Core Measures
EDTC: Emergency Department Transfer Communication
Emergency Department
Percentage of patients who are transferred from an ED to another health care facility that have all necessary communication with the receiving facility.
Importance
Timely, accurate, and direct communication facilitates the handoff to the receiving facility, provides continuity of care, and avoids medical errors and redundant tests.
Sample Size
Quarterly:
0-44 - submit all cases> 45 - submit 45 cases
Monthly:
0-15 - submit all cases> 15 - submit 15 cases
Data Elements
- Home Medications
- Allergies and/or Reactions
- Medications Administered in ED
- ED Provider Note
- Mental Status/Orientation Assessment
- Reason for Transfer and/or Plan of Care
- Tests and/or Procedures Performed
- Tests and/or Procedures Results
Data Reported To (Texas)
Data Source
- Manual Chart Abstraction
- Retrospective data sources for required data elements include administrative data and medical records.
Reporting Period
Quarterly
Improvement
Increase in the rate (percentage)
Data Collection Approach
Chart Abstracted, composite of EDTC data elements 1-8, using an all or none approach
Cases to Submit
Patients admitted to the emergency department and transferred from the emergency department to another health care facility (e.g., other hospital, nursing home, hospice, etc.)
Resources
| Name | Description |
|---|---|
| EDTC FAQ | Emergency Department Transfer Communication (EDTC) Frequently Asked Questions |
| Emergency Department Transfer Communications (EDTC) Data Specifications Manual | The ED Transfer Communication measure aims to provide a means of assessing how well key patient information is communicated from an ED to any healthcare facility. They apply 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. |
| Excel EDTC Data Collection Tool Manual | This manual is designed to assist critical access hospitals (CAH) in their ED Transfer Communication measures data collection and reporting using an Excel-based data collection tool. |
| Excel-based Data Collection Tool | Excel-based Data Collection Tool for Excel 2007 and Newer (Macro-enabled Excel Spreadsheet) |
| Specific Hospitals Excel-based Data Collection Tool | Excel-based Data Collection Tool Specifically for Hospitals Unable to Run Macros or Utilizing Non-Excel Spreadsheet Software (Excel spreadsheet) |
| EDTC Measure Data Collection Tool Training Videos |
A step-by-step guide on how to download the Excel-based data collection tool, enter
data, and run reports to calculate your measures. |
| EDTC State Reporting Spreadsheet Instructions | This document includes instructions for State Flex Programs to use for quarterly reporting of the Emergency Department Transfer Communication (EDTC) measure. |
Fibrinolytic Therapy Received Within 30 Minutes
Patient Experience/Outpatient
Percentage of outpatients with chest pain or possible heart attack who got drugs to break up blood clots within 30 minutes of arrival.
Importance
Time-to-fibrinolytic therapy is a strong predictor of outcome in patients with AMI. Nearly 2 lives per 1,000 patients are lost per hour of delay. National guidelines recommend fibrinolytic therapy within 30 minutes of hospital arrival for patients with STEMI.
Sample Size
Quarterly:
0-80 - submit all cases> 80 - see specifications manual
Monthly:
Monthly sample size requirements are based on anticipated quarterly patient populationData Elements
• Arrival Time
• Birthdate
• Discharge Code
• E/M Code
• Fibrinolytic Administration
• Fibrinolytic Administration Date
• Fibrinolytic Administration Time
• ICD-10-CM Principal Diagnosis Code
• Initial ECG Interpretation
• Outpatient Encounter Date
• Reason For Fibrinolytic Therapy Delay
Data Reported To
Measure Set
AMI
Reporting Period
Quarterly
Improvement
Increase in rate (percent)
Data Collection Approach
Chart Abstracted
Cases to Submit
Patients seen in a Hospital Emergency Department for whom all of the following are true:
• Discharged/transferred to a short-term general hospital for inpatient care or to a Federal
Healthcare facility
• A patient age ≥ 18 years
• An ICD-10-CM Principal Diagnosis Code for AMI An ICD-10-CM Principal Diagnosis Code for
AMI as defined in Appendix A, OP Table1.1, of the CMS Hospital OQR Specifications
Manual.
Median Time to Transfer to Another Facility for Acute Coronary Intervention
Patient Experience/Outpatient
Median number of minutes before outpatients with chest pain or possible heart attack who needed specialized
care were transferred to another hospital.
