MBQIP Monthly

MBQIP Monthly is a monthly e-newsletter that provides critical access hospitals(CAHs) with the support necessary for quality reporting and improvement. Additionally, it highlights current information about the Medicare Beneficiary Quality Improvement Project (MBQIP). State Flex Programs are encouraged to distribute MBQIP Monthly to their CAHs as an additional resource to supplement state-level MBQIP support.

MBQIP Monthly is produced in support of the Federal Office of Rural Health Policy by Rural Quality Improvement Technical Assistance, a program by Stratis Health. The current version of MBQIP Monthly is available for download below.

Year Month CAHs Can! Rural Success Data Tips Tools and Resources
October 2024 RQITA MONTHLY Edition: October 2024 Upcoming Deadlines and Reporting Reminders Our critical access hospital is looking to strengthen its antibiotic stewardship program. What are some key elements we should focus on, especially given our limited resources? Tools and Resources - Health Equity Self-Assessment Tool
September 2024 RQITA MONTHLY Edition: September 2024 Upcoming Deadlines and Reporting Reminders What can we do to encourage vaccination and meet the MBQIP HCP/IMM-3 benchmark? Tools and Resources - Critical Access Hospital Quality Inventory and Assessment
August 2024 RQITA MONTHLY Edition: August 2024 Upcoming Deadlines and Reporting Reminders Trying to submit the Hybrid Hospital-Wide Readmission measure for the first time. What format do the linking variables and the other Core Clinical Data Elements need to be in to ensure CMS is able to link the claims data elements? Tools and Resources - National Assistance to Address Social Drivers of Health
July 2024 RQITA MONTHLY Edition: July 2024 Upcoming Deadlines and Reporting Reminders The Screening for Social Drivers of Health measure specifications do not specify a screening tool that needs to be used by hospitals. What screening tools are used by other critical access hospitals? Tools and Resources - CY 2024 Medicare Promoting Interoperability Program eCQM Requirements
June 2024 RQITA MONTHLY Edition: June 2024 Upcoming Deadlines and Reporting Reminders What new resources are available that will help you navigate the MBQIP program? Tools and Resources - TeamSTEPPS Program Updates
May 2024 RQITA MONTHLY Edition: May 2024 Upcoming Deadlines and Reporting Reminders What new resources are available that will help you navigate the MBQIP program? Tools and Resources - Addressing the Substance Use Epidemic
April 2024 RQITA MONTHLY Edition: April 2024 Upcoming Deadlines and Reporting Reminders Where can I learn more about reporting the 2025 measures? Tools and Resources - SUDORS Dashboard: 2022 Fatal Overdose Data
March 2024 RQITA MONTHLY Edition: March 2024 Upcoming Deadlines and Reporting Reminders I hear there are new core measures for MBQIP. Where can I find more information? Tools and Resources - Rural Healthcare Outcomes Accelerator | American Heart Association
February 2024 RQITA MONTHLY Edition: February 2024 Upcoming Deadlines and Reporting Reminders I saw a new outpatient version of CART was released. What version of CART should I be using? Tools and Resources - Is Your Hospital Working Toward Health Equity?
