Quality and the Medicare Beneficiary Quality Improvement Program (MBQIP)
The Medicare Beneficiary Quality Improvement Project (MBQIP) for Critical Access Hospitals (CAHs) is a quality improvement activity under the Medicare Rural Hospital Flexibility (Flex) Program of the Health Resources and Services Administration’s (HRSA) Federal Office of Rural Health Policy (FORHP).
The goal of MBQIP is to improve the quality of care provided in CAHs, by increasing 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.
Although MBQIP reporting is optional to CAHs, it is required for CAHs who wish to participate in any Flex-funded opportunity in the areas of quality, finance and operations, EMS and/or population health. MBQIP's Core Improvement Initiatives fall under four domains:
- Patient Safety
- Patient Engagement
- Care Transitions
- Outpatient
Additional domains are recommended but not required. Details on the current domains are available here.
2024 Presentations
Measures Under Consideration (MUC) and Trends for the Future - Presenter: Susan Runyan
Leverage Your Data: A Closer Look into the Community Health Needs Assessment and MBQIP Through the Lens of Health Equity and Social Drivers of Health - Presenter: Courtnay Ryan
Rural Maternal Health Update - Presenter: Kristen Dillon
Southern Coos Hospital & Health Center - Journey to Enhance Patient Experience through Improved Staff Engagement & Culture - Presenters: Raymond T. Hino, Carmen Rodriguez, Amanda Bemetz
National CAH Quality Inventory & Assessment - Oregon - Presenter: Maddy Pick
Good Shepherd Health Care System’s Connexions Program - Presenters: Jessica Reker, Brittany Dunham
Accelerating Quality Improvement Across the Spectrum of Stakeholders - Presenters: Colleen Klamm, Svetlana Melnik, Cheryl Pell, Natalia Martinez-Paz, Zahra Kassamali Escobar
Wallowa Memorial Hospital and Clinics Community Balance and Fall Prevention Program - Presenters: Stacey Karvoski, Brooke Pace
Holler, "All Aboard!" Get the Front-Line Staff and your Board of Directors to Jump on the Quality Train - Presenter: Susan Runyan
2023 Presentations
Getting to Know the New Basics in Health Care Quality (by Susan Runyan)
Strengthening Relationships Between Hospital and Community to Reduce Hospitalization Utilization (by Seema Rathor)
Integrating Patient and Worker Safety in Critical Access Hospitals: A Need in the Pandemic Aftermath (by David Hurtado)
Overview of CMS Quality Programs and Initiatives (by Cecile Greenway)
Infection Prevention Staff at Your CAH (by Roza Tammer)
Heartbeats Behind the Headlines: Data Storytelling 101 (by Susan Runyan and Doug Morse)
Stop, Collaborate, and Listen: Leveraging Partnerships for Quality Improvement (by Natalia Martinex-Paz and Zahara Escobar)
Building a Quality Program and Patient Care and Safety Structure (by Terri Brandt-Correia, Becky Sanders and Debbie Gorst)
Improving the Timeliness of Stroke Care through Lean Process Improvement (by Theresa Via)
You Got This! How to Make Big Decisions at Small Hospitals (by Doug Morse)
2022 Presentations
CAH Quality Program Review (by Susan Runyan)
Changing Landscape of Quality Measurement (by Karla Weng)
Emergency Department Efficiencies (by Susan Runyan)
Introduction to Project Firstline (by Dr. Judy Guzman-Cotrell)
Leveraging TeleMentoring & TeleEducation During COVID 19 (by Zahra Kassamalli-Excobar & Natalie Martinez-Paz)
OHA Lessons Learned During COVID-19 (by Roza Tammer)
Reducing Readmission by Optimizing Transition of Care in Rural Settings (by Seema Rathor & Alena Acklin)
2024 Medicare Beneficiary Quality Improvement Project (MBQIP) & Quality Improvement Webinar Series
Webinar 1: Current Status MBQIP and Beyond: Meet the Telligen Staff
Presenters: Courtnay Ryan, Senior Quality Improvement Facilitator RQITA |Telligen and Ann Loges, Senior Quality Improvement Facilitator, RQITA |Telligen
Objectives:
- Meet the Telligen RQITA team. Hear about the expertise we bring to MBQIP
- Learn about MBQIP resources offered and the services provided by the RQITA team
- Quality Improvement and MBQIP: How can Telligen help?
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Learn about MBQIP performance for your region and state
Webinar 2: Learn About the New MBQIP Measures
Presenters: Courtnay Ryan, Senior Quality Improvement Facilitator RQITA |Telligen and Ann Loges, Senior Quality Improvement Facilitator, RQITA |Telligen
Objectives:
- Learn about the proposed New MBQIP Core Measure set.
- Understand the implementation timeline for the new MBQIP Core Measure set and how to report the measures.
- Hear best practices on data collection for the new MBQIP measures.
Webinar 3: Embedding Quality Improvement into Organizational Culture
Presenters: Courtnay Ryan, Senior Quality Improvement Facilitator RQITA |Telligen and Ann Loges, Senior Quality Improvement Facilitator, RQITA |Telligen
Objectives:
- Understand key quality improvement (QI) processes
- Learn about different QI tools and when to use them (PDSA, Fishbone, Root Cause Analysis)
- Learn how you can leverage MBQIP data for QI
- Learn what resources are available for you from RQITA including QI facilitation and workshops
Webinar 4: How to Leverage MBQIP Data for Improvement: Social Drivers of Health (SDOH) and Health Equity
Presenters: Courtnay Ryan, Senior Quality Improvement Facilitator RQITA |Telligen and Ann Loges, Senior Quality Improvement Facilitator, RQITA |Telligen
Objectives:
- Understand the SDOH and health equity measures in MBQIP and their importance to CAH quality improvement.
