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.

In reference to COVID-19:

MBQIP data submission will be optional over the coming months (see below for details) based on Critical Access Hospitals’ ability to report.

The current MBQIP policy change applies to data due for the upcoming reporting periods: Quarter 4, 2019 (Oct 1-Dec 31, 2019), Quarter 1, 2020 (Jan 1-Mar 31, 2020), Quarter 2, 2020 (Apr 1-Jun 30). Details on each MBQIP measure and impacted submission periods are available in an updated submission deadline schedule. FORHP will continue to monitor the developing COVID-19 situation and re-assess reporting requirements as needed.

Hospitals that are able to report MBQIP measures are encouraged to continue reporting, as measures will be used to inform FORHP about making improvements in care for rural populations. While hospitals direct their resources toward caring for ill patents and ensuring the health and safety of their staff, we at FORHP, recognize that any quality measure reporting during this national emergency may not be reflective of actual performance.

General Information and Resources

CART & QualityNet

MBQIP Required Measures entered into CART then uploaded to QualityNet:

  • CMS Inpatient ED-2: Admit Decision Time to ED Departure Time for Admitted Patients
  • 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 QualityNet:

  • 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 HIIN 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.

Montana MBQIP Guide - 2019 Encounters

A Ready to Print version that is effective with 1Q 2019-4Q 2019 encounters. This document is designed to be printed double sided. Please discard past versions after 4Q 2019 data submission.

Montana MBQIP Guide - 2020 Encounters

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.