnesota
  • Becky Heisinger, Director of Quality Integration, Becky.Heisinger@sdaho.org, 605-789-7529
Click on the buttons below to view more information


Avoid Opioid SD
Avoid Opioid SD is a joint effort between the South Dakota Department of Health and Department of Social Services to address opioid abuse and misuse in the state as part of the South Dakota Opioid Abuse Strategic Plan.
Great Plains Quality Innovation Network
Great Plains Quality Innovation Network (QIN) is the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Kansas, Nebraska, North Dakota and South Dakota. The development of Great Plains QIN reflects changes to legislation that impacts the structure of the QIO program. Great Plains QIN partner organizations have a long history of working collaboratively together, serving as their state’s QIO and improving the quality and efficiency of healthcare in the region.
South Dakota Foundation for Medical Care
The South Dakota Foundation for Medical Care (SDFMC) is committed to improve quality of care and to ensure all patients receive the right care, at the right time, every time. As the designated QIO-Like Entity for South Dakota, SDFMC performs medical case review for Medicaid patients across the state.
Quality Improvement Resource Guide
The purpose of this guide is to familiarize you with quality improvement processes as a way of improving clinical quality. While many of the examples within the guide are related to cardiovascular disease, the quality improvement process can be applied to any process or condition where improvements are needed.
Team-Based Care Toolkit
Team-based health care is the provision of health services to individuals, families, and/or their communities by at least two health providers who work collaboratively with patients and their caregivers—to the extent preferred by each patient—to accomplish shared goals within and across settings to achieve coordinated, high quality care.
Agency for Healthcare Research and Quality
The Agency for Healthcare Research and Quality (AHRQ) is the federal agency charged with improving health care through research.
The portion of Hospital Compare that displays information on patient perspectives of their hospital care.
Hospital Compare
A web site that displays information about inpatient hospital care.
Institute for Healthcare Improvement (IHI)
The Institute for Healthcare Improvement is a national organization that provides a number of free resources for quality improvement.
Institute for Safe Medication Practices
The Institute for Safe Medication Practices (ISMP) is a not-for-profit organization that works closely with healthcare practitioners and institutions, regulatory agencies, professional organizations and the pharmaceutical industry to provide education about adverse drug events and their prevention.
A business-sponsored, membership organization that seeks to publish information on hospital quality and safety practices.
National Quality Forum
The National Quality Forum (NQF) strives to improve health care through the endorsement of consensus-based national standards for measurement and public reporting of healthcare performance data.
Quality Check
The Joint Commission publishes information on hospital quality on its Web site “Quality Check.”
The Joint Commission
This national organization inspects hospitals to ensure they meet certain quality standards.

Quality News

Quality Corner: Observing Healthcare Quality Week October 15-21, 2023

The South Dakota Association of Healthcare Organizations (SDAHO) recognizes the hard work and dedication of all healthcare quality professionals as we make plans to...

Quality Corner: Workplace Violence in Healthcare: Has Your Facility Taken Action?

Workplace violence in healthcare is a serious concern. Workplace violence in healthcare is a growing concern. Did you know that of the victims experiencing trauma from...

CDC Launches Sepsis Program for Hospitals

The Centers for Disease Control and Prevention (CDC) Aug. 24 announced the launch of its Hospital Sepsis Program Core Elements initiative, a new program...


Purpose of MBQIP:  MBQIP is a quality improvement activity under the Federal Office of Rural Health Policy’s (FORHP) Medicare Rural Hospital Flexibility (Flex) grant program. Launched in 2011, the goal of MBQIP is to improve the quality of care provided in critical access hospitals (CAHs) by increasing quality data reporting by CAHs and then driving quality improvement activities based on the data. MBQIP provides an opportunity for individual hospitals to look at their data, compare their results against other CAHs, and partner with other hospitals around quality improvement initiatives to improve outcomes and provide the highest quality care to every patient. MBQIP/Flex program is brought to you by the SD Office of Rural Health. The SD Flex Coordinator is Michelle Hoffman. If you have questions on how this program is administered, please contact Michelle at: Michelle.Hoffman@state.sd.us

Did you know?

Did you know that by participating in the MBQIP/Flex program, SD hospitals have received benefits such as:

  • CPHQ exam preparation
  • Access to Antibiotic Stewardship education,
  • Trauma webinar series through SD Trauma program,
  • Emergency Nurse Pediatric course
  • Revenue cycle trainings,
  • Charge master reporting tool
  • Billing and coding education
  • Individual hospital performance improvement projects
  • Various Quality speakers

Without your participation in MBQIP/FLEX, these programs and benefits would not be available.

