Overview

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
RCHI	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

Introduction

What is MBQIP?

The Medicare Beneficiary Quality Improvement Project (MBQIP) is a national quality-improvement initiative designed specifically for Critical Access Hospitals (CAHs). Started in 2011, it operates under the Medicare Rural Hospital Flexibility ( Flex ) Program, administered by the Health Resources and Services Administration ( HRSA ), Federal Office of Rural Health Policy (FORHP).

Goal

The goal of MBQIP is to improve the quality of care provided in critical access hospitals. This can be achieved by increasing their reporting of quality data and using that data to drive meaningful quality improvements.

Critical Access Hospitals (CAHs)

MBQIP focuses these efforts in the 45 states that participate in the Flex Program. Through Flex, MBQIP works with 1,360 rural CAHs to use quality measure data for quality improvement activities.

How can my hospital participate in the MBQIP?

To qualify for the Flex program, your hospital must be a Critical Access Hospital as designated by Medicare. State Flex Programs, which are carried out by State Offices of Rural Health (SORH) , are responsible for implementing MBQIP within their state as part of the quality improvement program area under the Flex cooperative agreement.

Contact your State Flex Program to learn how to participate.

Reporting

Measure Domains

MBQIP aims to capture quality of care in the most relevant areas. Currently, MBQIP includes:

Care Transitions
Global Measures
Outpatient Care
Patient Engagement
Patient Safety/Inpatient

MBQIP Overview

These resources provide a detailed overview of the program:

Critical Access Hospital Reporting

Resources aimed at Critical Access Hospitals:

State Flex Reporting

Resources aimed at State Flex Program Coordinators:

Measure Hubs

Hospital Quality Reporting

The Hospital Quality Reporting (HQR) platform is a centralized location to report many measures for different CMS quality programs. The Data Submission platform contains multiple tabs and each of these tabs contains submission channels for multiple different measures:

eCQM
Web-Based Measures
Population & Sampling
Chart Abstracted
HCAHPS
Structural Measures
Hybrid Measures
PRO-PM

Resources:

National Healthcare Safety Networks

To report measures, your hospital must be enrolled in NHSN. If you are unsure of your hospital’s status with NHSN, email them at: nhsn@cdc.gov .

State Flex Programs

Resources aimed at Critical Access Hospitals:

Flex Monitoring Team

The data for the CAH Quality Infrastructure measure is reported once a year in the fall via the CAH Quality Inventory and Assessment. Your State Flex Coordinator will provide a link to complete the assessment in the fall when the reporting period begins.