The Medicare Beneficiary Quality Improvement Project (MBQIP) is a voluntary quality improvement initiative aimed at promoting better healthcare outcomes for patients treated in critical access hospitals (CAHs), which are often located in rural areas. MBQIP provides an opportunity for small hospitals to report on quality and outcomes data, fostering a culture of quality improvement and enhancing rural healthcare delivery.

Objective: MBQIP aims to improve the quality of care provided in rural communities by encouraging CAHs to:

• Collect and submit specific quality measures data.

• Use this data for quality improvement efforts.

• Benchmark their results against other CAHs nationally, enabling them to identify gaps in care and implement targeted improvement efforts.

Quality Measures: MBQIP focuses on a set of measures aligned with national healthcare priorities, including patient safety, patient engagement, care transitions, and outpatient measures. These measures address areas such as emergency department care, inpatient care, and patient experience.

Patient Safety / Inpatient:

• Core Measures:

  • HCP/IMM-3 (formerly OP-27): Influenza Vaccination Coverage Among Healthcare Personnel (HCP)

  • Antibiotic Stewardship: Measured via Center for Disease Control National Healthcare Safety Network (CDC NHSN) Annual Facility Survey

• Additional Measures:

  • Healthcare-Associated Infections (HAI)

    • CLABSI: Central Line-Associated Bloodstream Infection

    • CAUTI: Catheter-Associated Urinary Tract Infection

    • CDI: Clostridioides difficile (C.diff) Infection

    • MRSA: Methicillin-resistant Staphylococcus aureus

    • SSIs: Surgical Site Infections Colon or Hysterectomy

  • Perinatal Care

    • PC-01: Elective Delivery • PC-05: Exclusive Breast Milk Feeding (eCQM)

  • Falls

    • Falls with Injury

    • Patient Fall Rate

    • Screening for Future Fall Risk Adverse Drug Events (ADE)

    • Opioids

    • Glycemic Control

    • Anticoagulant Therapy

  • Patient Safety Culture Survey

  • Inpatient Influenza Vaccination

  • eCQMs

    • VTE-1: Venous Thromboembolism Prophylaxis

    • Safe Use of Opioids: Concurrent Prescribing

    • ED-2: Median Admit Decision Time to ED Departure Time for Admitted Patients

Patient Engagement:

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) The HCAHPS survey contains 21 patient perspectives on care and patient rating items that encompass eight key topics:

• Core Measures

  • Communication with Doctors

  • Communication with Nurses

  • Responsiveness of Hospital Staff

  • Communication about Medicines

  • Discharge Information

  • Cleanliness of the Hospital Environment

  • Quietness of the Hospital Environment

  • Transition of Care

• Additional Measures

  • Emergency Department Patient Experience

Care Transitions:

• Core Measures

  • Emergency Department Transfer Communication (EDTC)

  • 1 composite; 8 elements • All EDTC Composite •

    • Home Medications

    • Allergies and/or Reactions

    • Medications Administered in ED

    • ED provider Note

    • Mental Status/Orientation Assessment

    • Reason for Transfer and/or Plan of Care

    • Tests and/or Procedures Performed

    • Test and/or Procedure Results

• Additional Measures

  • Discharge Planning

  • Medication Reconciliation

  • Swing Bed Care

  • Claims-Based Measures Measures are automatically calculated for hospitals using Medicare Administrative Claims Data

    • Readmissions

    • Complications

    • Hospital Return Days

Outpatient

• Core Measures

  • ED Throughput

    • OP-18: Median Time from ED Arrival to ED Departure for Discharged ED Patients

    • OP-22: Patient Left Without Being Seen

• Additional Measures

  • Chest Pain/AMI

    • Aspirin at Arrival

    • Median Time to ECG

  • Door to Diagnostic Evaluation by a Qualified Medical Professional