Note: Hospital Compare described measure as "average number of minutes"
Importance
The early use of primary angioplasty in patients with STEMI results in a significant reduction in mortality and morbidity. The earlier primary coronary intervention is provided, the more effective it is. Times to treatment in transfer patients undergoing primary PCI may influence the use of PCI as an intervention. Current recommendations support a door-to-balloon time of 90 minutes or less.
Sample Size
Quarterly:
0-80 - submit all cases> 80 - see specifications manual
Monthly:
Monthly sample size requirements are based on anticipated quarterly patient populationData Elements
• Arrival Time
• Birthdate
• Discharge Code
• ED Departure Date
• ED Departure Time
• E/M Code
• Fibrinolytic Administration
• ICD-10-CM Principal Diagnosis Code
• Initial ECG Interpretation
• Outpatient Encounter Date
• Reason for Not Administering Fibrinolytic Therapy
• Transfer for Acute Coronary Intervention
Data Reported To
Measure Set
AMI
Reporting Period
Quarterly
Improvement
Decrease in median value (time)
Data Collection Approach
Chart Abstracted
Cases to Submit
Patients seen in a Hospital Emergency Department for whom all of the following are true:
• Discharged/transferred to a short-term general hospital for inpatient care or to a Federal
Healthcare facility
• A patient age ≥ 18 years
• An ICD-10-CM Principal Diagnosis Code for AMI as defined in Appendix A, OP Table1.1, of
the CMS Hospital OQR Specifications Manual.
OP-18: Median Time from ED Arrival to ED Departure for Discharged ED Patients
Emergency Department
Average time patients spent in the emergency department before being sent home
Importance
Reducing the time patients remain in the emergency department (ED) can improve access to treatment and increase quality of care, potentially improves access to care specific to the patient condition and increases the capability to provide additional treatment. In recent times, EDs have experienced significant overcrowding. Although once only a problem in large, urban, teaching hospitals, the phenomenon has spread to other suburban and rural healthcare organizations. When EDs are overwhelmed, their ability to respond to community emergencies and disasters may be compromised.
Sample Size
> 900 - Submit 96 cases
> 900 - Submit 96 cases
Data Elements
• Arrival Time
• Discharge Code
• E/M Code
• ED Departure Date
• ED Departure Time
• ICD-10-CM Principal Diagnosis Code
• Outpatient Encounter Date
Data Reported To
Data Source
Hospital Tracking
Reporting Period
Quarterly
Improvement
Decrease in median value (time)
Data Collection Approach
Chart Abstracted
Cases to Submit
Patients seen in a Hospital Emergency Department that have an E/M code in Appendix A, OP Table 1.0 of the CMS Hospital OQR Specifications Manual.
Resources
| Name | Description |
|---|---|
| Hospital Outpatient Quality Measure Specifications, ED-Throughput OP-18 | The Hospital Outpatient Quality Reporting (OQR) Program is a pay-for-reporting, quality data program finalized by the Centers for Medicare & Medicaid Services (CMS). |
| Hospital Outpatient Quality Reporting Specifications Manuals | The Hospital Outpatient Quality Reporting Specifications Manual was developed by the Centers for Medicare & Medicaid Services (CMS) to provide a uniform set of quality measures to be implemented in hospital outpatient settings. The primary purpose of these measures is to promote high quality care for patients receiving services in hospital outpatient settings. |
| Abstraction Resources | For questions related to specific data element abstraction guidelines, refer to the Specifications Manual. Resources include Emergency Department (ED) - Throughput and Stroke. |
| Improving Patient Flow and Reducing Emergency Department Crowding | This guide presents step-by-step instructions that can be used by hospitals in planning and implementing patient flow improvement strategies to ease emergency department crowding. |
OP-22: Patient Left Without Being Seen
Emergency Department
Percent of patients who leave the Emergency Department (ED) without being evaluated by a physician/advanced practice nurse/physician’s assistant (physician/APN/PA)
Importance
Reducing patient wait time in the ED helps improve access to care, increase capability to provide treatment, reduce ambulance refusals/diversions, reduce rushed treatment environments, reduce delays in medication administration, and reduce patient suffering.
Sample Size
No Sampling
Report all cases
Data Elements
• Numerator: What was the total number of patients who left without being evaluated
by a physician/APN/PA?
• Denominator: What was the total number of patients who presented to the ED?