January 2024 RQITA MONTHLY Edition: January 2024 Upcoming Deadlines and Reporting Reminders My hospital would like to begin reporting the Hospital Commitment to Health Equity measure. What key information do I need to know before reporting this measure? Tools and Resources - Antimicrobial Use and Resistance (AUR) Measure
December 2023 RQITA MONTHLY Edition: December 2023 Upcoming Deadlines and Reporting Reminders My hospital will be reporting the Hybrid Hospital-Wide Readmission (HWR) Measure. What does “hybrid” mean and how does that impact reporting? Tools and Resources - Rural-Urban Disparities
November 2023 RQITA MONTHLY Edition: November 2023 Questions from the Field Upcoming Deadlines and Reporting Reminders Rural Health: Addressing Barriers to Care & Measure Deadlines
October 2023 RQITA MONTHLY Edition: October 2023 (EDTC) measure for Q3 2023 encounters (July 1, 2023 - September 30, 2023) is due What happened to measures OP-2 and OP-3? Team is in the process of updating and producing MBQIP tools, resources, and trainings
September 2023 CAHs Can! QI Mentor Stories – Improving Swing Bed Quality CAHs Measure Up: Collaborative Impact Tips: Robyn Quips – New Centers for Medicare and Medicaid Services (CMS) Required Reporting Tools and Resources – MBQIP and Rural Health Improvement Resources
August 2023 CAHs Can! QI Mentor Stories – Reducing Avoidable Hospital Readmissions CAHs Measure Up: Influenza Vaccination Coverage Tips: Robyn Quips – CMS Reporting Structures Tools and Resources – MBQIP and Rural Health Improvement Resources
July 2023 CAHs Can! QI Mentor Stories – QI Mentor Stories Implementing Successful Fall Prevention Strategies CAHs Measure Up: Centers for Disease Control and Prevention (CDC) Core Elements of Hospital Antibiotic Stewardship Programs Tips: Robyn Quips – Data Submission Reminders Tools and Resources – Helping CAHs Succeed in Quality Reporting & Improvement
June 2023 CAHs Can! QI Mentor Stories – Building A Quality Warehouse CAHs Measure Up: Health Care Disparities in Rural Areas – A Data Driven Approach Tips: Robyn Quips – CMS Data Element Change Tools and Resources – Helping CAHs succeed in quality reporting & improvement
May 2023 CAHs Can! QI Mentor Stories - Improving Durable Medical Equipment Process CAHs Measure Up: OP-18 National Performance Robyn Quips - tips and frequently asked questions - Abstraction tidbits MBQIP and Rural Health Resources
April 2023 CAHs Can! Engaging Hospital Boards in Quality Data: CAHs Measure Up – New Birthing-Friendly Hospital Designation Tips: Robyn Quips – Annual Measures OP 22 and HCP Tools and Resources – Helping CAHs Succeed in Quality Reporting & Improvement
March 2023 CAHs Can! How Critical Access Hospitals Improved Patient Experience During the Pandemic Data: CAHs Measure Up – HCAHPS Performance in 2021 Tips: Robyn Quips – CART Tool Tools and Resources – Helping CAHs Succeed in Quality Reporting & Improvement
February 2023 CAHs Can! National Rural Virtual Quality Improvement Mentor Profile Series: Linda Webb Data: CAHs Measure Up – EDTC Measure Reporting Trends Tips: Robyn Quips – MBQIP Measure Updates Tools and Resources – Helping Critical Access Hospitals Succeed in Quality Reporting & Improvement
January 2023 CAHs Can! National Rural Virtual Quality Improvement Mentor Profile Series: Tammy Sudtelgte Data: CAHs Measure Up – MBQIP Annual Reports: What Are They, and What Do They Tell Us? Tips: Robyn Quips – Year-end and New Year Abstraction Reminders Tools and Resources – Helping Critical Access Hospitals Succeed in Quality Reporting & Improvement
December 2022 National Rural Virtual Quality Improvement Mentor Profile Series: Tammy Suchy CAHs Measure Up – Antibiotic Stewardship Program Education Implementation Update Abstraction and Reporting Resources Helping CAHs Succeed in Quality Reporting & Improvement
November 2022 National Rural Virtual Quality Improvement Mentor Profile Series: Katrina Strowbridge CAHs Measure Up – Antibiotic Stewardship Program Reporting Implementation Update Influenza Vaccination Coverage Among Healthcare Personnel Helping CAHs Succeed in Quality Reporting & Improvement
October 2022 Use Healthcare Quality Week To Show That Quality Matters Every Day Influenza Vaccination Coverage Among Healthcare Personnel CMS Quality Program Emails Helping CAHs Succeed in Quality Reporting & Improvement
