MBQIP Frequently Asked Questions

Frequently asked questions regarding the Medicare Beneficiary Quality Improvement Project (MBQIP) are grouped into the following three categories:

  • Programmatic: Information about the background and implementation of MBQIP
  • Reporting: Information about how to report MBQIP data
  • Data: Information about accessing, interpreting and utilizing MBQIP data

Programmatic Questions

Reporting Questions

Data Questions

How is MBQIP funded?

This project is funded out of existing Medicare Rural Hospital Flexibility (Flex) Program dollars within each state. These activities comprise the core Flex Program area of quality improvement. Given that Flex funds are limited, states will need to prioritize the needs of critical access hospitals (CAHs) and fund activities to target those specific needs.

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What are the current MBQIP measures?

Here is a list of the current MBQIP measures.

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Does every CAH have to report on these measures?

Participation in MBQIP is voluntary, but FORHP is asking that every hospital that is able, participate in and report on these measures. CAHs wishing to participate in any Flex funded activities must meet the MBQIP participation requirements.

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How is MBQIP participation defined? 

To be eligible to benefit from Flex grant funds and participate in Flex funded activities, CAHs must meet annual MBQIP participation requirements set out by the Federal Office of Rural Health Policy (FORHP), or have completed the necessary MBQIP Waiver. FORHP is implementing a phased approach when determining the minimum level of reporting requirements in MBQIP for participation in Flex-funded activities, with requirements increasing each year after 2015. For more information about the specifics of MBQIP participation requirements, please see the Flex Eligibility Criteria for MBQIP Participation.

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Does MBQIP replace the CMS Hospital Quality Measures?

No. Except for the EDTC and antibiotic stewardship measures, MBQIP core measures are a subset of measures from the CMS Hospital Inpatient and Outpatient Quality Reporting Programs. Hospitals currently reporting additional CMS measures are encouraged to continue that process.

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How were the MBQIP measures selected?

FORHP selected the current measures with the input of rural experts who have worked with or within CAHs, including CAH quality administrators, FMT,  state Flex Coordinators and rural clinical experts. FORHP adds measures to MBQIP as needed based on alignment with other Federal quality reporting programs, with a strong preference for standardized measures that are supported by a national reporting system. The measures are intended to remain consistent, but updates and adjustments are made regularly to ensure that measures continue to align with national quality priorities and reporting systems. For more information about how measures are added and removed from MBQIP, see the MBQIP Fundamentals Guide for State Flex Programs

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With a small caseload, does it make sense to have CAHs publicly report?

Yes. Public reporting of quality data is not going away and is increasingly being tied to reimbursement from a variety of payers. It is to the advantage of CAHs to participate in public reporting to demonstrate the quality of services they provide and ensure preparedness for future payer requirements.

Hospitals with low volumes should report all of their cases; for MBQIP, there is no minimum required number of cases. While available to hospitals at the individual level, MBQIP data is aggregated at the state and national level, providing FORHP the ability to show a more robust picture of the quality of care being provided in CAHs. The aggregation addresses the small caseload issues faced by individual CAHs, as the small numbers in each CAH add up to many patients receiving care in rural hospitals for each state and the nation as a whole.

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Where can I find a glossary of MBQIP terms or a list of MBQIP acronyms?

A list of MBQIP Acronyms can be found with the MBQIP Fundamentals Guide for State Flex Programs.

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How do I convince the CAHs in my state to participate in MBQIP reporting and improvement activities?

Although MBQIP has identified a common set of rural-relevant measures for reporting and improvement nationally, each state may have unique opportunities and challenges for engaging CAHs in reporting and improvement activities. Flex Programs are encouraged to work in partnership with other organizations such as state hospital associations, quality improvement network quality improvement organizations (QIN-QIOs), hospital innovation improvement networks (HIINs), and others to encourage CAH participation. This list of MBQIP Talking Points is intended to equip state Flex Program staff with summary statements to address concerns and encourage participation in quality reporting and improvement programs.

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How will data be submitted or reported?

Measures are submitted via a variety of methods, including reporting to QualityNet through CART (the CMS Abstraction and Reporting Tool) or a vendor; QualityNet via secure login; the National Healthcare Safety Network (NHSN); or to the state Flex Program for the EDTC measure. For more information on the currently required measures and where each is reported, see the MBQIP Quality Reporting Guide, or the Data Submission Deadlines Chart.

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Are there resources available to assist hospitals in finding an HCAHPS survey vendor? 