Data Reported To
Measure Set
ED Throughput
Reporting Period
Yearly
Improvement
Decrease in rate (percent)
Data Collection Approach
Hospital Tracking
Cases to Submit
Definition of patients who present to the ED:
Patients who presented to the ED are those that signed in to be evaluated for emergency
services.
Definition of provider includes:
• Residents/interns
• Institutionally credentialed provider
• APN/APRNs
HCAHPS: Hospital Consumer Assessment of
Healthcare Providers and Systems
Patient Experience
Percentage of patients surveyed who reported “Yes” or “Always” to questions involving their hospital stay
Importance
Growing research shows positive associations between patient experience and health outcomes, adherence to recommended medication and treatments, preventive care, health care resource use and quality and safety of care.
Sample Size
Sampling determined by HCAHPS vendor or self-administered if in compliance with program requirements
Data Elements
- Communication with Doctors
- Communication with Nurses
- Responsiveness of Hospital Staff
- Communication about Medicines
- Discharge Information
- Cleanliness of the Hospital Environment
- Quietness of the Hospital Environment
- Transition of Care
Data Reported To
Measure Set
HCAHPS
Reporting Period
Quarterly
Improvement
Increased in percent always
Data Collection Approach
Survey (typically conducted by a certified vendor)
Cases to Submit
Patients discharged from the hospital following at least one overnight stay sometime between 48 hours and 6 weeks ago who are over the age of 18 and did not have a psychiatric principal diagnosis at discharge.
Resources
| Name | Description |
|---|---|
| HCAHPS Overview: Vendor Directory (2023) | This guide, updated Fall 2023, 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. |
| HCAHPS Approved Survey Vendors 2026 | This website identifies vendors to guide small rural hospitals and CAH vendor selection of this important, patient-centered survey process. |
| CMS HCAHPS General Information | The HCAHPS Survey is administered to a random sample of patients continuously throughout the year. CMS cleans, adjusts, and analyzes the data, then publicly reports the results. |
| HCAHPS Survey Website | The intent of the HCAHPS initiative is to provide a standardized survey instrument and data collection methodology for measuring patients’ perspectives on hospital care. The site is the main location to find information about the survey. |
| HCAHPS FAQs | Frequently asked questions about the measure |
| HCAHPS Fact Sheet | Measure overview fact sheet |
Antibiotic Stewardship
Patient Safety
Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) Annual Survey
Importance
Improving antibiotic use in hospitals is imperative to improving patient outcomes,
decreasing antibiotic resistance, and reducing healthcare costs. According to the Centers
for Disease Control and Prevention (CDC), 20-50 percent of all antibiotics prescribed in
U.S. acute care hospital are either unnecessary or inappropriate, which leads to serious
side effects such as adverse drug reactions and Clostridium difficile infection.
Overexposure to antibiotics also contributes to antibiotic resistance, making antibiotics
less effective.
In 2014, CDC released the “Core Elements of Hospital Antibiotic Stewardship Programs” that
identifies key structural and functional aspects of effective programs and elements designed
to be flexible enough to be feasible in hospitals of any size.
Sample Size
No Sampling
Report all information as requested
Data Elements
Questions as answered on the
Patient Safety Component Annual Hospital Survey inform whether the hospitals have successfully implemented the following core elements
of antibiotic stewardship:
• Leadership
• Accountability
• Drug Expertise
• Action
• Tracking
• Reporting
• Education
Data Reported To
Reporting Period
Yearly
Improvement
Increase in number of core elements met
Data Collection Approach
Hospital Tracking
Cases to Submit
N/A
This measure uses administrative data and not claims to determine the measure's denominator
population.