September 2022 CAHs Can! National Rural Virtual Quality Improvement Mentor Profile Series: Jenifer Monzo Antibiotic Stewardship Program Core Elements Met by CAHs Outpatient Measure Abstraction Quiz Answers Helping CAHs Succeed in Quality Reporting & Improvement
August 2022 National Rural Virtual Quality Improvement Mentor Profile Series: Stacey Karvoski Top 10 States with Outstanding Quality Performance Outpatient Measure Abstraction Quiz Helping CAHs Succeed in Quality Reporting & Improvement
July 2022 National Rural Virtual Quality Improvement Mentor Profile Series: Marilyn Denno HCAHPS Response Rates EDTC Abstraction Quiz Answers Helping CAHs Succeed in Quality Reporting & Improvement
June 2022 National Rural Virtual Quality Improvement Mentor Profile Series: Cara Cruz Prioritize Your QI Projects EDTC Abstraction Quiz Helping CAHs Succeed in Quality Reporting & Improvement
May 2022 National Rural Virtual Quality Improvement Mentor Profile Series: Katherine Bryant Ensuring Data Accuracy Abstraction Tidbits Helping CAHs Succeed in Quality Reporting & Improvement
April 2022 National Rural Virtual Quality Improvement Mentor Profile Series: Caryn Bommersbach OP-18 Performance Snapshot Annual Measures OP-22 and HCP Helping CAHs Succeed in Quality Reporting & Improvement
March 2022 National Rural Virtual Quality Improvement Mentor Profile Series: Gloria Barth Missing Data on MBQIP Reports CMS Measure Resources Helping CAHs Succeed in Quality Reporting & Improvement
February 2022 Antibiotic Stewardship Profile Series: Astria Sunnyside Hospital Random Sampling Reporting Tidbits Helping CAHs Succeed in Quality Reporting & Improvement
January 2022 New Cohort of National Virtual Quality Improvement Mentors Ready to Help with QI Challenges EDTC Performance NHSN Annual Facility Survey Helping CAHs Succeed in Quality Reporting & Improvement
December 2021 Quality Time: Sharing PIE (performance improvement experience) Conversations How EDTC Measures Are Calculated Chart Abstracted MBQIP Measures Helping CAHs Succeed in Quality Reporting & Improvement
November 2021 Antibiotic Stewardship Profile Series: Forks Community Hospital Antibiotic Stewardship Reporting Implementation Update MBQIP Reports – Is Your HCP Data Showing? Helping CAHs Succeed in Quality Reporting & Improvement
October 2021 Use Healthcare Quality Week To Show Why Quality Matters Now More Than Ever Top 10 States with Outstanding Quality Performance In the Population or Not? Helping CAHs succeed in Quality Reporting & Improvement
September 2021 Resilience: Factors To Help Your Organization Bounce Back Antibiotic Stewardship Action Implementation Update Quality Reporting Notifications from CMS Helping CAHs succeed in Quality Reporting & Improvement
August 2021 Quality Time: Sharing PIE (performance improvement experience) Conversations Free Samples? Population and Sampling Data Are Here! Abstraction Tidbits Helping CAHs Succeed in Quality Reporting & Improvement
July 2021 Quality Time: Sharing PIE (performance improvement experience) Mentors Answer Your Burning Questions Overall Hospital Star Ratings Reporting Reminders and Hospital-Acquired Infection (HAI) Data Helping CAHs Succeed in Quality Reporting & Improvement
June 2021 Quality Time: Sharing PIE (performance improvement experience) Conversations When You Shouldn’t Use EHR Data For Quality Improvement Abstracting for Accuracy Helping CAHs Succeed in Quality Reporting & Improvement
May 2021 Quality Improvement Mentor Program: One-year Retrospective Reviewing Your Performance in EDTC Data Elements MBQIP Measures Submitted Yearly Helping CAHs Succeed in Quality Reporting & Improvement
April 2021 Quality Time: Sharing PIE (performance improvement experience) Mentors Answer Your Burning Questions CAHs Measure Up – MBQIP Hospital Data Reports Submitting OP-22 Helping CAHs Succeed in Quality Reporting & Improvement
March 2021 Quality Time: Sharing PIE (performance improvement experience) Conversations Guest Spotlight: CDC Infection Control Training Data Submission Helping CAHs Succeed in Quality Reporting & Improvement
February 2021 Quality Time: Sharing PIE (performance improvement experience) Conversations Annual Facility Survey Provides Antibiotic Stewardship Snapshot Data Submission Helping CAHs Succeed in Quality Reporting & Improvement
January 2021 Quality Time: Sharing PIE (performance improvement experience) Mentors Answer Your Burning Questions Monitoring HCAHPS Performance Data Submission Update Helping CAHs Succeed in Quality Reporting & Improvement
