The Medicare Beneficiary Quality Improvement Project (MBQIP) is a quality improvement activity under the Medicare Rural Hospital Flexibility (Flex) grant program. The goal of MBQIP is to improve the quality of care provided in small, rural Critical Access Hospitals (CAHs). This is being done by increasing the voluntary quality data reporting by CAHs, and then driving quality improvement activities based on the data. This project provides an opportunity for individual hospitals to look at their own data, measure their outcomes against other CAHs and partner with other hospitals in the state around quality improvement initiatives to improve outcomes and provide the highest quality care to each and every one of their patients.
IMPORTANT: To be eligible to benefit from Flex funds and participate in Flex-funded activities, CAHs must meet the annual MBQIP requirements. It is expected for CAHs to report on all measures. If unable to report on a measure due to extenuating circumstances, an attestation outlining the circumstances is needed to meet the requirements set by FORHP.
As of February 2026 there are 9 MBQIP measures that CAHs are responsible for reporting to the MT Flex Program. The measures are submitted across various platforms; HQR, NHSN, Cognito and finally Vendor responsibility for HCAHPS. All current information and resources can be found in the Winter 2026 CAH Quality Reporting Guide.
In this workbook you will find valuable resources to support your team’s quality improvement efforts, including an interactive timeline to follow, quality improvement goal statement template and ways to track progress during your organization’s quality improvement journey.
In 2020, CMS redesigned the way data is uploaded. As of 2Q 2020 encounter uploads (due November 2020), the QualityNet Secure Portal will no longer accept data uploads and all data submissions must be done using the HARP Log In to HQR (Hospital Quality Reporting). In addition to that, as of February 2025 CART is no longer a tool that CMS is using to abstract data.
MBQIP Required Measures directly entered in HQR through the HARP Log In:
CMS’ Center for Clinical Standards and Quality
The use of NHSN (National Health Safety Network) is quickly becoming a requirement for many programs supporting patient safety measures. Currently MT Flex Program requires the use of NSHN for reporting of Healthcare Worker Immunization and the NHSN Facility Annual Survey to measure Antibiotic Stewardship Programs. In addition, MT DPHHS utilize the program for Antibiotic Stewardship and other Patient Safety measures.
For facilities to fulfill the reporting requirements through NHSN, they must enroll in NHSN and activate the HPS (Healthcare Personnel Safety) and Patient Safety Components in NHSN.
NHSN Home Page
By joining the MHA Flex User group, you can eliminate and duplicate reporting for ongoing improvement activities driven by the Flex Grant. This user group also applies to patient safety components of NHSN that are applicable to the MT HQIC project.
