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The Medicare Beneficiary Quality Improvement Project (MBQIP) is a quality improvement activity under the Medicare Rural Hospital Flexibility (Flex) grant program of the Federal Office of Rural Health Policy (FORHP). The goal of MBQIP is to improve the quality of care provided by 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.

Nationwide, 96% of CAHs are participating in MBQIP.  In Wisconsin, all 58 CAHs participate.  In September 2015, FORHP made MBQIP participation mandatory for CAHs – meaning CAHs must participate in order to receive funding from the Medicare Rural Hospital Flexibility (Flex) Program Grant, and the Small Rural Hospital Improvement Program (SHIP) Grant.  Each State Office of Rural Health is tasked with administering the MBQIP program within their state.  Here in Wisconsin, the Wisconsin Office of Rural Health oversees the MBQIP program, and has successfully enrolled all 58 Critical Access Hospitals.  Through participation in MBQIP, CAHs are required to submit a select group of measures.  Those measures consist of: HCAHPS, Emergency Department Transfer Communications (EDTC) measures, nine outpatient measures, and two influenza immunization measures.


What are the mandatory MBQIP measures?  The mandatory measures are inclusive of:


Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

The HCAHPS survey contains 21 patient perspectives on care and patient rating items that encompass nine key topics:

Communication with Doctors
Communication with Nurses
Responsiveness of Hospital Staff
Pain Management
Communication About Medicines
Discharge Information
Cleanliness of Hospital Environment
Quietness of Hospital Environment
Care Transitions


Emergency Department Transfer Communication Measures (EDTC)

EDTC-1: Home Medications
EDTC-2: Allergies and/or Reactions
EDTC-3: Medications Administered in ED
EDTC-4: Ed Provider Note
EDTC-5: Mental Status/Orientation Assessment
EDTC-6: Reason for Transfer and/orPlan of Care 
EDTC-7: Tests and/or Procedures Performed
EDTC-8: Tests and/or Procedure Results

Outpatient (OP)

OP-2: Fibrinolytic Therapy Received within 30 minutes
OP-3: Median Time to Transfer to another Facility for Acute Coronary Intervention
OP-18: Median Time from ED Arrival to ED Departure for Discharged ED Patients
OP-22: Patient Left without Being Seen

Patient Safety 

ED-2: Admit Decision Time to ED Departure Time for Admitted Patients (This measure is being removed following Q4 2019 data submission. The last reporting date was May 15th, 2020.)

HCP/OP 27: Influenza Vaccination Among Healthcare Personnel

What does mandatory MBQIP participation mean?

Critical Access Hospitals must participate in MBQIP in order to get federal funding from the Wisconsin Office of Rural Health.  That includes funding from the following federal sources:

  • The Medicare Rural Hospital Flexibility (Flex) Grant (any Flex funded project, grants from our office, trainings etc.)
  • The Small Rural Hospital Improvement Program (SHIP) Grant

As of June 2016, all 58 WI CAHs are submitting one or more of the MBQIP (HCAHPs, Imm-2, HCP/OP-27, Emergency Department Transfer Communications (EDTC) and Outpatient measures).


For questions about MBQIP, please contact Kathryn Miller, Rural Hospitals & Clinics Program Manager, Wisconsin Office of Rural Health, 608-261-1891.


MBQIP Measures Fact Sheets

Stratis Health has produced MBQIP Measures Fact Sheets for current MBQIP Measures.  The Fact Sheets provide an overview of the data collection and reporting processes for the MBQIP required measures. The goal of this resource is to capture details regarding MBQIP measures and provide them in a basic, one-measure-per-page overview.


Interpreting MBQIP Hospital Data Reports for Quality Improvement

This guide, courtesy of the Rural Quality Improvement Technical Assistance Center, is intended to help CAH staff use MBQIP Hospital Data Reports to support quality improvement efforts and improve patient care.  It includes examples of how to interpret MBQIP Reports, some example reports that outline how you can identify opportunities for improvement, and a glossary of key words.


MBQIP Reporting Guide

Stratis Health has developed the MBQIP Reporting Guide to help MBQIP participating hospitals better understand the MBQIP measures and the reporting process.  The guide includes information on where measures are reported, and how to submit those measures.



MBQIP Monthly

This monthly e-newsletter, produced by the Rural Quality Improvement Technical Assistance, provides critical access hospitals (CAHs) with information and support for quality reporting and improvement and highlights current information about the Medicare Beneficiary Quality Improvement Project (MBQIP).



