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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.
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 |
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 |
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 |
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| 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.