MBQIP guidelines with respect to the whole program
Link 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
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.
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
Link 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.
pdf 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.