Yes. The Technical Assistance and Services Center (TASC) maintains an HCAHPS Vendor Directory, which includes:

  • Information regarding the benefits and challenges of implementing the HCAHPS survey process in CAHs
  • Self-completed profiles with information that may be useful for CAHs in selecting a certified vendor

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Can hospitals conduct HCAHPS surveys on their own?

Yes, although uncommon, hospitals participating in HCAHPS can self-administer the survey process if strict criteria are met. Visit the HCAHPS website Quality Assurance page for more details.

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What is “Population and Sampling” and is it required for CAHs participating in MBQIP?

Population and Sampling refers to the recording of the number of cases the hospital is submitting to the QualityNet Warehouse. This is done directly through the QualityNet Secure Portal. Entering a "zero" (0) when appropriate in population and sampling data is a mechanism that allows CAHs to report that they had no eligible cases for a measure set in a given quarter. CAHs are strongly encouraged to submit their population and sample size counts each quarter, but reporting of population and sampling data is not required for data to be submitted to CMS.

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How do hospitals submit their quarterly EDTC data for MBQIP?

Hospitals submit their quarterly EDTC data to the state Flex Program per whatever instructions are provided at the state-level.

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How do state Flex Programs submit quarterly EDTC data to FORHP?

FORHP provides a personalized template to each state Flex Program for capturing hospital-level EDTC data on a quarterly basis. State Flex Programs will submit one spreadsheet for their state that includes the data for each individual CAH. Submissions should be sent to MBQIP@hrsa.gov. CAHs with no MOU in place are not included on the state templates. See the MBQIP EDTC Reporting Instructions for Flex Programs for more information.

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What should state Flex programs submit for EDTC if not all CAHs report?

State Flex programs should submit EDTC data for all CAHs that did report. State Flex programs should follow up with those CAHs that did not report to determine the reason and identify opportunities to support and engage them in the process.

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Who will have access to the data? How are reports produced?

CAHs, state Flex Coordinators, FORHP, and relevant parties such as FMT, Rural Quality Improvement Technical Assistance (RQITA) and TASC have access to hospital-level data submitted through QualityNet, the National Healthcare Safety Network, and state Flex programs for all hospitals participating in MBQIP. MBQIP data reports are provided to FORHP through a contract with Telligen, the CMS data warehouse contractor that has proprietary privileges to collect and store the data. 

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What MBQIP reports are available (and when), and how do I access them?

MBQIP Data Reports are sent from the FORHP Flex Program project officer to a designated state Flex contact(s) through a National Institutes of Health (NIH) Secure Email and File Transfer.

Three sets of MBQIP reports are available on an approximately quarterly basis: Patient Safety/Inpatient and Outpatient, Care Transitions (EDTC) and Patient Engagement (HCAHPS). In addition to individual hospital-level reports, Flex Programs are provided a state summary report, a non-submission list and an Excel file with the underlying data for that quarter’s reports.

The Anticipated MBQIP Data Reports Release Timelines for State Flex Programs provides estimates of when data report will be released based on historical timelines. The dates provided are subject to change and do not account for the time required for state Flex programs to distribute data to hospitals.

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What if there are no MBQIP Data Reports for some of the hospitals?

If a CAH has not signed a memorandum of understanding (MOU) that is on record with FORHP, no MBQIP Data Reports will be produced, even if that CAH regularly submits quality data to QualityNet. State Flex Coordinators should contact their FORHP project officer to confirm whether or not they have an MOU on record for any CAH believed to be signed up for MBQIP but for which a report was not received.

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Will MBQIP data be shared publicly on Hospital Compare?

For inpatient quality data to be shared publicly on Hospital Compare, hospitals must complete the Inpatient Quality Reporting Program Notice of Participation (NOP) and must not opt out of publicly reporting inpatient quality data. If a CAH has completed the NOP and has not opted to suppress their quality data, then inpatient data submitted to QualityNet and/or NHSN is eligible to be posted to Hospital Compare so long as the necessary volume thresholds are met.

In the Fiscal Year (FY) 2019 Outpatient Prospective Payment System (OPPS) Proposed Rule, the Centers for Medicare & Medicaid Services (CMS) propose removing the NOP requirement for the Outpatient Quality Reporting Program. If this proposed change is finalized, all outpatient data reported to QualityNet is eligible to be posted to Hospital Compare so long as the necessary volume thresholds are met.

Please note, as of FY2016, hospitals participating in the Small Rural Hospital Improvement Grant Program (SHIP) are required both to conduct HCAHPS and to opt to publicly report HCAHPS data by completing the Inpatient Quality Reporting Program NOP. By doing so, all inpatient data reported to QualityNet is eligible for publishing on Hospital Compare so long as the necessary volume thresholds are met as determined by CMS

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My CAH says they are participating in HCAHPS, why does their data not show up in the MBQIP Patient Engagement (HCAHPS) reports?