Documents
| Name | Description |
|---|---|
| Antibiotic Stewardship Implementation: Suggested Strategies from High Performing CAHs | This resource shares antibiotic stewardship best practices of high performing critical access hospitals (CAHs) identified through focus group discussions with 34 hospitals from across 25 states. |
| Promoting a Culture of Safety: Use of the Hospital Survey on Patient Safety Culture in Critical Access Hospitals | This brief is one in a series of policy briefs identifying and assessing evidence-based patient safety and quality improvement interventions appropriate for use by state Flex Programs and Critical Access Hospitals (CAH)s, and discusses the use of patient safety culture surveys as a means to promote organizational learning and build a culture of safety. |
| Change Pathway: Antibiotic Stewardship | The change pathway tool is a topic-specific, step-by-step guide to quality improvement and was created using evidence-based practice resources and guidelines. |
| Appropriate Use of Medical Resources: Antimicrobial Stewardship Toolkit | This American Hospital Association Physician Alliance resource provides readers a toolkit composed of hospital and health system, clinician, and patient resources for antimicrobial stewardship. |
| 2023 Antibiotic Stewardship Detailed Data Summary Tool for State Flex Programs | State Flex Programs can use this tool to summarize and make use of the detailed antibiotic stewardship data. It provides a core element summary as well as a question-by-question summary of CAH responses at both the CAH- and state-level. |
Resources
| Name | Description |
|---|---|
| Core Elements of Antibiotic Stewardship |
CDC recognizes that there is no "one size fits all" approach to optimize antibiotic use for all healthcare settings. The complexity of medical decision-making surrounding antibiotic use and the variability in facility size and types of care in U.S. healthcare settings require flexible programs and activities. Guides include:
|
| Annual Surveys, Locations & Monthly Reporting Plans | At the beginning of each survey year, a new facility survey(s) must be completed to reflect data from the prior calendar year. For example, at the beginning of 2026, an acute care hospital completes a 2025 Annual Hospital Survey containing data from 2025. |
| Antibiotic Use & Stewardship in the U.S.: Progress and Opportunities 2025 | This annual report provides an overview of CDC's surveillance data on antibiotic use, along with guidance and example collaborations aimed at improving antibiotic use to optimize patient safety across all areas of health care. |
| FAQs: Annual Surveys | Frequently asked questions about annual surveys |
| Antibiotic Stewardship Resource Bundles | The Antibiotic Stewardship Resource Bundles organize CDC and partner stewardship resources for antibiotic stewards and healthcare professionals by setting of care, audience and type of resource. |
| Patient Education Resources | The Antibiotic Stewardship Resource Bundles organize CDC and partner stewardship resources for patients. |
Admit Decision Time to ED Departure Time for Admitted Patients
Patient Safety/Inpatient
Median time from admit decision time to time of departure from the emergency department for admitted patients.
Importance
Reducing the time patients remain in the emergency department (ED) can improve access to treatment and increase quality of care, potentially improves access to care specific to the patient condition and increases the capability to provide additional treatment. In recent times, EDs have experienced significant overcrowding. Although once only a problem in large, urban, teaching hospitals, the phenomenon has spread to other suburban and rural healthcare organizations. When EDs are overwhelmed, their ability to respond to community emergencies and disasters may be compromised.
Sample Size
Quarterly:
0-152 - 100% of initial pt. pop153-764 - 153
765-1529 - 20% of initial pt. pop
>1529 - 306
Monthly:
<51 - 100% of initial population51-254 - 51
255-509 - 20% of initial pt. pop
>509 - 102
Data Elements
• Decision to Admit Date
• Decision to Admit Time
• ED Departure Date
• ED Departure Time
• ED Patient
• ICD-10-CM Principal Diagnosis Code
Data Reported To
Measure Set
Emergency Department
Reporting Period
Quarterly
Improvement
Decrease in the median value
Data Collection Approach
Chart Abstracted
Cases to Submit
Global Initial Patient Population: All patients discharged from acute inpatient care with a length of stay less than or equal to 120 days.
HCP: Influenza Vaccination Coverage Among Health Care Personnel
Patient Safety
Percentage of health care workers given influenza vaccination
Importance
1 in 5 people in the U.S. get influenza each season. Combined with pneumonia, influenza is the 8th leading cause of death, with two-thirds of those attributed to patients hospitalized during the flu season.
Sample Size
No Sampling
Report all cases
Data Elements
3 categories (all with separate denominators) of HCP working in the facility at least one
day b/w 10/1-3/31:
• employees on payroll
• licensed independent practitioners
• students, trainees and volunteers 18yo+
A fourth optional category is available for reporting other contract personnel HCP
workers
who:
• Received vaccination at the facility
• Received vaccination outside the facility
• Did not receive vaccination due to contraindication
• Did not receive vaccination due to declination
Data Reported To
Data Source
Administrative DataReporting Period
Yearly
Improvement
Increase in rate (percent)
Data Collection Approach
Hospital Tracking
Cases to Submit
Each facility in a system needs to be registered separately and HCPs should be counted in the sample population for every facility at which s/he works. Facilities must complete a monthly reporting plan for each year or data reporting period. All data reporting is aggregate (whether monthly, once a season, or at a different interval).
