Medicare Beneficiary Quality Improvement Project Reporting

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: MBQIP is a required activity of the MT Flex Grant. To receive benefits from Flex Grant funds MT CAHs will need to report: at least 1 measure, for 2 quarters, in at least 3 of the four quality domains within a certain reporting period.

General Information and Resources


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).

MBQIP Required Measures entered into CART then uploaded to HQR through the HARP Log In:

  • CMS Outpatient OP-2: Fibrinolytic Therapy received by patient w/i 30 minutes of arrival.
  • CMS Outpatient OP-3: Median Time to Transfer to Another Facility for Acute Coronary Intervention
  • CMS Outpatient OP-18: Median Time from ED Arrival to ED Departure for Discharged ED Patients

MBQIP Required Measures directly entered in HQR through the HARP Log In:

  • CMS Outpatient OP-22: Patient left without being seen.
  • HCAHPS Survey: uploaded by vendor if not self-administered by CAH.

NHSN (National Health Safety Network)

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 and MT HQIC 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.