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MBQIP Measure Definitions for Quality Improvement
September 1, 2017 – August 31, 2019

Patient Safety/Inpatient

  • OP-27: Influenza Vaccination Coverage among Healthcare Professionals
    Facilities report a single rate for their critical access hospital (CAH) to the Centers for Disease Control and Prevention National Healthcare Safety Network (NHSN).
    Reported to the NHSN
  • Inpatient Emergency Department (ED) Measures
    • ED-1: Median Time from ED Arrival to ED departure for Admitted ED patients
    • ED-2: Admit decision time for ED departure time for admitted patients
    Reported to Centers for Medicare & Medicaid Services (CMS) using Inpatient CMS Abstraction and Reporting Tool (CART) Module
  • Antibiotic Stewardship
    Annual facility survey
    Reported to the NHSN
  • IMM-2 Influenza Immunization
    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

Patient Engagement

  • 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
    • Cleanliness of the hospital environment
    • Communication about medicines
    • Communication with doctors
    • Communication with nurses
    • Discharge information
    • Pain management
    • Quietness of the hospital environment
    • Responsiveness of hospital staff
    • Transitions of care

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
    • Medication information
    • Nurse generated information
    • Patient information
    • Physician or Practitioner generated information
    • Procedures and tests
    • Vital signs


  • ED Chest Pain and Heart Attack AND ED Throughput Measures
    • ED Chest Pain and Heart Attack
      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-5: Median time to electrocardiography (ECG) in the ED
    • ED Outpatient
      OP-18: Median time from ED arrival to departure for discharged patients
      OP-22: Left without being seen
    Reported to CMS Using Outpatient CART Module