This table lists the core MBQIP Measure for South Dakota. There are 4 domains: Patient safety/inpatient, patient engagement, care transitions and outpatient. Currently, South Dakota hospitals, at a minimum, are required to be reporting from one measure under each domain per quarter.

Below is information that will help to answer questions you may have or provide you with additional resources. If you are not finding the information you are looking for, please contact the SDAHO Quality Team by emailing Loretta.Bryan@sdaho.org or Michelle Hofer at Michelle.Hofer@sdaho.org.

HCP/IMM-3 (formerly OP-27): Antibiotic Stewardship:
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS):
Emergency Department Transfer Communication (EDTC):
AMI (OP-2 & OP-3): ED Throughput Measures (OP-18): Patient left without being seen (OP-22):
  • This data is collected yearly and entered into HARP
  • MBQIP Monthly April 2022: Scroll to page 4, you will find detailed instructions on how to enter OP-22 into HARP
  • To check if your OP-22 data has been received by CMS, please click here and type in your hospital 6-digit CNN number. Click enter and you will see information stating Yes/No about your OP-22 data. Please note the dates the page was last updated to ensure you did not submit after that timeframe.
  • Resources
  • How to set up a new account in HARP: Both steps need to be done to be able to enter data into HARP
    • Step 1: Click here and follow video instructions on HARP Registration Training Video
    • Step 2: Click here and follow the instructions under “To Register as a Basic User or Security Administrator/Official in the new Hospital Quality Reporting (HQR) System. We recommend asking for Security Administrator/Office.
  • When you register, you will have 2 different webpages to use for HARP. Your same username and password can be used on both pages; however, your HARP data gets uploaded to the Hospital Reporting Page (#2 below)
    1. HCQIS Access Roles and Profile page = HARP Access Roles and Profile link
    2. CMS.gov: Hospital Quality Reporting page = HARP Hospital Quality Reporting link



HQIC stands for Hospital Quality Improvement Contractor. SDAHO is contracted with Iowa Health Collaborative (IHC) to support hospital efforts to increase patient safety and improve quality of care. This is the fourth Centers for Medicare and Medicaid (CMS) led hospital quality improvement program since 2012. It is a national initiative which began in 2020, continues through 2024, and is designed to support critical access hospitals, and hospitals that are low performing and serve vulnerable populations. IHC and partner organizations collectively known as the Compass Network includes SDAHO, Kansas Healthcare Collaborative, and Mississippi Hospital Association. IHC’s mission is to facilitate exceptional healthcare quality, safety, and value in the nation. HQIC guiding themes are:  Patient Centered, High Reliability and Culture of Safety, Strategic Partnerships and Collaboration, and Partnering Beyond the Quality Team. The data collected for this project is entered into the Compass Data Portal and NHSN. We highly encourage entering data monthly, the data is due 45 days after the month end.

Did you know? 

Did you know that participating in the HQIC program provides benefits such as:

  • Responding to emerging patient safety issues via an agile and responsive approach
  • Evaluating population-based data that is specific to the facility or area of the country
  • Access to patient level data for quality improvement efforts
  • Education and networking opportunities
  • Participating in a program specifically designed for Critical Access Hospitals
  • Facilitating healthcare transformation through identification, use and spread of evidence-based practice
  • Access to quality improvement guidance via state-specific quality consultant
  • Ongoing action to adapt and test practices in support of achieving the following goals:
    • Goal 1: Improve Behavioral Health Outcomes with a focus on decreased opioid misuse
    • Goal 2: Increase Patient Safety with a focus on reduction of harm
    • Goal 3: Increase the Quality-of-Care Transitions with a focus on high utilizers in an effort to improve overall utilization

Below is information that will help to answer questions you may have or provide you with additional resources. If you are not finding the information you are looking for, please contact the SDAHO Quality Team by emailing Loretta.Bryan@sdaho.org or Michelle.Hofer@sdaho.org

