Organizations


Rural Center
National Rural Health Resource Center

Collaborating and innovating to improve the health of rural communities

The Center is a nonprofit organization dedicated to sustaining and improving health care in rural communities. It focuses on five core areas: Transition to Value and Population Health, Collaboration and Partnership, Performance Improvement, Health Information Technology, and Workforce.

Rural Health Info
Rural Health Information Hub

Your First STOP for Rural Health INFORMATION

The Rural Health Information Hub, formerly the Rural Assistance Center, is funded by the Federal Office of Rural Health Policy to be a national clearinghouse on rural health issues. They provide access to current and reliable resources along with tools for learning about rural health needs and ways to address them.

Texas Department of Agriculture
State Offices of Rural Health

Commissioner Sid Miller

The Texas State Office of Rural Health (SORH) joined the Texas Department of Agriculture in October 2011. Dedicated to serving the health needs of rural Texas, SORH staff work with local health care providers, county leaders and state partners to support access to quality health care for rural Texans.

Stratis Health
Stratis Health

Leading collaboration and innovation in health care quality and safety

Stratis Health, based in Bloomington, Minnesota, is a nonprofit organization that leads collaboration and innovation in health care quality and safety, and serves as a trusted expert in facilitating improvement for people and communities.

Texas Hospital Association
Texas Hospital Association

Leading change to support all Texas hospitals to deliver accessible, affordable, high-quality health care

Serving Texas hospitals as the trusted source and unified voice to influence excellence in health care for all Texans. Leading change to support all Texas hospitals to deliver accessible, affordable, high-quality health care.

MBQIP Data Abstraction Training Series

This recorded training series is for critical access hospital (CAH) staff with responsibility for data collection of Centers for Medicare & Medicaid Services (CMS) Inpatient and Outpatient quality measures. Pick individual topics that you have questions about, or listen to the full series for a comprehensive overview of the process to identify each measure population and abstract the required data elements. To view with captions, click the "CC" icon in the lower right of the video.

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EDTC Specifications Manual Training

A step-by-step guide on how to download the Excel-based data collection tool, enter data, and run reports to calculate your measures along with a guided overview of how to abstract the EDTC measure using the Data Specifications Manual.

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Guides

MBQIP guidelines with respect to the whole program
Link Guide Last Updated Description
MBQIP Data Submission Deadlines June 2022 Updated data submission deadlines.
MBQIP Quality Reporting Guide April 2022 This guide is intended to help Flex Coordinators, critical access hospital (CAH) staff and others involved with the Medicare Beneficiary Quality Improvement Project (MBQIP) understand the measure reporting process. For each reporting channel, information is included on how to register for the site, which measures are reported to the site and how to submit those measures to the site.
MBQIP Data Reporting Reminders October 2022 State Flex Coordinators can tailor this template as needed and send to critical access hospitals (CAHs) reminding them of upcoming data submission deadlines for Medicare Beneficiary Quality Improvement Project (MBQIP) measures, as well as corresponding collection time periods and submission processes.
Quality Director Handbook August 2018 The Quality Director Handbook was created in response to a specific request from hospitals participating in the CAHQI project. The intent of the document is to provide up-to-date information, guidance, and resource links to those managing quality programs in critical access hospitals, with special attention toward those that may be new to the role. For questions or comments regarding the handbook, contact Karen Kendrick at (512) 465-1091 or Sheila Dolbow at (512) 465-1026.
Abstracting for Accuracy Project June 2021 This project offers an opportunity for critical access hospitals (CAHs) to participate in an abstracting review process to help increase the validity of data collection and identify opportunities for additional training and clarification as it relates to chart abstraction. Review the Project Description and Guidelines for more information and to learn how to sign up.

Measures

Resources related to specific measures
Link Name Last Updated Description
MBQIP Measures February 2021 Chart outlining the required and optional MBQIP measures. Measures are broken down into two categories: core and additional and then into four domains: patient safety/inpatient, patient engagement, care transitions, and outpatient. MBQIP is a Medicare Rural Hospital Flexibility (Flex) quality improvement grant program for Critical Access Hospitals.
pdf MBQIP Measures Fact Sheets October 2021 The Measure Fact Sheets provide an overview of the data collection and reporting processes for current Medicare Beneficiary Quality Improvement Project (MBQIP) Core Measures and MBQIP Additional Measures with federally established means of data collection and reporting. The intended audience for the MBQIP Measures Fact Sheets is critical access hospital personnel involved with quality improvement and/or reporting and state Flex Program personnel.
EDTC Measure Data Reporting Resources February 2020 The Emergency Department Transfer Communication (EDTC) measure aims to provide a means of assessing how well key patient information is communicated from an emergency department to any healthcare facility. They are applicable to patients with a wide range of medical conditions (e.g., acute myocardial infarction, heart failure, pneumonia, respiratory compromise and trauma) and are relevant for both internal quality improvement purposes and external reporting to consumers and purchasers. The results of the field tests suggest that significant opportunity exists for improvement on these measures.
Antibiotic Stewardship Core Elements Mapping August 2020 The National Healthcare Safety Network (NHSN) uses responses from several questions on the Patient Safety Component–Annual Hospital Survey to determine whether a single core element of Antibiotic Stewardship is met. This resource crosswalks questions on the survey to the core element, allowing state Flex programs to do a deeper analysis of the antibiotic stewardship data and identify high performers and opportunities for improvement.
HCAHPS Overview: Vendor Directory April 2022 This guide, updated April 2022, provides information on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) including the benefits and challenges of implementing an HCAHPS survey process with small rural hospitals, specifically critical access hospitals (CAHs). Identifies vendors to guide small rural hospitals and CAH vendor selection of this important, patient-centered survey process.
National Healthcare Safety Network Annual Survey Resources January 2018 This document provides instructions for how to access and complete the National Healthcare Safety Network (NHSN) Annual Facility Survey required for reporting Antibiotic Stewardship under the Medicare Beneficiary Quality Improvement Project (MBQIP).

Data Reports

Reports and feedback for MBQIP
Link Guide Last Updated Description
Interpreting MBQIP Hospital Data Reports for Quality Improvement March 2021 This guide is intended to help critical access hospital (CAH) staff use Medicare Beneficiary Quality Improvement Project (MBQIP) Hospital Data Reports to support quality improvement efforts and improve patient care.
Interpreting MBQIP Hospital Data Reports for Quality Improvement (Archived - Telligen Reports) October 2018 This guide is intended to help critical access hospital (CAH) staff use Medicare Beneficiary Quality Improvement Project (MBQIP) Hospital Data Reports to support quality improvement efforts and improve patient care.

Articles

Articles containing useful information about the program and measures
Link Guide Description
How Small is Too Small? This single page document discusses the importance of data reporting regardless of the number of cases or patients.
Eliminate the Denominator This document discusses the importance of eliminating the denominator for performance indicators in order for health care organizations to compare against the theoretical ideal baseline, rather than comparing themselves to the competition.
Confirming That Your Data Has Been Accepted by the QualityNet Warehouse This document provides a step-by-step guide to confirm your data has been accepted by QualityNet.