Online MBQIP Data Abstraction Training Series

Stratis Health has developed a series of seven training videos to help Critical Access Hospital Staff with data abstraction of MBQIP measures including OP1-OP5, OP18, OP20-OP22 and IMM-2.



Ask Robyn – Quarterly Open Office Hour Calls for Data Abstractors

Stratis Health has announced the addition of open office hours for MBQIP data abstraction questions.  Office hours are staffed by Quality Reporting Specialist Robyn Carlson of Stratis Health.

MBQIP Data Submission Deadlines

The Federal Office of Rural Health Policy has put together a chart showing the MBQIP data submission deadlines.

MBQIP Data Submission Deadlines (for Q4 2019 — Q2 2020)


Inpatient and Outpatient Quality Reporting Specifications Manuals

The quality reporting specifications manuals are uniform guidelines defining hospital inpatient and outpatient data to be collected and how data is to be reported. They contain the information necessary for abstractors to ensure data are standardized and comparable across hospitals. Because updates to the manuals are necessary overtime, find the data collection time period for which you are reporting and select the associated specifications manual.

Specifications Manual for National Hospital Inpatient Quality Measures
Hospital Outpatient Quality Reporting Specifications Manual


The Centers for Medicare & Medicaid Services (CMS) Abstraction & Reporting Tool (CART)

The Centers for Medicare & Medicaid Services (CMS) Abstraction & Reporting Tool (CART) is used for inpatient and outpatient data collection and analyses to inform quality improvement efforts. CART is available from QualityNet for use on a stand-alone, Windows-based computer, in a computer network or in environments without computing resources (paper tool). The application is available at no charge to hospitals or other organizations seeking to improve quality of care. Basic information about CART can be found on the QualityNet website at the following webpages:

Additional CART resources can be found here.

Frequently Asked Questions


How are the MBQIP measures submitted?

OP 2, 3, and 18 are reported to QualityNet via a vendor or the CMS Abstraction & Reporting Tool (CART)
OP-22 is reported to QualityNet via Secure Log In
HCP (formerly OP-27) is reported to the National Healthcare Safety Network (NHSN)
Emergency Department Transfer Communication measures are reported to the Wisconsin Office of Rural Health on a quarterly basis
HCAHPS is reported to QualityNet via a vendor


How do I find out if my hospital is participating?  

All 58 Wisconsin CAHs are participating in MBQIP.  If you would like to find out which measures you are submitting, please contact Kathryn Miller, Rural Hospitals & Clinics Program Manager, Wisconsin Office of Rural Health, 608-261-1891.

How can I receive updates and information about MBQIP?

To be added to our distribution list, please contact Kathryn Miller, Rural Hospitals & Clinics Program Manager, Wisconsin Office of Rural Health, 608-261-1891.

Does MBQIP replace the CMS Hospital Quality Measures?

No, MBQIP includes a set of rural relevant quality measures to help CAHs focus data reporting and improvement efforts. With the exception of the EDTC measure, the MBQIP measures are currently a sub-set of measures from the CMS Hospital Inpatient and Outpatient Quality Reporting Programs. Hospitals currently reporting additional CMS measures are encouraged to continue that process.

Will MBQIP data be shared publicly on Hospital Compare?

In order for quality data to be shared publicly on Hospital Compare, the appropriate Notices of Participation must be completed for reporting hospitals. If a CAH has completed the related Notice of Participation and has not opted to suppress their quality data, then data submitted to QualityNet is eligible to be posted to Hospital Compare so long as the necessary volume thresholds are met. If a hospital has not completed the related Notice of Participation, but is reporting data to QualityNet for the purposes of MBQIP, data will not be shared publicly on Hospital Compare.

While public reporting of data on Hospital Compare is not a requirement of MBQIP participation, FORHP strongly encourages hospitals to do so.

What is the difference between “0” and “N/A” on the MBQIP Data Reports?

“N/A” for a measure indicates any of the following:

  • The CAH chose not to report
  • The CAH did not have any patients who met the population criteria for the measure in the given timeframe and therefore had no cases to report for that measure or measure-set
  • Cases submitted by the CAH were rejected by QualityNet due to technical issues

“0” for a measure indicates the CAH did submit data that met the population criteria, but none of those cases met the measure inclusion criteria.

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