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 4 main mbqip domains: Care Transitions, 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
HCAHPS	Hospital Consumer Assessment of Healthcare Providers and Systems
HCP	Healthcare personnel
HCP	Influenza Vaccination Coverage Among Health Care Personnel
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 transitions 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
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.
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.
MBQIP 2025 Information Guide	December 2023	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.

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
Name	Last Updated	Description
MBQIP Measures	December 2023	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.
MBQIP Data Submission Deadlines	January 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 Measure Change Summaries	January 2023	These summaries provide information about measures added and removed from the Medicare Beneficiary Quality Improvement Project (MBQIP) since fall 2017.
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	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.
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 FAQ	July 2020	Emergency Department Transfer Communication (EDTC) Frequently Asked Questions
EDTC Final Summary Report	July 2014	As part of this one-year special innovation project through the Medicare Quality Improvement Organization Program, just over 100 critical access hospitals (CAH) in eight states worked to improve transitions of care during emergency department (ED) transfers. Participating CAHs collected and submitted the National Quality Forum (NQF) endorsed Emergency Department Transfer Communication Measures, and were encouraged to develop and implement improvement action plans based on their results.
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.

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).