All MBQIP Measures in One Place

Get Dexur’s Personalized Hospital Specific Presentation on Quality, Safety, Compliance & Education

This article is part of the Dexur's Rural Health Newsletter, which is focused on Rural Healthcare’s operations, technology, quality, safety, risk, compliance and learning topics. Please email to join this newsletter and receive updates (not more than once per week)

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:

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 Measures

Patient safety is paramount in healthcare delivery, and MBQIP prioritizes it through several core and additional measures.

Core Measures-

  1. HCP/IMM-3 (Influenza Vaccination Coverage Among Healthcare Personnel): This measure underscores the importance of immunizing healthcare workers to prevent influenza transmission within healthcare settings, protecting both staff and patients.

  2. Antibiotic Stewardship (CDC NHSN Annual Facility Survey): Antibiotic stewardship programs are vital in combating antibiotic resistance, a growing public health concern. This measure evaluates how hospitals manage antibiotic prescribing and usage to ensure effectiveness and minimize resistance.

Additional Measures

  1. Healthcare-Associated Infections (HAI): HAIs are infections patients acquire while receiving treatment for medical or surgical conditions. MBQIP tracks several types of HAIs:

  1. Perinatal Care (PC-01 and PC-05): Perinatal care is critical as it encompasses the health of both the mother and the newborn. Within MBQIP, specific measures such as PC-01 focus on elective delivery, which entails the scheduling of childbirth at the convenience of the patient or physician without a medical necessity. The aim is to reduce unnecessary elective deliveries prior to 39 weeks of gestation, as this can lead to better health outcomes for both infants and mothers. PC-05 centers on the promotion of exclusive breast milk feeding, measured by the electronic Clinical Quality Measure (eCQM), recognizing the numerous benefits of breastfeeding for both infants and mothers, including the provision of essential nutrients and antibodies to newborns.

  1. Falls: Falls within a hospital setting can lead to significant morbidity, prolonged hospital stays, and increased healthcare costs. Measures related to falls include tracking the overall patient fall rate and falls with injury. These statistics help hospitals to identify potential risks and implement preventive strategies. Additionally, screening for future fall risk is crucial in preventing such incidents and ensuring patient safety.

  1. Patient Safety Culture Survey: A hospital's culture of safety is assessed through surveys that provide insights into the attitudes and perceptions of healthcare staff regarding their institution's commitment to safety. This feedback is essential for developing strategies to strengthen safety protocols and promote a culture of continuous improvement.

  2. Inpatient Influenza Vaccination: Inpatient influenza vaccination is another crucial measure, as it helps prevent the spread of flu within the hospital, protecting both patients and healthcare workers.

  3. Electronic Clinical Quality Measures (eCQMs): eCQMs like VTE-1, which focuses on venous thromboembolism prophylaxis, play a vital role in preventing potentially fatal blood clots in patients who are hospitalized. Another measure, ED-2, tracks the median time from the decision to admit to the time of departure from the emergency department for admitted patients, providing a benchmark for hospital efficiency and patient flow. Safe Use of Opioids emphasizes the importance of cautious and judicious prescribing practices for opioids, particularly when they are prescribed concurrently with other medications, to prevent adverse interactions and reduce the risk of addiction and overdose.

Patient Engagement Measures

Patient engagement is a key factor in improving healthcare quality and patient satisfaction. Engaged patients are more likely to take an active role in their health, leading to better outcomes and a more efficient healthcare system. Central to assessing and enhancing patient engagement in hospitals is the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.

The HCAHPS survey has become a standard for measuring patients’ perspectives on hospital care, with 21 items that reveal valuable insights into various aspects of the patient experience. These insights are instrumental in guiding improvements in healthcare delivery and patient satisfaction. The survey encompasses several core measures:

  1. Communication with Doctors: This measure reflects how effectively doctors communicate with patients. Good communication is the cornerstone of quality care and ensures patients understand their health conditions and treatments.

  2. Communication with Nurses: Nurses often spend the most time with patients, and their ability to communicate clearly and compassionately is vital for patient care and understanding.

  3. Responsiveness of Hospital Staff: The willingness and ability of hospital staff to respond quickly to patients' needs is a critical component of patient satisfaction and safety.

  4. Communication about Medicines: Patients must receive clear instructions about the medications they are prescribed, including how to take them and potential side effects, to ensure safe and effective use.

  5. Discharge Information: Providing patients with comprehensive discharge information is crucial for post-hospitalization care and can reduce the likelihood of readmissions.

  6. Cleanliness of the Hospital Environment: A clean environment is essential for patient safety, comfort, and overall satisfaction with the hospital experience.

  7. Quietness of the Hospital Environment: A quiet environment contributes to patient comfort and stress reduction, which is essential for recovery.

  8. Transition of Care: Smooth transitions of care as patients move from the hospital to other care settings or home are crucial for maintaining the continuity and quality of care.

