Guides

Acronym	Definition
AA	Aortic aneurysm
ADE	Adverse drug events
AFIB	Atrial fibrillation
AHA	American Hospital Association
AHRQ	Agency for Healthcare Research and Quality
AMI	Acute myocardial infarction
ARCHI	A&M Rural & Community Health Institute
C.Diff/CDI	Clostridium difficile
CAC	Children’s asthma care
CAH	Critical access hospital
CAH-QI	Critical Access Hospital Quality Improvement Program
CAP	Community-acquired pneumonia
CART	CMS Abstraction and Reporting Tool
CAUTI	Catheter-associated urinary tract infection
CCN	CMS certification number
CDC	Centers for Disease Control and Prevention
CDE	Common duct exploration
Chole	Cholecystectomy
CLABSI	Central line-associated blood stream infection
CMS	Centers for Medicare & Medicaid Services
COPD	Chronic obstructive pulmonary disease
CQM	Clinical quality measure
CT	Computerized tomography
DACA	Data Accuracy and Completeness Acknowledgement
Domain	The category where MBQIP Measures belong. There are 5 main mbqip domains: Care Coordination, Global Measures, Outpatient, Patient Engagement, and Patient Safety/Inpatient
DVT	Deep vein thrombosis
ECG	Electrocardiogram
eCQM	Electronic clinical quality measure
ED	Emergency department
EDHI	Early hearing detection and intervention
EDTC	Emergency Department Transfer Communication
EHR	Electronic health record
EMS	Emergency medical service
ESI	Emergency Severity Index
ESRD	End Stage Renal Disease
Flex	Medicare Rural Hospital Flexibility Program
FORHP	Federal Office of Rural Health Policy
FY	Fiscal year
GI	Gastrointestinal
HAI	Healthcare-associated infections
HARP	Health Care Quality Information Systems (HCQIS) Access Roles and Profile
HCAHPS	Hospital Consumer Assessment of Healthcare Providers and Systems
HCP	Healthcare personnel
HCP	Influenza Vaccination Coverage Among Health Care Personnel
HCQIS	Health Care Quality Information Systems
HIIN	Hospital Improvement and Innovation Network
HIQR	Hospital Inpatient Quality Reporting Program
HF	Heart failure
HIP-KNEE	Total hip arthroplasty and/or total knee arthroplasty
HOQR	Hospital Outpatient Quality Reporting Program
HRET	Health Research & Education Trust
HRSA	Health Resource and Services Administration
HTN	Hypertension
HWR	Hospital-wide all-cause unplanned readmission
ICU	Intensive Care Unit
IMM	Immunization
IQR	Inpatient Quality Reporting
IVAC	Infection-related ventilator-associated complications
IVR	Interactive Voice Response
MBQIP	Medicare Beneficiary Quality Improvement Project
MBQIP-DB	Medicare Beneficiary Quality Improvement Project Database
Measure	The basic unit or component which the MBQIP program keeps track. Measures are divided into two categories: core and additional. Measures are further divided into four domains: patient safety/inpatient, patient engagement, care coordination and outpatient.
MMA	Medicare Prescription Drug Improvement and Modernization Act
MORT	Mortality
MOU	Memorandum of Understanding
MRI	Magnetic Resonance Imaging
MSPB	Medicare spending per beneficiary
MRSA	Methicillin-resistant Staphylococcus aureus
NHSN	National Healthcare Safety Network
NRHRC	National Rural Health Resource Center
NoP	Notice of Participation
ONC	Office of the National Coordinator for Health Information Technology
OP	Outpatient
OP-2	Fibrinolytic Therapy Received Within 30 Minutes
OP-3	Median Time to Transfer to Another Facility for Acute Coronary Intervention
OP-18	Median Time from ED Arrival to ED Departure for Discharged ED Patients
OP-22	Patient Left Without Being Seen
OQR	Outpatient Quality Reporting
P4P	Partnership for Patients
PC	Perinatal Care
PCI	Primary percutaneous coronary intervention
PE	Pulmonary embolism
PN	Pneumonia
PI	Promoting Interoperability
POD	Postoperative day
PPS	Prospective Payment System
PSI	Patient Safety Indicators
QIN-QIO	Quality Innovation Network – Quality Improvement Organization
QIO	Quality Improvement Organization
QMP	Qualified medical professional
QNet	QualityNet
QRDA	Quality reporting document architecture
READM	Readmission
RHIhub	Rural Health Information Hub
RQITA	Rural Quality Improvement Technical Assistance
RN	Registered nurse
SA	System administrator
SCIP-Inf	Surgical care improvement project-infection
Sfusion	Spinal fusion
SORH	State Office of Rural Health
SSI	Surgical site infection
STEMI	ST-Segment Elevation Myocardial Infarction
THA	Texas Hospital Association
THA	Total hip arthroplasty
THAF	Texas Hospital Association Foundation
TKA	Total knee arthroplasty
UTI	Urinary tract infection
VAE	Ventilator-associated event
VBP	Value-Based Purchasing
VKG	Virtual Knowledge Group
VTE	Venous thromboembolism

