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MBQIP Measure Definitions for Quality Improvement
September 1, 2015 – August 31, 2018

Outpatient Measures (Patient Safety, Care Transitions and Outpatient AMI & Chest Pain)

  • (Patient Safety) Influenza Vaccination Coverage Among Healthcare Professionals
    OP-27: Facilities report a single rate for their CAH to the CDC National Healthcare Safety Network (NHSN).
    Reported to the National Healthcare Safety Network (NHSN)
  • (Care Transitions) Emergency Department Transfer Communication (EDTC)
    To improve the transitions of care from the CAH to other healthcare settings in order to improve patient outcomes.
    Reported to Quality Health Associates (REDCap program) on behalf of the CAH Quality Network/Flex
    Seven Elements:
    • Administrative communication
    • Patient information
    • Vital signs
    • Medication information
    • Physician or Practitioner generated information
    • Nurse generated information
    • Procedures and tests
  • (Outpatient ED Chest Pain and Heart Attack AND ED Throughput Measures
    Reported to CMS Using Outpatient CART Module
    • ED Chest Pain and Heart Attack
      OP-1: Median time to fibrinolysis in the Emergency Department (ED)
      OP-2: Fibrinolytic therapy received within 30 minutes of ED arrival in the ED
      OP-3: Median time to transfer to another facility for acute coronary intervention in the ED
      OP-4: Aspirin on arrival
      OP-5: Median time to ECG in the ED
    • ED Throughput
      OP-18: Median time from ED arrival to departure for discharged patients
      OP-20: Door to diagnostic evaluation by a qualified medical personnel
      OP-21: Pain management for long bone fracture
      OP-22: Left without being seen

Inpatient Measures (Patient Engagement)

  • (Inpatient) IMM-2 Influenza Immunization
    IMM-2: This prevention measure addresses acute care hospitalized inpatients age 6 months and older who were screened for seasonal influenza immunization status and were vaccinated prior to discharge if indicated.
    Reported to CMS Using Inpatient CART Module
  • (Inpatient) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
    The survey contains 21 patient perspectives on care and patient rating items that encompass nine key topics.
    Reported Using a Vendor of Your Choice with Partial Funds from Flex
    • Communication with doctors
    • Communication with nurses
    • Responsiveness of hospital staff
    • Pain management
    • Communication about medicines
    • Discharge information
    • Cleanliness of the hospital environment
    • Quietness of the hospital environment
    • Transitions of care
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