Resources
| Name | Description |
|---|---|
| Healthcare Personnel (HCP) Safety: Influenza |
NHSN resources on influenza vaccinations. |
| HCP Influenza Summary Reporting FAQs |
Frequently asked questions about the measure and reporting |
Additional Measures
| Care Coordination | Outpatient | Patient Engagement | Patient Safety/Inpatient |
|---|---|---|---|
| Discharge Planning § |
(formerly OP-4) Aspirin at Arrival § |
Emergency Department Patient Experience Survey § |
CLABSI Central Line-Associated Bloodstream Infection |
| Medical Reconciliation § |
(formerly OP-5) Median Time to EDG § |
CAUTI Catheter-Associated Urinary Tract Infection |
|
| Swing Bed Care § |
(formerly OP-20) Door to Diagnostic Evaluation by a Qualified Medical Professional § |
CDI Clostridioides Difficile Infection |
|
|
Claims-Based Measures Measures are automatically calculated for hospitals using Medicare Administrative Claims Data |
MRSA Methicillin-resistant Staphylococcus Aureus |
||
|
SSIs Surgical Site Infections Colon or Hysterectomy |
|||
|
PC-01 Elective Delivery |
|||
| Falls § | |||
| Adverse Drug Events (ADE) § | |||
| Patient Safety Culture Survey | |||
|
(formerly IMM-2) Inpatient Influenza Vaccination § |
§No nationally standardized or standard reported measure currently available, however, Flex programs can propose work on these measures if there is a data collection mechanism in place.
Archived Measures
| Care Coordination | Emergency Department | Global Measures | Patient Experience/Outpatient | Patient Safety/Inpatient |
|---|---|---|---|---|
|
SDOH Screening Screening for Social Drivers of Health |
Hospital Commitment to Health Equity |
OP-1 Median Time to Fibrinolysis |
ED-1 Median Time from ED Arrival to ED Departure for Admitted ED Patients |
|
| SDOH Screening + Screen Positive for Social Drivers of Health |
OP-21 Median Time to Pain Management for Long Bone Fracture |
ED-2 Admit Decision Time to ED Departure Time for Admitted Patients |
||
|
OP-2 Fibrinolytic Therapy Received Within 30 Minutes |
||||
|
OP-3 Median Time to Transfer to another Facility for Acute Coronary Intervention |
Hybrid Hospital-Wide Readmission
Care Coordination
Hospital-level, all-cause, risk-standardized readmission measure that focuses on unplanned readmissions 30 days of discharge from an acute hospitalization.
Importance
Returning to the hospital for unplanned care disrupts patients’ lives, increases risk of harmful events like healthcare-associated infections, and results in higher costs absorbed by the health care system. High readmission rates of patients with clinically manageable conditions in primary care settings, such as diabetes and bronchial asthma, may identify quality-of-care problems in hospital settings. A measure of readmissions encourages hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans and, in turn, reduce avoidable readmissions and costs.
Sample Size
No Sampling
Report on all information requested in denominator and numerator
Data Elements
Numerator
If a patient has more than one unplanned admission (for any reason) within 30 days after discharge from the index admission, only one is counted as a readmission. The measure looks for a dichotomous yes or no outcome of whether each admitted patient has an unplanned readmission within 30 days. However, if the first readmission after discharge is considered planned, any subsequent unplanned readmission is not counted as an outcome for that index admission because the unplanned readmission could be related to care provided during the intervening planned readmission rather than during the index admission.
Denominator
1. Enrolled in Medicare FFS Part A for the 12 months prior to the date of admission and
during the index admission;
2. Aged 65 or over;
3. Discharged alive from a non-federal short-term acute care hospital;
4. Not transferred to another acute care facility.
Exclusions
The measure excludes index admissions for patients:
1. Admitted to Prospective Payment System (PPS)-exempt cancer hospitals;
2. Without at least 30 days post-discharge enrollment in Medicare FFS;
3. Discharged against medical advice (AMA);
4. Admitted for primary psychiatric diagnoses;
5.Admitted for rehabilitation; or
6. Admitted for medical treatment of cancer
Data Reported To
HARPData Source
- Manual Chart Abstraction
- Retrospective data sources for required data elements include administrative data and medical records.
Reporting Period
Yearly
Improvement
No actual measure score will be generated by hospitals. Instead, hospitals will report the data values for each of the core clinical data elements for all encounters in the Initial Population. These core clinical data elements will be linked to administrative claims data and used by CMS to calculate results for the Hybrid HWR measure.
