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MBQIP Core Measure Sets
Your Essential Overview
MBQIP measure sets help rural hospitals improve care quality through key performance metrics, ensuring
patient safety, effective clinical care, and overall patient satisfaction.
Global Measures
These measures assess a hospital’s capacity, systems, and practices to support organization-wide
quality improvement and sustainability.
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| Measure | Last Updated |
|---|---|
| CAH Quality Infrastructure | Coming soon |
|
Structural measure to assess CAH capacity, processes, and infrastructure for quality
activities based on the eight core elements of CAH quality infrastructure. |
Patient Safety
These measures aim to reduce infections, promote responsible antibiotic use, and ensure opioid
safety.
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| Measure | Last Updated |
|---|---|
| HCP/IMM-3 | 2024 Q1 |
|
Influenza Vaccination Coverage Among Healthcare Personnel (HCP) |
|
| Antibiotic Stewardship | 2023 |
|
Measured via Center for Disease Control National Healthcare Safety Network (CDC NHSN)
Annual Facility Survey |
|
| Safe Use of Opioids (eCQM) | Coming soon |
|
Proportion of inpatient hospitalizations for patients 18 years of age and older
prescribed, or continued on two or more opioids, or an opioid and benzodiazepine
concurrently at discharge. |
Patient Experience
These measures assess patient satisfaction with care, communication, and the hospital environment.
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| Measure | Last Updated |
|---|---|
| HCAHPS | 2023 Q4 |
|
Hospital Consumer Assessment of Healthcare Providers and Systems |
Care Coordination
These resources focus on quality improvement related to unplanned hospital readmissions and the
social drivers that influence patient outcomes.
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| Measure | Last Updated |
|---|---|
| Hybrid Hospital-Wide Readmission | Coming soon |
|
Hospital-level, all-cause, risk-standardized readmission measure that focuses on
unplanned readmissions 30 days of discharge from an acute hospitalization. |
|
| Social Drivers of Health Screening | Coming soon |
|
Whether a hospital implements screening for all patients that are 18 years or older at
time of admission for food insecurity, housing instability, transportation needs,
utility difficulties and interpersonal safety. |
|
| Social Drivers of Health Screening Positive | Coming soon |
|
Patients who screen positive for one or more of the following five HRSNs: Food
insecurity, housing instability, transportation problems, utility difficulties, or
interpersonal safety. |
Emergency Department
These measures focus on timely care, patient transfers, and efficient communication in the emergency
department.
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| Measure | Last Updated |
|---|---|
| EDTC | 2025 Q1 |
|
Emergency Department Transfer Communication |
|
| OP-18 | 2024 Q1 |
|
Median Time from ED Arrival to ED Departure for Discharged ED Patients |
|
| OP-22 | 2024 Q1 |
|
Patient Left Without Being Seen |
About MBQIP.com
This site was created to share and use as a quick and easy reference when researching best practices
and how-to’s for each area of MBQIP.
The Medicare Beneficiary Quality Improvement Project (MBQIP) is a quality improvement activity under
the Medicare Rural Hospital Flexibility (Flex) grant 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 critical access hospitals (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.