December 2020 Quality Time: Sharing PIE (performance improvement experience) Conversations Finding and Using Benchmarking Data Hospital Quality Reporting Site Updates Helping CAHs Succeed in Quality Reporting & Improvement
November 2020 Rural Success: Avera Holy Family Hospital, IA Random Sampling Using CART Helping CAHs Succeed in Quality Reporting & Improvement
October 2020 Rural Success: Pembina County Memorial Hospital, ND New EDTC Measure Data QualityNet Updates Helping CAHs Succeed in Quality Reporting & Improvement
September 2020 Rural Success: Paris Community Hospital, IL Top 10 States with Outstanding Quality Performance QualityNet Updates Helping CAHs Succeed in Quality Reporting & Improvement
August 2020 Second Episode Now Available: Quality Time: Sharing PIE (performance improvement experience) Conversations New Trend Line Feature in CAHMPAS Quality Data Abstracting for Accuracy Helping CAHs Succeed in Quality Reporting & Improvement
July 2020 Rural Success: Improving Your Antibiotic Stewardship Program Antibiotic Stewardship Program Core Elements Met by CAHs FAQ: QualityNet Updates Helping CAHs Succeed in Quality Reporting & Improvement
June 2020 Rural Success: Kit Carson County Health Service District, Burlington, CO Make Prioritizing Quality Improvement Easier FAQ: Current MBQIP Reporting Guidelines Helping CAHs Succeed in Quality Reporting & Improvement
May 2020 Quality Time: Sharing PIE (performance improvement experience) Conversations Reviewing Your Performance in EDTC Data Elements FAQ: Setting Up a HARP Account Helping CAHs Succeed in Quality Reporting & Improvement
April 2020 Focus on COVID-19 Quality Reporting Updates Due to the COVID-19 Pandemic COVID-19 and MBQIP Resources
March 2020 Rural Success: Ellenville Regional Hospital CAHs Measure Up – Improving HCAHPS Scores FAQ: EDTC Abstraction Quiz Answers Helping CAHs Succeed in Quality Reporting & Improvement
February 2020 Antibiotic Stewardship Profile Series: Pointe Coupee General Hospital MBQIP Hospital Data Reports FAQ: Take the EDTC Abstraction Quiz! Helping CAHs Succeed in Quality Reporting & Improvement
January 2020 Virtual Quality Improvement Mentor Program Data Quality and Accuracy FAQ: Comments and Observations on the EDTC Training Sessions Helping CAHs Succeed in Quality Reporting & Improvement
December 2019 Antibiotic Stewardship Profile Series: Clarke County Hospital, IA Measuring the Influenza Season FAQ: Upcoming EDTC Measure Specifications Manual Training Helping CAHs Succeed in Quality Reporting & Improvement
November 2019 Antibiotic Stewardship Profile Series: Greene County General Hospital, IN Benchmarking with CAHMPAS FAQ: Is Your HCP Data Showing? Helping CAHs Succeed in Quality Reporting & Improvement
October 2019 Rural Success: Power County Hospital District, ID Benchmarking to Improve Antibiotic Stewardship FAQ: What’s Showing on Your MBQIP Report? Helping CAHs Succeed in Quality Reporting & Improvement
September 2019 Rural Success: Riverview Regional Medical Center, TN CAHs Measure Up – Core Elements of Antibiotic Stewardship Tips and Frequently Asked Questions: MBQIP Chart-abstracted Measures – What’s Been Removed and What’s Staying Helping CAHs Succeed in Quality Reporting & Improvement
August 2019 Rural Success: Upper Connecticut Valley Hospital, NH CAHs Measure Up – 2019 MBQIP Awards FAQ: EDTC Updates Helping CAHs Succeed in Quality Reporting & Improvement
July 2019 Rural Success: Dahl Memorial Healthcare Association, MT CAHs Measure Up – MBQIP Hospital Data Reports – Understanding N/A, D/E, and 0 FAQ: EDTC Data Submission Helping CAHs Succeed in Quality Reporting & Improvement
June 2019 Rural Success: High-performing CAHs Take Action for Antibiotic Stewardship CAHs Measure Up – Annual Facility Survey Provides Antibiotic Stewardship Snapshot FAQ: New Year Means New Manuals Helping CAHs Succeed in Quality Reporting & Improvement
May 2019 Rural Success: Abrom Kaplan Memorial Hospital, LA Finding and Using Benchmarking Data FAQ: Open Office Hours Calls Helping CAHs Succeed in Quality Reporting & Improvement
April 2019 Rural Success: Avera Marshall Regional Medical Center, MN Internally Monitoring OP-22 FAQ: OP-22 and HCP/IMM-3 (Formerly OP-27) Helping CAHs Succeed in Quality Reporting & Improvement
March 2019 Rural Success: Titusville Area Hospital, PA Tools and Resources: Helping CAHs Succeed in Quality Reporting & Improvement Data: CAHs Measure Up – HCAHPS Performance in 2017 Tips: Robyn Quips – Tips and Frequently Asked Questions: OP-27: Is it Really Gone?
