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MBQIP Measure Definitions for Quality Improvement
Updated September 2025

Global Measures

  • CAH Quality Infrastructure: structural measure to assess CAH capacity, processes, and infrastructure for quality activities based on the eight core elements of CAH quality infrastructure
    Reported annually through Qualtrics survey administered by the Flex Monitoring Team

Patient Safety

  • HCP: Influenza Vaccination Coverage Among Healthcare Professionals
    Facilities report all HCP who worked in their facility during flu season (Oct 1 – Mar 31) and:
    • Received vaccination at the facility
    • Received vaccination outside of the facility
    • Did not receive vaccination due to a medical contraindication
    • Did not receive vaccination due to declination
    • Had an unknown vaccination status
    Reported annually to NHSN
  • Antibiotic Stewardship: Improving antibiotic use in hospitals is imperative to improving patient outcomes, decreasing antibiotic resistance, and reducing healthcare costs Annual facility survey
    Reported annually via the Annual Facility Survey to NHSN
  • Safe Use of Opioids: Proportion of inpatient hospitalizations for patients 18 years of age and older prescribed, or continued on, two or more opioids or an opioid and benzodiazepine concurrently at discharge
    Reported annually through Hospital Quality Reporting (HQR)

Patient Experience

  • Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
    A standardized survey instrument for measuring patients' perspectives on hospital care.
    Reported quarterly using a vendor of your choice
    • Communication with nurses
    • Communication with doctors
    • Restfulness of Hospital Environment
    • Care Coordination
    • Responsiveness of hospital staff
    • Communication about medicines
    • Discharge information
    • Cleanliness of the hospital environment
    • Information about Symptoms
    • Overall rating of hospital
    • Willingness to recommend hospital

Care Coordination

  • Hybrid Hospital-Wide Readmission: hospital-level, all-cause, risk-standardized readmission measure that focuses on unplanned readmissions 30 days of discharge from an acute hospitalization.
    Reported Annually to Hospital Quality Reporting

Emergency Department

  • Emergency Department (ED) Transfer Communication
    To improve the transitions of care from the Critical Access Hospital 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
  • OP-18: Median time from ED arrival to departure for discharged patients
    Reported quarterly to CMS using Hospital Quality Reporting (HQR)
  • OP-22: Left without being seen
    Reported quarterly to CMS Using Hospital Quality Reporting (HQR)