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MBQIP Measure Definitions for Quality Improvement
September 1, 2021 – August 31, 2022

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 (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
    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


  • 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