February 2019 CAHs Can!: Fairview Regional Medical Center, OK Random Sampling FAQ: Emergency Department Transfer Communication Helping CAHs Succeed in Quality Reporting & Improvement
January 2019 CAHs Can!: Year-end Review: What Makes Great CAHs Antibiotic Stewardship Tracking FAQ: Year-end and New Year Abstraction Reminders Helping CAHs Succeed in Quality Reporting & Improvement
November 2018 Rural Success: St. Elizabeth Healthcare, KY Enhanced Hospital Data Reports FAQ: Current MBQIP Core Measures Helping CAHs Succeed in Quality Reporting & Improvement
October 2018 Rural Success: Jefferson Healthcare Medical Center, WA Measuring Influenza Season Robyn Quips – Tips and Frequently Asked Questions: Abstracting for Accuracy Findings, Determining Measure Populations, Part Two Helping CAHs Succeed in Quality Reporting & Improvement
September 2018 Rural Success: Abbeville Area Medical Center, SC 2018 Annual Facility Survey FAQ: Abstracting for Accuracy Findings, EDTC Population Helping CAHs Succeed in Quality Reporting & Improvement
August 2018 Rural Success: Fairview Hospital, MA 2018 MBQIP Awards FAQ: Quarter 2 2018 Outpatient Measure Abstraction and Submission Helping CAHs Succeed in Quality Reporting & Improvement
July 2018 Rural Success: Antibiotic Stewardship in Action Preliminary Abstracting for Accuracy Results FAQ: CART Tool Updates Helping CAHs Succeed in Quality Reporting & Improvement
June 2018 Rural Success: First Care Health Center, ND National OP-5 Performance Tips and Frequently Asked Questions Helping CAHs Succeed in Quality Reporting & Improvement
May 2018 Rural Success: Hampshire Memorial Hospital, WV Variation and Improvement Tips and Frequently Asked Questions Helping CAHs Succeed in Quality Reporting & Improvement
April 2018 Rural Success: Aultman Orrville Hospital, OH ED-1 and ED-2 Measures Now in MBQIP Hospital Data Reports Tips and Frequently Asked Questions Helping CAHs Succeed in Quality Reporting & Improvement
March 2018 Rural Success: Carroll County Memorial Hospital, MO Emergency Department Transfer Communication (EDTC) Measures Tips and Frequently Asked Questions Helping CAHs Succeed in Quality Reporting & Improvement
February 2018 Rural Success: Polk Medical Center, GA HCAHPS Performance in 2016 Tips and Frequently Asked Questions Helping CAHs Succeed in Quality Reporting & Improvement
January 2018 Rural Success: Margaret Mary Health, IN Data Quality & Accuracy Tips and Frequently Asked Questions Helping CAHs Succeed in Quality Reporting & Improvement
December 2017 Year-end Review: What Makes Great Critical Access Hospitals (CAH) Antibiotic Stewardship Reporting and Improvement Removed Outpatient Measures, Year-end Review Helping CAHs Succeed in Quality Reporting & Improvement
November 2017 Rural Success: Barrett Hospital & Healthcare, MT New Emergency Department (ED) Measures Equal New Improvement Opportunities Outpatient Population and Sampling Fix; Inpatient ED Measures Reporting Helping CAHs Succeed in Quality Reporting & Improvement
October 2017 Rural Success: Elizabethtown Community Hospital, NY Measuring Influenza Season Inpatient Emergency Department Measures Helping CAHs Succeed in Quality Reporting & Improvement
September 2017 Rural Success: St. Luke's Hospital, NC Charting MBQIP Reporting Rates Emergency Department (ED) Admits Helping CAHs Succeed in Quality Reporting & Improvement
August 2017 Rural Success: Spanish Peaks Hospital, CO 2017 MBQIP Awards Abstraction Tidbits Helping CAHs Succeed in Quality Reporting & Improvement
July 2017 Rural Success: Upland Hills Health, WI Data Reports - Understanding N/A, D/E and 0 Data Reports - Understanding N/A, D/E and 0 Helping CAHs Succeed in Quality Reporting & Improvement
