RCAH Data and Reporting Tools

Tools and strategies for using your data

The Washington State Office of Rural Health is focused on empowering rural and critical access hospitals with better data, stronger connections, and continued innovative improvement.

Although the information provided on this page focuses on reporting for the Medicare Beneficiary Quality Improvement Project (MBQIP) program, PPS and rural hospitals also 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. Furthermore, it is clear that some CAHs are not only participating in national quality improvement reporting programs but 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.

Because CAHs are paid under a cost-based reimbursement model from Medicare, they have historically been excluded from federal quality reporting and incentive programs linked to payment, such as the 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 (PPS) 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 are divided into five domains:

• Global Measures
• Patient Safety
• Patient Experience
• Care Coordination
• Emergency Department

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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.

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MBQIP Reporting Resources

CAH Quality Infrastructure Assessment

Safe Use of Opioids

Hybrid Hospital-Wide Readmissions

Social Drivers of Health Screening

Social Drivers of Health Screen Positive

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

Emergency Department Transfer Communications (EDTC)

OP18 – ED Throughput

OP22 – Patient Left Without Being Seen

Healthcare Provider Influenza (HCP)

Antibiotic Stewardship

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MBQIP Data Reporting Deadlines

MBQIP Data Reporting Deadlines (Canva document)

HARP (CMS)

NHSN (CDC)

Outpatient Spec Manuals (CMS)

Inpatient Spec Manuals (CMS)

Rural Quality Improvement Technical Assistance (RQITA)

MBQIP Reporting Guide (PDF)

FAQ (Canva document)

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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

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Additional Reporting Programs

Program and Description	Voluntary or Required for CAHs	Participants	Lead Organization
Medicare Beneficiary Quality Improvement Project (MBQIP) This is a federal grant program administered by the Washington State Flex Program to support CAHs to report common, rural-relevant quality measures that are appropriate to low-volume hospitals.	Voluntary	CAHs only	HRSA FORHP Washington State Office of Rural Health
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).	Voluntary	CAHs (MBQIP) PPS Hospitals	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.	Voluntary	CAHs (MBQIP) PPS Hospitals	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)).	Required	CAHs PPS Hospitals	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).	Required if using Method II billing with eligible providers	Eligible professionals and practices	CMS

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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.

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