CAHQI Toolkits


This toolkit is designed to support the Medicare Beneficiary Quality Improvement Project (MBQIP) goal to improve the quality of care provided in small, rural critical access hospitals (CAHs) by increasing quality data reporting and using data to drive QI activities. (Stratis Health, 2017)

This toolkit specifically addresses the MBQIP program domains for Patient Safety, Care Transitions, Outpatient and Patient Engagement. Funds to support this initiative are offered through the Texas Flex Grant through the Texas State Office of Rural Health. Critical Access Hospitals are required to participate in the Medicare Beneficiary Quality Improvement Program (MBQIP) to receive Flex Benefits.

The MBQIP measures are intended to improve the quality, safety and financial stability of participating organizations. This toolkit provides guidance to improve reporting into the state and national databases. By participating in these data resources, the entity is provided with benchmarking and quality data essential to improving the health of the populations they serve. Through timely receipt and acknowledgement of data, organizations can effectively identify and initiate improvement strategies, thereby enhancing the reliability of care and services.

Best practice plans and processes are provided to help organizations incorporate mechanisms to obtain concurrent information necessary to make rapid cycle changes to improve quality and safety.

It is important to stress that each facility work to determine the root cause of low performance. Awareness by staff and providers along with intentional efforts toward improvement is essential. Another key and often overlooked component of top performing facilities is full support by Senior Leadership. Evidence of senior leader support involves participation in daily huddles where patient safety and “quality misses” are at the forefront. Additional support must be evident through resources to facilitate quality work.

This document will outline tools and best practices to help you meet the requirements for safe and effective care. In addition to the resources listed here, please visit the Texas Hospital Association Foundation (THAF) website for additional tools, policies and guidelines to help you deliver, record and report safe and effective care.

The resources included in the toolkits are offered as examples and do not constitute expressed or implied endorsement by the Texas Hospital Association Foundation.


Karen Kendrick, director of clinical initiatives and quality, 512/465-1091

CAHQI Toolkit
Download the CAHQI Toolkit for Strategies, Tools and Best Practices for MBQIP Measure Success