June 2017 Rural Success: St. Francis Memorial Hospital, NE Reviewing EDTC Data Elements to Improve Performance EDTC Clarifications Helping CAHs Succeed in Quality Reporting & Improvement
May 2017 Rural Success: CrossRidge Community Hospital, AR HCAHPS Best Practices You Can Use FAQ: In the Population or Excluded: How do I Know? Helping CAHs Succeed in Quality Reporting & Improvement
April 2017 Rural Success: Allegan General Hospital, MI Submitting Outpatient Population and Sampling Data Population and Sampling Questions & Answers Helping CAHs Succeed in Quality Reporting & Improvement
March 2017 Rural Success: Avera DeSmet Memorial Hospital, South Dakota Finding and Using Benchmarking Data Communications from the Centers for Medicare and Medicaid (CMS) Helping CAHs Succeed in Quality Reporting & Improvement
February 2017 Rural Success: TriStar Ashland City Medical Center, TN Using the Internal Quality Monitoring Tool with CART Reports How to Run Reports in CART Helping CAHs Succeed in Quality Reporting & Improvement
January 2017 Rural Success: Rural Success: Heber Valley Hospital, UT MBQIP Hospital Data Reports New Year Reminders Helping CAHs Succeed in Quality Reporting & Improvement
December 2016 Rural Success: CAHs Can. Absolutely, CAHs Can New MBQIP Measures New CMS Specifications Manuals and Highlights from This Year’s Tips Helping CAHs Succeed in Quality Reporting & Improvement
November 2016 Rural Success: Floyd Valley Healthcare, LeMars, IA Variation and Improvement CART Tips Helping CAHs Succeed in Quality Reporting & Improvement
October 2016 Rural Success: North Canyon Medical Center, Gooding, ID Measuring the Influenza Season Population and Sampling: What, Why, When, Where, How? Helping CAHs Succeed in Quality Reporting & Improvement
September 2016 Rural Success: Ojai Valley Community Hospital, Ojai, CA HCAHPS Response Rates Potpourri of Abstraction Reminders Helping CAHs Succeed in Quality Reporting & Improvement
August 2016 Rural Success: Kimble Hospital, Junction, TX - The powerful influence of hospital nursing leaders How EDTC Measures Are Calculated Entering Population and Sampling Counts and QualityNet Helpdesk Hint Helping CAHs Succeed in Quality Reporting & Improvement
July 2016 Rural Success: Mariners Hospital, Tavernier, FL State CAH Hospital Comparison Reports Take the Abstraction Quiz! Helping CAHs Succeed in Quality Reporting & Improvement
June 2016 Rural Success: Petersburg Medical Center, Petersburg, AK All About HCAHPS Outpatient AMI and Chest Pain Measures Helping CAHs Succeed in Quality Reporting & Improvement
May 2016 Rural Success: West Valley Hospital, Dallas, OR Comparison Data Understand a Measure's Population Helping CAHs Succeed in Quality Reporting & Improvement
April 2016 Rural Success: Neosho Memorial Regional Medical Center Progress on EDTC Measures Tips: FAQ: New CART Versions, IMM-2 Risk of Case Rejection Helping CAHs Succeed in Quality Reporting & Improvement
March 2016 CAHs Can! Rural Success: Mount Desert Island Hospital, Bar Harbor, ME Internally Monitoring OP-22 Measure Sets, Paper Tools, Current EDTC Spec Manual, Due Date Change Tools and Resources
February 2016 Rural Success: Wabash General Hospital, Mount Carmel, IL ED Transfer Communication Measure reporting on the rise Get your data accepted by QualityNet warehouse Helping CAHs Succeed in Quality Reporting & Improvement
January 2016 Rural Success: Bigfork Valley Hospital (MN) and HCAHPS HCAHPS Reporting Snapshot EDTC Measure Updated for Nurse to Nurse Communication Tools and Resources