Tuesday, January 31, 2023

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

Cheri Fast and Jessica Danko first in the NATION to be awarded the CBIC Long-Term Care Certification in Infection Control

Congratulations! Cheri Fast and Jessica Danko, South Dakota Foundation for Medical Care project managers, are among the first in the NATION to be awarded the...

Quality Corner: Quality data due 1st quarter of 2023

The quality team at SDAHO wants to remind participating member hospitals of the quality data due for the first quarter of 2023. These items...

Quality Corner: A Successful Year

As 2022 wraps up, the SDAHO Quality Integration team wants to thank you for your commitment over the past year. We have seen tremendous...


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
  • 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
To learn more about process improvement tools to help you manage your improvement project click here.  


The South Dakota Association of Healthcare Organizations excited to is offer, once again, the online HQ Principles Course: Fundamentals for Healthcare Quality and Safety Professionals. This is a self-paced, online course through the National Association of Healthcare Quality (NAHQ) to assist frontline quality staff in South Dakota Critical Access Hospitals with quality certificate. This opportunity is made possible through the South Dakota Flex Grant for quality professionals at South Dakota Critical Access Hospitals with no cost to attendees.

HQ Principles is an on-demand certificate program that instills key learnings about quality and patient safety to healthcare professional and leaders. Participants must complete the course by May 31st, 2023.

The program, which takes approximately five hours to complete, provides a clear understanding of healthcare quality through six learning modules:


  1. The Evolution of Healthcare Quality
  2. Principles of Quality Improvement and Patient Safety
  3. Quality Improvement Processes and Methods
  4. Using Data to Make Decisions
  5. Teamwork at All Levels (Stakeholders)
  6. Putting IT ALL TOGETHER: Driving Quality into the Future

Upon completing the modules and passing the post-test, you’ll earn an HQ Principles certificate. This certificate validates your knowledge and understanding of patient safety and quality of care as well as key principles, tools and methodologies needed for quality improvement.  This program is approved for 5.75 nursing contact hours.


  • Individuals new to healthcare quality
  • Individuals with newly added responsibilities in healthcare quality
  • Healthcare quality leaders seeking quality-focused education for their team

Click here to register for the class. Once you register, you will receive and email from Klari Carlson, SDAHO’s Office Assistant, with information on how to log into the class.

The project/publication/ program and website are supported by the Health Resources and Services Administration (HRSA), which is part of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $136,374 The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by HRSA, HHS or the US Government.