There are several possible reasons: 

  • HCAHPS data in the MBQIP reports reflect the most recent four quarters. Thus, CAHs must have at least four consecutive quarters of HCAHPS data reported before they are included in the MBQIP Data Reports
  • Some HCAHPS vendors have not been submitting CAH HCAHPS data, and/or are using vendor identified volume thresholds for submission (and CAHs may not always meet that threshold). CAHs should check with their HCAHPS vendor to ensure the vendor is submitting HCAHPS data to QualityNet on their behalf (and if not, request that they do so).  
  • If the CAH recently converted, or had an ownership change that resulted in a change to their CMS Certification Number (CCN number), they must have at least four consecutive quarters of HCAHPS data under their new CCN number before the data will appear in the reports

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The MBQIP reports indicate my HCAHPS scores are adjusted – what does that mean?

HCAHPS survey results are adjusted for patient-mix and mode of data collection to help ensure that differences in HCAHPS results reflect differences in hospital quality. Only the adjusted results are publicly reported and are considered the official results. Several questions on the survey, as well as items drawn from hospital administrative data, are used for the patient-mix adjustment. Examples of factors used for adjustment include the mode of survey implementation (mail, phone, mixed, interactive voice response) and patient-mix such as age, education, self-rated health, language, and under which service line they received care (surgery, maternity, medical). Neither patient race or ethnicity is used to adjust HCAHPS results. The adjustment model also addresses the effects of non-response bias. More information about how the adjustments are made can be found under “Mode and Patient-Mix Adjustment” at HCAHPS Online.

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I see data from one of my CAHs on the MBQIP reports, but they are not listed as reporting in the FMT reports, why?  

The FMT HCAHPS and Hospital Compare Participation reports utilize data from Hospital Compare rather than the MBQIP data files. Except for the EDTC measure, the data source for both the Hospital Compare data and the MBQIP data is the same (the QualityNet Warehouse), but there are some key differences:

  • The timeframes may be different. MBQIP Data Reports are typically more recent than the data available on Hospital Compare or in the FMT reports
  • To have inpatient measure data publicly reported on Hospital Compare, CAHs must have an active NOP and must not opt out of publicly reporting inpatient quality data
  • In the FY2019 OPPS Proposed Rule, CMS proposes removing the NOP requirement for the Outpatient Quality Reporting Program. However, for data reported before the calendar year 2018 to be publicly reported on Hospital Compare, hospitals must have completed the quality reporting NOP.

Although CMS suppresses data from public reporting when CAHs fall under low volume case thresholds for individual measures, FMT has access to the suppressed data, so all CAHs that have submitted data and have active NOPs should be reflected on the FMT reports.

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What should state Flex Programs do with the available MBQIP data?

State Flex Programs should use the data to determine appropriate quality improvement activities to support CAHs through the Flex grant. Individual hospitals can use the MBQIP reports as an opportunity to review CAH comparison data at a state and national level.
 
State Flex Programs and CAHs should review the MBQIP Data Reports each quarter as one mechanism to identify opportunities to improve patient care. Data can be used for tracking CAH MBQIP participation, benchmarking, and identifying opportunities for quality improvement activities at the individual hospital and state level.

When reviewing MBQIP Data Reports, the key column from a quality improvement perspective is the “Aggregate Rate for All Four Quarters." This is the most stable number; CAHs should focus on this to see what their strengths and weaknesses are. CAHs could plot their data in a graph over time to look at trends and carefully review any quarter that is an outlier (drilling down to the patient level). The Quality Improvement Implementation Guide and Toolkit for CAHs includes an Internal Quality Monitoring Tool and related video tutorial that provides a template for CAHs to use specific to the required MBQIP measures.

State Flex Programs are also encouraged to work with CAHs to coordinate local sharing of quality data in more real-time than is possible relying on the MBQIP Data Reports.

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What is the difference between "0", "N/A" and "D/E" on the MBQIP Data Reports? 

Zero (0) means that the CAH entered a zero into the population and sampling grid on QualityNet, indicating there were no eligible patients in a measure set population for the reporting quarter. 

N/A (Not available) can mean two different things:

  • Data were not submitted/reported by the CAH
  • Data were submitted by the CAH but was rejected/not accepted into the QualityNet Warehouse. The MBQIP Quality Reporting Guide includes instructions on how to run a case status summary report to ensure that data has been accepted to the QualityNet Warehouse

Note: If the CAH had no eligible cases in a quarter to submit, but did not enter a zero (0) into population and sampling (see below), the report will indicate N/A. 

