MBQIP Frequently Asked Questions


What are the current Medicare Beneficiary Quality Improvement Project (MBQIP) measures?

A list of the current MBQIP measures can be found here.

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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 CAHs and fund activities to target those specific needs.

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Does every critical access hospital (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? 

In order 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 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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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 log in; the National Healthcare Safety Network (NHSN); or to the state Flex Program for the EDTC measure. For more information on the current required measures and where each is reported, see the MBQIP Quality Reporting Guide, or the Data Submission Deadlines Chart.

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Does MBQIP replace the Centers for Medicare and Medicaid Services (CMS) Hospital Quality Measures?

No. With the exception of the EDTC measure, the MBQIP 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 works with CMS to ensure that the measures are aligned with national priorities. The measures are anticipated to remain consistent for the three-year Flex project period, but updates and adjustments may be made to ensure that measures continue to align with national quality priorities and reporting systems.

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

Data submitted by hospitals participating in MBQIP will be provided to FORHP through a contract with Telligen, the CMS Quality Improvement Organization (QIO) data warehouse contractor that has proprietary privileges to collect and store the data submitted to Hospital Compare. Telligen creates individual hospital and aggregated state-level reports that are distributed to each state Flex Program to be shared with their CAHs and key MBQIP partners in the state.

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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/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 raw data for that quarter’s reports.

Patient Engagement (HCAHPS) reports may take between three to four months after the submission deadline to be sent to designated state Flex contacts. All other reports may take between two to three months after the submission deadline. 

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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?

In order for quality data to be shared publicly on Hospital Compare, the appropriate Notices of Participation (NOPs) must be completed for reporting hospitals. The NOPs must indicate "Public Reporting", not just "Quality Improvement’’. If a CAH has completed the related NOP and has not opted to suppress their quality data, then data submitted to QualityNet is eligible to be posted to Hospital Compare so long as the necessary volume thresholds are met. If a hospital has not completed the related NOP, but is reporting data to QualityNet for the purposes of MBQIP, data will not be shared publicly on Hospital Compare.

Please note, as of fiscal year (FY) 2016, 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

While public reporting of data on Hospital Compare is not a requirement of MBQIP participation, FORHP strongly encourages hospitals to do so.

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My CAH says they are participating in Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), why does their data not show up in the MBQIP Patient Engagement (HCAHPS) reports?

There can be a couple of reasons: 

  • HCAHPS data in the MBQIP reports reflects 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.  
  • 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). 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).  
  • 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 newCCN 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?

To help ensure that differences in HCAHPS results reflect differences in hospital quality, HCAHPS survey results are adjusted for patient-mix and mode of data collection. 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 what service line they received care in (surgery, maternity, medical). Neither patient race nor 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 http://www.hcahpsonline.org/home.aspx.

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I’m seeing data from one of my CAHs on the MBQIP reports, but they are not listed as reporting in the Flex Monitoring Team (FMT) reports, why?  

The FMT HCAHPS and Hospital Compare Participation reports utilize data from Hospital Compare rather than the MBQIP data files. With the exception of 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 data publicly reported on Hospital Compare, CAHs must have an active NOP for both the inpatient and outpatient quality reporting programs. The NOPs must indicate "Public Reporting", not just "Quality Improvement’’. 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 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, and CAHs should focus on this to see what their strengths and weaknesses are, then perhaps plot their data in a graph over time to look at trends and closely 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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Are there resources available to assist hospitals in finding a HCAHPS survey vendor? 

Yes. The Technical Assistance and Services Center (TASC) maintains a 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. CAHs are strongly encouraged to submit their population and sample size counts each quarter, but reporting of population and sampling data is not required in order for your data to be submitted to CMS. Entering a "zero" (0) when appropriate in population and sampling data is also a mechanism that allows CAHs to report that they had no eligible cases for a measure set in a given quarter.

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

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

  • Data was not submitted/reported by the CAH
  • Data was submitted but was rejected/not accepted into the QIO Clinical Warehouse

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

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

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

For 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 the 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. Remember to engage any important quality partners in the state as well.

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For the state-level reports and the state and national averages, are all CAHs included?

The MBQIP Data Reports for HCAHPS show state and national averages for all hospitals, both CAHs and non-CAHs. The state and national averages on all other MBQIP Data Reports only include data for CAHs participating in MBQIP that submitted data for the reflected quarter. 

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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, Outpatient and 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 here. CAHs may also have benchmarking data available through their HCAHPS vendor.

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How do hospitals submit their quarterly Emergency Department Transfer Communication (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 the Federal Office of Rural Health Policy (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 CAH individually. CAHs with no MOU in place are not included on the state templates. 

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

After Flex Coordinators and CAHs receive quarterly EDTC reports, review the 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. The hospital’s 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 wrong, 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 reflects 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 to MBQIP@hrsa.gov. Hospital names will be updated in next quarter’s MBQIP Data Reports. 

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If not all CAHs report on EDTC, should Flex Coordinators just submit the data they do receive?

Yes, please submit data for all reporting CAHs. If some CAHs do not submit data, please follow up with them to determine the reason and identify opportunities to support and engage them in the process.

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

Yes. Public reporting of quality data is not going away and, in time, it is likely that reimbursement from a variety of payers, including Medicare, will be tied to performance across all hospitals. It is to the advantage of CAHs to begin the process of reporting to ensure preparedness for future payer requirements. 

When reporting, hospitals with low volumes should report all of their 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 case load issues faced by individual CAHs, as the small numbers in each CAH add up to a lot of patients receiving care in rural hospitals for each state and the nation as a whole.

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Because of the small volumes in some CAHs, even one missed patient makes the percentages look bad. 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 issue with 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 do 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 a lot of patients for each state and the nation as a whole!

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

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

A glossary of MBQIP reporting related terms can be found at the end of Interpreting MBQIP Hospital Data Reports for Quality Improvement. A list of MBQIP Acronyms can be found at the end of the MBQIP Quality Reporting Guide.

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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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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.