  • Orientation guide
    • This orientation guide is very important to any new quality improvement professional. It is the first step in learning about the Compass HQIC, including its measures, resources and much more.  Please read through it carefully and follow any instructions.
    • Compass HQIC Network Overview
  • Getting started: Compass Checklist
    • Follow the 3 steps on this form to get connected, registered for Compass education, and get access to the Compass Portal. We encourage you do the 3 steps as soon as possible when first starting the HQIC program.
Compass HQIC self-reported data is due into the portal 45 days from the month end. For example: January data would be due March 15th.
  • Compass HQIC Measure Set
    • This measure set serves as a guide for the states within our HQIC network (including SD) on each individual measure.
  • Review the key closely at the top of the measure set to better understand the data sources. Some measures are required, and some are optional. Please note data sources include:
    1. Self-reported (Compass portal)
    2. Administrative claims
    3. NHSN
  • Specific resources under each measure set section are listed in the next tab called “Measure Set Resources”.
  • Central Line Associated Blood Stream Infections (CLABSI)
    • This is reported in the NHSN portal monthly
    • FAQs: Bloodstream Infection (BSI) Events this site has a great amount of information about CLABSI.
    • If you would like to email NHSN to verify a CLABSI- use the FAQ link above and scroll to number Q31. It will tell you exactly how to email them and what template to use.
    • NHSN Healthcare‐associated Infection (HAI) and Present on Admission Infection (POA) Worksheet Generator - This calculator on the NHSN website provides a working document to help guide hospitals in identifying Healthcare-associated infections.   It helps identify the 7-day window period, date of event, present on arrival, Healthcare-associated infection determination, 14 days repeat infection, and secondary bloodstream infection attribution period
  • Health Equity Organizational Assessment (HEOA)
    • These questions are on the Compass portal and are answered bi-annually.
    • A three-part course on HEOA – This course is very helpful going through each question on the HEOA assessment.
  • Patient and Family Engagement (PFE)
  • iCompass Academy eLearning this website has multiple educational opportunities. It is free and we recommend all Compass users register for this website.
  • REAL Readmission Report Guide
  • Health Equity Pledge
    • Health Equity Roadmap - This document explains the Health Equity Pledge and gives an excellent roadmap on health equity.
  • SMARTIE Goals
    • SMARTIE goals require us to think of inclusion and equity in setting goals that will
      lead to better outcomes and the change we are all working toward

NHSN stands for National Healthcare Safety Network. It is a secure, internet-based surveillance system managed by the Centers for Disease Control and Prevention. Data entered NHSN include vaccination coverage among healthcare personnel, antibiotic stewardship, and patient safety component. The patient safety component includes MDRO (multidrug-resistant organisms), procedure-associated module and the device-associated module.

** the NHSN items and guidance contained here are specific to FLEX/MBQIP and Compass HQIC programs and may not include all details for other hospital specific data entry requirements