Guides

MBQIP guidelines with respect to the whole program
Guide	Last Updated	Description
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.
MBQIP Fundamentals Guide for State Flex Programs	February 2021	This guide provides an overview of the current status and history of the Medicare Beneficiary Quality Improvement Project (MBQIP). It is intended to help state Flex program personnel and relevant subcontractors understand the basics of MBQIP, including key resources available to support them in their work. The guide is organized by topic, and each section provides an overview of the topic and links to related resources that give more detail and direction. Users are strongly encouraged to review all linked materials.
MBQIP Quality Reporting Guide	August 2023	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 2025 Information Guide	April 2024	The MBQIP 2025 Core Measures is a list of quality measures the Federal Office of Rural Health Policy (FORHP) at the Health Resources and Services Administration (HRSA) is adopting for use in the Medicare Beneficiary Quality Improvement Project (MBQIP) within the Medicare Rural Hospital Flexibility Program. Starting in calendar year 2025, hospitals will collect data to report on the updated MBQIP core measures set as part of the Flex Program.
MBQIP 2025 Measures	February 2024	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 coordination, and outpatient. MBQIP is a Medicare Rural Hospital Flexibility (Flex) quality improvement grant program for Critical Access Hospitals.
MBQIP Data Submission Deadlines	August 2024	Updated data submission deadlines.
MBQIP Measures Fact Sheets	August 2023	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.
MBQIP 2025 Timeline for Critical Access Hospitals	July 2024	This outlines an implementation timeline for critical access hospitals regarding MBQIP 2025 implementation. This graphic has been available in other resources. Requests were made to have it a standalone resource.
Quality Improvement Workbook	January 2024	In this workbook you will find valuable resources to support your team’s quality improvement efforts, including an interactive timeline to follow, quality improvement goal statement template and ways to track progress during your organization’s quality improvement journey.
Future of MBQIP Webinar	August 2024	This recording provides an overview of the MBQIP 2025 measures including reporting details, submission information, and resources for implementation.

Data Reports and feedback for MBQIP
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.
Quarterly MBQIP Report Updates	February 2024	Dates are estimated based on historic timelines. All dates are subject to change and do not account for the time required for state Flex programs to distribute data to hospitals.
Interpreting MBQIP Hospital Data Reports (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.