Data Collection Approach
Hybrid – chart extraction of electronic clinical data and administrative claims data.
Cases to Submit
- Enrolled in Medicare FFS Part A for the 12 months prior to the date of admission and during the index admission;
- Aged 65 or over;
- Discharged alive from a non-federal short-term acute care hospital;
- Not transferred to another acute care facility
Resources
| Name | Description |
|---|---|
| Data Submission Guide for Hybrid Hospital-Wide Readmissions | This RQITA Data Submission Guide provides detailed instructions on how to collect and submit data for the Hybrid Hospital-Wide Readmission measure. It includes measure details, linked trainings and step-by-step data submission instructions for the measure. |
| How to submit Hybrid Measures and View Outcomes | This RQITA Data Submission Guide provides detailed instructions on how to collect and submit data for the Hybrid Hospital-Wide Readmission measure. It includes measure details, linked trainings and step-by-step data submission instructions for the measure. |
| Hybrid Hospital Wide Readmission Training 2026 | This recorded training provides an in-depth exploration of the MBQIP core measure: Hybrid Hospital-Wide Readmission. Participants will gain a comprehensive understanding of the measure, learn step-by-step strategies for successful data collection, and discover how to accurately report the measure in the hospital quality reporting system. Slides and Facilitation Guide also available. |
| Hybrid Measure Overview | This Quality Net resource provides an overview of the Hybrid Hospital-Wide Readmission and Hospital-Wide Mortality Measures. It also discusses voluntary and mandatory reporting of hybrid measures and provides access to resources for further information regarding the measures. |
| Core Clinical Data Elements | This link will take you to an overview of the Hybrid Hospital-Wide Readmission (HWR) measure. It provides a description of the measure and information regarding measure scoring, stratification, risk adjustment, the rationale, guidance, the initial population and more. |
| QRDA - Quality Reporting Document Architecture | Here you will find information regarding the data submission standard, Quality Reporting Document Architecture (QRDA), used to report quality measures to regulatory agencies, payers and quality improvement organizations. |
Screening for Social Drivers of Health
Care Coordination
The Screening for Social Drivers of Health Measure assesses whether a hospital implements screening for all patients that are 18 years or older at time of admission for food insecurity, housing instability, transportation needs, utility difficulties and interpersonal safety.
Importance
The recognition of health disparities and impact of health-related social needs (HRSN) has been heightened in recent years. Economic and social factors, known as drivers of health, are known to affect health outcomes and costs, and exacerbate health inequities. This measure is derived from the Center for Medicare and Medicaid Innovation’s Accountable Health Communities (AHC) model and has been tested in large populations across states. The intent of this measure is to help ensure hospitals are considering and addressing social needs in the care they provide to their community.
Sample Size
No sampling – report on all information requested in denominator and numerator.Data Elements
Numerator
The number of patients admitted to an inpatient hospital stay who are 18 years or older on the date of admission and are screened for all of the following five HRSNs: Food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety during their hospital inpatient stay
Denominator
The number of patients who are admitted to a hospital inpatient stay and who are 18 years or older on the date of admission.
Exclusions
The following patients would be excluded from the denominator:
(1) Patients who opt-out of screening.
(2) Patients who are themselves unable to complete the screening during their
inpatient stay and have no legal guardian or caregiver able to do so on the
patient’s behalf during their inpatient stay.
(3) Patients who expire during the inpatient stay.
Data Reported To
HARPData Source
Hospital trackingReporting Period
Yearly
Improvement
Increase in the rate.
Data Collection Approach
Chart Abstracting
Cases to Submit
The number of patients who are admitted to a hospital inpatient stay and who are 18 years or older on the date of admission.
Screen Positive for Social Drivers of Health
Care Coordination
The Screen Positive Rate for Social Drivers of Health Measure provides information on the percent of patients admitted for an inpatient hospital stay who are 18 years or older on the date of admission, were screened for an HRSN (health-related social needs), and who screen positive for one or more of the following five HRSNs: Food insecurity, housing instability, transportation problems, utility difficulties, or interpersonal safety.
Importance
The recognition of health disparities and impact of health-related social needs (HRSN) has been heightened in recent years. Economic and social factors, known as drivers of health, are known to affect health outcomes and costs, and exacerbate health inequities. This measure is derived from the Center for Medicare and Medicaid Innovation’s Accountable Health Communities (AHC) model and has been tested in large populations across states. The intent of this measure is to help ensure hospitals are considering and addressing social needs in the care they provide to their community.