Did you know?
  • CDC’s National Healthcare Safety Network is the nation’s most widely used healthcare-associated infection tracking system.
  • NHSN began decades ago, starting with 300 hospitals but now serves over 25,000 medical facilities.
  • Current participants in NHSN data tracking include acute care hospitals, long-term care acute care hospitals, psychiatric hospitals, rehabilitation hospitals, outpatient dialysis centers, ambulatory surgery centers and nursing homes.
  • NHSN provides facilities, states, regions, and the nation with data needed to identify problem areas, measure progress of prevention efforts, and ultimately eliminate healthcare-associated infections.
  • NHSN allows healthcare facilities to track blood safety errors and important healthcare process measures such as healthcare personnel influenza vaccine status and infection control adherence rates.
  • While ensuring data security, integrity, and confidentiality, NHSN gives healthcare facilities the ability to see their data in real-time and share that information with clinicians and facility leadership, as well as with other facilities (e.g., a multihospital system) and partners such as health departments or quality improvement organizations. CDC provides the standard national measures for HAIs as well as analytic tools that enable each facility to assess its progress and identify where additional efforts are needed.
  • NHSN is the conduit for facilities to comply with Centers for Medicare and Medicaid Services (CMS) infection reporting requirements.
  • NHSN data is posted publicly on the Department of Health and Human Services’ Hospital Compare website for patients’ use.
  • Determine if your facility is enrolled in NHSN and/or find the name of facility administrator: click here.
  • Acute Care Hospital 5-Step Enrollment
  • CAH Enrollment Guide
  • Reassign facility administrator with current facility administrator still available:
    1. If the current facility administrator is still at the facility but need to reassign the role: To make the change as the present facility administrator, go to left navigation panel. Select > Facility> then > Add/Edit component>. Select Reassign, a pop-up will appear asking you to find and select an existing user or add a user who will be reassigned this role. Select their name and then select the Reassign button at the bottom of the page.
      • Request access if NO site administrator/Facility Administrator Reassignment: click here
  • Add an additional user to a facility (must be done by assigned administrator):
    1. After selecting NHSN reporting, from the left navigational bar, click on Users>ADD and complete the required fields (marked with *) and SAVE at the bottom of the page. You will then be prompted to assign the new user rights needed to use NHSN. Click SAVE at the bottom of the page. To get access to NHSN, users must have an active SAMS account. If users are not active in SAMS, after being added as a user they will receive a Welcome to NHSN email. They should follow the prompt to accept the Rules of Behavior which will prompt the SAMS invitation.
Patient Safety Component (PCS) Training - on this page, you will find:
  1. NHSN overview: 8-minute video on navigating in NHSN. Scroll to PSC/Quick Learns and click on video under Navigating the NHSN Application.
  2. Mapping: 10-minute video on how to determine your populations in NHSN for location mapping: Scroll to PSC overview and click on video under Patient Safety Component Location Mapping.
  3. HAI Present on Admission - scroll to PSC overview/Quick Learns and click on video under Determining Health Care Association or Present on Admission Infections and other Rules.
Most of your NHSN data will be under Patient Safety Component, however your annual flu summary will be under Healthcare Personnel. See additional information on Annual Flu Survey in the tab below.
  1. What does this mean? Hospitals need to give rights to SDAHO and the Iowa Health Collaborative (both are important) to allow us to see your data. We put this data into run charts and help you interpret what your data means. Also, by seeing your data we can best serve you with education in the NHSN portal.
  2. Here are instructions on how to confer rights with the Iowa Health Collaborative.
  3. To Confer Rights with SDAHO, follow the same guidelines in the instructions above, but use the number 48047 – SD HINN (SDAHO) instead.
  • We recommend putting your reporting plan in for 1 full year after you finish your Annual Survey. The video below will show you how to enter your reporting plans, you can do multiple months at one sitting, or you can add your reporting plan each month before entering your data. If you put in the full year at one sitting, then the missing data link will show up at the end of the reporting month.
  • Quick “How To” video: How to Enter a Reporting Plan into NHSN
  • We highly encourage you to enter your data monthly. This allows better tracking of your data and will keep your records more in real time.
  • Currently, CMS and the HQIC program require hospitals to enter data into the NHSN portal for:
    • CLABSI
    • CAUTI
    • C-diff
    • MRSA
    • CRE
  • Quick “How To” video: How to Enter Monthly Data into NHSN
  • If you think you have a CAUTI, CLABSI or C-diff event, the video below gives one example of how to enter this data into NHSN. However, if you are not sure if it qualifies as a true event, we recommend you:
    • Contact your SDAHO consultant for additional support.
    • Email NHSN for clarification.
      • To email NHSN on CAUTI Clarification: FAQs: UTI Events Scroll to bottom of the page and follow directions under Q20.  Most hospitals are hearing back in about 2 weeks.
      • To email NHSN on CLABSI Clarification: FAQs: BSI events Scroll to bottom of the page and follow direction under Q31.  Most hospitals are hearing back in about 2 weeks.
    • Quick “How To” video: How to Enter an Event into NHSN
Additional CAUTI education: Additional CLABSI education:
  • BSI Training . This link has multiple videos and slides on CLABSI education.  Here are some of the most common:
    • Self-paced Training – CLABSI training
    • Quick Learns – Denominator Device Day and Central Line Day Counts for Device Attribution
    • Quick Learns – Secondary Bloodstream infections.
    • Quick Learns – BSI Definition changes.
  • FAQs: Bloodstream Infections (BSI) Events
  • Your annual survey will need to be completed each year by March 1. You will be entering data for the previous year.  For example, in 2023, by March 1 you need to have your 2022 annual report finished. NHSN will not allow you to put in more reporting plans after March of 2023 until your annual survey questions are completed.
  • Quick “How To” video: How to Enter your Annual Survey into NHSN
  1. Log into Compass Portal:  https://compassdataportal.ihconline.org/Account/Login
  2. Click on “Report” on the left side of the screen and select “Run Charts” or “Dashboard” from the drop-down menu, depending on the type of report you would like to run
  3. Enter the start and end date for the time frame you are interested in
  4. Select the Focus Area specific to data you enter into NHSN
  5. Select the Measures specific to the focus area
  6. Click “Generate Report” button at the top of the screen
*NHSN data in the Compass Portal is updated around the 10th of every month