MBQIP Measure Definitions for Quality Improvement
September 1, 2023 – August 31, 2024
Patient Safety/Inpatient
HCP: 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
Antibiotic Stewardship
Annual facility survey Reported to the NHSN
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
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
Eight Elements:
Allergies and/or Reactions
ED Provider Note
Home Medications
Medications Administered in ED
Mental Status/Orientation Assessment
Reason for Transfer and/or Plan of Care
Tests and/or Procedures Performed
Tests and/or Procedures Results
Outpatient
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