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Data Reporting and Use

These resources provide information for critical access hospitals (CAHs) about how, where, and when to submit Medicare Beneficiary Quality Improvement Project (MBQIP) data and how to interpret data reports to inform quality improvement efforts.


This guide is intended to help Flex Coordinators, critical access hospital (CAH) staff, and others involved with MBQIP understand the measure reporting process. For each reporting channel, information is included on how to register, which measures are reported where, and how to submit data.

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This chart outlines the current MBQIP measures.


Federal Office of Rural Health Policy (FORHP)

This single-page document contains a chart showing the MBQIP Core Measure data submission deadlines through Quarter 2, 2024 encounters.


RQITA Resource Center

Resources to support abstraction and reporting of the EDTC measure, including manuals, tools, and instructional videos.

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Flex Monitoring Team

View a recorded training series created for CAH staff that collects and reports CMS Inpatient and Outpatient quality measures.

Provides an overview of MBQIP Measures in a one-measure-per-page format. Includes information about the data collection and reporting processes, as well as details such as the measure set, description, and significance of each measure.

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Analyzing MBQIP Data Resources

This guide is intended to help CAH staff use MBQIP Hospital Data Reports to support quality improvement efforts and improve patient care.

Centers for Medicare and Medicaid Services (CMS) QualityNet Reporting Resources

Resources to support abstracting, submitting, and confirming data submission to the CMS QualityNet Warehouse, including the CMS CART tool and reporting specifications manuals.

The CART tool is used for inpatient and outpatient data collection and analyses to inform quality improvement efforts. CART is available from QualityNet for computers or as a paper tool. The application is available at no charge to hospitals or other organizations seeking to improve quality of care.

Quality reporting specifications manuals are uniform guidelines defining hospital inpatient and outpatient data to be collected and how data is to be reported. They contain the information necessary for abstractors to ensure data are standardized and comparable across hospitals.

Training videos available from the QualityNet Training page. Topics of interest include new user enrollment for the QNet Secure Portal, Hospital Quality Reporting Notice of Participation, Outpatient Quality Reporting for Web-Based Measures and Hospital Inpatient Quality Reporting Web-Based Measures.

View information, including contact information, about the QualityNet (QNet) Help Desk for use with technical questions related to the QNet website, HARP account login, password, browser or navigation issues.

HCAHPS Data Reporting Resources

Resources to support hospitals with participating in HCAHPS.

This guide, updated twice per year, provides information on HCAHPS, including the benefits and challenges to implementing an HCAHPS survey process with small rural hospitals, specifically CAHs. It also identifies vendors to guide small rural hospitals and CAH vendor selection of this important, patient-centered survey process.

National Healthcare Safety Network (NHSN) Data Reporting Resources

Resources to support data submission to the National Healthcare Safety Network (NHSN) for MBQIP-related measures – healthcare personnel influenza vaccination and antibiotic stewardship implementation through the NHSN Annual Facility Survey.

Access resources such as training, protocols, data collection forms, and frequently asked questions to support reporting and improvement of the Healthcare Personnel (HCP/IMM-3) Influenza Immunization measure.

This document provides instructions for how to access and complete the National Healthcare Safety Network (NHSN) Annual Facility Survey required for reporting Antibiotic Stewardship under the Medicare Beneficiary Quality Improvement Project (MBQIP).


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