- Benefits of Participation
- Additional Reporting Programs
- Hospital Quality Reporting Crosswalk for CAHs
Helpful Links
Data Reporting Partners
RCAH Data and Reporting Tools
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Tools and strategies for using your data
The Washington State Office of Rural Health is focused on empowering rural and Critical Access Hospitals (CAHs) with better data, stronger connections, and continued innovative improvement.
The information provided on this page focuses on reporting for the Medicare Beneficiary Quality Improvement Project (MBQIP) program. It may also be useful for prospective payment system (PPS) and rural hospitals, as they report on many of these measures. See measure crosswalks at the bottom of this page.
Medicare Beneficiary Quality Improvement Project (MBQIP)
MBQIP takes a proactive approach to help ensure CAHs are prepared to meet future quality requirements. Because of this program, it is clear that CAHs are excelling across multiple rural relevant topic areas.
MBQIP is a quality improvement activity launched in 2011 under the Flex program. The goal of the program is to improve the quality of care provided in Critical Access Hospitals by increasing quality data reporting and then driving quality improvement activities based on the data. MBQIP provides an opportunity for individual hospitals to look at their data, compare their results against other CAHs, and partner with other hospitals around quality improvement initiatives to improve outcomes and provide the highest quality care to every patient.
CAHs are paid under a cost-based reimbursement model from Medicare. This means they have historically been excluded from federal quality reporting and incentive programs linked to payment. These include Inpatient and Outpatient Quality Reporting, Hospital Value-Based Purchasing, and other such pay-for-reporting and -performance programs that impact Medicare reimbursement for prospective payment system hospitals. As the U.S. moves rapidly toward a health care system that pays for value versus volume of care provided, it is crucial for CAHs to participate in federal, public quality reporting programs to demonstrate the quality of the care they are providing.
MBQIP Core Measures (PDF) are divided into five domains:
- Global Measures
- Patient Safety
- Patient Experience
- Care Coordination
- Emergency Department
Benefits of Participation
Improve Patient Care
Track and enhance clinical quality to achieve better outcomes.
Benchmark Performance
Compare with national peers to identify gaps and adopt best practices.
Demonstrate Value
Show commitment to quality and accountability to patients and payers.
Sustain Funding
Participation is required to receive Flex Program funding.
Access Support
Benefit from technical assistance, education, and resources from Flex Program and Federal Office of Rural Health Policy.
Foster a Quality Culture
Build staff engagement and a continuous improvement mindset.
MBQIP Reporting Resources
CAH Quality Infrastructure Assessment
Hybrid Hospital-Wide Readmissions
Social Drivers of Health Screening
Social Drivers of Health Screen Positive
Hospital Consumer Assessment of Healthcare Providers and Systems
Emergency Department Transfer Communications
OP22 – Patient Left Without Being Seen
Healthcare Personnel Influenza safety
MBQIP Data Reporting Deadlines
MBQIP Data Reporting Deadlines (PDF) (RQITA)
HARP (CMS)
NHSN (CDC)
Outpatient Spec Manuals (CMS)
Inpatient Spec Manuals (CMS)
Rural Quality Improvement Technical Assistance (RQITA)
MBQIP Abstraction & Reporting 2024 Training Series Recordings
Current Status MBQIP and Beyond: Meet the Telligen Staff
Learn About the New MBQIP Measures
Embedding Quality Improvement into Organizational Culture
How to Leverage MBQIP Data for Improvement: SDOH & Health Equity
CAH Quality Infrastructure Implementation
Additional Reporting Programs
Hospital Outpatient Quality Reporting (OQR)
Includes outpatient measures collected and submitted by acute care hospitals and claims-based outpatient measures calculated by CMS. PPS hospitals are subject to a payment penalty if they do not report all OQR measures (pay-for-reporting).
Participation: Voluntary
Participants: CAHs (MBQIP), PPS Hospitals
Lead Organization: CMS
Hospital Inpatient Quality Reporting Programs
Includes a suite of CMS programs with inpatient measures collected and submitted by acute care hospitals and claims-based inpatient measures calculated by CMS.
Inpatient Quality Reporting Program (IQR)
Pay-for-reporting program that requires PPS hospitals to submit data on quality measures, also includes CMS calculated claims-based measures.
Hospital Readmissions Reduction Program (HRRP)
Pay-for-performance program that includes condition specific 30-day readmissions measures.
Hospital Acquired Condition Reduction Program (HAC)
Pay-for-performance program that uses patient safety measures calculated from claims or submitted to the National Healthcare Safety Network (NHSN).
Hospital Value-Based Purchasing Program (VBP)
Adjusts Medicare payment to PPS hospitals based on quality of care. Includes claims-based mortality and complication measures, patient experience (HCAHPS), chart-abstracted safety measures, and CMS calculated efficiency and cost measures.
Participation: Voluntary
Participants: CAHs (MBQIP), PPS Hospitals
Lead Organization: CMS
Promoting Interoperability Program (includes eCQM reporting)
Reporting electronic clinical quality measures (eCQMs) is one requirement for hospitals under the Promoting Interoperability Program (PI) Formerly called the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs, sometimes referred to as Meaningful Use (MU).
Participation: Required
Participants: CAHs, PPS Hospitals
Lead Organization: CMS
Quality Payment Program (QPP)
Payment incentive and penalty program for eligible clinicians. QPP has two payment tracks Advanced Alternative Payment Models (APMs) and the Merit-Based Incentive Payment System (MIPS).
Participation: Required if using Method II billing with eligible providers
Participants: Eligible professionals and practices
Lead Organization: CMS
Hospital Quality Reporting Crosswalk for CAHs
The MBQIP Data Reporting Crosswalk (PDF) was developed as a collaborative effort across State Flex Programs and Stratis Health.
The Washington Rural Hospital Quality Reporting Guide available on the SmartSheet platform is a collaborative effort with WSHA, TRC, Comagine.