Sample Size
No sampling – report on all information requested in denominator and numerator.Data Elements
CMS is not recommending specific value sets currently.
Numerator
The number of patients who are admitted to a hospital inpatient stay and who are 18 years or older on the date of admission, who were screened for all five HSRN, and who screen positive for having a need in one or more of the following five HRSNs (calculated separately): Food insecurity, housing instability, transportation needs, utility difficulties, or interpersonal safety.
Denominator
The number of patients who are admitted to a hospital inpatient stay and who are 18 years or older on the date of admission and are screened for all of the following five HSRN (food insecurity, housing instability, transportation needs, utility difficulties and interpersonal safety) during their hospital inpatient stay.
Exclusions
The following patients would be excluded from the denominator:
(1) Patients who opt-out of screening.
(2) Patients who are themselves unable to complete the screening during their
inpatient stay and have no legal guardian or caregiver able to do so on the
patient’s behalf during their inpatient stay.
(3) Patients who expire during the inpatient stay.
Data Reported To
HARPData Source
Hospital trackingReporting Period
Yearly
Improvement
This measure is not an indication of performance
Data Collection Approach
Chart abstraction
Cases to Submit
The result of this measure would be calculated as five separate rates. Each rate is derived from the number of patients admitted for an inpatient hospital stay and who are 18 years or older on the date of admission, screened for an HRSN, and who screen positive for each of the five HRSNs—food insecurity, housing instability, transportation needs, utility difficulties, or interpersonal safety—divided by the total number of patients 18 years or older on the date of admission screened for all five HRSNs.
Critical Access Hospital Quality Infrastructure
Global
Structural measure to assess CAH quality infrastructure based on the nine (9) core elements of CAH quality infrastructure
Importance
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.
Sample Size
No sampling – Report all information as requested.Data Elements
Data is collected via the National CAH Quality Inventory and Assessment based on the nine (9) core elements of CAH quality infrastructure:
- 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
- Integrating Equity into Quality Practices
- Engagement of Patients, Partners, and Community
- Collecting Meaningful and Accurate Data
- Using Data to Improve Quality
Data Reported To
Flex Monitoring Team (FMT) administered Qualtrics platformData Source
N/AReporting Period
Yearly
Improvement
Increase in number of core elements met
Data Collection Approach
Hospital Tracking
Cases to Submit
N/A - This measure uses administrative data to determine the measure's denominator population.
Resources
| Name | Description |
|---|---|
| CAH Quality Infrastructure Measure Data Specifications Manual | This includes more information about how the measure is collected and how each question from the Assessment maps to the core elements and criteria of CAH Quality Infrastructure. |
| 2025 National CAH Quality Inventory & Assessment National Report | This report uses 2025 Assessment data to provide a national overview of some key components of the Assessment. |
|
CAH Quality Infrastructure Detailed Data Codebook ( 2023 & 2024 ) |
This codebook lists all multiple-choice options from the CAH Quality Infrastructure Measure submission section of the 2023 National CAH Quality Inventory and Assessment. This spreadsheet provides the question numbers associated with each response option, in addition to the core element(s) and criteria that each response option maps to. |
| CAH Fact Sheet | This Fact Sheet is designed to provide additional information about the background and components of the Assessment for CAHs. |
| CAH Quality Infrastructure Measure Submission Guide | This resource is intended to be used by critical access hospital personnel involved in MBQIP and State Flex personnel. |
| 2026 Assessment Questions & Instructions | This document includes all of the questions on the Assessment, as well as instructions for each question. CAHs should use this to review the questions for the Assessment prior to going to the portal to complete their submission. This document can also be used by CAHs to fill in answers as they collect data, before they submit their responses on the Assessment portal. |
| CAH Quality Inventory & Assessment - State Flex Program Resources | The resources on this page are ancillary materials related to the 2025 CAH Quality Inventory & Assessment (Assessment) for State Flex Programs (SFPs). |
Hospital Commitment to Health Equity
Global
This structural measure assesses hospital commitment to health equity. Hospitals will receive points for responding to questions in five (5) different domains of commitment to advancing health equity.
Importance
The recognition of health disparities and inequities has been heightened in recent years and it is particularly relevant in rural areas. Rural risk factors for health disparities include geographic isolation, lower socioeconomic status, higher rates of health risk behaviors, limited access to health care specialists and sub-specialists, and limited job opportunities. Rural residents are also less likely to have employer-provided health insurance coverage, and if they are poor, often are not covered by Medicaid. The intent of this measure is to help ensure hospitals are considering and addressing equity in the care they provide to their community.