Additional Measure

Care Transition

Care transition measures are pivotal in ensuring that patients move safely and smoothly between different care settings, such as from the emergency department (ED) to inpatient wards or from the hospital to home. Effective transitions are crucial to avoid adverse events that can occur when there are gaps in care.

Emergency Department Transfer Communication (EDTC)

The EDTC measure evaluates the communication of essential information when a patient is transferred from the ED to another setting. This comprehensive measure consists of eight elements, forming a single composite that includes:

  1. Home Medications: Accurate documentation and communication of a patient’s home medications to prevent any potential drug interactions or duplications.

  2. Allergies and/or Reactions: Noting any known allergies or adverse reactions ensures that these are considered in the patient's subsequent care.

  3. Medications Administered in ED: A record of all medications given in the ED is crucial for continuity of care.

  4. ED Provider Note: This includes a summary of care and the ED provider's assessment, offering valuable insights for the next healthcare provider.

  5. Mental Status/Orientation Assessment: Documenting the patient’s mental status helps in planning further care and assessing the need for additional support.

  6. Reason for Transfer and/or Plan of Care: Communicating the reason for transfer and the proposed plan of care aids in preparing the receiving facility and team for the patient’s arrival.

  7. Tests and/or Procedures Performed: Information on any tests or procedures done in the ED can help avoid duplication and inform ongoing care.

  8. Test and/or Procedure Results: Results are vital for diagnosing, treating, and managing the patient's condition post-transfer.

Additional measures to aid in care transitions include:

  1. Discharge Planning: Effective discharge planning ensures that the patient has a clear understanding of post-discharge instructions, follow-up appointments, and any necessary home care services.

  2. Medication Reconciliation: A process to ensure that the patient's medication list is accurate and complete at each transition point. This helps to prevent medication errors, which are among the most common healthcare mistakes.

  3. Swing Bed Care: In rural hospitals, a "swing bed" can be used for acute care or skilled nursing care as needed. Proper management of swing bed care is essential for optimal patient outcomes and resource utilization.

Claims-Based Measures

Outpatient Measures

Outpatient care, particularly in emergency departments (EDs), is a crucial aspect of healthcare delivery. The efficiency and effectiveness of outpatient services significantly impact patient outcomes and satisfaction. Within this domain, the Medicare Beneficiary Quality Improvement Project (MBQIP) focuses on several core and additional measures to assess and improve the quality of outpatient care.

ED Throughput Measures

ED throughput measures are designed to assess the efficiency of emergency departments in providing timely care to patients. These include:

  1. OP-18: Median Time from ED Arrival to ED Departure for Discharged ED Patients: This measure tracks the median time patients spend in the emergency department, from arrival to departure. It's a critical indicator of ED efficiency, affecting patient satisfaction and the overall flow of the department.

  2. OP-22: Patient Left Without Being Seen: This measure records the number of patients who leave the ED before being seen by a healthcare provider. A high rate may indicate long wait times or inadequate staffing, both of which can lead to diminished patient satisfaction and potentially poorer health outcomes.

Additional Outpatient Measures for Chest Pain/AMI:

For patients presenting with chest pain or acute myocardial infarction (AMI), timely diagnosis and treatment are vital. The additional measures for this category include:

  1. Aspirin at Arrival: This measure evaluates whether patients with chest pain or suspected AMI receive aspirin upon arrival at the ED. Early administration of aspirin has been shown to reduce mortality in cases of suspected myocardial infarction.

  2. Median Time to ECG: This metric records the median time taken to perform an electrocardiogram (ECG) on patients who present with chest pain or symptoms of AMI. A shorter time to ECG is associated with quicker diagnosis and initiation of appropriate treatment, which can be lifesaving in cases of AMI.

Door to Diagnostic Evaluation by a Qualified Medical Professional:

This measure assesses the time taken from the patient’s arrival at the ED to their initial evaluation by a qualified medical professional. Quick assessment is crucial in identifying serious conditions and initiating timely interventions.

These outpatient measures are essential components of MBQIP's strategy to enhance the quality of care in emergency departments, especially in critical access hospitals. By focusing on these key areas, hospitals can optimize their outpatient services, ensuring patients receive timely and effective care. This not only improves patient outcomes but also enhances the overall efficiency of the healthcare system in rural areas.


The MBQIP initiative represents a significant step forward in enhancing healthcare quality in rural America. By providing a framework for critical access hospitals to collect and analyze data across various quality measures, MBQIP enables these institutions to pinpoint areas for improvement and implement targeted strategies. The project’s comprehensive approach addresses the entire spectrum of patient care, from inpatient safety to outpatient efficiency and care transitions, ensuring that rural healthcare settings can offer high-quality, patient-centered care. Through MBQIP, rural hospitals are not only empowered to improve their own services but are also provided with the tools to benchmark their performance against national standards. This benchmarking is crucial for continuous improvement and helps in fostering a culture of excellence in rural healthcare, ultimately leading to healthier communities across rural America.