D/E (data excluded) means that the CAH submitted eligible cases to QualityNet. Data were considered submitted and accepted to the QualityNet Warehouse; however, case(s) were excluded from a particular measure. 

For a more detailed description of this information, including several examples, see pages 4–5 in Interpreting MBQIP Hospital Data Reports for Quality Improvement.

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How can Flex Programs find out which hospitals did not submit data?

With each quarter of MBQIP Data Reports, FORHP provides state Flex Programs a non-submission list that summarizes which CAHs did not submit a particular measure in the given quarter.
 
FORHP recommends state Flex Programs follow up with any CAHs that did not successfully submit data each quarter and ask them what challenges or barriers they may be facing that prevented them from submitting data. This will be important information to identify the needs of CAHs and provide appropriate technical assistance to increase reporting in future quarters. 

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Are all CAHs included in the state-level reports and the state and national averages?

The Patient Safety/Inpatient and Outpatient MBQIP Data Reports include state and national averages and 90th percentiles for all CAHs participating in MBQIP as well as a national average for all hospitals, including prospective payment system (PPS) hospitals. 

The HCAHPS MBQIP Data Reports include state and national averages for all hospitals combined (both CAHs and PPS). CAH specific averages are not provided.

The EDTC MBQIP Data Reports include state and national averages and 90th percentiles for CAHs only. Prospective Payment System (PPS) hospitals do not report EDTC, and therefore data is not available.

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How are the benchmarks on the MBQIP reports calculated?

90th percentile benchmarks are provided for measures on the MBQIP Patient Safety/Inpatient and Outpatient Care, and the Care Transitions (EDTC) reports. The benchmarks indicate the results on individual measures for the top 10% of CAHs reporting at a state and national level.
 
Top performing CAH benchmarks are not currently available as part of the MBQIP Patient Engagement (HCAHPS) reports. Benchmarking data for all hospitals participating in HCAHPS can be found in the HCAHPS percentile tables that are updated quarterly on the HCAHPS Online website. CAHs may also have benchmarking data available through their HCAHPS vendor.

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How do I get an error corrected in the EDTC data reports for my state?

Flex Coordinators and CAHs are encouraged to review quarterly EDTC reports as soon as possible. If there are any errors in the reports, Flex staff should update the EDTC State Reporting Excel Spreadsheet and email the updated EDTC spreadsheet to MBQIP@hrsa.gov before the next quarter’s submission deadline. Corrected data will be updated in next quarter’s EDTC data reports.

  • Example: After receiving quarter 1, 2016 (1Q16) EDTC data reports, a hospital notices that there is an error in the data. The Flex Coordinator corrects the data in the 1Q16 state reporting Excel spreadsheet and emails MBQIP@hrsa.gov by the EDTC submission deadline for 2Q16. The hospital’s correct data will be reflected in 2Q16 EDTC reports. This process only applies to data that is incorrect, not for data that was submitted late to Flex Programs or FORHP
  • Data errors can only be corrected if the quarter of data is within the four most recent quarters of EDTC data reports. For example, if next quarter’s EDTC reports reflect data from 1Q16-4Q16, data previous to 1Q16 cannot be corrected

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How do I get hospital names updated on the MBQIP Data Reports?

Please submit updated hospital names, including the hospital CCN (CMS Certification Number) to MBQIP@hrsa.gov. Hospital names will be updated in next quarter’s MBQIP Data Reports. 

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Because of the small volumes in some CAHs, one case can skew performance data significantly. How can hospitals address this issue?

MBQIP is an initiative to encourage all CAHs to report their data, regardless of how many patients they have, and FORHP recognizes the issues variation when reporting small volumes. While it is true that a percentage at the individual hospital level is not significant with such low volumes, it is important to remember that each number is a patient. Whether one out of four patients does not receive the recommended care, or one out of 400, hospitals should be using the data to determine which processes should be improved to ensure that every patient receives the highest quality care.

State Flex Programs are encouraged to not lose sight of the bigger picture by focusing too narrowly on one measure for one quarter in one CAH. Instead, begin to look at trends and the aggregate data for the state. The small numbers in each CAH start adding up to many patients for each state and the nation as a whole!

Note that while MBQIP eligibility requires hospitals to report data publicly, Hospital Compare suppresses data if certain volume thresholds are not met.

For additional information, see How Small is Too Small and Eliminate the Denominator.

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This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UB1RH24206, Information Services to Rural Hospital Flexibility Program Grantees, $1,100,000 (0% financed with nongovernmental sources). This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.