Sample Size
No sampling – Report all information as requested.Data Elements
Data is used to assess hospital commitment to health equity in the following domain areas:
- Domain 1 – Equity is a Strategic Priority
- Domain 2 – Data Collection
- Domain 3 – Data Analysis
- Domain 4 – Quality Improvement
- Domain 5 – Leadership Engagement
Data Reported To
HARPData Source
N/AReporting Period
Yearly
Improvement
Increase in the total score (up to 5 points).
Data Collection Approach
Attestation - Hospital Tracking
Cases to Submit
N/A - This measure assesses hospital and leadership commitment.
eCQM: Safe Use of Opioids
Patient Safety
Proportion of inpatient hospitalizations for patients 18 years of age and older prescribed, or continued on two or more opioids, or an opioid and benzodiazepine concurrently at discharge.
Importance
Unintentional opioid overdose fatalities have become an epidemic and major public health concern in the United States. Concurrent prescriptions of opioids, or opioids and benzodiazepines, places patients at a greater risk of unintentional overdose due to increased risk of respiratory depression. Patients who have multiple opioid prescriptions have an increased risk for overdose, and rates of fatal overdose are ten (10) times higher in patients who are co-dispensed opioid analgesics and benzodiazepines than opioids alone. A measure that calculates the proportion of patients with two or more opioids or opioids and benzodiazepines concurrently has the potential to reduce preventable mortality and reduce costs associated with adverse events related to opioids.
Sample Size
No Sampling
Report all patients that meet data elements
Data Elements
Numerator
Inpatient hospitalizations where the patient is prescribed or continuing to take two or more opioids or an opioid and benzodiazepine at discharge.
Denominator
The number of patients who are admitted to a hospital inpatient stay and who are 18 years or older on the date of admission.
Exclusions
Inpatient hospitalizations (inpatient stay less than or equal to 120 days) that end during the measurement period, where the patient is 18 years of age and older at the start of the encounter and prescribed one or more new or continuing opioid or benzodiazepine at discharge.
Data Reported To
Data Source
Certified electronic health record technology (CEHRT)Reporting Period
Yearly
Improvement
Decrease in rate
Data Collection Approach
Electronic Extraction from EHRs via Quality Reporting Document Architecture (QRDA) Category I File
Cases to Submit
Inpatient hospitalizations (inpatient stay less than or equal to 120 days) that end during the measurement period, where the patient is 18 years of age and older at the start of the encounter and prescribed one or more new or continuing opioid or benzodiazepine at discharge.
Resources
| Name | Description |
|---|---|
| Data Submission Guide for Safe Use of Opioids Concurrent Prescribing | This guide includes tips for hospitals to get started with reporting new measures, measure details, linked trainings, and step-by-step data submission steps for the Hospital Commitment to Health Equity measure. |
| QRDA – Quality Reporting Document Architecture | Here you will find information regarding the data submission standard, Quality Reporting Document Architecture (QRDA), used to report quality measures to regulatory agencies, payers, and quality improvement organizations. |
| eCQM 101 | Document goes over which resources are helpful to successfully test/implement eCQMs and where to find them. |
| Measure specifications and data elements | This resource provides information about the Safe Use of Opioids-Concurrent Prescribing measure. It includes details such as the measure’s description, scoring, type, rationale, clinical recommendation statement, improvement notation, definition, guidance, denominator, numerator, and exclusions. |
| Get Started with eCQMs | The Centers for Medicare & Medicaid Services (CMS) use eCQMs in a variety of quality reporting and value-based purchasing programs. |
| Safe Use of Opioids Concurrent Prescribing Training 2026 | This recorded training provides an in-depth exploration of the MBQIP core measure: Safe Use of Opioids-Concurrent Prescribing. Participants will gain a comprehensive understanding of the measure, learn step-by-step strategies for successful data collection, and discover how to accurately report the measure in the hospital quality reporting system. Slides and Webinar Facilitation Guide are also available. |
| CAH ECQM Resource List | This document outlines the inpatient eCQM reporting requirements and the alignment between two Centers for Medicare & Medicaid Services (CMS) programs: the Promoting Interoperability (PI) Program and the Hospital Inpatient Quality Reporting Program. |