- Learn what data and resources may be available to help address health equity and SDOH.
- Hear from peers who are addressing health equity in their hospitals
- Learn how CAHs have partnered with organizations in their communities to address SDOH
Webinar 5: CAH Quality Infrastructure Assessment Implementation
Presenters: Courtnay Ryan, Senior Quality Improvement Facilitator RQITA |Telligen and Ann Loges, Senior Quality Improvement Facilitator, RQITA |Telligen
Objectives:
- Learn more about the CAH Quality Infrastructure Implementation measure.
- How can critical access hospitals leverage what we know about the CAH Inventory to improve quality?
2023 Medicare Beneficiary Quality Improvement Project (MBQIP) & Quality Improvement Webinar Series
Medicare Beneficiary Quality Improvement Project (MBQIP) & Quality Improvement Webinar Series
Webinar 1: MBQIP Overview and Current State | March 14, 2023
Presenters: Sarah Brinkman & Janelle Shearer, RQITA
Objectives:
- Articulate the purpose of the Medicare Beneficiary Quality Improvement Program (MBQIP) program and its position in the national quality reporting landscape.
- Understand requirements of MBQIP, how data is reported, and current national performance trends.
- Identify ways to utilize MBQIP data and suggested strategies to drive improvement.
Webinar 2: Abstraction Data + CART Overview | April 23, 2023 | 10 a.m. - 11 a.m. PST
Presenter: Robyn Carlson, RQITA
Objectives:
- Identify resources to support abstracting, submitting and confirming data submission to the Centers for Medicare & Medicaid Services (CMS) Hospital Quality Reporting (HQR) secure platform.
- Describe how to use the CMS Hospital Outpatient Quality Reporting Specifications Manuals for abstraction guidance and technical specifications to submit the core MBQIP measures.
- Discuss how to use CART, the CMS Abstraction & Reporting Tool, for the collection and submission of the core MBQIP measures.
Webinar 3: Embedding Quality Improvement into Organizational Culture | May 9, 2023 | 10 a.m. - 11:30 a.m. PST
Presenters: Sarah Brinkman & Janelle Shearer, RQITA
Objectives:
- Identify characteristics of a culture of quality.
- Assess current state of organizational culture as it relates to quality and identify short- and long-term opportunities for improvement.
- Describe strategies for embedding quality improvement into organizational culture.
Webinar 4: Changing Landscape of Quality Reporting | June 20, 2023 | 11:30 a.m. - 1:00 p.m. PST
Presenters: Sarah Brinkman & Janelle Shearer, RQITA
Objectives:
- Identify trends in quality measure reporting and discuss implications for critical access hospitals.
- Review the recent MBQIP Measures Under Consideration request for information and related updates.
- Explore topics such as the CMS Overall Quality Hospital Star Ratings and electronic Clinical Quality Measures (eCQM) and how the impact critical access hospitals.
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CAH Quality 101
The CAH Quality 101 Training Series, led by Susan Runyan of Runyan Health Care Quality Consulting is aimed to teach best practices in quality improvement, data abstracting, data reporting and process improvement within the CAH setting. This series is targeted toward new quality professionals and acts as a refresher course for seasoned quality professionals.
o Session One Recording
o Session One Slides
o Session Two Recording
o Session Two Slides
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Quality Improvement Implementation for CAHs (by Stratis Health)
o Guides and Toolkits -
Quality Improvement Basics (by Stratis Health)
This QI Basics course is designed to equip professionals with the knowledge and tools to start quality improvement projects at their facilities.
o Course Resource Page - MBQIP Measure Fact Sheet
- Emergency Department Transfer Communications (EDTC) Data Specification Resources & Tools
- Online MBQIP Data Abstracting Training Series (5 sessions) by Stratis Health
- Quality Net
- Quality Net CART Basics by Quality Net (recording)
- CART Patient Set-Up | Abstraction | Import & Export (recordings) by Quality Net
- CART Overview and Resources
- Enrolling in Hospital Quality Reporting System (HQR) Training Materials Playlist (recordings) by CMS.gov
- Known issues and maintenance
- Training and Portal Resources
- National Healthcare Safety Network (NHSN) Training and Resources (by CDC)
- For step-by-step guidance on enrolling with the various reporting portals, see the Critical Access Hospital Quality Reporting Overview Guide (Section 3, Reporting)
- Critical Access Hospital Quality Reporting Overview Guide to assist new and experienced Quality Officers with reporting requirements at their CAH.
- Oregon’s CAH Quality Network encourages CAH quality professionals collaborate and learn together. All CAHs are encouraged to join monthly calls and participate in regional networking activities. For more information about the Oregon CAH Quality Network, contact Stacie Rothwell at rothwels@ohsu.edu.
- Additional MBQIP resources from the National Rural Health Resource Center are available at the MBQIP Resource Page or FAQs.
- MBQIP Monthly is a monthly e-newsletter that 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). To view current, or past issues of RQITA Monthly, click here.