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.
The MBQIP Measures Fact Sheets provide an overview of the data collection and reporting processes for Medicare Beneficiary Quality Improvement Project (MBQIP) required measures in a one‐measure‐per‐page overview.
This Excel document is intended to provide users with technical information regarding Medicare Beneficiary Quality Improvement Project (MBQIP) measures. The goal of this resource is to capture details regarding the MBQIP required measures from a variety of sources and provide them in one, easy to access location.
Offers strategies and resources to help CAH staff organize and support efforts to implement best practices for quality improvement.
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:
MBQIP Required Measures directly entered in HQR through the HARP Log In:
Many CAHs may have no occurrences for outpatient AMI measures. To be counted for participation in MBQIP, CAHs are required to submit “zero cases” to HQR (Hospital Quality Reporting).
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.
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.
A Ready to Print version that is effective with 1Q -4Q 2020 encounters. This document is designed to be printed double sided. Please discard past versions after 4Q 2020 data submission.
For CART/QualityNet Updated information please visit the resources here: https://mtpin.org/mbqip-reporting/#cart.