Resources related to specific measures
Measure	Name	Last Updated	Description
Antibiotic Stewardship	Antibiotic Stewardship Core Elements	March 2024	This document provides guidance on practical strategies to implement antibiotic stewardship programs in small and critical access hospitals.1,2 It was developed as a collaboration between The Centers for Disease Control and Prevention, The American Hospital Association, The Federal Office of Rural Health Policy and The Pew Charitable Trusts.
HCAHPS	HCAHPS Overview: Vendor Directory	Fall 2023	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.
Antibiotic Stewarship	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).
EDTC	EDTC FAQ	July 2020	Emergency Department Transfer Communication (EDTC) Frequently Asked Questions
EDTC	EDTC Data Specifications Manual	October 2019	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.
Social Drivers of Health	Screening for Social Drivers of Health Data Submission Guide	June 2024	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 Screening for Social Drivers of Health Measure.
Social Drivers of Health	Screen Positive Rate for Social Drivers of Health Data Submission Guide	June 2024	This guide includes tips for hospital to get started with reporting new measures, measure details, linked trainings, and step-by-step data submission steps for the Screen Positive Rate for the Social Drivers of Health measure.
Social Drivers of Health	National Assistance to Address Social Drivers of Health	2024	This list contains resources to address social drivers of health. Many of the organizations listed offer nationwide services or contain databases to identify local resources.
Social Drivers of Health	RQITA Website: Social Drivers of Health	2024	Listed here are measure specifications and tools to help hospitals report, submit, and improve quality for these measures.
Hospital Commitment to Health Equity	Data Submission Guide for Hospital Commitment to Health Equity	July 2024	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.
Hospital Commitment to Health Equity	RQITA Website: Hospital Commitment to Health Equity	2024	Listed here are measure specifications and tools to help hospitals report, submit, and improve quality for this measure.
Safe Use of Opioids	Data Submission Guide for Safe Use of Opioids Concurrent Prescribing	July 2024	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.
Safe Use of Opioids	RQITA Website: Safe Use of Opioids Concurrent Prescribing	2024	Listed here are measure specifications and tools to help hospitals report, submit, and improve quality for this measure.
Hybrid Hospital-Wide Readmissions	Data Submission Guide for Hybrid Hospital-Wide Readmissions	September 2024	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.
Hybrid Hospital-Wide Readmissions	RQITA Website: Hybrid Hospital Wide Readmissions	2024	Listed here are measure specifications and tools to help hospitals report, submit, and improve quality for this measure.
CAH Quality Infrastructure	CAH Quality Infrastructure Specifications	August 2024	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.
CAH Quality Infrastructure	CAH Quality Inventory & Assessment Resources for CAHs	August 2024	This page includes several resources for Critical Access Hospitals to use to complete the 2024 CAH Quality Inventory and Assessment (Assessment). Included is a CAH Fact Sheet, Assessment Questions & Instructions, the 2023 Assessment National Report and an Assessment Informational Recording.
CAH Quality Infrastructure	Assessment Information Recording	October 2024	This recording provides detailed information about the background, purpose, and content of the Assessment for CAHs to learn more about the Assessment prior to completing it.
CAH Quality Infrastructure	RQITA Website: CAH Quality Infrastructure	2024	Listed here are measure specifications and reporting details.

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.
	Past MBQIP Award Winners and Methodology	This document contains information about the methodology used to determine MBQIP Award winners each year since the awards were launched in 2015.

Websites and external links with useful information
Link	Name	Description
	QualityNet Training & Guides	QualityNet Secure Portal (QSP) has officially been retired and replaced with hqr.cms.gov and eqrs.cms.gov for Hospital Quality Reporting (HQR) and End Stage Renal Disease (ESRD) Quality Reporting, respectively.
	Frequently Asked Questions	Frequently asked questions regarding the Medicare Beneficiary Quality Improvement Project (MBQIP)
	Texas State Office of Rural Health	The Texas State Office of Rural Health (SORH) contracts with the Texas Hospital Association and Texas A&M Rural and Community Health Institute to provide technical assistance on the Medicare Beneficiary Quality Improvement Project (MBQIP). Technical assistance consisted of 14 virtual quality improvement site visits, quarterly quality improvement webinars, a focus group of 15 CAH quality champions who were tasked with developing a Texas quality improvement (QI) scorecard, and development and deployment of a one-stop MBQIP reporting portal (MBQIP Portal).